May 29, 2007

 
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Legislature Completes Busy Week; Health Care Items Starting to Move

The Maine Legislature finished up a very busy week on Friday and legislators headed home for a three day Memorial Day weekend.  When they return on Tuesday, they will begin a final stretch of less than four weeks where they will attempt to pass a two-year budget, reform the Governor's Dirigo Health initiative, continue other efforts at health system reform, and perhaps enact legislation reforming Maine's tax laws.

The Health and Human Services Committee completed work on a number of bills of interest to physicians last week, including bills amending the Certificate of Need laws, broadening the authority and scope of the Advisory Council on Health Systems Development, and a Proposed Joint Order authorizing the Committee to meet ten times between adjournment and January to review the MaineCare program.

The Proposed Joint Order regarding  a review of MaineCare provides that the Committee would review the following issues:

  1. The efficiency, effectiveness, performance and fiscal soundness of the MaineCare program:
  2. The potential for maximizing third-party liability collections and other cost savings;
  3. Analysis of program delivery and options for improving delivery;
  4. The roles that care coordination and disease management play in improving health outcomes and consequent reductions in utilization and costs;
  5. Fulfillment of the obligations of the State in operating the program;
  6. The implementation of health care reforms in the program during 2007, including clinical management and managed behavioral health care;
  7. The relationship of the program to the Dirigo Health and the Elderly Low-cost Drug program;
  8. The effect of the merger of the Department of Health and Human Services and the Department of Behavioral and Developmental Services on the MaineCare program and the delivery of MaineCare services; and
  9. The transformation of the Department of Health and Human Services Office of MaineCare Services.

If the Joint Order passes, which is expected, the committee would be authorized to submit legislation regarding the MaineCare program to the Second Regular Session of the 123rd Legislature.   The Joint Order replaces L.D. 1820, An Act to Create a Program to Implement Choice of Health Plans in the MaineCare Program and Amend the MaineCare Program, a bill sponsored by Republican legislators to amend the MaineCare program based upon the federal Deficit Reduction Act.

MaineCare to Hold "Visioning" Session on New MMIS System

The Office of MaineCare Services will hold a special meeting of the Professional Advisory Committee and the Technical Advisory Committee on Thursday, June 7 from 9:00am to noon at the OMS offices in Augusta.  At 10:00am a facilitated "visioning" session will take place, providing attendees with the opportunity to provide input into the new system being designed to replace the poorly functioning MECMS system.

Persons unable to get to Augusta but who are interested in the session may call in, although there will be no ability of the callers to ask questions.  Watch the Weekly Update the next two weeks for the call-in number which is not yet available.

A pre-visioning document has been placed on the MMA website at mainemed.com (look under the Spotlight section).  Providers attending should think about what functions a new payment system could provide which would be helpful.  One place to look would be to see what other health plans are doing that you find useful in terms of claims processing.

At the Provider Advisory Committee meeting on this past Friday (May 25), a presentation was made by Brenda McCormack of the OMS staff regarding the expansion of the care management program.  A small pilot program has been operated since Dec. 2006 with 300 high cost patients participating.  The pilot is operated by a care management firm, Schaller-Anderson.  Recently, an expanded program was put out to bid with five out of state firms responding.  Schaller-Anderson's bid was accepted and (assuming passage of a state budget) the program will be expanded to most of the MaineCare population beginning July 1.  Some groups will be exempt from the care management program, including patients with HIV, cancer and the elderly.  The program is expected to save MaineCare over $100 million during the two-year budget.

Ten percent of MaineCare patients represent 63% of the cost.  The high cost drivers, as cited by McCormack, include inpatient hospitalizations, re-admissions, and emergency room usage. 

While Schaller-Anderson will begin the project, it is hoped that regional PHO's will eventually develop the staff and expertise to perform the care management program without the necessity of utilizing out of state firms.

Other proposed cost-saving strategies in the proposed budget include decreasing the five brand-name drug limit to four.  When a fifth script is written, the prescriber will be sent a profile of the patient's prescribing.

Weekly metrics for MECMS showed the following for the week ending May 20.

  • Suspended claims inventory stands at 67,893 which is an increase from previous weeks.
  • Processing of paid or denied "fresh" claims was 95.33%
  • For Cycle #44, the total carry forward of capped claims decreased by 3.2 million but for Cycle #45, caped claims and the carry forward increased by $10.8 million.  $56.8 million in claims have now been subject to the cap.
  • The weekly capping of claims will stop during the first week of the new fiscal year in July.  There is no plan to continue the capping of claims in the new fiscal year, but it may take a few weeks to pay all the past claims held up because of the capping.

Remember that there is a hold on claims with dates of service prior to Oct. 1, 2006 if the provider has an interim payment balance.  If your claims are still not processing regularly, you can request that the hold not take place at this time.

The prospect for the MaineCare physician fee increase currently pending before the Legislature looks good presently.  The increase would take effect July 1, 2008.  Securing this $8 million increase (state and federal) is the MMA's highest legislative priority. [return to top]

Physician Golfers and Corporate Affiliates Invited to Participate in 4th Annual MMA Golf Tournament

The Augusta Country Club is in excellent shape and will be the site of MMA's Fourth Annual Golf Tournament on Monday, June 18th.  We hope to have a minimum of 25 teams participating and a wealth of prizes will be awarded to the leaders in both net and gross categories, with the usual closest to the pin and longest drive awards for women and men as well.  Brian Jumper, M.D. will again serve as Chair of the Tournament.

The event begins with lunch served on the deck beginning at 11:00am with a shotgun start promptly at noon.  The format will be a traditional scramble, rather than the "bramble" we tried last year.

For the first time this year, an award will be given to any team made up exclusively of physicians in one specialty. 

If you have not received a brochure containing registration materials and would like to play, call Gail Begin at 622-3374 ext. 210.  The cost is $125 per player or $500 per team.  Sponsorship opportunities are also available. [return to top]

State's Surgeons Meeting in Bar Harbor this Weekend

A wide array of clinical education and practice management assistance awaits surgeons who attend the upcoming Annual Meeting of the Maine Chapter of the American College of Surgeons June 1-3 at the Bar Harbor Regency Hotel.  First District Congressman Thomas Allen will speak on Friday afternoon as part of a program featuring the topic of legislative involvement.  The after-dinner speaker on Saturday evening is former NASA astronaut Story Musgrave, M.D.  Dr. Musgrave achieved fame as the astronaut chosen to walk in space and fix the Hubble Telescope.

Congratulations to Chapter President Brad Cushing, M.D., District Governor Charles "Tom" McHugh , M.D. and Maine Chapter Secretary Joel Lafleur, M.D. for another outstanding program.

Surgeons or practice managers interested in attending may contact Dr. Lafleur at jlafleurmd@gmail.com. [return to top]

HHS Committee Approves Two CON Bills

Following several weeks of negotiations among representatives of the Department of Health & Human Services and the MMA, Maine Hospital Association, MaineHealth, Eastern Maine Health Care, the Maine Ambulatory Surgical Center Coalition, and the Maine Health Care Association, the legislature's HHS Committee last week approved a consensus amendment to L.D. 1763, An Act to Amend the Maine Certificate of Need Act of 2002.  The bill makes the following amendments to the CON statutes:

  • It clarifies when the "acquisition of major medical equipment" requires CON review to make it clear that replacement of major medical equipment, even if the replacement cost is above the dollar threshold for review, does not require a CON, so long as the capability of the new equipment is substantially the same as that of the old equipment.  It gives the Department the authority to take action if it determines that equipment has been transferred between related entities at less than fair market value.  Also, it states that replaced major medical equipment must be removed from service.
  • It clarifies the Department's rights of "subsequent review" following a determination that CON review was not required to ensure that the Department can take enforcement action if it finds that an applicant "withheld significant and relevant information" or made "material misrepresentations" in order to avoid CON review.
  • Finally, the bill amends the Department's authority to take enforcement action, including the withholding of funds.

The group of interested parties was unable to resolve several other contentious issues, including the the application of the CON law to situations in which a facility has been providing a service through an agreement with a mobile service provider and then wishes to purchase a piece of equipment to continue providing that service. 

During the same work session, the HHS Committee also recommended passage of L.D. 1535, Resolve, to Establish the Work Group to Review and Recommend Improvements for the Certificate of Need Program.  This bill is similar to a bill that failed for lack of funding in the 122nd Legislature.  The group is empowered to study the following issues:

  • Recent changes made by law or rule to the certificate of need program and the need for any modifications to the law or rule;
  • The current dollar amount threshold used in determining whether a project requires review and, if inadequate, a potential process for identifying projects that fall below the threshold;
  • The current statutory authority of and methods used by the Department to determine whether review is needed. 
  • The current statutory authority of and methods used by the Department to define community need for new services or facilities;
  • The relationship between the State Health Plan, the certificate of need process, and the Capital Investment Fund;
  • The roles of the Maine Quality Forum, the Department, the Maine CDC, and the Bureau of Insurance in the CON review process;
  • The criteria used by the Department for evaluating a CON application along with procedures for public hearings and the use of review panels;
  • Historical review of revenues and expenditures in the CON unit to identify and determine the amount of resources that are adequate to have a highly functioning unit;
  • Historical review of the CON application process including number of submissions, approvals, disapprovals and withdrawn applications and associated timelines to determine any improvements needed;
  • Review of the most recent studies on the impact that the competitive market versus regulation has on health care costs and access; and
  • Additional topics determined by unanimous agreement of the work group members.

Rep. Bob Walker, M.D. (R-Lincolnville) was the only member of the Committee to vote against L.D. 1535 and he stated that he did so because he does not support CON generally.  The MMA expects neither bill to face serious opposition on the floor. [return to top]

Hospital Rate Regulation Bill Amended to Expand Role of Dirigo Advisory Council

At a joint work session of the HHS & IFS Committees on Thursday, May 24, 2007, HHS Committee House Chair Anne Perry (D-Calais) presented an amendment to L.D. 1849, An Act to Protect Consumers from Rising Health Care Costs.  Instead of restoring a regulatory system, the bill now will expand the membership of the Dirigo Advisory Council on Health System Development to include legislators and representatives of the business community and insurance industry and will expand the duties of the Council to include the following cost containment efforts:

  • Systemic review of cost drivers in Maine's health care system, including but not limited to, market failure, supply and demand for services, provider charges and costs, public and commercial payor policies, consumer behavior, cost and pricing of pharmaceuticals, and the need for and availability and cost of capital equipment and services;
  • Collecting and reporting on health care cost indicators, including the cost of services and the cost of health insurance.  The Council shall report on both administrative and service costs.  The indicators must include at a minimum:
    • The annual rate of increase in the unit cost of key components of the total cost of health care, including without limitation hospital services, surgical and diagnostic services provided outside of a hospital setting, primary care physician services, specialized medical services, the cost of prescription drugs, the cost of long term care and home health care, and the cost of laboratory and diagnostic services;
    • The interaction of indicators including but not limited to cost shifting among public and private payors and cost shifting to cover uncompensated care to persons unable to pay for items or services, and the effect of these practices on the total cost paid by all payment sources for health care;
    • The administrative costs of health insurance and other health benefit plans, including the relative costliness of private insurance as compared to Medicare and MaineCare, and the potential for measures and policies that would tend to encourage greater efficiency in the administration of public and private health benefit plans provided to Maine consumers;
    • Geographic distribution of services with attention to appropriate allocation of high-technology resources;
    • Regional variation in quality and cost of services; and
    • Overall growth in utilization of health care services.
  • The Council's objective must be to identify specific potential reductions in total health care spending without shifting costs onto consumers and without reducing access to needed items and services for all persons, regardless of individual ability to pay.  The goal of the Council's duties is to make health care and health coverage more affordable for Maine people by recommending specific methods to reduce the rate of increase in overall health care spending and the rate of increase in health care costs to a level that is equivalent to the rate of increase in the cost of living; and
  • The Council shall make specific recommendations to the joint standing committees with jurisdiction in matters of insurance and financial services and health and human services, and where rulemaking may be appropriate, to the state agency with such rulemaking authority.

This amendment won the unanimous support of both the HHS and IFS Committees. [return to top]

Appropriations Committee Votes In MaineCare Physician Fee Increase

During a work session last week on tabled items in the HHS section of the FY 2008-2009 biennial state budget (L.D. 499), members voted in the $3 million General Fund increase in the second year of the biennium for the MaineCare physician fee schedule.  They did so with little discussion.  The Appropriations Committee continued work well into Friday evening before the long holiday weekend.  While the fee increase is not certain until the budget finally is closed, this action certainly is a good sign.  Thanks to all members who contacted members of the Appropriations Committee and/or your own legislators to tell them how important it is to raise MaineCare rates - eventually to Medicare's rates - to ensure your ability to continue serving MaineCare beneficiaries. [return to top]

NovaHealth Physicians Recognized For Excellence In Diabetes Care

The National Committee for Quality Assurance (NCQA) and the American Diabetes Association (ADA) have announced that forty-five physicians at InterMed and PrimeCare, two leading physician groups in Southern Maine, have received recognition from the Diabetes Physician Recognition Program for providing quality care to their patients with diabetes.

The Diabetes Physician Recognition Program was designed to improve the quality of care that patients with diabetes receive by recognizing physicians who deliver quality diabetes care, and by motivating other physicians to document and improve their delivery of diabetes care. To receive recognition, which is valid for three years, each physician submitted data that demonstrated performance that meets the program’s key diabetes care measures. These measures include blood sugar, eye exams and blood pressure tests, among others. When people with diabetes receive quality care as outlined by these measures, they are less likely to suffer complications such as heart attacks, stroke, blindness, kidney disease and amputations.

More than 5,000 Maine patients choose InterMed and PrimeCare primary care physicians to help them with their diabetes care. As a result, this group benefited directly from a unique program developed here in Maine. In 2004, NovaHealth, an Independent Physician Association founded by InterMed and PrimeCare, initiated a practice-wide computerized registry program to ensure that these patients regularly received important tests for diabetes control. The registry, named Touch Every Life, was developed by NovaHealth and Pinnacle, a Maine-based software development company. It identifies patients who have not been seen recently, have not had scheduled lab evaluations or clinical tests, or who are below the recommended levels for the three most important measures affecting diabetes outcomes: blood sugar, blood pressure, and cholesterol.

 “The American Diabetes Association calls its national effort the ‘ABC’ campaign,” said Michael Albaum, Medical Director at both NovaHealth and PrimeCare. “A for hemoglobin A1c or blood sugar, B for blood pressure, and C for cholesterol – all of which play critical roles in maintaining health in patients with diabetes, especially to prevent cardiac and vascular complications.”

Diabetes and blood sugar control is much more complicated than simply taking a pill or a daily insulin injection. It requires day-to-day, even meal-to-meal determinations of calorie input, carbohydrate concentrations, amount of exercise, stress, and other illnesses all of which can affect blood sugar and are difficult to predict. Add to that the daily monitoring of blood sugars, involving as many as six tests per day, which at times can be somewhat painful and not inexpensive. Diabetes is a minute-to-minute job, 99% of which is under the patient’s control, not the physician’s. For this reason, InterMed and PrimeCare asked their patients to step up to the challenge of helping themselves by taking greater personal control of their health.

Whether it is a matter of diet or lifestyle, the patient’s decisions ultimately make the greatest difference in the risk of subsequent eye, kidney, nerve and vascular complications. To support this notion of self-management NovaHealth has developed a communication strategy entitled “It’s My Life” to inspire patients and empower them with the knowledge they need to adopt healthier, more proactive attitudes. InterMed and PrimeCare use posters, brochures, personal calendars and personal contact with physicians and staff as a means of more actively engaging patients in their own care. Patients are actually working to help each other by supporting and sharing self-management strategies at NovaHealth hosted group sessions.

The InterMed/PrimeCare diabetes program is one of several initiatives in its efforts to improve the delivery of care for patients with conditions such as asthma, acute back pain and heart disease. Each of these programs was created to support the goals crafted earlier by NovaHealth physicians: to improve clinical quality, patient satisfaction, healthcare value and the level of provider satisfaction.

To find out if your physician has been recognized by the Diabetes Physician Recognition Program or for further information, please visit www.ncqa.org/dprp or call (202) 955-1721. To order application materials, call (888) 275-7585 or order online at www.ncqu.org/communications/Publications/dprppubs.htm.

Diabetes is a serious disease that affects the body’s ability to produce or respond properly to insulin, a hormone that allows blood sugar to enter the cells of the body and be used for energy. An estimated 16 million Americans have diabetes; it is the sixth-leading cause of death by disease in the U.S. and it has no cure.

NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations, recognizes physicians and physician groups in key clinical areas and manages the evolution of HEDIS®, the tool the nation’s health plans use to measure and report on their performance. NCQA is committed to providing health care quality information through the Web, media and data licensing agreements in order to help consumers, employers, and others make more informed health care choices.

The American Diabetes Association is the nation’s leading voluntary health organization supporting diabetes research, information and advocacy. Founded in 1940, the association has offices in every region of the country, providing services to more than 800 communities. [return to top]

Register Today for June 20 Practice Education Seminar in Auburn

Register today for the Association's 16th Annual Practice Education Seminar to be held on Wednesday, June 20th at the Hilton Garden Inn in Auburn.  The all-day program, featuring plenary sessions in the morning and a choice of twelve break-out sessions in the afternoon, will run from 8:30am to 4:00p.m.  The keynote presenter is Erik Steele, D.O. of Eastern Maine Healthcare  System, a well known columnist for the Bangor Daily News and a health administrator for the EMHS.  An update will also be provided by the new MaineCare Director.  Federal officials will present information on the new CMS Physician Quality Reporting Initiative, which begins on July 1.

The Annual Practice Education Seminar, which regularly attracts about one hundred attendees, presents the Association with an annual opportunity to share with practice managers and members the major issues affecting medical practice in Maine.

Call the MMA office at 622-3374 to register or register online at the MMA website at www.mainemed.com. [return to top]

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