Superintendent of Insurance Finds $48.7 Million in Dirigo Savings
Last Tuesday, Maine Superintendent of Insurance Mila Kofman announced her decision in the latest proceeding to determine savings in the Dirigo Health Program in order to allow the Dirigo Agency Board of Directors to set the "Savings Offset Payment" (SOP) for the next plan year. Superintendent Kofman found that the Dirigo program had saved payers $48.7 million. While this amount was far less than the Agency Board recommended, it was the most annual savings determined to date and will allow the DirigoChoice insurance product to continue for the existing enrollees should Question One on the November 4 ballot pass and the new funding for the program be repealed.
Ballot Question One is the result of a petition drive mounted by the wine and beer wholesalers and other beverage interests who oppose the increases in the current taxes on beer, wine, and soda. The alternative funding for Dirigo also established a flat 1.8 % assessment on paid claims, charged to health insurers and third party administrators. While the assessment is actually less than the previous Savings Offset Payment (SOP), business interests including the Maine State Chamber of Commerce have supported the beverage industry in its attempt to repeal the new law. Yet, the state chamber continues to state its opposition to the SOP and its support for an alternative.
While not featured in the current advertising on the repeal effort, the new funds would also pay for high-cost claims in the individual health insurance market in an attempt to moderate the high costs associated with the plans in the individual market which is dominated by a single insurer (Anthem). The new law broadened the community rating bands in the individual market in an attempt to lower the cost for younger subscribers. This change had been supported for years by the Chamber of Commerce and other business interests.
MMA, the Maine Chapter of the American Academy of Pediatrics, the Maine Primary Care Association, the Maine Society of Eye Physicians and Surgeons, the Maine Division of the American Heart Association, and the American Cancer Society have joined with several other organizations, including the AARP, in opposing the ballot question.
MMA members and others wishing to support the NO ON ONE effort may contribute through the website www.healthcoveragemaine.org or may send a check payable to Health Coverage for Maine to P.O. Box 15312, Portland, Maine 04112. Jo Linder, M.D. is the Treasurer of Health Coverage for Maine.
Maine Physicians Attend New England State Medical Societies Leadership Development Program
Four Maine physicians participated in the first-ever New England States Medical Societies' Leadership Development Program this past weekend at the Massachusetts Medical Society in Waltham. MMA President-elect David McDermott, M.D., MPH, Executive Committee Chair Jo Linder, M.D., Nancy Cummings, M.D., and Charles Pattavina, M.D. participated with emerging leaders from the other five New England states. Robert McAfee, M.D., former AMA and MMA President, and MMA EVP Gordon Smith, Esq., were two of the presenters at the conference, intended to be an annual opportunity to bring together emerging leaders of organized medicine throughout New England.
Subjects presented during the program included communications, current and emerging policy issues on the state and federal level, and the importance of public service.
Any MMA members wishing to participate in future leadership programs should contact MMA EVP Gordon Smith at firstname.lastname@example.org. [return to top]
Update on HealthInfoNet Stakeholders Group
The HealthInfoNet Stakeholder Process continued on Friday, Sept.ember 26th with its 4th of 6 anticipated meetings. The next meetings are scheduled for October 30th and November 20th and a draft report is to be circulated by the next meeting. Following conclusion of the meetings, a final report will be presented to the Legislature's Health & Human Services Committee. Minutes of the meetings may be found at www.hinfonet.org. The Process began with passage of a Legislative Resolve in the Spring of 2008.
The first item of business was an update on the HealthInfoNet pilot, presented by Dev Culver, Director of HealthInfoNet and co-convener of the Stakeholder's group. November 1, 2008 is the date of the roll-out of the first phase of the project which includes six clinical organizations in the state. The first phase of the information exchange involves emergency rooms and lab, and imaging and testing results. Beginning in November, the content of the system will be developed and the information will be available to physicians and other health care providers in April, 2009. Currently the six organizations have been connected through private networks.
In a recent development, HIN officials received a communication from CMS indicating that the HealthInfoNet project was an important benefit to Medicaid, thus allowing HIN important access to MaineCare prescribing data.
The second item on the agenda was a report of the subgroup established to make recommendations regarding a Health Information Technology Fund. It is anticipated that such a Fund will be established in the state to support the HIN work and to assist physicians in purchasing electronic medical records systems. A draft of the Technology Fund Work Group report was distributed and the recommendations reviewed (a copy of the draft report can be found on the MMA website at www.mainemed.com). It is hoped that a new HIT fund will be established in the state and will pay for approximately one-third of the annual HIN operating expenses of $6 million. One-third of the benefits of HIN are expected to represent the public benefit of the project.
The draft report of the Technology Fund Work Group recommends that the Fund be governed by an existing state organization rather than be dependent on the formation of a new organization expressly for this purpose. It was also suggested that the Fund's governance reflect the public-private partnership approach that led to the original development of the health information exchange. Possible organizations would include the Finance Authority of Maine (FAME) or the Maine Health & Higher Education Facilities Authority (MHHEFA).
The HIT Fund Work Group did not make any recommendations regarding revenue sources for the Fund which drew the attention of several members of the Work Group. Several members suggested that it would not be possible to arrive at any final conclusions regarding the housing and governance of the Fund without first addressing the funding.
The final portion of the meeting was devoted to a presentation by Shaun Alfreds of the University of Massachusetts Medical School Center for Health Policy and Research regarding the potential return of investment from the establishment of HIN. The Center was asked to estimate the potential achievable savings associated with health information exchange in Maine. A previous study had been conducted by Baker Newman & Noyes in 2004. The study concludes that the range of potential savings to Maine associated with avoidable services (emergency room usage, duplicate tests etc.) and productivity opportunities ranges from $38 million to $46 million annually. Of this amount, $28 to $36 million relates to avoidable services and $10 million relates to improved productivity. The study noted that other analysis may be needed to assess potential savings for additional services not included in the demonstration phase of the project.
The savings estimate focused primarily on savings from avoidable outpatient laboratory tests and outpatient imaging studies.
Copies of the 21-page report are available by calling the MMA at 622-3374, ext. 219 (Lisa Merrill).
Read the Weekly Update regularly for updates on the progress of the HealthInfoNet project. [return to top]
FAME Advisory Committee on Medical Education Hears Report on MMC-Tufts U. Medical School Program
The Finance Authority of Maine (FAME) held its regular quarterly meeting on Thursday, September 25th. The majority of the meeting was dedicated to a report from Peter Bates, VPMA at Maine Medical Center on the MMC-TUSM Medical School Program.
Dr. Bates described the joint program and noted that it followed a strong 28-year affiliation between MMC and the University of Vermont. The program with Tufts will begin with 36 students in the first class beginning in August 2009. It is hoped that twenty of the student will be either Maine residents or students who have attended a college in Maine. Twenty -five applications already have been received with 18 of these applications from one of these two categories.
An innovative curriculum is being developed with Tufts and the following seven themes are being featured: quality/safety, community/rural medicine, team-based care, systems-based practice, lifelong learning, informatics, and clinical skills.
Fundraising is taking place in hopes of raising enough funds to support each student's tuition in the amount of $25,000. TUSM tuition is currently $48,386 annually. This level of support would approximately level the playing field so that Maine students would be paying an amount similar to in-state tuition in most other states. To fund such an effort for the twenty Maine students, $500,000 annually would have to be raised, or a total amount of $2 million for four years with a total of 80 students.
Though its prospects are uncertain, the legislature will be one of the sources looked to for funding along with private philanthropy.
MMA is represented on the Advisory Committee by EVP Gordon Smith but a number of MMA members serve on the Committee as well, including David Dixon, M.D. of Farmington, Robin Pritham, M.D. of Bangor, and Catherine Morrow of the Maine Dartmouth Family Practice Rsidency in Augusta. [return to top]
Patient-Centered Medical Home Meetings Continue
All three groups working on physician payment reform in Maine met this past Wednesday, September 24th in Auburn to continue their work. The Maine Coalition for the Advancement of Primary Care (formerly called the Maine Multi-Payor Pilot Patient-Centered Medical Home Planning Group) met first at 9:00 am, followed by a meeting of the PCMH Working Group at 11:00 am. In the afternoon, the Physician Payment Reform Committee, organized by the Maine Health Management Coalition, met.
The first two groups meet every month to put together a multi-payer pilot project advancing the concept of the patient-centered medical home. The groups reviewed documents establishing the PCMH Mission and Vision, and Guiding Principles. These documents will be available on the MMA website at www.mainemed.com.
Ten primary care practices are expected to participate in the pilot which could begin by early next year. Draft applications and the criteria for participation were discussed extensively at the meeting. It is anticipated that practices participating would be required to meet NCQA level one recognition standards. However, the payers have not yet agreed to participate, although the major payers are represented around the table. The payers are not expected to agree on participation until a payment model is developed and agreed to.
Lisa Letourneau, M.D., MPH is the medical consultant to the Maine Quality Forum, heading up the effort. Elizabeth Fowlie Mock, M.D. has agreed to chair the Coalition meetings. Dr. Mock is President-elect of the Maine Academy of Family Physicians. Watch the Weekly Update for further information regarding the development of the PCMH pilot. [return to top]
J. Elizabeth Mitchell Named New Executive Director of Maine Health Management Coalition
J. Elizabeth Mitchell of Portland, Senior Director for Public Policy for MaineHealth, has accepted the position of Executive Director of the Maine Health Management Coalition. The Coalition's current and only Executive Director, Douglas Libby, R.Ph., is retiring from the position. The Management Coalition is Maine's largest coalition of businesses working on health care issues in the state, focusing particularly in the areas of accountability and public reporting and well as the more traditional issues surrounding cost and quality. Among other projects, the Coalition sponsors Pathways-to-Excellence.
Prior to joining MaineHealth, Elizabeth served a fellowship in Public Policy in London from the Commonwealth Fund and the British Council. After completing her fellowship, she spent four more years in London pursuing a doctorate in health policy from the London School of Economics.
Prior to leaving for London, Elizabeth had served two terms in the Maine Legislature, including one term as House Chair of the Health & Human Services Committee. She currently resides in Portland with her husband and four children. She is the daughter of "Libby" Mitchell, currently majority leader of the Maine State Senate and Kennebec County Probate Judge James Mitchell of Vassalboro. Libby Mitchell served as the first woman Speaker of the Maine House of Representatives.
"MMA works closely with the Maine Health Management Coalition which has become a major player in the state's health care policy debates," noted Gordon H. Smith, MMA Executive Vice President. "We wish Doug all the best in his retirement. We know Elizabeth well from her years at the State House and her time at MaineHealth. She is an exceptional person from an exceptional family and we look forward to working with her in her new position." [return to top]
Maine Immunization Rates Decline in Maine for children 19-35 months of age from 89% to 82%
The Maine Immunization Coalition, of which the MMA is an active member, will hold simultaneous press conferences in Portland and Bangor at 9:00 am on Thursday, October 2nd. Maine has reached critically low levels in its immunization program funding and coalition members are taking a public stance to halt the erosion of our number one public health cornerstone. With the exception of providing safe drinking water, no other health intervention reduces disease and mortality rates as effectively and safely as immunization. Immunization prevents suffering and illness from occurring in the first place, thus yielding other benefits such as enhanced worker productivity, greater access to education, greater lifetime earnings, and reduction of treatment costs related to preventable diseases.
The Portland press conference will be held at Portland City Hall in the State of Maine Room and the Bangor press conference will be held at the Bangor office of Penobscot Pediatrics. For more information, contact Kellie Miller, Director of Public Health Policy at 207-622-3374, ext. 229 or via email at email@example.com.
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MaineCare Podiatry Service Changes Effective October 1, 2008
This is a follow-up to several communications from the Office of MaineCare Services on this matter.
To achieve savings as required by the 123rd Maine Legislature, MaineCare has made changes to the MaineCare Benefits Manual, Chapter II, Section 90, Physician Services and Section 95, Podiatry Services regarding prior authorization.
After an initial visit, all foot and ankle care services will be covered only for a member who meets the following medical eligibility requirements with supporting documentation:
- Has any illness, diagnosis, or condition that if left unattended may cause loss of function or may risk loss of limb; and
- For whom self-care or foot care by a nonprofessional person would be hazardous and pose a threat to the member's condition.
Several procedures now require prior authorization. A complete listing is posted on the MaineCare web site at: http://www.maine.gov/bms/member/innerthird/mecms_portal_news.html#podiatry.
Also, procedure code 28890 - High Energy ESWT, plantar fasciitis, will no longer be a MaineCare covered service as of October 1, 2008. This decision was made after finding the data inconclusive to support the use of ESWT for the treatment of plantar fasciitis. [return to top]
Advisory Council on Health Systems Development Considers New CIF Proposal
The Advisory Council on Health Systems Development, a Dirigo Health group tasked with advising on the development of the State Health Plan and newly tasked with tackling health care cost containment, held one of its regular meetings on Friday, September 26th. The Council is chaired by Brian Rines, Ph.D. and includes physicians Maroulla Gleaton, M.D., Lani Graham, M.D., M.P.H., and MQF Director Josh Cutler, M.D. Members received a variety of updates from Governor's Office of Health Policy & Finance Director Trish Riley. Maine Health Access Foundation Executive Director Wendy Wolf, M.D., M.P.H. provided an update on several aspects of the MeHAF's work, including a recently released RFP, Promoting Strategic Cost Containment Policies to Preserve and Expand Access. This RFP and other information about the MeHAF may be found on the web at: http://www.mehaf.org/.
The group spent a substantial portion of the meeting discussing a DRAFT Capital Investment Fund (CIF) Proposal developed by a subcommittee of the Council formed to address various issues of concern with the CIF, especially difficulties Maine hospitals have experienced in planning capital projects under the CIF.
The following is an excerpt from the Proposal.
"The proposal has two separate parts.
1. The CIF process. The CIF will operate on a three year time-frame to accommodate concerns that the current CIF rule impedes hospital planning:
- After a one year transition period in 2009, set the CIF for three years at a time, and announce the value well in advance of the coming three year period.
- Require in the CIF rule that CON applicants notify DHHS and GOHPF of any projects that an applicant is considering for the next three years.
- Regardless of the size of a project the year in which the project is reviewed, costs will be fully debited by the end of the third year of the three CIF years.
2. The CIF calculation. Here we present two options for your consideration.
Option 1: The rule will specify a process rather than a formula:
Use hospital depreciation schedules to determine the cost of replacing all CON-reviewable plant that will reach end of useful life during the coming three year period. This cost number would be the starting point upon which GOHPF and ACHSD will consider a range of factors specified in the revised rule - including the State Health Plan, impact on operating expenses and premiums, whether full replacement is necessary, whether any new services are necessary, etc. - to determine the CIFs. GOHPF and ACHSD would hold a public hearing to get input on those criteria and then set the final CIFs based on that input.
Option 2: Set the CIF at an amount that is based on amounts that have resulted from the current rule, but without the adjustments cited by hospitals as problematic.
This is a much more simple approach that would result at a CIF set at 0.31% of statewide hospital operating expenses, which is higher than the 0.25% calculation resulting from the first four CIFs. "
At the end of the discussion, the Council voted 10-2 to send the CIF Proposal out for public comment. The Council will then revisit the Proposal before proceeding. While there was general agreement about the first part of the proposal on the timeframe of the CIF in the future, there was no consensus on the second part concerning the CIF calculation.
You can find the agenda for the meeting along with meeting attachments, including the DRAFT Capital Investment Fund (CIF) Proposal on the web at: http://www.maine.gov/tools/whatsnew/index.php?topic=Gov_Health_Policy_Meetings&id=61658&v=article. [return to top]
Quality Counts Announces New Associate Director
Quality Counts is very pleased to announce the
hiring of Katrin Teel as its new Associate Director.
Katrin brings a
wide range of clinical and administrative experience to the position, having
worked as an RN in hospital and ambulatory settings and as a school health coordinator. In
her most recent role as Director of the Wellness Council of Maine, Katrin worked
with employers throughout Maine to support employee wellness programs using the
Wellness Councils of America’s Well Workplace process. Since its inception, the
Wellness Council (formerly Bangor Region Wellness Council) has trained hundreds
of participants in the Well Workplace process. Under Katrin’s leadership, the
Wellness Council received the 2006 Distinguished Service Award from the American
Lung Association of Maine, and the first “Well Region” designation in the nation
by the Wellness Councils of America. Katrin is also currently pursuing graduate studies working towards
a Master of Science in Business at Husson University with a focus in Non-Profit
Management. Quality Counts is eager to welcome Katrin Teel to her new
position on October 14, when she can be reached at Katrin.Teel@mainequalitycounts.org,
or tel. 622.3374, X215.
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BPH Featured in Latest AMA Therapeutic Insights Online Program
The American Medical
Association announces the release of Medical treatment of lower urinary tract
symptoms secondary to BPH, the latest AMA Therapeutic Insights newsletter.
NEW! View a one-page
overview of the BPH (Benign
Maine physicians can access their
free personal prescribing
profile showing their prescribing patterns
for BPH alongside state, national and specialty prescribing patterns for the
□ is free
□ highlights one disease
□ features state and national prescribing data* and evidence-based treatment
written by top disease experts in collaboration with the
□ offers AMA PRA
category 1 creditTM
While most treatment-oriented CME
programs focus solely on disease management, AMA Therapeutic Insights takes it
one step further. This program delivers the actual prescribing patterns for the
disease. Never before have physicians been able to see exactly which medications
are being prescribed for the featured
Visit AMA Therapeutic
Insights to read this issue,
as well as previous newsletters covering Depression, Osteoporosis and Asthma in
*The prescribing data in AMA
Therapeutic Insights are provided by IMS Health. The AMA does not collect or
have access to physician prescribing data in any form.
The AMA is accredited
by the ACCME to provide continuing medical education for
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New Guidance from MaineCare Prior Authorization Unit
If your office needs to submit a prior authorization
request for a MaineCare member, please provide the following identifying information
on all documentation faxed or mailed to the Prior Authorization Unit:
clearly or type on each Prior Authorization request:
Full Name of MaineCare Member (ex. John A. Example)
MaineCare ID Number of MaineCare Member (ex. 123455678A)
Date of Birth of MaineCare Member (ex. 09/02/1979)
As the requesting provider, include your MaineCare Provider
9-Digit Billing Provider ID Number (ex.
Â Include All Supporting Information & DocumentationÁ
All faxes to the Prior Authorization Unit should
include a cover sheet providing the
name and phone number of the contact person sending the prior
If your office needs to send us additional
information to complete the prior
authorization request, please include the member’s name and MaineCare ID number
on the fax cover page so we can easily match this information to the original
For out-of-state requests, please specify the provider facility name
such as “Boston Children’s Hospital” or “Lahey Clinic”. Our database requires
the name of the medical facility where the service will be provided.
The goal of the Prior
Authorization Unit is to provide prompt processing of authorization requests
and to reduce the number of phone calls between our office and your office due to
insufficient information. Providing us with complete and accurate information
with any and all supporting documentation will help us to meet our goal and
better serve MaineCare providers and members.
Please call us at 287-2033 or
1-866-796-2463, if you have any questions. Thanks so much for your cooperation!
Prior Authorization Unit, DHHS
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