May 12, 2008

 
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All Members Invited to First Congressional District Candidate Forum Tuesday Night at MMA

MMA members and their guests are invited to attend Tuesday night's First District Congressional Candidate Forum at the MMA offices in Manchester.  Seven of the eight candidates have confirmed their attendance, inluding MMA member Steve Meister, M.D.  The evening begins with a reception at 5:30 pm with the Forum discussion following from 6:00 pm to 8:00 pm. 

 

Candidates will have an opportunity to make an opening statement and then will respond to the following:  Discuss 3 steps you would take to improve the health care system of the United States.  The audience also will have an opportunity to pose questions to the candidates. 

Candidates attending will be Democrats Michael Brennan, Adam Cote, Steve Meister, M.D., Chellie Pingree, and Ethan Strimling, and Republicans Dean Scontras and Charlie Summers.

If you are interested in attending, please call MMA at 622-3374 (Press O) and let us know so that we will have sufficient refreshments and materials.

Maine's First Congressional District is heavily contested this year because it is an "open seat."  The current Congressman, Tom Allen, is vacating the seat in order to run against U.S Senator Susan Collins who is seeking a third term.

Following the Forum, physicians may stay and discuss with the Trustees of the Maine Physician Action Fund (MPAF) their observations on the Forum.  The MPAF is a Maine-based political action committee established by MMA.  While the MPAF may contribute only to state races, it does make recommendations to the American Medical Association Political Action Committee (AMPAC) which contributes to federal races.

Hurley Travel Experts Presents Luxury Explorers Showcase

Hurley Travel Experts cordially invites you to its inaugural
Luxury Explorers Showcase
Saturday, May 17, from Noon to 8pm,
at The Woodlands Club in Falmouth, Maine

Enjoy refreshments on the terrace, listen to a private concert by the Portland String Quartet, and learn about the hottest trends in experiential travel.

The day promises to be filled with exciting travel exhibits, informative speakers, and exclusive travel incentives for all who attend.  Our international travel suppliers will showcase their cultural, educational, culinary, spa, wellness, adventure, family, and conservation vacations.

Please RSVP by Monday, May 12, by calling Hurley Travel Experts at 800.874.1743 or rsvp@travelexperts.com.

Visit hurleytravelexperts.com for complete details and updates.

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Stakeholder Process Aimed At Creating Statewide Health IT Fund

Maine Governor John Baldacci and the Maine Legislature have established an intensive multi-stakeholder planning process aimed at accelerating adoption of electronic clinical systems through the creation of a new statewide Health IT Fund.  Maine's recently released State Health Plan has identified the development of electronic systems as a statewide priority.

A "Resolve" approved by the Governor and the Legislature directs HealthInfoNet (Maine's health information exchange or HIE) and the Maine Quality Forum to coordinate the planning process.  Representatives from 20 organizations identified in the Resolve have been invited to conduct a thorough review of the development of electronic health information exchanges or HIE's across the nation.  Beginning in late May and continuing through the end of this year, the process will then examine Return on Investment projections associated with greater information-sharing and explore a range of possible funding options. 

The Resolve calls for the stakeholders to use this research to develop a set of recommendations for establishing and financing a new statewide quality improvement and technology fund.  This fund would initially contribute to HealthInfoNet's establishment and sustainability, and then help make it possible for health care providers with limited financial resources to obtain electronic medical record and other electronic clinical systems that support improved patient care and coordination of care across the State. Recommendations developed by the group will be presented to the Legislature's Health and Human Services Committee in December.  Legislation based on these recommendations may then be introduced following a review by the Committee. [return to top]

People's Veto Campaign Underway to Overturn New Taxes to Fund Dirigo

A coalition of the state's business associations representing restaurants, grocers, innkeepers, and beverage interests filed a request on May 2 with the Secretary of State's office to initiate a petition drive to overturn the new taxes passed by the legislature in April to support the Dirigo Health Program.  The Secretary of State has until May 12 to approve petition language for a people's veto of the taxes.  In order to get the question on the ballot this coming November, the coalition must collect the signatures of 55,087 registered voters by July 17.

Newell Auger, head of the Maine Beverage Association, is the head of the new coalition, which is expected to be heavily funded by national beverage interests such as Coca-Cola, beer manufacturers, and McDonalds. 

If the petition drive is successful, the new law would not take effect as planned on July 18 and would be held in abeyance until the November election. 

At the Dirigo Health Agency Board meeting last week, Board members and staff acknowledged that the current processes surrounding the determination and collection of the savings offset payment would have to continue until the uncertainty of the new law is resolved.  Hearings will have to be held in July of this year to determine the amount of the assessment for next year.  This year's assessment was set at 1.7 percent of paid claims, representing approximately $33 million.  Unfortunately, the delay in moving to the new funding will result in the state having to spend upwards of $1 million in consulting fees related to the determination of the SOP. [return to top]

Only Two Weeks Until the 17th Annual MMA Practice Education Seminar

Call MMA today to reserve your spot at the 17th Annual Practice Education Seminar (formerly called the Physician Survival Seminar).  This year's program will be held at the Augusta Civic Center, a convenient venue which provides ample space for attendees, exhibitors, and twelve breakout sessions.  The all-day program is being held on Wednesday, May 28th, beginning at 8:30 am with a keynote presentation by the U.S. Attorney for the District of Maine, the Honorable Paula Silsby.

This year's program is one of the strongest ever with presenters on the topics of prescription drug abuse, quality improvement, physician profiling, tiered networks, the workforce shortage, and the relatively new Stark Phase III regulations, among others.

Register Online!

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Next First Friday Program: Patient Disclosure Following an Unanticipated Outcome, June 6

MMA's next First Friday education presentation will be held on Friday, June 6th, on the subject of "Patient Disclosure Following an Unanticipated Outcome."  The program begins at 9:00 am and runs until noon and will be held at the MMA offices in the Frank O. Stred Building in Manchester.

The program has been approved for three category one CME credits.  The program will be presented by three experienced risk managers from Medical Mutual Insurance Co. of Maine, including Jackie Madore, RN, CEN, CCRN, Cheryl Peaslee, RN, BSN, MBA, CPHQ, and Nancy Brandow, MS.

"What constitutes an unanticipated outcome?  How should disclosure to patient and family members be handled?"  Attend the program and find out.

The program will also address disclosure, apology, and related liability.  Program participants will be provided with practical risk management advice to assist the practitioner with development of a thoughtful and consistent disclosure process applicable to the private practice and hospital-based setting.  Review of case studies will walk the program participants through actual patient disclosure discussions and allow ample opportunity for questions.

The state law granting limited protection in the case of an apology will also be covered.

Physicians, Practice Managers, Risk Managers, and others will benefit from this presentation.

Registration is available by calling MMA at 622-3374 (Press 0) or by going to the MMA website at www.mainemed.com [return to top]

Report of Maine Quality Forum Advisory Council

The Maine Quality Forum Advisory Council met this past Friday (May 9) and received updates on a number of items.  The Council, which is chaired by former MMA President Robert Keller, M.D., is one of the entities established in the original Dirigo Health legislation enacted in 2003.  The Executive Director of the Maine Quality Forum is D. Joshua Cutler, M.D.

After receiving an update on the activities of the Dirigo Health Agency by Director Karenlee Harrington, Dr. Cutler presented an update on the following items:

  • Pressure Ulcer Initiative
  • CMS EHR Demonstration Project
  • Patient-Centered Medical Home
  • Activities of the Maine Health Management Coalition
  • Recently released State Health Plan

MMA EVP Gordon Smith presented an update on the current status of the MQF funded Voluntary Practice Assessment Initiative (VPAI).  The Initiative is expected to be extended to the end of the calender year in order to give MMA more opportunity to complete the goal of assessing 150 physicians.

Jim Leonard reviewed the current Maine Quality Forum website.  There was a lot of discussion about the extent to which the current information was understandable by and useful to patients.  There was general consensus that the site could be improved, subject to budgetary concerns.

Ted Rooney, project director for the Robert Wood Johnson funded project entitled, "Aligning Forces for Quality" provided an update to the Council on the goals and objectives of the Project.

The Council will meet next on Friday, September 12, 2008.

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2008-09 Maine State Health Plan (MeSHP) Quality Elements Presented at the MMA’s Committee on Physician Quality

The MMA Committee on Physician Quality met last week and received a presentation regarding the Quality Elements outlined in the 2008-09 Maine State Health Plan (MeSHP).  The MMA will follow closely the major quality elements that are included in the MeSHP plan.  These elements related to quality improvement are:

I.                 Improving Health (MeSHP, pages 38-44)

a.     Integration of Care – 1)  Through the Patient Centered Medical Home model, a  demonstration pilot to occur to improve the health of all patients receiving care from the practice to: Create a vital and sustainable practice team, Reduce costs by controlling inappropriate utilization and unwarranted variations in care, Promote an integrated system that supports coordinated care across settings and be supported by an appropriate payment method that recognizes the infrastructure and systems needed to support this type of primary care;  2) Coordinate public health and behavioral health systems and, 3) include other Maine-based integration initiatives that are engaged in promoting integrated, patient-centered care, such as those funded by the Maine Health Access Foundation (MeHAF) and the Chronic Disease Partners.

II.               Assuring Best Practices/Less Variation in Care Delivery (MeSHP, pages 56-61)

a.     Reducing Variation in Medical Practice – to reduce unwarranted variations in healthcare in Maine.

b.     Expansion of the programs, “In a Heart Beat and Stroke Systems of Care” to change the behavior and treatment of heart attacks/strokes and save more lives by early recognition.

c.     Finding the right place of care for the elderly and disabled in need of assistance to determine the proper balance of home-based and facility based services in Maine.

III.             Efficiency and Effectiveness (MeSHP, pages 64-73)

a.     Electronic Health Information (HealthInfoNet or HIN) – building a health information superhighway to build connectivity that supports patient management across multiple points of service.  A 24-month demonstration project with over 2,000 healthcare providers to occur winter of 08-09.

b.     Healthcare-Associated Infection – Development of a hospital infection control collaborative through the Maine Quality Forum (MQF) leadership to promote best practices and share resources for infection control.

c.     Sentinel Event Reporting – to review the system to improve compliance & utility.

d.     Critical Access Hospital Collaborative – 14 hospitals convening to collaborate on projects related to patient safety in the area of medication safety. [return to top]

Central Maine Orthopaedics Wins Workers' Compensation Dispute Before Law Court

On May 8, 2008, the Maine Supreme Judicial Court issued a decision in favor of Central Maine Orthopaedics in a dispute with several employers about the determination of facility fees under the Maine Workers Compensation Act.  You can find the 4-3 decision in Leanne Fernald v. Shaw's Supermarkets, Inc. and William J. Babine v. Bath Iron Works, 2008 ME 81 on the web at:  http://www.maine.gov/tools/whatsnew/attach.php?id=55429&an=1

Under current law, a specific fee schedule (WCB Rule Chapter 5) governs professional services, but facility fees for hospitals and ASCs are based on "usual and customary" charges, less a 5% "prompt payment" discount if such terms are met.  The employers argued that they could judge the reasonableness of facility charges on a case-by-case basis and that "usual and customary" charges should be determined according to what providers accepted from other third party payers.  The Court's majority rejected these arguments and found that "the statutory language plainly supports CMO's position."  Prior to review by the Law Court this dispute played out before a Hearing Officer and the full Workers' Compensation Board.  The MMA and the Maine Hospital Association participated as amici at the Hearing Officer and Board level and the MHA submitted an amicus brief to the Law Court.  The medical community's policy disagreement with the business community regarding medical costs in the workers' compensation system dates back to proposed amendments to Rule Chapter 5 in 2003. 

In a related matter, as reported in Maine Medicine Weekly Update last week, the Board has convened a so-called "consensus-based" rulemaking process in an effort to draft a facility fee schedule.  A second meeting of a stakeholder group is scheduled to meet at the Workers' Compensation Board tomorrow, May 13, 2008 at 1 p.m.  You may direct any comments on the following proposal from the Board staff to Andrew MacLean, Deputy EVP at amaclean@mainemed.com or by phone at 622-3374, ext. 214.

Section 1.  Definitions.

            (a)  Acute care hospital.  A health care facility as defined in 22 M.R.S.A. § 7932 (2-A).  An acute care hospital must be licensed by the Department of Health and Human Services pursuant to 10-144 COMAR Chapter 112.

            (b)  Ambulatory Payment Classification System (APC).  Medicare’s grouping methodology for determining payment for outpatient services.  Medicare assigns CPT/HCPCS codes to an APC group which is then given a relative weight.

            (c)  Ambulatory Surgical Center (ASC).  A health care facility as defined in 22 M.R.S.A. § 7932(9).  An ASC must be licensed by the Department of Health and Human Services pursuant to 10-144 COMAR Chapter 125.  

            (d)  Critical Access Hospital.  A health care facility as defined in 22 M.R.S.A. § 7932 (10).  A critical access hospital must be licensed by the Department of Health and Human Services pursuant to 10-144 COMAR Chapter 112, subchapter XXVII. 

            (e)  Durable Medical Equipment.  Durable medical equipment means durable medical appliances or devices used in the treatment or management of a condition or complaint, along with associated nondurable materials and supplies required for use in conjunction with the appliance or device.

            (f)  Health Care Common Procedure Coding System (HCPCS).  A code set created by Medicare that serves as an extension of the American Medical Association’s CPT codes.

            (g)  Implantable.  Implantable means an object or device that is made to replace and act as a missing biological structure that is surgically implanted, embedded, inserted, or otherwise applied.  The term also includes any related equipment necessary to operate, program, and recharge the implantable.

            (h)  Inpatient services.  Inpatient services means services rendered to a person who is formally admitted to a hospital and whose length of stay exceeds 23 hours.

            (i)  Medicare Severity-Diagnosis Related Group (MS-DRG).  A system adopted by the Centers for Medicare and Medicaid Services which groups related hospital admissions based on diagnosis codes, surgical procedures and patient demographics.

            (j) Outpatient services.  Outpatient means a patient who is not admitted for inpatient or residential care.

 

Section 2.  Inpatient

            (a)  Billing for inpatient services must be submitted on a CMS Uniform Billing (UB-04) form.

            (b)  A critical access hospital shall be reimbursed at 95% of its usual and customary charge.

 

            (c)  Payments for inpatient services in an acute care hospital are based on the MS-DRG system.  The payment must be calculated by multiplying the base rate times the current MS-DRG weight.  The base rate for inpatient services at acute care hospitals is $8923.00.

 

            (d)  Except as provided in subsections (e) and (f), acute care hospitals shall be paid the maximum allowable payment established in Appendix IV or its usual and customary charge, whichever is less, for inpatient services. 

 

            (e)  The threshold for outlier payments is $50,000.00 plus the maximum allowable charge established in Appendix IV If the outlier threshold is met, the outlier payment must be the maximum allowable charge plus the charges above the sum of the threshold and the maximum allowable charge multiplied by 75%.  The total payment for the services is the outlier payment plus the maximum allowable charge. 

            (f)  Where an implantable exceeds $10,000 in cost, acute care hospitals may seek additional reimbursement beyond the maximum allowable charge.  For invoiced items, reimbursement is set at the actual amount paid plus 20%.  If an item is not invoiced, the payment must be 75% of charges.  When a hospital seeks additional reimbursement pursuant to this rule, the implantable charge is excluded from any calculation for an outlier payment.  Handling and freight charges must be included in the facility's invoiced cost and are not to be reimbursed separately.

 

            (g)  All services provided during an uninterrupted patient encounter leading to an inpatient admittance must be included in the inpatient stay.

 

            (h)  The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two acute care hospitals:

            (1)  A hospital transferring a patient is paid as follows:  The MS-DRG reimbursement amount is divided by the number of days duration listed for the DRG; the resultant per diem amount is then multiplied by two for the first day of stay at the transferring hospital; the per diem amount is multiplied by one for each subsequent day of stay at the transferring hospital; and the amounts for each day of stay at the transferring hospital are totaled.  If the result is greater than the MS-DRG reimbursement amount, the transferring hospital is paid the MS-DRG reimbursement amount.  Associated outliers and add-ons are then added to the payment.

            (2)  A hospital discharging a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons.

            (3)  Facility transfers do not include costs related to transportation of a patient to obtain medical care. 

 

            (h)  Services provided by an acute care hospital that do not have a maximum charge in Appendix IV shall be paid at 75% of the acute care hospital’s usual and customary charge.

            (i)  Services provided by an inpatient rehabilitation facility shall be paid at 75% of the inpatient rehabilitation facility’s usual and customary charge.

            (j)  Individual medical providers who furnish professional services in a hospital, ASC, or other facility setting must bill insurers directly and must be reimbursed using the maximum fees set forth in Appendix III.  The individual medical provider’s charges are excluded from any calculation of outlier payments.

 

Section 3.  Outpatient and ambulatory surgical care centers 

            (a)  Billing for outpatient services must be submitted on a CMS Uniform Billing (UB-04) form.

            (b)  The base rate for outpatient services at acute care hospitals is $108.42.

            (c)  The base rate for inpatient services at ambulatory surgical care centers is $81.32.

            (d)  Outpatient services include observation in an outpatient status.

            (e)  Except as provided in subsections (g) and (h), acute care hospitals and ambulatory surgical care centers shall be paid the maximum allowable payment established in Appendix V or its usual and customary charge, whichever is less, for outpatient services. 

            (f)  Payments for outpatient services in an acute care hospital or an ambulatory surgical care centers are based on the APC system.  The payment must be calculated by multiplying the base rate times the APC weight. 

            (1) If the APC weight is not listed or if the APC weight is listed as null for items with status codes A, B, C, D, E, F, K, L, M, Q, S, T, V, X, Y then  reimbursement must be paid at 75 percent of usual and customary charges. For items with status code of N or items with no CPT/HCPCS code, there is no separate payment.

            (2)  When two or more T status code items are on the same claim, the highest weighted code is paid at 100 percent of the APC payment and subsequent T status code items are paid at 50 percent of the APC payment. 

            (3)  “Q” status indicator codes will not be discounted.

            (g)  The threshold for outlier payments is $2,500 per CPT code plus the maximum allowable charge as defined in paragraph (e).  If the outlier threshold is met, the outlier payment must be the maximum allowable charge as defined in paragraph (e), plus the charges above the threshold multiplied by 75 percent.

            (h)  Where an implantable exceeds $5,000.00 in cost, hospitals or ambulatory surgical care centers may seek additional reimbursement.  For invoiced items, reimbursement is set at the actual amount paid plus 20 percent.  If an item is not invoiced, the payment must be 75 percent of charges.  When an ambulatory surgical care center or hospital seeks additional reimbursement pursuant to this rule, the implantable charge is excluded from any calculation for an outlier payment.  Handling and freight charges must be included in the facility's invoiced cost and are not to be reimbursed separately.

            (i)  The following applies to patient transfers from an acute care hospital or ambulatory surgical care center to an acute care hospital:

            (1)  An acute care hospital or ambulatory surgical care center transferring a patient is paid the maximum allowable charge established in this section.

            (2)  The acute care hospital to which the patient is transferred is paid the maximum allowable charge established in section 2.

            (3)  Facility transfers do not include costs related to transportation of a patient to obtain medical care.

            (j)  Individual medical providers who furnish professional services in a hospital, ASC, or other facility setting must bill insurers directly and must be reimbursed using the maximum fees set forth in Appendix III.  The individual medical provider’s charges are excluded from any calculation of outlier payments. [return to top]

Prescription Monitoring Program Medical Advisory Group Meets – New tools emerging

MMA EVP Gordon Smith reported that the Maine Medical Association is in its third year of partnering with the Office of Substance Abuse to provide CME education to prescribers with more than 8 trainings occurring per year.  These programs are free and can be tailored to meet the needs of any practice wishing to receive an in-house training.  Mr. Smith also reported that the Board of Licensure in Medicine’s contract for chronic pain/diversion prevention provides resources on the MMA website, the development of a CME home study course on pain management, as well as in-practice confidential consultations by a Physician Assistant to assist practices in addressing prescribing issues.

PMP Program Manager Dan Eccher updated the advisory group on the most recent and pending program updates to continuously improve the program.  These include:

  • Transition to one website this fall, instead of the two sites for different information needs.
  • The American College of Emergency Physicians is focusing on narcotics prescribing issues in ER’s during the next two years and is becoming more actively involved with the program.
  • OSA has responded to more requests for de-identified data from researchers, so it is necessary  to ensure that the program knows how complete the data is, as well as the percentage of all pharmacies reporting.   
  • Expansion of stakeholders for the medical advisory group will extend to representatives from the drug courts, law enforcement, addictions treatment staff, legislators, and most recently, the Federal Qualified Health Centers.
  • Requests have been received to allow for interactive features on the website, however, HIPAA regulations need to be reviewed to understand the parameters of the law and to determine if this interactive request could occur.
  • Beginning this fall, quarterly threshold reports will be sent to pharmacies to improve communication between prescribers and pharmacists.  
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Senate Finance Committee Continues Work on Medicare Physician Payment Fix

Following a meeting on May 7, 2008, Senate Finance Committee Chairman Max Baucus (D-MT) said that his committee continues to work on a bill to avert a 10.6% cut in Medicare payment rates scheduled to take effect on July 1, 2008.  Senator Baucus said he hopes to have a bill costing between $15 and $18 billion available for consideration by the Senate in early June.  As in the past, the principal issue is how to pay for the fix with many Democrats pushing for cuts to Medicare Advantage plans to help fund the solution while Republicans and the Bush Administration oppose that approach.  The Committee continues to favor an 18-month fix, if it can find a way to pay for it.  Maine's senior Senator Olympia J. Snowe sits on the Senate Finance Committee and has always been supportive of the MMA's efforts to address the Medicare SGR problem. [return to top]

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