July 28, 2008

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Dirigo Board Holds Hearing on 4th Year Savings Offset Payment (SOP)

The Dirigo Board finds savings of $149.6 million in administrative proceeding required under current law since fate of new funding mechanism will not be known until Election Day 2008.

Because of the so-called "People's Veto" of the alternative funding mechanism for the Dirigo Health Program, the Dirigo Health Agency has initiated its procedure to determine the "savings offset payment" (SOP) for year 4 of the Program.  The Dirigo Board held two days of hearings last week on a savings recommendation of $190 million by staff and consultants.  The Board found savings of $149.6 million, composed of $119.4 million from hospitals meeting cost containment targets, $23.6 million in the reduction of bad debt and charity care, and $6.6 million from insurance administrative efficiencies.  The Maine State Chamber of Commerce, Anthem, the Maine Association of Health Plans, the Maine Auto Dealers Association Health Trust, and Consumers for Affordable Health Care all participated in the hearing.  The Dirigo Board is expected to file its findings with Superintendent of Insurance Mila Koffman in August and the Superintendent is expected to make a decision in September.

The Maine Association of Health Plans called the savings figure "extremely overstated" and "not credible."  The Superintendent historically has reduced the amount of estimated savings. 

You can find the statutes governing the Dirigo Health Program, including the SOP methodology, on the web at:  http://janus.state.me.us/legis/statutes/24-A/title24-Ach87sec0.html.

Highlights of July 23 MMA Executive Committee Meeting

The MMA Executive Committee, consisting of 28 physicians, met this past week at the home of President William Strassberg for its summer meeting.  Among the items discussed were the following:

  • The passage of the Medicare Payment reform legislation by the Congress, overriding the President's veto;

  • The future of the Coding Center given the resignation of Jana Purrell, CPC, the current Director;

  • The Association's upcoming 155th Annual Session, to be held Sept. 4-7, 2008 at the Samoset Resort in Rockport;

  • The current efforts in the state to conduct a pilot project involving at least ten primary care practices that would develop a Patient Centered Medical Home;

  • The Association's efforts to defeat the upcoming referendum involving the so-called "People's Veto" of L..D. 2247, an alternative funding mechanism for the Dirigo Health Program;

  • A review of the financial performance of the Association through the first six months of the year and

  • An upcoming membership survey to be sent to a scientifically selected random sample of members.

The Executive Committee will meet next at the Association's Annual Meeting on Friday morning, September 5. [return to top]

Office of MaineCare Services Issues Proposed Consolidated Behavioral Health Care Rule

As anticipated for months, the Office of MaineCare Services has published a revised version of MaineCare Benefits Manual (MCBM), Chapter II, Section 65 to be entitled Behavioral Health Services.  This will incorporated the following current sections of the MCBM:

  • Section 58, LCSW, LCPC, & LMFT Services;
  • Section 65, Mental Health Services;
  • Section 100, Psychological Services; and
  • Section 111, Substance Abuse Services.

The following is the "Concise Summary" from the rulemaking notice:

The proposed rule consolidates Outpatient Services under one Section of the MaineCare Benefits Manual, ensuring better coordination of services.  Emergency Services, which used to be covered as a stand alone service, has been incorporated into Outpatient Services.  Comprehensive Assessment, which was incorporated into Outpatient Services, is being covered and coded for reimbursement as a stand alone service.  This rulemaking also adds proration language for partial months of Children's Assertive Community Treatment (ACT) in Chapter II.  Crisis Services have been renamed and redefined to better reflect current services being provided.  Child and Family Behavioral Health Treatment and Community Based Treatment for Children Without Permanency have been merged into one service and renamed Children's Home and Community Support Services for better coordination.  Collateral contacts have also been added as a stand alone service for children who receive Children's Home and Community Support Services.  Independent providers not employed by a Mental Health Agency will be able to provide within the scope of their licensure and be reimbursed for services provided to MaineCare members.  Additionally, the Chapter III of this new Section will contain HIPAA compliant coding.  Other than providers of these specific services, this rule is not expected to fiscally impact or create new recording burdens for other small businesses and is not expected to yield new costs for municipal or county governments.  

You can find the proposed rule on the web at:  http://www.maine.gov/bms/rules/downloads/c_ii_iii_s_65_p_07_10_08.pdf.

The Department has adopted the proposed rule on an emergency basis effective August 1, 2008.  A public hearing on the rule has been scheduled for Monday, August 11, 2008 at 12:30 p.m. in Conference Rooms 1A&B at the DHHS, OMS Office at 442 Civic Center Drive, Augusta, Maine 04333.

The deadline for written comments is August 21, 2008.

The agency contact person for comments or questions is Ginger Roberts-Scott, Comprehensive Health Planner, State House Station 11, Augusta, Maine 04333-0011; 287-9369.

If you have further questions or comments about this rulemaking proposal, please contact Andrew MacLean, Deputy EVP, at amaclean@mainemed.com or 622-3374, ext. 214.  [return to top]

Law Court Finds No "Timely Payment" Obligation in DHHS Payment Dispute with Hospital

The MMA staff periodically (such as in the MECMS situation) is asked whether any "prompt payment" rule requires the State to pay Medicaid claims within a specific period of time.  As you may remember, because of efforts of the MMA and the Maine Hospital Association at the legislature, Maine insurance law requires commercial health insurance carriers to pay "clean claims" within 30 days of submission or face an interest penalty.  Maine's Law Court addressed this issue directly in H.D. Goodall Hospital v. Department of Health & Human Services, 2008 ME 105 decided on June 26, 2008.  In rejecting the hospital's claims regarding its FY 2005 Interim MaineCare Settlements, the Court found that:

  • "federal Medicaid payment regulations and procedures providing specific time periods for payment do not govern."
  • "[s]imilarly, no binding period for payment can be gleaned from the State Medicaid Regulations or statutes."
  • there is "no binding period of payment [in the Provider Agreement], either express or implied."

You can find the decision on the web at:  http://www.courts.state.me.us/court_info/opinions/2008%20documents/08me105hd.pdf. [return to top]

MHMC Physician Payment Reform Workgroup Holds Inaugural Meeting

Efforts by the Maine Health Management Coalition, Quality Counts, and the Maine Quality Forum to reform payment for primary care continued on July 22 with the first meeting of the Physician Payment Reform Committee held at the Augusta Civic Center.  The group is funded by the MHMC and is chaired by David Howes, M.D., President of Martin's Point Health Care.  Nearly fifty persons representing more than thirty organizations participated in the session, including representatives of MMA.  The Committee has been chartered as an advisory body to the Maine Health Management Coalition Executive Committee and Board of Directors and to the Patient Centered Medical Home Planning Group. 

Membership of the Committee includes representatives of health plans, providers, employers, and brokers/consultants who are members of the MHMC and other invited parties.  To be noted is the fact that the Regional Office of CMS had a representative present, William Kassler, M.D., MPH.

The current charge to the committee is to develop, by 1/1/09, a model for reforming Primary Care Physician payment that will support the Maine Patient Centered Medical Home Multipayor pilot and that is endorsed for implementation by MaineCare, the major health plans in Maine, and large, self-insured employer members of the Coalition.  A future goal is to develop a methodology for evaluating the financial impact of the PCMH Mutipayor Pilot implementation including the return-on-investment for both payors and providers.

At the meeting, Committee members reviewed a document entitled Principles and Planning Assumptions, as follows:

  1. This program will advance patient centered care.
  2. There will be an increase in current payment levels to Primary Care practices (PCPs) that is commensurate with the increased value provided by these practices.
  3. There will be no increase in direct health costs to Health Plans, Employers, and other purchasers which are not explicitly off-set by savings.
  4. There will be every effort made to simplify and avoid any duplicative administrative requirements associated with the payment reform model.
  5. Attendance and participation in this Committee represents an organizational commitment to support the payment reform model.

The Multipayor Pilot is an effort by Quality Counts, the Maine Quality Forum, and the MHMC to develop a proposal to lead a multi-stakeholder effort to develop, implement, and evaluate a Maine Multipayor Pilot of the Patient Centered Medical Home (PCMH) model, as the first step in achieving the goal of statewide implementation of a patient centered medical home model throughout the state.  Following a 6-month planning period, the group hopes to launch a 3-year pilot to implement the PCMH model with 5-10 primary care practices from across the state. 

The proposal has been developed by an ad hoc planning group led by Quality Counts (Lisa Letourneau, M.D., MPH); the Maine Quality Forum (Joshua Cutler, M.D., and Jim Leonard); the MHMC (Doug Libby and Ted Rooney); MaineCare (Rod Prior, M.D.); Anthem BCBS of Maine (Jeff Holmstrom, D.O.), and Martins Point Health Care (David Howes, M.D.).  Questions about the project may be directed to Dr. Letourneau at lmlmd@maine.rr.com.

  [return to top]

HealthInfoNet Stakeholders Group Holds Third Meeting

The Stakeholders Group asked by the Legislature to examine permanent funding sources for HealthInfoNet held its third meeting on July 24.  Following is a synopsis of what occurred at the meeting:

  • Participants reviewed what a few other states had done to establish and fund health technology initiatives and similar efforts.  Generally speaking, other states, such as Vermont and Oregon,  have used a variety of funding sources.  Vermont enacted a fee on each prescription written.  Minnesota has a provider tax and has used some of the revenue from that source.
  • Participants discussed how to measure the "public good" dividend from the project.  Examples would include reductions in the use of emergency rooms, reduction in the duplication of tests, and better management of medications.
  • Participants discussed how a Technology Fund would be administered, i.e., through an existing organization or a new entity, and what it would cover.
  • Partial funding from MaineCare and Medicare were discussed.

Potential funding sources include the State General Fund, MaineCare and Medicare, new taxes or assessments.  The discussion at the conclusion of the meeting related to whether to take the entire issue of new taxes and fees off the table, thus recommending to the legislature that such approaches not be utilized.  While the majority of attendees favored such a recommendation, a few members were not comfortable with such a recommendation and the item will be discussed further at the next meeting.

The funding being sought in this effort relates to the approximately one-third cost of the project with the other two-thirds anticipated to be covered by user fees.

Currently, HealthInfoNet is putting together a demonstration phase of the project that will connect up a group of hospitals and ambulatory providers in the state.  While the demonstration phase is for two years, the system will only be operational for about a year, once the system is built.

The group does not meet again until September, but a smaller work group will meet in August to discuss details of a Technology Fund. [return to top]

Dirigo Health Systems Development Advisory Council Meets

The state's Health System Development Advisory Council met on Friday, July 25, 2008 and received updates on a number of initiatives in which the Council is involved.  These include a study of the usage of emergency rooms, a review of the State's capital investment fund which imposes a limit on the CON approvals, and a patient safety initiative being conducted through a collaborative involving 14 of the state's 15 critical access hospitals.  A report also was presented on the state healthcare workforce by Charles Dwyer of the Office of Rual Health and Primary Care which is a part of the Maine CDC.

The Council is chaired by Brian Rines, Ph.D., a forensic psychologist who also currently serves as Chairman of the Board of Spring Harbor Hospital.  Physicians on the Council include Lani Graham, M.D., M.P.H. and Maroulla Gleaton, M.D.

  [return to top]

William Chernin, M.D., Elected to MMA Executive Committee Representing York County

At the MMA Executive Committee Meeting last week, William Chernin, M.D., of Sanford was elected to fill the vacant Executive Committee seat in York County brought about by the resignation of Edward Jaccoma, M.D.

Dr. Chernin is a family physician practicing in Sanford in a solo private practice.  He is a native of Nova Scotia, Canada and received his undergraduate and medical degrees from Dalhousie University.  He also completed his residency in family medicine at the Dalhousie Family Medicine Program in Halifax. 

After practicing several years in the Canadian health care system, Dr. Chernin and his family moved to Sanford, Maine approximately 10 years ago.  For eight of the ten years, Dr. Chernin was associated with the family practice owned and operated by Goodall Hospital.

MMA welcomes Dr. Chernin to the Executive Committee and acknowledges as well the contributions made by Dr. Jaccoma during his years of service. 

Members in York County wishing to communicate with Dr. Chernin about MMA issues may contact him at his office at 324-2955. [return to top]

House Committee Approves Health IT Bill Despite Privacy Concerns

On July 23, 2008, the House Energy & Commerce Committee approved a bill to encourage the adoption of health information technology by providers.  The Protecting Records, Optimizing Treatment, and Easing Communication Through Healthcare Technology Act of 2008 (H.R. 6357) would do the following:

  • make permanent the Office of the National Coordinator for Health Information Technology at DHHS;
  • make available $560 million in grants and loans for providers to adopt health IT; and
  • give support for local and regional organizations to develop IT plans.

The bill is a compromise and some members and advocates still have concerns about patient privacy issues.  It is uncertain whether there remains sufficient time for the current Congress to reach agreement on health IT legislation.  The House Energy & Commerce Committee shares jurisdiction over this issue with the House Ways & Means Committee which is expected to draft its own bill.  Also, a Senate health IT bill (S. 1693) has made no progress because of continuing privacy concerns. [return to top]

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