December 18, 2006

 
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Blue Ribbon Commission on Dirigo Health To Hold Final Meeting on Tuesday

The Governor's Blue Ribbon Commission on Dirigo Health will hold its final meeting on Tuesday, Dec. 19 and is expected to cast a series of votes supporting alternative means of raising the $57 million needed to fund the Dirigo Health program over the next 12 months.  At a meeting last Monday (Dec. 11) , Commission members cast a series of non-binding votes related to various cost-containment strategies and revenue strategies.  The Commission unanimously rejected a proposed provider tax but a strong majority endorsed higher taxes on cigarettes, alcohol, snacks and sweetened drinks.   Along with final votes on these items, the Commission will also consider a motion to endorse the concept of an employer or individual mandate.

The Commission has met eight times to consider both cost-containment strategies for Dirigo and alternative revenue sources to replace all or a portion of the controversial "savings offset payment."   MMA Executive Vice President Gordon H. Smith, Esq. represents MMA on the Commission.

Among the areas considered for cost containment are the following:

  • more transparency with regard to insurance rate setting.
  • allowing sole proprietors to purchase small group coverage
  • allowing dependents to stay on family coverage plans through age 29
  • requiring discounts for worksite willness programs and nonsmokers.
  • expanding the availability of health savings account

The Commission is also considering cost-reduction strategies unique to Dirigo, including the option of self-insurance rather than offering the Dirigo Choice product through commercial health insurance carriers (currently Anthem).

Commission recommendations will be presented to the Governor by the end of the month and any of these changes have to be presented to and considered by the full legislature prior to adoption.

MECMS Back on the Front Pages

The state's MaineCare claims management system (MECMS), a major disappointment since going live in January of 2005, was back in the news this week following release of a federally mandated audit by the firm of First Data Government Solutions.  The so-called IV&V  (Independent Valuation and Validation) review is required by DHHS for such large scale projects.  The firm had been previously engaged in reviewing MECMS but was pulled back into the review in May of this year.  The report, released to the members of the Governor's Provider Advisory Committee on Thursday (Dec. 14), sheds new light on some of the problems plaguing the system. 

The Executive Summary of the report notes that the decision to go-live with a partially developed MECMS, in January, 2005 was very high risk, as the vendor, CNSI, had never built a Medicaid Management Information System (MMIS) and the State had no fall-back plan or parallel operation strategies.  As stated in the report, "Since January, 2005, CNSI and the State have been in a reactionary mode, fixing defects and attempting to stabilize the system.  Significant new functionality and enhancements have not been implemented.  Software releases continue to be problematical because of insufficient regression testing and vague or undocumented requirements." 

In addition to delays in payment, physicians have been most effected by the need to resubmit claims and the failure of the system to be able to process Part B cross-over claims (for patients who are on both MaineCare and Medicare) electronically.  The need to reconcile the interim payments with claims eventually paid also was a major burden.

Perhaps the most alarming portion of the audit findings involves the financial status of the vendor and the communications problems on-going between the vendor and the state, exacerbated by  alleged ill-will between CNSI and some of the contractors brought in by the state to assist with fixing the problem, most notably X Wave.

Rather than paraphrase, the following are two telling paragraphs from the report:

      At CNSI, financial concerns are prevalent throughout all levels of project staff and management.  CNSI's financial statement for Q2, 2006 showed very little cash on hand in comparison to their accounts receivable; $1.8 million in available CD's and cash, $49 million in receivables.  Mid-level management expressed grave concern regarding the expense of retaining personnel during periods of state indecision, and admitted to releasing software with known issues due to internal financial pressure.

    FDGC (First Data Governmental Solutions) does not believe that CNSI has the resources to complete MECMS without additional financial assistance.  This is problematical for the State because CMS has stopped supplying the 90/10 funding for MECMS development.  Even if funding were not an issue, we believe it may stil be some time before CNSI can deliver a federally certified MMIS to the State of Maine.

     In responding to the report, HHS Commissioner Brenda Harvey on Friday stated that all options were on the table, including the possibility of pulling the plug on the system and outsourcing the processing of claims.  Several states use EDS or other vendors to process their claims, including the medicaid program in Vermont.

 A front page article in the weekend edition of the Bangor Daily News discusses the report and the state's reaction to it.  The Provider Advisory Committee meets again this coming Thursday (Dec. 21) and the FDGS audit will be on the agenda. [return to top]

Updated Sentinel Event Statistics

As of June 30, 2006, the Joint Commission's sentinel event statistics have been updated and are available on the Joint Commission website, www.jointcommission.org. Sine the sentinel event database was implemented in January 1995, the Joint Commission has received 3,811 reports of sentinel events. A total of 3,935 patients were affected by these events, with 2,857 or 73 percent, resulting in patient death. The 10 most frequently reported sentinel events are:

Patient Suicide 

501 

Wrong-site Surgery 

496

Operative/post-operative complication 

473

Medication error 

369

Delay in treatment 

286 

Patient fall 

207

Patient death or injury in restraints 

147

Assault, rape or homicide 

128

Perinatal death/loss of function 

117

Transfusion error 

97

[return to top]

MMA Submits 7 Bills for Consideration by 123rd Maine Legislature

The deadline for submission of bills for the 123rd Maine Legislature was Friday, December 15, 2006.  The MMA has submitted the following bills for consideration, as recommended by the Legislative Committee:

  • An Act to Maintain Patient Access to the MaineCare Network of Individual Health Care Practitioners, sponsored by Rep. Janet Mills (D-Wilton).  This bill proposes a $3 million General Fund increase in Medicaid or MaineCare reimbursement rates for physicians & other practitioners. 
  • An Act to Establish a Pilot Program for Return of Unused Prescription Drugs, sponsored by Rep. Anne Perry (D-Calais).  This bill proposes to appropriate $300,000 to establish a mail return program as recommended by the Maine Drug Return Implementation Group.
  • An Act to Increase Funding for the Maine Immunization Program, sponsored by Rep. Lisa Miller (D-Somerville).  This bill proposes to appropriate $6 million plus funding for 4 positions to maintain Maine's immunization program at levels recommended by the federal CDC.
  • An Act to Further Limit Retrospective Denials of Previously Paid Health Insurance Claims, sponsored by Sen. Lisa Marrache, M.D. (D-Kennebec).   This bill would shorten the "look-back" period permitted under Maine law for retrospective audits from 18 months to 12 months.
  • An Act to Establish Health Care Practitioner Immunity for Consulting Physicians in Critical Specialties or Sub-specialties, sponsored by Rep. Robert Walker, M.D. (R-Lincolnville).  This bill would amend the "Good Samaritan" law to provide limited immunity protection to specialty or sub-specialty physicians who provide volunteer, unpaid consultation services to treating physicians in their area of expertise.
  • An Act to Authorize the Board of Pharmacy to Establish a Pharmacists Health Program, sponsored by Rep. Anne Perry (D-Calais).  This bill would make the statutory changes necessary to permit the Board of Pharmacy to join the MMA Physician Health Program.
  • An Act to Postpone the Repeal Date on Non-Hospital Expenditures in the Capital Investment Fund, sponsored by Sen. Karl Turner (R-Cumberland).  This bill would extend the sunset provision on the CIF statute setting aside 12.5% of the amount of the fund each year for non-hospital projects by one year.

The MMA Legislative Committee and staff also will be busy with many other bills dealing with health care policy in Maine, including the future of the Dirigo Health Program.  During the legislative session, the MMA staff produces a weekly e-newsletter on legislative activities, including a list of all bills identified as being of interest to the physician community and alerts to important grassroots action, called Political Pulse.  Any interested member may receive this newsletter.  If you would like to be added to the distribution list, please contact Charyl Smith, Legislative Assistant, at csmith@mainemed.com. [return to top]

Who's Who at MMA

Have a question?  Not sure who to contact at the Maine Medical Association?

Let us help!  Visit the MMA web site at www.mainemed.com and click on Contact the MMA.  You will then be able to get contact information for staff listed alphabetically OR you can find out who you need to contact based on a particular topic.

The Maine Medical Association is open from 7:00am until 5:00pm Monday through Friday and has 24hr. voicemail coverage as well.  We are ready to serve you! [return to top]

Contacting a Peer Made Easy

Need to contact a peer and don't have their contact information readily available?

Don't fret.  Instead, click on the MMA web site at www.mainemed.com and use our convenient PEER LOCATOR.  The Peer Locator can be found in the members-only area of the web site.  You can search for any active member of the Maine Medical Association.  This search facility lets you find members based on their name, their location, or their area of expertise.  Choose the items that interest you, then click the Search button.  To perform another search, click the Reset button, then make new selections.  If you are not certain of the specialty or location, just search by last name and it will give you all physicians whose name begins with the letter you selected for any specialty, located anywhere.

If you have not registered to access the members-only area of the web site, you must do so first.  It's easy, just click on the REGISTER button in the upper right-hand corner of the MMA web site home page, complete the brief form and press submit.  After your registration is validated by an MMA staff member, you will receive an email granting you access. [return to top]

National Medicaid Commission Adopts Reform Plan

The national commission to study Medicaid created 18 months ago by DHHS Secretary Michael Leavitt made its final recommendations Nov. 16-17 with members approving the report 11-1, with one abstention and two absentees.

Former Maine Governor Angus King served as Vice-chair of the Commission which was chaired by former Tennessee Govenor and Congressman Donald Sundquist. 

The Commission recommended that states be given more flexibility with Medicaid.  Members also endorsed enrollees having electronic medical records and a medical home.  Members suggested that long-term care might be best delievered in one's own home.  The Commission also indicated an intention to include in its report the following:

  • Emphasize health care quality with enhanced matching funds for Medicaid programs that use pay-for-performance at the physician and hospital levels.
  • Create Medicaid Advantage plans, modeled on a similar Medicare managed care program, to integrate Medicaid and Medicare benefits.
  • Provide tax incentives to buy long term-care insurance and allow health savings accounts to be used to pay for long-term care expenses.
  • Provide Medicaid beneficiaries electronic medical records by the year 2012.

The Commission's final report is not due until Dec. 31.  Whether the report will find any favor on capitol hill given the change in party control is a major question.  Democrats on the Hill had declined to participate in the work of the Commission. [return to top]

MEMGMA Announces 2007 Third Party Payer Seminars

The Maine Medical Group Management Association is Pleased to Present:

2007 THIRD PARTY PAYER SEMINARS

Two Dates and Convenient Locations:
Wednesday, January 10, 2007
Ramada Conference Center, 490 Pleasant Street, Lewiston, Maine

Wednesday, January 17, 2007
Jeff’s Catering, 5 Coffin Avenue, Brewer, Maine

Provider representatives from the major payers will be speaking at this seminar and providing updates as to the status of claims processing. Representatives from the following insurance companies have been scheduled to attend:

  • CIGNA
  • MAINE CARE / MEDICAID
  • ANTHEM
  • AETNA
  • MARTIN’S POINT
  • HARVARD PILGRIM
  • MEDICAL NETWORK (MEDNET)
  • MEDICARE
  • **MAINE NETWORK FOR HEALTH
  • **MAINE HEALTH ALLIANCE

(** Brewer Only)

Participants will have the opportunity to ask questions concerning reimbursement issues affecting physician practices in general, but should not expect answers to questions concerning individual account situations.

Seminar Schedules:

  • Registration for both seminars begins at 8:30 AM.
  • Continental breakfast served at 8:30 AM.
  • Sessions begin at 9:00 AM.
  • A full buffet lunch is included with registration.
  • Speakers for each insurance company may be
  • presenting at different times each day, so an exact
  • schedule is not available.
  • The final speaker will conclude by 4:00 PM.

Registration Information:

  • Space may be limited at both locations so please register as early as possible by phone or mail.
  • The cost for either seminar is only $40.00 for
  • MEMGMA members or $50.00 for non-members.
  • If you have questions concerning this seminar, or for
  • late registration, please contact Kim Anderson at (207)
  • 774-8277 or at kanderson@maineeyecenter.com.
  • Please print and complete the registration form and send to the address specified.
[return to top]

Wanted: Peer Reviewers in Radiology and Dermatology

For over fifteen years, the MMA has operated a very successful external peer review program.  The program provides three board certified reviewers to perform chart reviews in various locations across the state, the most frequent example would be a small hospital with single specialists.  In such an instance, internal peer review is difficult, if not impossible.

2006 has been a very good year for the program with nearly 25 reviews being ordered or completed.  We are currently in need of reviewers in radiology and dermatology.  Reviewers are paid for their time.  If you are interested in volunteering for this worthwhile endeavor and are board certified in your specialty, please contact either Gordon Smith at 622-3374 ext. 212 or via e-mail to gsmith@mainemed.com; or Warene Chase-Eldridge at 622-3374 x 227 or via e-mail to weldridge@mainemed.com. [return to top]

AMA Offers EMR Info Clearinghouse

The American Medical Association has launched a Web site all physicians can use to learn about electronic medical records issues and how to evaluated and implement systems for their practices.

The goal of the AMA Health Information Technology site, launched November 1, is to provide a centralized information clearinghouse offering doctors an easy, convenient way to access information about EMR systems.

"We think that there are a lot of organizations out there that have done a lot of good work, but your average general physician doesn't have the time to go out and find that information," said Amanda Ervin, director of health informaiton technology initiatives at the Association. "It's a starting point for physicians to start thinking through some of the issues that are around information technology from a policy side and also from a more practical operational side."

The site (http://www.ama-assn.org/go/hit) includes content developed by the AMA.

Other useful sites include:

[return to top]

Seminar on Health Insurance Reform in New England

Dear Health Care Members,

The New England Council was proud to host the "State Approaches to Improving Healthcare Access: A Seminar on Health Insurance Reform in New England" along with the University of New England.  If you were unable to attend the event, or if you are interested in viewing the panelist presentations again, they have been posted on the University's Center for Health Policy Planning and Research website for your review:  www.chppr.org (see box at the lower right).

  [return to top]

The Coding Center's Coding Tip of the Week

V Codes
Used to report instances when a patient is seen for other than disease/injury 

  • A person who is not currently sick but comes in contact with health services for other reasons—organ donation, screening, counseling regarding health issues
  • A situation that could affect the health status of the patient in the future—personal or family history of a disease
  • A resolving injury/illness or long-term chronic condition requires care – dialysis, cast change
    Newborns to indicate birth status- outcome of delivery

Questions? Call the Coding Center: 1-888-889-6597 [return to top]

Medicare Officials Have Started Making Public, Prices It Pays Physicians for Certain Services

For the physician office setting, available so far, 19 commonly performed services with the average prices for each Medicare locality.

http://www.cms.hhs.gov/HealthCareConInit/04_Physician.asp#TopOfPage [return to top]

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