May 10, 2010

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Only Ten Days Left to Register for Practice Education Seminar: Two New Speakers Confirmed

Robert D. Otten, Vice President, Health Policy at the American Medical Association and Trish Riley, Director of the Governor's Office of Health Policy & Finance will share the Keynote Luncheon presentation at the May 19th Practice Education Seminar and they will present information on what physicians need to know about the federal health care reform bill.  This seminar, being held for the 19th year, will be at the Augusta Civic Center and physicians and practice staff may register to attend via the MMA website at

 The seminar runs from 8:30 a.m. to 4:15 p.m. and registration is available beginning at 8:00 a.m.  The annual seminar provides an opportunity for MMA to present to members and their staffs the practical information that can assist in operating a practice in today's environment and to note the many trends about which physicians should be aware.  Registration materials have been mailed to all MMA members and their office staff managers (if known to us). 

Mr. Otten is a 25-year employee of the AMA and currently serves as Vice President of the Association's Health Policy Group.  Prior to being appointed Vice President in 2006, Mr. Otten served the Association in a number of other capacities including as Director of the Division of Socioeconomic Policy Development.  He received his BA and MS degrees in health education, with distinction, from Purdue University.  He has written extensively on health care financing and delivery and has published articles in a variety of health policy journals, including the Journal of Health and Hospital Law, the Medical Staff Counselor, and The Journal of Medical Practice Management.

Ms. Riley has served Govermor Baldacci as the Director of GOHPF since its establishment in 2003.  She is a graduate of the University of Maine and served as President of the National Academy for State Health Policy prior to taking the position in the Baldacci administration.

For further information or to discuss exhibit opportunities at the Seminar,  call Gail Begin at 622-3374, ext. 210. 

Act Now to Help Preserve Medicare Physician Payments!

With the Medicare payment cut for physicians now delayed only until May 31, 2010, Maine physicians need to take action now to advocate that the Congress once and for all repeal the flawed sustainable growth rate (SGR) formula and establish a new payment system that reimburses physicians fairly for the cost of providing services to Medicare recipients.  Pushing the payment cut down the road year-to-year and now month-to-month is as unfair to physicians and their Medicare patients as it is financially irresponsible.  Each month that passes without repeal adds to the ultimate cost of replacing the formula.

The cost to repeal the formula and freeze payment rates is estimated by the independent Congressional Budget Office (CBO) to be nearly $250 billion.  But by 2015, the cost is estimated to be $500 billion.  Maine physicians and MMA staff made the point to Maine's congressional delegation in meetings in Washington this past week that it will never be less costly that it is right now to permanently repeal the formula.  Maine Senators Olympia Snowe and Susan Collins are critical to the effort to permanently repeal the formula as it will take sixty votes in the Senate and therefore any solution must have an element of bi-partisanship.

Maine is uniquely unsuited for the payment cut, as we have the oldest population in the country and thus a higher percentage of Medicare patients than other states. And we have a large number of Medicaid patients (MaineCare) and a significant shortage of physicians.  While physicians in some other states may simply choose not to accept Medicare patients, that solution is not available in many areas of the state, nor is it the solution most Maine physicians would prefer.

As it is essential that the permanent solution to the SGR be enacted before the May 31st deadline, physicians need to communicate to Senators Snowe and Collins the urgency of the situation and urge them to support legislation that would permanently repeal the sustainable growth rate and replace it with targets similar to those included in the House bill last Fall. 

Republicans do not currently support a permanent repeal of the SGR without the cost of such a solution being paid for, as opposed to increasing the already burgeoning federal deficit.  Senators Snowe and Collins should be encouraged to find sufficient offsets in the President's budget to pay for the SGR fix.

You can help with this important effort as follows:

1.  Communicate with Maine's congressional delegation (Senators Snowe & Collins, in particular) through the AMA's grassroots action center:

2.  MMA is also participating in a petition drive initiated originally by the Texas Medical Association but now supported by all fifty state medical societies and several national specialty societies.  The goal is to deliver a petition with more than a million signatures to members of Congress stating support for a permanent solution to the SGR problem.  The petition is available for your signature on line at:

We can't emphasize enough the importance of contacting our influential Senators and encouraging them to help bridge the partisan gap that is making this issue so difficult to resolve.


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Restrictive Covenant Upheld in Androscoggin County Superior Court Case

A restrictive covenant in physician employment agreements was upheld in a Maine Superior Court case this past week involving three physicians who left their employment at St. Mary's Regional Medical Center to accept positions at Central Maine Medical Center.  The physicians were ordered to pay the Sisters of Charity Health Systems Inc. (owner of St. Mary's Regional Medical Center) $100,000 each.  Each of the primary care physicians had signed contracts in 2004 prohibiting them from practicing medicine within a 25-mile radius of the 99 Campus Avenue facility of St. Mary's for a two-year period after leaving employment.  A liquidated damages clause in the contracts provided the option of paying $100,000 to the medical center rather than waiting the prescribed two-year period.  Each of the physicians began practicing with CMMC during the two-year period and did not pay any of the liquidated damages amount.

According to the court's decision, the physicians appeared to have taken with them 1,374 of the 4800 patients at their former office. 

The physicians defended the case on the grounds that the restrictive covenant clauses were against public policy.  Their position undoubtedly was based upon AMA Code of Medical Ethics Opinion 9.02, Restrictive Covenants and the Practice of Medicine.  This opinion frowns upon restrictive covenants because they limit the supply of medical services available to patients.  You can find Opinion 9.02 on the web at:  However, Superior Court Justice Thomas Delahanty II noted that medicine and health care today were big businesses and that governing corporate entities could act to protect their continued viability to provide for the overall well-being of its patient base and the community.  He concluded that the restrictions were "reasonable."

During the trial, it was revealed that prior to employment, CMMC has agreed to pay any damages the physicians might incur resulting from the lawsuit.

(Excerpted from article by Christopher Williams in the Lewiston Sun Journal, May 7)

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Dirigo Board Discusses Federal Reform, Agency Finances & Enrollment, and Individual Practitioner Data Reporting at Today's Meeting

New Board Chair Jonathan Beal presided over his second meeting of the Dirigo Health Agency Board of Trustees this morning at the DHA offices at 211 Water Street in Augusta.  Chairman Beal, a Portland attorney, is a long-standing member of the DHA Board who succeeds Robert McAfee, M.D., the Agency's first Board Chair.   Governor's Office of Health Policy & Finance Director (GOHPF) Director Trish Riley led an initial discussion of the board about the Agency's role in responding to the national health care reform law.  In particular, Ms. Riley talked about a Letter of Intent filed April 26, 2010 with DHHS Secretary Sebelius seeking authorization to build upon the Dirigo Health Program as an alternative to establishing a high-risk pool to cover a specific portion of the high-risk population:  persons uninsured for six months with pre-existing conditions.  The Board also discussed briefly the newly established executive and legislative task forces recently established by Executive Order and legislative Joint Order to assist the State in responding to the new health care reform law.  The Board expects to devote more time at its next meeting to this topic.

Next, DHA Director Karynlee Harrington and her staff presented an update on the Agency's financial statements and enrollment numbers.  She stated that the Agency is on track to pay back a $25 million General Fund advance by June 30, 2010.  With more stable cash flow because of the assessment (rather than the SOP), Ms. Harrington expects the Agency to have a balanced operating budget in FY 2011.  She presented an interesting graphic representation of the Agency's proposed FY 2011 income and expenditures in its $85 M annual budget.

The income breaks down as follows:

  • Membership fees:  $0.7 M (1%)
  • Healthy ME:  $4.4 M (5%)
  • HRSA Grant:  $8.0 M (9%)
  • Member & Employer Payments:  $29.7 M (35%)
  • Access Payments:  $42.1 M (50%)

The expenditures break down as follows:

  • Quality Initiatives:  $1.0 M (1%)
  • Agency Operating Expenses:  $3.3 M (4%)
  • DC Subsidy (prior years):  $4.2 M (5%)
  • Parent Expansion:  $5.1 M (6%)
  • Voucher:  $8.9 M (11%)
  • DC Member Share:  $29.7 M (35%)
  • DC Subsidy:  $32.7 M (38%)

During his Maine Quality Forum update, Director Josh Cutler, M.D. discussed his office's work with other stakeholders in responding to a legislative directive in L.D. 1444, An Act to Protect Consumers and Small Business Owners from Rising Health Care Costs (P.L. 2009, Chapter 350) to publish data at the individual practitioner level on cost and quality.  You can find this legislation on the web at:  During conversations with Quality Counts and consumer representatives so far, three potential approaches to practitioner-specific data have been discussed, including those based upon:

  1. the medical home/Health Dialogue model;
  2. the MaineCare primary care case management (PCCM) model; and
  3. the "patient experience of care" model based on a patient survey tool known as CAHPS or "consumer assessment of hospital processes and systems."

At this point, the stakeholders seem to be leaning towards the third model above.  This matter will be on the agenda of the Advisory Council on Health Systems Development (ACHSD) this Friday.

The next DHA Board meeting is scheduled for Monday, June 14, 2010 from 9:00 a.m. to 11:00 a.m.

You can find information about the Dirigo Health Agency on the web at:

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MaineCare Announces New PA Process for Atypical Antipsychotics

Recent studies show that atypical antipsychotic medications are frequently being prescribed inappropriately.  For example, one study noted that of 279,778 patients who received at least one prescription of an antipsychotic in 2007, 60.2% had no record of a diagnosis for an FDA approved indication (  Manufacturers of atypical antipsychotics have been fined large amounts for fraudulent marketing of these products, behavior which has contributed to high rates of inappropriate use.  The off label use of these drugs have made them the most costly medication class to MaineCare.

Examples of inappropriate use include prescribing these medications for insomnia, dementia related psychosis, attention deficit disorder, and anxiety disorders.  Not only are they expensive, atypical antipsychotics have side effects that include weight gain, diabetes, lipid abnormalities, and potentially irreversible movement disorders such as tardive dyskinesia, amongst others.

Effective July 1, 2010, MaineCare will introduce a prior authorization process for atypical antipsychotics which will apply to all non-psychiatric prescribers.  The prior authorization process will require that use of this medication class be in accordance with FDA approval or literature-supported evidence-based best practices. Examples of appropriate utilization includes the treatment of schizophrenia, bipolar disorder, agitation related to autism, and severe behavioral dyscontrol with risk of imminent need to access emergency services such as the emergency room, crisis services, or an inpatient psychiatric facility.

Atypical antipsychotics are also being increasingly utilized in combination with antidepressants to treat patients with major depression.  This use will be permitted upon demonstration that a patient has previously tried two distinct antidepressants from two distinct classes (SSRIs, SNRIs, TCAs, bupropion).

This policy will foster appropriate use of these medications resulting in cost savings and improved patient care without imposing an undue burden upon patients and prescribers.

For those who may be interested in what MaineCare may be implementing for cost saving or safety measures, you may attend the Drug Utilization Review Committee meetings.  These meetings are held 9 times a year, the second Tuesday of the month, excluding December, July and August from 6-8 p.m.  The location is 442 Civic Center Drive at the Office of MaineCare Services.

If you have questions you may contact Goold Health Systems at 1-888-445-0497 or Jennifer Palow, Pharmacy Division Manager at [return to top]

MaineCare Proposes National Criteria for PA on Certain Services

The Maine DHHS has proposed revisions to the MaineCare Benefits Manual (MCBM) Chapters II & III, Section 90, Physician's Services that would apply "industry recognized criteria utilized by a national company under contract."  The "national company" apparently is McKesson.  The rulemaking notice goes on to state, "In cases where the portal requires that certain criteria  be met, and the provider fails to meet those criteria, such services will not be covered or allowed under the MaineCare program."  Apparently, there is no avenue for appeal of a denial of coverage on the basis of any other standard other than the McKesson standard, such as a waiver.

The proposal lists the following services that will be covered with prior authorization:

  • Out-of-state services;
  • Vagus Nerve Stimulation;
  • Orthognathic Surgery;
  • Breast Reduction and Mastopexy;
  • Gastric Bypass, Gastroplasty and Adjustable Gastric Banding;
  • Breast Reconstruction; and
  • Removal of Excess Skin and Subcutaneous Tissue of Abdomen.

The proposal lists the following services that will be covered "when special criteria are met:"

  • Abortion Services;
  • Sterilization Procedures and hysterectomies;
  • Circumcision;
  • Cochlear Implants;
  • Cosmetic Procedures;
  • Hyperbaric Oxygen Therapy; and
  • Infertility Treatments.

You can find the rulemaking documents and may comment online at:

The comment deadline is Thursday, June 3, 2010.  If you would like to share comments with the MMA, please contact Andrew MacLean, Deputy EVP at 622-3374, ext. 214 or by email at

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EMHS Awarded HIT Grant as One of 15 "Beacon" Communities Nationwide

Last week, Vice President Joe Biden and DHHS Secretary Kathleen Sebelius announced that Eastern Maine Health System (EMHS) is one of 15 "Beacon" communities chosen from among 130 applicants where health care leaders will "take responsibility for making health better in measurable ways through health information technology," according to National Coordinator for HIT David Blumenthal, M.D.  DHHS has awarded EMHS $12.75 million to, "[e]xpand community connectivity, including long-term care, primary care and specialist providers, to existing Health Information Exchange and promote the use of telemedicine and patient self-management in order to improve care for elderly patients and individuals needing long-term or home care."

You can find EMHS' news release on the award on the web at: [return to top]

Red Flags Rule Compliance Date Now is June 1st; Prospects for Further Delay Unclear

The most recent delay in the compliance deadline for the controversial FTC "red flags" rule expires May 31st, meaning that compliance by health care providers is expected June 1st.  The AMA has provided some excellent guidance on this subject on the web at: [return to top]

Study Says Medical Home Demonstrations Provide Guidance for Reform

An analysis published in the May edition of Health Affairs entitled, Driving Quality Gains and Cost Savings Through Adoption of Medical Homes, identified four key elements of successful medical homes and suggested that the analysis of the medical home model has important implications for the future of reform.  The study cites the following as the four key features of a medical home:

  • a dedicated non-physician care manager to coordinate a patient's care;
  • easy access for patients to care managers and, if necessary, to physicians in order to avoid ER visits and avoidable inpatient admissions;
  • care coordinators' ability to easily track data as their patients move through the health care system as well as their ability to track their own performance; and
  • targeted, though not necessarily large, incentive payments.

The analysis was based upon seven medical home projects considered to be of "high value," such as the Geisinger Health System, and the authors acknowledged the limits of the analysis.

You can find the study on the web at:

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Health Professions Team up with Scientists to Discuss Health Impacts of Climate Change on May 20th

Health Professions Team up with Scientists to Discuss Health Impacts of Climate Change 


May 20th                                                                                                                                                                                   8:30am-11:30am                                                                                                                                                                   Holiday Inn by the Bay, Portland, Maine                                                                                                                         Limited to 50 attendees  (There is no registration fee)                             

The earth's climate is in the midst of significant change and with it comes the impact upon human health.  Increased respiratory allergies, asthma attacks, days lost from work due to respiratory disease, emergency room visits, hospitalization rates, and mortality are all symptoms of climate changes.

Physicians, Physician Assistants, Nurse Practitioners and Nurses are being called upon to increase their involvement in educational efforts on the impending health problems due to climate change and the adaptive and mitigating actions that can be taken in the public health policy arena. 

A limited number of seats (50) are available for clinicians to attend this forum that will address the scientific underpinnings of climate change and identify human health effects and implications for public health.

Expert Faculty to include:

Paul R. Epstein, MD, MPH, Associate Director Harvard Center for Global Health and the Environment.  Dr. Epstein received recognition for his contributions on the work of the Intergovernmental Panel on Climate Change (IPCC), awarded the Nobel Peace Prize in 2007.

Paul A. Mayewski, PhD, Explorer and Scientist Director & Professor, The Climate Change Institute, University of Maine.  Dr. Mayewski has developed integrated understanding of multiple controls on climate and unique role of human impact, demonstrated associations between climate and disruptions to civilization.

The program will conclude with a reactor panel of experts to facilitate an in-depth discussion with attendees.

To register, email and indicate in the subject line that you would like to register for the Climate Change Forum on May 20th.  When your registration is received, a detailed agenda with directions will be sent to you via email prior to the forum.

This forum will provide 2.0 hours of CME and CEU credits.

The American Medical Association is sponsoring only three Climate Change forums across the country on Climate Change and this program is one of the three. [return to top]

New Campaign to Emphasize the Importance of Childhood Vaccinations

Protect Tomorrow Campaign is a national education awareness campaign that reminds parents about the importance of childhood immunizations.  The campaign encourages parents to talk with their pediatricians about the benefits of vaccines, the importance of the recommended immunization schedule, and how to best protect their children.

This public service announcement (PSA) from the American Academy of Pediatrics (AAP) contains a powerful message – a message that can have a real impact on our children and their future.  The PSA reminds parents about the devastation of diseases of the not-so-distant past and urges them to talk with their pediatricians about immunizing their children so that history does not repeat itself.  The PSA features several people who tell their true stories of watching loved ones struggle with, and even succumb to, diseases that can now be prevented by vaccines.

These eyewitnesses want to tell today’s parents to take advantage of one of the greatest advances in modern medicine – immunizations.  Through these voices of wisdom and experience, the AAP wants to remind parents to vaccinate their children according to the recommended schedule as provided by the CDC and its Advisory Committee on Immunization Practices, the AAP, and the American Academy of Family Physicians.

To view the PSA’s go to:

On the Heels of National Infant Immunization Week, April 24 to May 1st  - Maine’s Groundbreaking Law to establish a universal childhood immunization program will be ceremonially signed by Governor John E. Baldacci on May 7th [return to top]

Not Too Early to Plan for MMA's 157th Annual Meeting, September 10-12, in Bar Harbor

MMA's 157th Annual Meeting will be held in Bar Harbor from September 10-12, 2010.  The educational sessions will begin again at Jackson Laboratories on Friday afternoon, September 10th at 1:00 p.m.  The theme for this year's meeting is Life Transitions for Patients, Families and Communities  and features presentations on aging and related topics, including scientists from Jackson's Center for Aging matched with practicing clinicians.  Sunday morning will feature a Gubernatorial Forum with candidates addressing issues related to public health.

Following the Friday sessions at Jackson Laboratories, the Saturday and Sunday morning sessions will be held at the conference center (The Bar Harbor Club) associated with the Harborside Hotel and Marina. The Saturday afternoon CME session is entitled, Transitions in Health - Transitions in Care and will feature a panel moderated by Laurel Coleman, M.D. highlighting some of the challenges faced by patients and health care providers when health status changes.

On Saturday evening, MMA President David McDermott, M.D., M.P.H. will turn the Presidential gavel over to Jo Linder, M.D.  The Mary Cushman Humanitarian Award will also be presented during the Annual Banquet.

On Sunday morning, preceding the Gubernatorial Forum, interested attendees will run the 30th Annual Edmund Hardy Road Race.  MMA is making an attempt to invite all previous runners to join us for this special anniversary race.  Andrew MacLean, Deputy EVP, will once again serve as the Race Director.

Watch for registration materials which will be in the mail to members later this month.  Registration will also be available on the MMA website at after June 1st.  For more information contact Diane McMahon at 622-3374, ext. 216 or via e-mail to  For information on exhibiting, contact Lisa Martin at 622-3374, ext. 221 or via e-mail to


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Free Online Environmental Health Continuing Education Course

In 2007, the Maine Medical Association approved the Safe and Healthy Approach to Chemical Release in the Environment Resolution, ensuring that physicians and patients alike are informed about toxic exposures.  Physicians for Social Responsibility (PSR) announces three opportunities for you to learn more about the chemicals that Maine children and families are exposed to every day, as well as the impact of environmental toxins on pediatric health.

Free Online Environmental Health Continuing Education Course

Based on PSR’s Pediatric Environmental Health Toolkit, this course features an introduction to environmental health, environmental health case studies, taking an environmental health history, and much more.  This course was developed by the Centers for Disease Control and Prevention, the Agency for Toxics Substance and Disease Registry, UCSF Pediatric Environmental Health Specialty Unit, and Physicians for Social Responsibility.

Free 1 ½ Credit Hours for Physicians, Nurses, Nurse Practitioners and Other health professionals (check the course site for details).  For more information and to take the course, visit .

Download the Pediatric Environmental Health Toolkit

The Toolkit is a combination of easy-to-use reference guides for health providers and user friendly health education materials on preventing exposures to toxic chemicals and other substances that affect infant and child health.  The Toolkit is endorsed by the American Academy of Pediatrics (AAP).  Download Toolkit materials at

Toolkit Training Opportunity

Designed for conferences, grand rounds, and other professional gatherings, PSR has developed a one-hour presentation, complete with case studies, that equips health care professionals with the knowledge and tools they need to provide parents of pediatric patients with anticipatory guidance on identifying and avoiding toxic chemical exposures.  The Pediatric Environmental Health Toolkit Training uses case examples to highlight the relationship between environmental exposures and children’s health.

To schedule a presentation at your practice or conference, contact Susan Kring at 207-772-6714 or [return to top]

AMA Provides Overview of New Payment & Delivery Reform Models in New Reform Law

New Payment and Delivery Reform Models

The Patient Protection and Affordable Care Act establishes several demonstration programs to test and evaluate new Medicare health care delivery and payment models.  This is in an effort to improve care coordination and quality while reducing the rate of spending growth.  These models include bundled payments, accountable care organizations (ACOs or shared savings programs) and the medical home.  The law also establishes a new Center for Innovation within the Centers for Medicare & Medicaid Services (CMS) that can test other care models, and it gives the secretary of Health and Human Services (HHS) the authority to expand the scope and duration of the new models, including the authority to expand them nationwide.

Participation in all of these demonstrations is strictly voluntary for Medicare providers, and physician practices must fully evaluate their capacity to join in these programs before pursuing them.  Under these models, physicians will have to work collaboratively with other practices and/or with other providers, such as hospitals, and they may need to invest in tools and systems that are required to coordinate care and measure performance.

There may be distinct advantages to practices that are able to participate in these demonstrations.  While these projects generally do not begin until at least 2012, it is important for interested physicians to begin evaluating their ability to participate now, since organizing a practice to join in these demonstrations may require long-term planning.  Even for those who do not want to participate in these particular projects, it is important to recognize their goal to test and refine these new models as potential federal payment and delivery reforms in the future. Further, many of these models may already be underway in the private market in some areas.  Therefore, physicians should be familiar with the underlying concepts and overall approaches.

The AMA will work closely with the administration as these demonstrations are developed and implemented to ensure that physicians can fully participate, and will work to assist its physician members who are seeking to participate.  The AMA also will be launching a series of educational materials and programs in the near future for physicians on the pathways to successfully participating in delivery reform models.

CMS Center for Medicare and Medicaid Innovation (Sec. 3021)

By January 1, 2011, the HHS secretary is required to establish a CMS Center for Innovation to test care models that improve quality and slow the rate of growth in Medicare costs.  The secretary must publicly make an evaluation of each model, including an assessment of the quality of care provided.  The secretary may limit model testing to certain geographic areas, and model designs do not initially have to ensure budget neutrality. The secretary also has discretion to develop any model that meets certain requirements, although the law suggests a number of specific models that may be tested. For example, models may include:

  • Promoting broad payment and practice reforms in primary care, including patient-centered medical home models for high-need individuals and medical homes that address women's unique health care needs
  • Using geriatric assessments and comprehensive care plans to coordinate care for patients with multiple chronic conditions who are unable to perform daily living activities or who have cognitive impairments
  • Supporting care coordination for chronically ill individuals at high-risk of hospitalization through a health information technology-enabled provider network
  • Establishing community-based health teams to support small-practice medical homes by assisting primary care providers in chronic care management, including patient self-management activities
  • Assisting individuals in making informed health care decisions by compensating physicians and other providers for using patient decision-support tools to improve understanding of medical treatment options

Medicare Shared Savings Program (Sec. 3022)

By January 1, 2012, the HHS secretary is required to establish certain Medicare shared savings programs commonly known as ACOs for various providers.  These providers include groups of physicians, networks of individual practices, partnerships or joint ventures between hospitals and physicians, hospitals employing physicians, and any other provider groups that the secretary determines is appropriate.  To qualify, an ACO must agree to be accountable for the quality, cost and overall care for the Medicare fee-for-service beneficiaries assigned to it.  An ACO must have at least 5,000 assigned Medicare beneficiaries and have in place, among other things, the following: (1) a formal legal structure that would allow the organization to receive and distribute payments for any shared savings; (2) a leadership and management structure that includes clinical and administrative systems; (3) defined processes to promote evidence-based medicine; and (4) processes to report on quality and cost measures. Payments will continue to be made to physicians and other ACO participants under the usual Medicare payment structure (e.g., the Medicare fee schedule).  Additionally, ACOs would share among their provider participants a portion of any savings achieved in excess of a threshold benchmark. ACOs must agree to participate in the demonstration for at least three years.

National Pilot Program on Payment Bundling (Sec. 3023)

By January 1, 2013, the HHS secretary is required to establish a Medicare pilot program for integrated care.  This will include episodes of care involving a hospitalization to improve the coordination, quality and efficiency of health care services, such as: (1) physician services delivered inside and outside of an acute care hospital setting; (2) other acute care inpatient services; (3) outpatient hospital services, including emergency department services; (4) post-acute care services, including home health, skilled nursing, inpatient rehabilitation, and inpatient services furnished by long-term care hospitals; and (5) other services the secretary determines are appropriate. The secretary will also establish a payment methodology, including bundled payments or bids for episodes of care. Payment will be made to the entity that is participating in the pilot program.

Independence at Home Demonstration Program (Sec. 3024)

By January 1, 2012, the HHS secretary is required to establish an independent at-home demonstration program to bring primary care services to the homes of high-cost Medicare beneficiaries with multiple chronic conditions. Health teams could be eligible for shared savings if they achieve high-quality outcomes, patient satisfaction and cost savings.  The secretary will estimate an annual per capita spending target for the estimated amount that would have been spent under Parts A and B in the absence of the demonstration, with the target adjusted for certain risks. A medical home practice could receive an incentive payment based on actual savings achieved in comparison to the target.

Extension of Gainsharing Demonstration (Sec. 3027)

The existing Medicare gainsharing demonstration project is extended for almost two years.  This project was established to test and evaluate methodologies and arrangements between hospitals and physicians governing the use of inpatient hospital resources and physician work to improve the quality and efficiency of care provided to Medicare beneficiaries.  Under this arrangement, the hospital provides payments to physicians that represent a share of savings attributable to collaborative efforts between the hospital and the physician.

Community Health Team Support for Patient-Centered Medical Homes (Sec. 3502)

The HHS secretary is required to provide grants or enter into contracts with eligible entities to establish community-based interdisciplinary, inter-professional "health teams" to support primary care practices (including obstetrics and gynecology practices) within their local hospital service areas, and to provide capitated payments to primary care providers according to criteria established by the secretary.  The health teams could, for example, collaborate with patient-centered medical homes in coordinating prevention and chronic disease management services, or develop and implement care plans that integrate preventive and health promotion services.

Additional resources

For general background information on payment and delivery reforms, read reports from the AMA Council on Medical Service about Medicare physician payment reform (PDF) and the patient-centered medical home (PDF).

Also, read more about payment and delivery reforms in the Journal of the American Medical Association, in an issue brief (PDF) from The Commonwealth Fund, and in an article (PDF) from the Center for Healthcare Quality and Payment Reform. [return to top]

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