October 30, 2006

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Blue Ribbon Commission on Dirigo Continues its Preparation

The 19-member Blue Ribbon Commission on Dirigo Health met on Oct. 24 but continues to collect information and has yet to discuss in any depth alternative financing for the DirigoChoice program. At the meeting last week, Commission members received the results of a study on the uninsured population in Maine, some data on DirigoChoice Spending, a presentation on the State Employee Health Plan (which is now self-insured), a presentation on the activities of the Maine Quality Forum and a presentation on risk management in the health insurance market.  The risk management presentation included a discussion on reinsurance and high risk pools.  The Commission meets again on Nov. 9 and has only 3 more meetings scheduled before presenting its report by Dec. 15.

Many of the presentations made to the Commission are available at www.dirigohealth.maine.gov/dhsp07ja.htm.

The study of Maine's adult uninsured population was conducted by the Muskie School of Public Service at USM and provided some interesting observations.  Between 2002 and 2005 there was a shift in uninsurance toward higher income groups, most likely reflecting both the greater availability of MaineCare and Dirigo coverage for the lowest income adults in the intervening years and the erosion of coverage among moderate income adults as health insurance costs climb.

Some highlights from the study are the following:

  • Among employed adults in Maine, the highest rate of uninsurance is among workers with incomes below poverty who work for businesses of less than 25 employees - with more than 1 in 4 uninsured.
  • The rate of being uninsured is higher for very small business employees (businesses of less than 25) with low to moderate incomes (100% to 300% of poverty) than it is for very poor workers in medium to large firms.
  • The largest number of uninsured working adults are in households making more than 300% of poverty income, but working in very small firms.
  • In terms of age, the highest rate of being insured is among 18 to 29 year olds with incomes between 200 and 300 percent of the federal poverty level, with over 26 percent of this group lacking coverage.
  • For adults below  poverty, the rate of being uninsured does not vary greatly by age.  Among those between the ages of 45 and 59 , over 26 percent are uninsured.  In all other ages (below age 65) among very poor adults, the rates are 23 to 25 percent.
  • For adults with incomes above 200 percent of poverty, the rates of uninsurance are substantially higher among young adults (18 to 30) than other adults.
  • The largest number of uninsured adults is among 45 to 59 year olds with incomes above 300 percent of the federal poverty level.
  • Part-time workers in Maine have much higher rates of being uninsured than do full-time workers. Close to 27,000 of the uninsured adults in Maine work fewer than 35 hours per week.

In addition to looking at alternatives to the controversial "savings offset payment" , the Commissioner can examine cost containment strategies including decreasing benefits or eligibility.  In order to examine these issues, members requested a lot of background information regarding Dirigo spending and the target audience for DirigoChoice coverage.

While the first five meetings have produced a lot of information and not much discussion, members seem to be ready to begin discussing the difficult issues at the Nov. 9 meeting.  The Commission is chaired by former UNE President Sandra Featherman and members include Robert McAfee, M.D., Peter Toussaint, M.D., and Gordon Smith, Esq.  MHA President Steven Michaud also is a member.

Update on MaineCare MECMS

The Governor's Provider Advisory Committee on MECMS met on Thursday (Oct. 26).  The best news was the significant drop in the number of suspended claims to a new low of 91,962.  This is over a 20,000 drop from the previous week and the first time since early 2005 that the total has been under 100,000.  On the other hand, physicians remain the group of providers with the most money tied up in suspended claims with over $27 million still outstanding.  This figure is more than double the amount owed by physicians in interim payments (which is the primary reason most physicians have not been required yet to repay the interim payments).

The weekly metrics showed that of "fresh" claims submitted, 77% were paid, 15% denied and 7% went into suspension. 

The current balance of interim payments made to providers stands at $513 million.  Through the week of Oct. 20, $290.9 million (57%) had been recovered and an additional $71.4 million have recovery agreements in place.

At the request of MMA, MaineCare officials have set up a meeting for 9:00am on November 9th in Augusta to discuss the process for requesting a portion of the $1 million appropriated by the legislature to reimburse providers for interest on loans made necessary because of the MECMS problem.  This meeting will be one hour before the regular meeting of the Provider Advisory Committee.

Progress to correct problems with the July 1 Release are going slow and many of the corrections and enhancements originally scheduled for this Fall have been delayed until sometime next year.  MaineCare officials are reluctant to even give a schedule for future "Releases" until the problems associated with the July 1 Release are corrected.  Among the 2007 work should be the electronic processing of Part B cross-over claims.

Also on Thursday, MMA representatives spoke again with Region 1 DHHS officials in Boston regarding the continuing problem.  All parties involved are frustrated with the long period of time the corrections are taking. [return to top]

Are You Receiving the Maine Quality Forum Newsletter?

The Maine Quality Forum is now regularly publishing a newsletter that is being sent to all physicians in the state.  Six thousand copies are distributed.  If you are not receiving the publication, contact the MQF at mqf@maine.gov

The newsletter is now 8 pages and contains articles on the various initiatives the Forum is involved with.  The June 2006 issue had articles entitled,  Does Volume = Quality and Maine Medical Communities Using Inpatient Services Less. 

The Maine Quality Forum was authorized in the Dirigo Health legislation in 2003 and was established in 2004.   It is directed by Dennis Shubert, M.D., PhD who is advised by an Advisory Committee  appointed by the Governor and approved by the legislature.

This month, four new members were named to the MQF Advisory Committee including Steven Gefvert, D.O., a retired gastroenterologist from the Portland area.  Other new members include Jim Case, Esq., Maureen Kenney of Bath Iron Works and Kathy Boulet, D.C. of Lewiston.  Members re-appointed were Charles Morrison of Auburn, Laureen Biczak, D.O, medical director of MaineCare and David White, a small business owner from Mount  Desert Island. [return to top]

First Friday Program 11/3 to Educate Physicians on Disability Determinations

Two experienced speakers will present at MMA's next First Friday CME presentation this coming Friday, Nov. 3, at the MMA offices in Manchester.  The topic involves the Social Security Administration's process of determining medical disability.  Three hours of CME are available for the program which runs from 9:00am to noon.

Persons interested in attending may register on -line at the MMA website at www.mainemed.com or may call the office at 622-3374 (press 0 and ask for Jess). [return to top]

DHHS Assistant Secretary for Health to Visit Maine re CMS Transparency Initiative

DHHS Assistant Secretary  for Health John Agwunobi, M.D. will visit Maine on Friday, Nov. 17 to receive input from Maine physicians on CME initiatives in the area of transparency, pay for performance and quality improvement.   Approximately 20 physicians will be invited to provide input to Dr. Agwunobi who is a pediatrician.  While a final time and location haven't been confirmed, the meeting is likely to be in the Freeport area sometime in the morning.   The session is expected to last 90 minutes.

This is an opportunity to provide input on Medicare payment policy at the highest level (the Assistant Secretary for Health is one of the highest ranking health officers in the federal government.  With the resignation of Dr. McClellan, Dr. Agwunobi is functioning as the acting Director of CMS.)

If you would like to be invited to attend and think you can be available that morning, contact Gordon Smith at gsmith@mainemed.com or call him at 622-3374 x212. [return to top]

MMA Testifies at Hearing on Anthem Rate Increase

MMA Executive Vice President Gordon H. Smith, Esq. presented the Association's testimony last Wednesday, Oct. 24, at the Bureau of Insurance hearing on Anthem's request to increase premiums on HealthChoice PPO products in the individual market by an average of 20.4%.  The increase, if approved, would take effect on Jan. 1, 2007.

Following up on op ed pieces and a letter to the editor prepared by President-elect William Strassberg, M.D. and President Kevin Flanigan, M.D. respectively, attorney Smith noted that the increase in premium would drive more persons out of the insurance market thereby increasing the cost for those individuals remaining insured.  The uninsured also will be reluctant to seek medical assistance on a timely basis when they need it, Smith added.

Twenty-nine thousand persons are in the individual market currently, down from 36,000 two years ago.  The individual market is in a death spiral, which was indentified in a "White Paper" issued by the Bureau of Insurance four years ago.  Smith noted that whatever the Superintendent does on this rate increase request, the individual market would continue to deteriorate and that other legislative solutions to the problem would be required.  At least 35 states have so-called high risk pools that take some of the pressure off the individual market.

One percent of the individuals in the current market are responsible for 40% of the costs, another fact calling for reform.

Smith did note in his testimony that Anthem is the only company offering coverage in the individual market and that they are to be congratulated for doing so.  Nonetheless, the fact that the company earned over $35 million in premium in Maine in 2005 and likely will equal or exceed those profits this year is cause for concern, even though it is undeniable that the individual market product lost money ($3 million in 2005 and likely double that amount in the current year).

Smith also expressed appreciation for the fact that Anthem was contracting with the state to offer the DirigoChoice product, when no other company had stepped up to the plate to do so. [return to top]

More Response on Flu Vaccine Issue Desired

A huge thank you to those practices which responded last week to the request for input on the current situation in the state regarding the availability of and distribution of flu vaccine.  MMA President Kevin Flanigan, M.D. and EVP Gordon Smith will be meeting with Maine CDC Director Dora Mills, M.D., MPH on this coming Wednesday to discuss the issue.

The Maine CDC is not making flu vaccine available to private practices this year, which has caused concern and discontent.  MMA has expressed dismay at the situation and noted the fragmentation of care that happens when patients are sent from their physician to a location outside such as a church or pharmacy.   On the other hand, some members have expressed a preference for outside clinics.  Reigster your opinion and share what your practice is doing by communicating with Gordon Smith at gsmith@mainemed.com or calling him at 622-3374 x212. 

The more information we have to present on Wednesday, the better the likelihood of developing policies in the future that will benefit you and your patients. [return to top]

MaineCare to Consider PA Requirement for Suboxone/Subutex Prescriptions

The MaineCare Drug Utilization Review (DUR) Committee is scheduled to consider whether to require prior authorization for all Suboxone/Subutex prescriptions at its next meeting on Tuesday, Novermber 14, 2006 at 6 p.m.  You can find more information about the MaineCare preferred drug list (PDL) and DUR Committee on the web at:  http://www.mainecarepdl.org/.  The draft agenda for the 11/14 meeting, while not there now, should be posted prior to the meeting date.

You may wish to comment on the likely impact of a PA requirement on:

  • the patients seeking office-based treatment;
  • access to treatment on demand;
  • physicians who are considering taking on office-based opioid treatment and becoming certified to treat; and
  • physicians currently practicing office-based opioid treatment.

The DUR Committee generally meets in a conference room at the Office of MaineCare Services, 442 Civic Center Drive, Augusta, Maine and takes public comment immediately upon convening at 6 p.m.  You may communicate with the Committee in writing by contacting Jessica Oesterhold, M.D., Director, DUR & Medical Education, DHHS, State House Station 11, Augusta, Maine 04333-0011.  You may email correspondence to mouellette@ghsinc.com. [return to top]

All Members & Specialty Society Representatives Welcome at Legislative Committee Meeting to Plan Agenda for 2007-2008

The MMA's Legislative Committee, Chaired by Katherine S. Pope, M.D., will hold its next meeting at the MMA office in Manchester on Tuesday, November 28, 2006 from 6 to 9 p.m.  This meeting is very important because we will review the election results, the composition of the next legislature, the likely committee assignments, and the leadership races.  Also, we will be deciding upon those bills that will constitute the MMA's legislative agenda for the next two years.  Any interested member of the MMA and any specialty society legislative chair or liaison is welcome, and indeed urged, to attend this meeting.  Please RSVP to Charyl Smith, Legislative Assistant, at csmith@mainemed.com.

Several members have brought issues to the staff's attention for consideration by the Committee for legislative action.  If you have an issue you would like added to the list for consideration on your behalf or on behalf of a specialty society, please contact Andrew MacLean, Deputy Executive Vice President, at amaclean@mainemed.com. [return to top]

NQF Updates List of Serious, Reportable Health Care Events

The non-profit National Quality Forum (NQF) has updated its list of serious, reportable health care events. First published in 2002, the list outlines events that are, in the consensus opinion of NQF members, “serious, largely preventable, and of concern to both the public and healthcare providers for the purpose of public accountability.” Currently, 11 states use the NQF list partially or wholly as the basis for their public reporting systems, due at least in part to its emphasis on clearly identifiable and measurable events. One new event—artificial insemination with the wrong donor sperm or egg—has been added to what is now a 28-item list. Seven previously identified events have been adjusted, including: unintended retention of a foreign object in a patient after surgery or other procedure and patient death or serious disability associated with patient disappearance, a medication error, a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products, an electric shock or elective cardioversion while being cared for in a healthcare facility, or a fall while being cared for in a healthcare facility. For more information:
Specifications of the list and recommendations for additional research can be found at:
[return to top]

Aetna Profit Rises 28%

The New York Times , October 27, 2006
Aetna, Inc.'s quarterly revenue increased 28%. Aetna 's commercial medical cost ratio, or the percentage of premiums used to pay medical bills, increased slightly to 79.3%, from 79%. The medical cost ratio was an issue earlier in the year when second quarter earnings were published, when it increased to 81.4%. This contributed to the insurer's stock falling 16.8% that day. Although Aetna 's shares have fallen approximately 18 percent this year, it expects to make $3.26 a share for 2007. [return to top]

WellPoint Profit Rises, Buoyed by Lower Costs

Market Watch , October 25, 2006
WellPoint, Inc., cut its operating revenue and enrollment forecasts for next year despite a 27% rise in third-quarter profit. The net income for the three-month period ending September 30 reached $810.8 million or $1.29 per share. The increase is attributed to the newly added New York state prescription drug contract and increases in medical enrollment due to the acquisition of WellChoice. [return to top]

MMA/OSA Program on Preventing Prescription Drug Diversion in York on Nov. 17

The Maine Medical Association along with the Office of Substance Abuse will be offering a program entitled "Preventing Prescription Drug Abuse" on November 17th from 4:00 - 7:00 p.m. at the York Harbor Inn, York Maine.  The featured speaker is Nathaniel Paul Katz, MD, President of Analgesic Research in Needham, MA.  Dr. Katz will provide a provider's perspective and share "best practices" in the area of pain control, addiction treatment and abuse prevention.  Also presenting are Chris Baumgartner, Coordinator of the PMP program at the Office of Substance Abuse, who will discuss the state's Prescription Monitoring Program and Gordon Smith, Esq. Executive Vice President of the Maine Medical Association who will explain the laws and regulations (state and federal), governing the sharing of prescribing information with other health professionals and law enforcement.  If you would like more information or registration materials for this program, please call Gail Begin at the Maine Medical Association at 622-3374 ext. 210 or visit us on our website at www.mainemed.com. [return to top]

The Coding Center's Continuing Education Series - E/M Chart Auditing

Six Mondays at St. Joseph's Hospital, Bangor, November 13 - December 18, 2006, 1pm- 5pm

Topics covered:

  • Understand the elements of an audit
  • Issues around documentation
  • Step by step auditing: the key components
  • Helpful information about a variety of visit codes
  • Develop a template for your audit program
    • How to get started
    • Identify focus of audit
    • Timing and volume
    • Who will perform the audit
    • Tools
    • Education and follow-up


Theory into practice:

  • Hands-on case studies
  • Use your new knowledge to audit charts appropriately

Dynamic Environment:

  • Group discussion
  • Networking
  • Fun and fast paced program

Course requirements

  • Basic knowledge of E/M principles
  • Experience with chart auditing helpful but not required
  • Coding Certification NOT necessary
  • Please bring CPT books to class!

For more information, or to register, call Jess at 207-622-3374 x219 or email jviolette@mainemed.com [return to top]

For more information or to contact us directly, please visit www.mainemed.com l ©2003, Maine Medical Association