April 16, 2007

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Highlights of MaineCare MECMS Provider Advisory Group, April 12

MaineCare and MECMS continue to be a hot topic in legislative circles and in the public with the Provider Advisory Committee  receiving a briefing on a number of significant issues this past Thursday.  In an important development, CMS has given preliminary approval to the Draft  Advanced Planning Document by DHHS to authorize transition from the current system to a new Fiscal Agent.  This approval paves the way for preparation of a detailed Request for Proposals which is anticipated to take a few months.  It is likely to take up to 24 months (and this may be optimistic) before a full transition can take place.   In other MaineCare news, Tony Marple has accepted the positon as MaineCare Director (he previously was Acting Director) and a new Medical Director is expected to be named shortly.

Hightlights from the Providers' Advisory Group include the following:

  • With respect to the recovery of interim payments, 65% have been recovered with an additional $70 million in a recovery plan.  An additional $60 million needs to be recovered prior to the end of the state's fiscal year (June 30, 2007). 
  • An offset of claims with pre-2006 dates of service has been implemented effective the week of April 16.  The automatic offset date will be extended in May to pre-Oct. 1, 2006 dates.
  • Reviewing the interim payments owed by provider type, physicians are still collectively owed more in suspended claims ($13,906,619) than is owed back in interim payment recovery ($$11,196,150).
  • Most of the interim payment balance is owed by nursing facilities, behavioral health providers and out of state hospitals. 
  • MECMS metrics for the week ending 4/8/07 showed that fresh claims were processed at a rate of 95.2% (paid or denied).  When recycled claims are included, the processing rate was 90%.  Suspended claims inventory was 69,736.
  • CNSI has contracted to provide services for another 18 months while the state transitions to a fiscal agent.  The contract provides for additional payments of $13 million, with $9.5 million paid for continuing to operate the flawed system and another $3.5 million to complete development work on some additional functions such as the ability to void a claim.  Unfortunately, the ability to process electronically the Part B cross-over claims is unlikely to be a high priority on this list.

An unfortunate dialogue occurred at the Appropriations Committee this past week resulting in media articles indicating that the focus of the Committee was on getting tough on providers regarding the interim payments, resulting in physicians and other providers feeling that the legislators did not fully understand the pain they had been through the previous 27 months.  Both Commissioner Harvey and the MMA's Andrew MacLean did respond to the committee members, with Andy noting that physicians were still owed more in suspended claims than they owed back in interim payments.

The weekly capping of claims continues at a more aggressive level ($34.7 million) because of concern that there will not be sufficient funds to pay claims through the end of the fiscal year.

Finally, Deputy Commission of Finance Kirsten Figueroa confirmed at the Provider Advisory Committee meeting that the $1 million appropriated last year ($4 million had been requested) to reimburse interest expense of providers who had borrowed funds to stay afloat during the period of limited or no payments would in all likelihood not be made available this year because of the financial difficulties in the MaineCare account.  Gordon Smith, MMA EVP made appropriate objections.

Contingency Plan Announced for National Provider Identifier

Due to strong advocacy efforts by the AMA and others, the Centers for Medicare & Medicaid Services announced a 12-month contingency plan for compliance with the National Provider Identifier (NPI) deadline of May 23. The NPI will become the single, unique identifier for physicians, required for use when doing business electronically with all payers - including Medicare - and is intended to replace the multiple, proprietary identifiers that health plans have assigned to physicians. Still, the AMA advises physicians to obtain their NPI by May 23 if they have not already done so. Payers, including Medicare, will have the option of allowing physicians to use their old identifiers on electronic claims and other transactions for up to 12 months. Physicians should contact each of their payers to find out how they will apply this policy. [return to top]

More on Dirigo 2.0

The Governor's new package of healthcare legislation, now known as Dirigo 2.0, continues to receive mixed reviews at the State House.  Highlights of the package was included in last week's Weekly Update and will be placed on the MMA website at www.mainemed.com.  The proposal was the subject of a full-page editorial in the April 15 Maine Sunday Telegram.  The Telegram editorial reacted quite favorably to the plan and encouraged legislators to enact all of it rather than passing some of the provisions and defeating others.

The controversial proposal includes a transition from the Savings Offset Payment (but not until July, 2008), establishment of a new financing vehicle based upon hospital surcharges related to the actual amount of savings associated with Dirigo enrollees having coverage, a play-or pay system for employers and an individual mandate requiring persons earning over 400%  of the federal poverty level to purchase insurance, a reinsurance pool for high-risk patients and changes to the existing community rating bands.  The rating bands would be increased from a maximum differential currently of 20% to a maximum differential of 30%  next year and eventually be increased to 50%.  In addition, the funding of the MaineCare parents will be moved to the general fund, although those individuals will stilll be counted on the Dirigo rolls.  This move will free u p $5 million to $6 million that will be set up in reserves in the event that Dirigo becomes self insured. The actual legislative language has not yet been released but is expected within the next two weeks.  Following its release, public hearings will be scheduled on the proposal.

The proposal has received low marks from the Republicans, which was predictable.  Consumer interests have expressed strong opposition to the liberalization of the community rating bands while business interests are expected to vigorously oppose the play or pay option for businesses. 

MMA's Legislative Committee will meet on Tuesday evening, April 24th at the MMA offices in Manchester at 5:30pm and the meeting will focus on Dirigo.  Among the guests will be Trish Riley, Director of the Governor's Office of Health Policy and Finance and several legislators involved in the Dirigo debate.  Any interested MMA member is welcome to attend but please contact Charyl Smith at 622-3374 (Press O) or via e-mail to csmith@mainemed.com to let us know.  Dinner will be available. [return to top]

Patient Can Appeal Medicare Part D Rulings

When a pharmacist tells your patient a drug you prescribed is not covered by Medicare Part D, does the patient accept that decision and not get that medication? Do your patients know they can appeal?

Often patients do not have the information they need to pursue an appeal on a drug. However, the Centers for Medicare & Medicaid Services (CMS) now has a one-page document that advises beneficiaries of their appeal rights and offers steps for seeking an exception.

Download the document to make available for your patients at www.ismanet.org/pdf/MedicarePrescriptionRights.pdf

Physicians who encounter problems with a Medicare Part D drug plan can report the problem by sending an email to CMS at PRIT@cms.hhs.gov with a copy to PartD@ama-assn.org so the AMA will be aware of the situation. [return to top]

CMS Launches the Doctor’s Office Quality Information Technology (DOQ-IT) University

Last week the Centers for Medicare & Medicaid Services (CMS) announced the national launch of DOQ-IT (Doctor’s Office Quality Information Technology) University, or DOQ-IT U, to support the adoption of health information technology (HIT) in physicians’ offices.  DOQ-IT U is an interactive, Web-based tool that will assist solo and small-to-medium sized physician practices with the adoption and implementation of electronic health records and care management practices.  The first learning sessions focus on physician office workflow redesign, culture change, and communication.  The next set of learning sessions will include disease specific modules that will contain a patient self-management component.     

  “CMS is pleased to launch DOQ-IT University, the first of its kind e-learning platform, to provide assistance to physicians across the United States in the adoption and implementation of electronic health records and care management practices,” said CMS Acting Administrator Leslie V. Norwalk, Esq.  “DOQ-IT U’s interactive platform, self-paced curriculum, and associated tools provide physicians with easy access to the resources they need to help ensure that patients receive the highest quality of care at all times.”

Please find attached a press release regarding this announcement.  For questions or additional information, please contact Melissa Reisman (202-205-1741) or Erin Clapton (202-690-5705) in the CMS Office of Legislation, or visit the DOQ-IT website at http://elearning.qualitynet.org.  Thank you. [return to top]

Maine Quality Forum Advisory Council Meets; Dr. Cutler Assumes Position

The Maine Quality Forum Advisory Council met on April 13 and welcomed the new MQF Acting Executive Director Josh Cutler, M.D.  Following an update on Dirigo Agency activities from Karenlee Harrington, its Director, the Council heard a report on employee activation (from Jim Kupel of Crescendo Consulting Group) and a report from the Maine Health Access Foundation. 

The Council also heard a report on nursing ratios and determined that it would not make a recommendation  to the Maine Quality Forum on the issue of collecting information from each hospital on hospital acquired infections.

As a follow-up to its February meeting, the Council discussed the report presented by Health Dialog Analytic Solutions on the status of the Maine Health Data Organization paid claims data base.  Under a contract with the MQF, HDAS conducted a pilot project that was intended to determine whether the MHDO database could support a robust set of performance measures.  In other words, was the all-payor claims data base accurate enough to conduct some quality analysis?  The conclusion of the firm was that the data warehouse could be used to measure differences across the dimensions of care and that opportunities existed to look at differences in patterns of care at the patient level.  Mike DeLorenzo, Director of Research and Modeling at HDAS declared that HDAS and MQF could utilize the unwarranted variations in care demonstrated by the data in the warehouse to pursue MQF's health care quality transformation efforts.  A lot of the education efforts aimed at consumers would be focused on the Forum's website.

In February, the Council agreed that the Performance Indicator Committee should review the detailed HDAS charts taken out of Mr. DeLorenzo's presentation due to time constraints.  The Committee will discuss future opportunities for practitioner-level assesssment and work with MQF and HDAS staff to design the next phase of analysis.  The Council agreed that the Committee could review possible next steps and make a recommendation to the full Council.  The Committee did meet on Friday and reviewed the detailed information with Mr. DeLorenzo.  The Committee was comfortable in recommeding to the full Council that an additional contract be entered into with Health Dialogue and that the work continue to focus on family practice and cardiology at this point.

The MQF Advisory  Council generally meets the second Friday of each month at the offices of the Dirigo Health Agency on Water St. in Augusta. [return to top]

John Barry Named Director of Quality Counts

John Barry of Falmouth has been named as Director of Quality Counts!, a unique collaboration among several healthcare organizations in Maine, including MMA.  John takes over from Jean Eichenbaum who's obligation was through April 30.  Jean decided to pursue an opportunity to continue her education in health care administration.  John has already begun his work and Jean will be available to advise for a few weeks.

John has both a clinical background (in social work) and a strong business background (MBA).  He has previously held positions in Massachusetts and Colorado.  He and his wife and son recently re-located to the Portland area.

In addition to directing Quality Counts, John will be the Project Manager for the Aligning Forces for Quality grant received through the efforts of the coalition.  The three-year, $600,000 grant from the Robert Wood Johnson Foundation is intended to align efforts relative to the implementation of the chronic care (planned care) model within and across the following market areas:

  • Public reporting of provider quality measurement
  • Improving opportunities for providers to improve the quality of care they deliver
  • Helping patients and consumers understand and take a more active role in recognizing and demanding high quality care

Direction of the project is through an Executive Leadership Team which includes MMA EVP Gordon Smith.  MMA may also put in a proposal to be the "administrative home" of Quality Counts!  A Request for Proposals was recently sent out to seven organizations, including MMA.  Responses are required by April 23. 

John will also assist in completing the Voluntary Practice Assessment Initiative, a quality improvement project conducted by MMA and the Maine Osteopathic Association and funded by the Maine Quality Forum.  The existing contract was recently extended to June 30, 2007. [return to top]

May 4 First Friday Presentation to Feature CMS Quality Reporting Initiative

The May 4 First Friday CME offering will feature presentations on the Medicare Physician Quality Reporting Initiative (PQRI) .  The presenters will include Andrew Finnegan from the Region I CMS office in Boston and Jana Purrell, CPC, Director of the Coding Center.  The PQRI begins on July 1, 2007 and offers the opportunity to enhance Medicare reimbursement by a small amount.

The program will run from 9:00am through noon at the MMA offices in Manchester, Maine.  The cost is $60 which includes breakfast and all course materials. 

Anyone interested may register through the MMA website at www.mainemed.com or call 622-3374 and ask for Jess Violette (Press 0).  [return to top]

MMA Legislative Committee Forum on Dirigo Health on 4/24: All Welcome!

The MMA Legislative Committee’s next meeting will be:

Date:                            Tuesday, April 24, 2007

Subject:                        the Dirigo Health Program and the health care reform debate in Maine

Time:                            5:30 p.m. to 7:30 p.m. with program beginning at 6 p.m.

Location:                      Frank O. Stred Building, Manchester, Maine Medical Association

Other:                           Hors d’oeuvres and beverages available

Guests:                         Trish Riley, Director, Governor's Office of Health Policy & Finance, Senator Peter Mills (R-Somerset), Representative Wes Richardson (R-Warren), and two Democratic legislators TBA.

 Come hear varying perspectives on the Dirigo Health Program and learn more about Governor Baldacci's Dirigo 2.0.  Please RSVP to Charyl Smith, Legislative Assistant, at csmith@mainemed.com.


[return to top]

General Accounting Office Informs Congress that CMS Can Profile Physicians

At a Congressional hearing last month, the General Accounting Office (GAO) shared information on how to foster efficiency under Medicare.  The GAO stated that physician profiling - the collection of data to assess physician performance - coupled with incentives to encourage efficiency can create a system that operates at the individual physician level.  To fulfill a 2003 mandate to examine aspects of physician compensation in Medicare, the GAO conducted a study that concludes physician profiling could address the prinicipal criticism of the problematic sustainable growth rate (SGR), which operates on an aggregate physician level.

The study looked at how 10 health care purchasers assessed physicians' performance against an efficiency standard.  The purchasers, who also evaluated physicians on quality, linked their efficiency analysis results and other measures to a range of strategies - from steering patients toward the most efficient providers to excluding a physician from the purchaser's provider network because of poor performance.  Some of the purchasers said these efforts produced savings.

The GAO then conducted an analysis of generalist physician practices in Medicare using the term "efficiency" to mean providing and ordering a level of services that is sufficient to meet patients' health care needs but that is not excessive, given a patient's health status.  The GAO concluded that CMS has the tools to identify physicians who are likely to practice medicine inefficiently so that CMS can make statistically valid comparisons.  These tools include comprehensive medical claim information, sufficient numbers of physicians in most areas to construct adequate sample sizes, and methods to adjust for differences in beneficiary health status.  The GAO stated that physician profiling programs may have the potential to generate savings and pointed to CMS's risk adjustment methodologies, which have been increasingly sophisticated over the past decade, to set payment rates for beneficiaries enrolled in managed care plans.  The full report will be released at the end of April. [return to top]

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