November 6, 2006

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Maine Quality Forum Seeks Enhanced Reporting of Hospital/ASC Infections

On Thursday, Nov. 2, Maine Quality Forum Director Dennis Shubert, M.D., PhD., testified at a rule-making hearing before the Maine Health Data Organization, asking for more reporting from hospitals and ambulatory surgical facilities of "healthcare associated" infections.  No one testified in oppostion to the proposed revisions to current MHDO rules found in Chapter 270.   Dr. Shubert's testimony can be found on the MMA website at  Once on the site, look for Spotlight to find the testimony.

The Maine Health Data Organization is the state's health data depository and is governed by a board representing various stakeholders including physicians. Currently, Sidney Sewall, M.D.,an Augusta-area pediatrician represents Maine physicians on the Board.

The Maine Quality Forum promoted the proposed changes to Chapter 270, citing data showing that healthcare associated infections (HAI) are the most common complication affecting hospitalized patients with between 5% and 10% of inpatients acquiring one or more infections during their hospitalization.  Overall, an estimated 2 million hospital acquired HAI occur each year in the United States accounting for an estimated 90,000 deaths and adding $4.5  to $5.7 billion in healthcare costs.  Dr. Shubert noted, in his testimony, that experts generally believe that at least 20% to 30% of such infections are preventable.

The specific reporting obligations added to Chapter 270 would include:

  • Cardiac Surgery Patients with Controlled 6:00AM Postoperative Serum Glucose
  • Surgery Patients with Appropriate Hair Removal (refers to clipping vs. shaving)
  • Colorectal Surgery Patients with Immediate Postoperative Normothermia
  • Surgery Patients with Recommended Venous Thromboembolism "VTE" Prophylaxis Ordered
  • Surgery Patients who Received Appropriate Venous Thromboembolism "VTE" prophylaxis within 24 hours prior to Surgery to 24 hours after Surgery.

Another standard to be reported includes a measure of coordination of care across settings of care.  The process measure addresses first, whether or not the hospital staff understood and utilized a patient's own preferences during discharge planning, second, when the patient left the hospital the patient had, by their own evaluation, a good understanding of their responsibilities for managing their own health and third, when the patient left the hospital the patient clearly understood the purpose for taking each of their medications.

The MHDO will accept written comments on the proposed rule until the close of the comment period on Monday, Nov. 13th at 5:00pm.

Anthem, Inc. Outsourcing Tier One Provider Calls to the Philippines

MMA has learned that Anthem Blue Shield and Blue Cross has entered into a partnership with APAC, a U.S.-based customer service company with operations in several countries, including the Philippines.  In Anthem's words, "this initiative is designed to improve provider service levels and operational efficiency whle ensuring member demands for affordable products and innovative services."

Calls from providers that dealt with issues such as eligibility or whether a claim had been paid started to be routed to the call center in the Phillipines Oct.1, 2006.  If the provider needed more complex information, the call is forwarded back to personnel in South Porltand.

Both Anthem and MMA are interested in provider experience with the outsourcing.  If you have experiences either positive or negative, please direct them to Bill Parkin, Manager, Provider Call Center of Anthem Blue Cross Blue Shield of Maine at 822-7491.  We assume that call is answered in Maine. [return to top]

Bath Iron Works Sues Workers' Compensation Board for Lack of Hospital/ASC Fee Schedule

Bath Iron Works is suing the state Workers' Compensation Board, claiming the panel is 14 years in arrears in establishing a fee schedule for hospital procedures and ambulatory surgical facilities.  A 1992 law reforming the state's workers' compensation laws required the board to establish a list of fees for various medical procedures by Jan. 1, 1993.  The board did establish fees for physicians and other individual health providers but has never established a fee schedule for hospitals or ASC's.

Because there is no fee schedule for these facilities, BIW and other employers pay charges which can significantly exceed what is paid by other insurers for the same or similar procedures or treatments. [return to top]

Update on Flu Vaccine Availability

MMA representatives including President Kevin Flanigan, M.D., of Pittsfield, met last week with Maine CDC Director Dora Mills, M.D., MPH. and other Bureau staff to discuss this season's distribution of flu vaccine.  The vaccine, despite assurances to the contrary, is in short suppply currently but is expected to be plentiful by the end of the year.  The problem is essentially one of timing.

Although an estimated 151 million doses will ultimately be produced this year, there is no adequate distribution system, noted Dr. Mills.  The Maine CDC is currently waiting for over one-half of its 145,000-dose order.

The state has distributed what it has received among rural health centers, nursing homes and pediatricians.  The Office is not distributing adult vaccine to private offices this year, a fact of concern to MMA and one of the issues that led to the meeting.

The meeting provided a lot of information, including the history of the distribution of vaccine which was not distributed by the state for adult vaccinations until the shortage year of 2004-2005.

Most private offices providing treatment to adult patients purchase privately from manufacturers and can also contract with Maxim Health Systems to do clinics for the office, just as the company does for large employers, pharmacies and grocery stores including Hannaford.  One current drawback to using Maxim is their inability to provide shots to MaineCare patients, a gap that MMA is currently discussing with the company and MaineCare.

At least one manufacturer, Sanofi Aventis, states that its vaccine is taking longer than usual to manufacture.  This year, the CDC also expanded the age range for children at risk , raising the age to 5 years.

In addition to discussing the availability and distribution of the flu vaccine, the meeting focused also on the current status of childhood vaccines in the face of data suggesting that Maine's previous high rate of immunization had now fallen below the national average.  Several factors were cited for this decline, including the increasing cost, the increasing number of shots given and the concern of parents of the side effects.

Representatives of the Maine Chapter of the American Academy of Pediatrics also participated in the meeting.  It was agreed to hold a similar meeting in the Spring to discuss the supply for 2006-2007 and to work on an improved plan for distribution.

For more information, go to or Maxim's  The later site provides a listing of upcoming clinics. [return to top]

Blue Ribbon Commission on Dirigo to Meet on Thursday

The 19-member Blue Ribbon Commission on Dirigo Health will hold its 6th meeting on this coming Thursday, Nov. 9th, at 9:30am in conference room 105 in the Cross Office Hilding in the state house complex in Augusta.

The agenda is as follows: 

9:00-9:35       Call to Order

9:35 - 10:00   Review & discuss findings from members survey - (HAT)

10:00 - 11:00   Discussion:  Clarifying our goal.  What is the role of DirigoChoice in reaching universal access?

11:00 - 12:15    What is the target population for DirigoChoice?

12:15 - 12:45    Lunch

12:45-1:45        Preliminary brainstorming of funding sources & cost savings strategies.

1:45-2:00         Other Business [return to top]

Tomorrow is Election Day!

Tuesday, November 7th is Election Day 2006 and we encourage you to exercise your right to vote.  With both houses of the state and federal legislature so close that control may change, a tightening race for Maine Governor, two physicians running for seats in the Maine legislature, and a MMA staff member on the ballot in a municipal race, it is sure to be an exciting election evening.

The MMA and our Political Action Committee, Maine Physicians Action Fund (MPAF), hope to have two physicians in the 123rd Maine Legislature.  Three-term House member Lisa T. Marrache, M.D. (D) is a candidate in Senate District 25 in the Waterville/Winslow area.  Dr. Marrache is a family physician who practices with her husband in Waterville.  Robert P. Walker, M.D. (R), a radiologist from Lincolnville, is a candidate in House District 44 including the municipalities of Appleton, Hope, Lincolnville, Isleboro, Liberty, Searsmont, and Morrill.  The MPAF ran ads in support of each candidate in appropriate local papers late last week or over the weekend.

You can find basic information about the 2006 elections on the Secretary of State's web site:  On Tuesday evening and Wednesday you will find early election results at the Bangor Daily News web site:  You may have to register to use the site.

Also, please remember that the MMA's Legislative Committee is meeting on Tuesday, November 28, 2006 at 6 p.m. at the MMA headquarters in Manchester to plan the organization's legislative agenda for the 123rd Legislature.  Any interested member or specialty society representative is welcome.  Please RSVP to Charyl Smith, Legislative Assistant, at [return to top]

Physician Reimbursement Cut 5% in Final CMS Payment Rule

In action only slightly different than expected, on November 1, 2006, CMS issued the final Medicare physician fee schedule rule including a 5% cut for 2007.  The rule proposed in August included a 5.1% cut.  The so-called SGR formula compares spending growth for physician services to a target rate decreases the update if the actual rate exceeds the target.  The rule affects approximately 900,000 physicians who will receive approximately $61.5 billion for Medicare services.

During the expected "lame duck" session of Congress, the AMA and other national physician organizations, with help from state societies, will lobby to eliminate the 5% cut.  You can find more information about this effort on the AMA's web site:

The final rule makes a number of other regulatory changes affecting the practice of medicine.  It raises the work component for evaluation and management (E&M) services.  For example, CMS states that the work component for RVUs for an intermediate office visit, the most common physician service, will increase by 37%.  Also, it amends the methodology for determining practice expenses from a "top down" cost allocation approach to a "bottom up" method.  Many of the changes are the result of recommendations of the AMA's Relative Value Update Committee (RUC), a group that reviews the methodology every 5 years. 
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Study Says U.S. Primary Care Physicians Lag in IT Adoption

On November 2, 2006, the Commonwealth Fund released a study entitled, On the Front Lines of Care:  Primary Care Doctors' Office Systems, Experiences, and Views in Seven Countries published online by Health Affairs.  The study's authors reviewed the use of information technology and quality improvement incentives by 6000 physicians in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the U.S.  The study concludes that U.S. physicians do not have the electronic tools or support to ensure high quality care.

The study includes the following comparative data about the use of electronic medical records:

  • U.S.:  28%
  • Netherlands:  98%
  • New Zealand:  92%
  • U.K.:  89%
  • Australia:  79%

It includes the following comparative data about computerized alerts for potential harmful drug doses or interactions:

  • U.S.:  23%
  • Netherlands:  93%
  • U.K.:  91%
  • New Zealand:  87%
  • Australia:  80%
  • Germany:  40%
  • Canada:  10%

It found the following comparative data about after-hours access to physician services which can lower ER use:

  • U.S.:  40%
  • Netherlands:  95%
  • U.K.:  87%

The U.K. has the highest percentage (81%) use of multidisciplinary teams to manage chronic medical conditions (compared to 32% in the U.S.).  The U.K. also had the greatest use of systems to track medical errors (79%, compared with 37% in the U.S.).  Fifty percent of U.S. physicians reported that their patients had trouble paying for medical care compared with 7% to 27% of physicians in other countries.  Finally, U.S. physicians are the least likely to receive financial incentives for improving the quality of care (30% compared with 95% of physicians in the U.K. and 79% of physicians in New Zealand).

The study concludes that a greater national commitment to supporting IT and quality improvement are worthy goals.  The study is available on the web at: [return to top]

US DHHS Office of the Inspector General Issues 2007 Work Plan

The OIG recently has issued its 2007 Work Plan that outlines the office's priorities for investigation and enforcement in the next fiscal year.  It is a helpful compliance guide because it identifies areas that may be subject to increased scrutiny in 2007.  You can find the Work Plan on the web at:

The following areas may be of particular interest to physicians and other health care practitioners:

  • The OIG will examine whether CMS' systems are able to identify and prevent payment for potential duplicative claims for physical therapy reimbursement submitted by health care providers.
  • The OIG will examine the extent to which providers are billing beneficiaries in excess of amounts allowed by Medicare requirements.  In conjunction with this evaluation, the OIG will monitor beneficiary awareness of their rights and responsibilities regarding Medicare billing violations and coverage guidelines.
  • The OIG will determine whether providers are properly billing Medicare for inpatient psychiatric services.  Some providers are more likely to bill a session as an "individual session" because they are reimbursed at a higher rate than group therapy sessions.
  • The OIG will study the factors contributing to the rise in Medicare reimbursement for polysomnography (a test for diagnosing sleep apnea), and whether it is appropriate to bill for this procedure.
  • The OIG will determine whether providers were improperly reimbursed for false claims for outpatient alcoholism and substance abuse services.
  • The OIG will determine if Medicare Part B long distance physician services are inappropriately billed for beneficiaries of home health and skilled nursing facility services.
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MMA Office Open on Veterans Day

This coming Friday, Nov. 10 is Veterans Day, a federal holiday honoring those men and women who have served in the armed forces defending our nation.  The MMA office in Manchester will nonetheless  be open on Friday from 7:00am through 5:00pm to serve your needs. [return to top]

NQF Endorses Patient Safety Practices

The Wall Street Journal reports that the National Quality Forum (NQF), along with a coalition of health care purchasers, quality groups and government agencies has agreed to endorse a set of 30 “safe practices” designed to increase patient safety. Patient safety procedures can vary widely among various health care providers, but the NQF practices are designed to reduce confusion and standardize procedures across institutions. Additionally, it is predicted that the guidelines will have an influence on the processes of coalition members such as the Joint Commission on Accreditation of Health Care Organizations and the Leapfrog Group—an organization of large employers that uses hospital safety surveys to steer employees toward using high-scoring facilities. Release of the final set of practices is planned for sometime after the close of a comment period scheduled to end on Nov. 14, 2007. For more information: [return to top]

Physician Reimbursement Reduced By 5 Percent in 2007 Under Final Rule

Medicare payments to physicians will be cut by 5 percent in 2007 under a final physician fee schedule rule issued Nov. 1 by the Centers for Medicare & Medicaid Services.

The 5 percent cut is a slight change from the 5.1 percent reduction calculated when the rule was published in proposed form in August. The formula compares the actual growth of physician services in spending to a target rate. If the actual rate exceeds the target, the update is decreased.

Physician organizations are lobbying Capitol Hill to override the statutorily mandated cut during the lame duck congressional session that begins this month.

The rule affects 900,000 physicians who will receive an estimated $61.5 billion in Medicare reimbursements.

The final 2007 physician fee schedule rule combines regulatory changes from two proposals published earlier in 2006. A first proposal, published in June, focused on revisions to relative value units (RVUs), including evaluation and management services that comprise office visits to manage care. The RVUs determine how payment rates vary by service.

Increased Work Component for RVUs

The final rule increases the work component for the RVUs for evaluation and management services. For example, CMS said, the work component for RVUs associated with an intermediate office visit, the most frequently billed physician's service, will rise by 37 percent.

However, during a telephone news conference on the rule, Acting Deputy Administrator Herb Kuhn said that some of the individual evaluation and management services codes may decrease, depending on various factors.

The overall increase in the work component for evaluation and management services is the result of a review of RVUs that is conducted every five years with the American Medical Association's Relative Value Update Committee (RUC). CMS estimated that changes from the review would increase expenditures by approximately $4 billion in a year.

Kuhn said that CMS accepted all of the RUC's recommendations on the 400 codes that physician groups suggested for review and the 150 suggested by CMS.

The June proposal also dealt with the methodology for calculating practice expenses, switching from the current "top down" cost allocation methodology to a "bottom up" methodology. CMS said that will be phased in over four years.

"This methodology will be more transparent than the existing methodology, allowing specialties and other stakeholders to predict the effects of proposals to improve accuracy of practice expense payments," CMS said.

The second proposal, published in August, dealt with all other issues, including overall rates and changes to payments for imaging services, as required by the Deficit Reduction Act of 2005.

In the area of imaging, the final rule caps payment rates for the technical component of imaging services at the amount paid for in hospital outpatient departments, as required by the DRA. [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 [return to top]

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