AMA House of Delegates Decisions on ACA, Two Midnight Rule and Maternity Care

In addition to the discussions at the AMA Annual Meeting last week and highlighted in last week's Update on the controversial topic of Maintenance of Certification and Maintenance of Licensure, other topics featured were ACA implementation challenges, maternity care, the CMS observation rules and the ACA primary care payment boost through Medicaid.

The Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) topics were discussed in last week's Update (all archived on the MMA website).  This week, we will provide information on other significant topics dealt with by the AMA's House of Delegates which completed its Annual meeting last Wednesday in Chicago.

ACA Implementation Challenges

The House of Delegates endorsed a report from the AMA Council on Medical Service and considered by Reference Committee A (Medical Service and Health System Reform) that expressed broad support for the ACA goals of covering the uninsured and expanding choice for patients but that also directed the AMA to focus its advocacy and lobbying resources for the coming year on operational problems undermining the goals of the law.  The report specifically lists five continuing implementation challenges:

1. Large numbers of uninsured patients in those states, such as Maine, that have not expanded Medicaid as expected in the original law.
2. Affordability of Exchange Plan coverage.
3. Enrollment in State Exchange Risk Pools.
4. Narrow health plan networks.
5. Inadequate physician payment levels from Medicaid and exchange-transacted plans.

"The council has actively monitored the implementation of the ACA since its enactment in 2010," the council stated in its report.  "With the implementation of health insurance exchanges, the Medicaid expansion and other provisions of the law, issues have emerged that have the potential to impact patient access to care, physicians and other practices and the patient-physician relationship."

The report also references an earlier proposal that identified twenty challenges to the ACA.  The Council had been charged with reviewing these issues and providing the AMA with recommendations that would improve the ACA.  The council provided the following nine recommendations reaffirming previous AMA policy:

1. Repeal the Independent Payment Advisory Board (IPAB) and the nonphysician provider nondiscrimination provision, and enact antitrust reforms.
2. Repeal or reform the Value-based payment Modifier program.
3. Support a system of individually selected and owned health insurance.
4. Support health insurance tax credits and subsidies.
5. Support health savings accounts.
6. Support insurance coverage of high-risk patients through direct risk-based subsidies such as high-risk pools, risk adjustment and reinsurance, rather than indirect methods that rely on market regulations.
7. Support health insurance market regulations.
8. Support individual responsibility for obtaining a minimum level of catastrophic and preventive coverage; and 
9. Repeal the sustainable growth rate (SGR) formula for Medicare physician payment and enactment of meaningful professional liability reform.

CMS Two-Midnight Policy

The House of Delegates also approved a resolution calling upon CMS to take another look at its hospital observation rules and the so-called two-midnight policy.  Medicare has a policy of reimbursing hospitals for providing in-person services at outpatient rates if the patient does not remain in the hospital for two midnights.  Such outpatient rates generally apply when patients are kept in a hospital for observation, instead of being admitted on an inpatient basis.

The resolution calls for CMS to educate the public on its reimbursement policies and develop tools for patients and physicians outlining the financial implications of the two-midnight policy.

Maternity Care

The House of Delegates also approved a resolution calling for an expansion of maternity care options under the ACA.  The resolution noted that the ACA permits young adults to remain on their parent's policies through age 26, but that the average age for a woman having her first child is age 25.7.  There is a coverage problem because some health insurance policies do not provide maternity coverage for dependents.

The resolution calls for large group health plans to provide maternity care to dependent women under age 26.  The resolution further suggests 60 days of newborn coverage for all infants born to dependents under the age of 26.

Medicaid

The House of Delegates approved a report recommending that the AMA advocate that the ACA's primary care payment increases for evaluation and management codes and vaccine administration codes include obstetricians and gynecologists as a qualifying specialty.  Significantly, the report also calls for the ACA's Medicaid primary care payment increase to continue beyond 2014. 

Maine's delegates to the AMA, Maroulla Gleaton, MD (L) and Richard Evans, MD (R) review meeting materials.  

Registration Deadline for Wednesday's Practice Education Seminar Extended through Tomorrow

MMA's 23rd Annual Practice Education Seminar this Wednesday (June 18) features a variety of presentations aimed at preapring medical practices in Maine for a future that is both challenging and uncertain. The Augusta Civic Center will once again be the site of the Seminar which is intended to present physicians and practice managers with the information and trends in medical practice in Maine and across the country.  

The program will be held from 8:15am to 4:00pm and practice managers, physicians and others interested may register on-line (see link below) or by calling the MMA office at 622-3374.  Registration has been extended through the end of the day tomorrow.

The theme of this year's program is "Preparing Your Practice for the Rough Road Ahead."  The focus will be on payment reform and best practices.  Carol Vargo from the American Medical Association will present data from the Rand survey conducted for the AMA which asked physicians questions about their level of satisfaction with their work and also elicited opinion about practice sustainability.  Kevin Flanigan, M.D., Medical Director for MaineCare will present a keynote luncheon talk on the State Innovation Model grant and its role in reforming the payment and delivery system in the state.  CMS Regional Medical Director William Kassler, M.D., MPH will also speak and bring attendees up to date on current CMS initiatives in both Medicaid and Medicare.

The full agenda, speaker list and registration are now available on the MMA website. 

This year's program is supported by a Payment Reform grant from the Maine Health Access Foundation (MeHAF). [return to top]

MMA Releases Updated Physician's Guide to Maine Law

The Maine Medical Association is pleased to announce that its Physician's Guide to Maine Law has now been updated to reflect additions and changes in statues through the 126th Maine Legislature (2014).  The MMA legal staff continually work to make this resource a useful compendium of state statutes and select federal law impacting the practice of medicine in Maine. This year, the Guide contains several new sections on issues such as record retention and jury duty. Over time, the Guide has changed to include more links to websites, statutes and resources - rather than reprints of full statutes - and so MMA is now making the Guide available largely in electronic forms - on its website or, by request, on CD. 

New Laws Impacting Your Practice: Changes to Maine's Medical Marijuana Law

Each week MMA will be running articles highlighting new laws passed by the 126th Legislature that impact the practice of medicine in Maine.  We are also happy to present an overview of new laws to your medical staff, practice or specialty society and have posted a slide presentation overview of all health care-related legislation enacted by the 126th Legislature on the MMA website.

Every year the Maine Legislature considers a number of changes to the medical use of marijuana statute.  In 2013, the Legislature added post-traumatic stress disorder, inflammatory bowel disease and dyskinetic and spastic movement disorders to the list of conditions for which patients may qualify for medical marijuana  (LD 1062).  This year, the Legislature enacted several other changes (LD 1739).  Of significance to physician practices, the legislature clarified that certifications for medical marijuana can be written for less than one year.  Interpretations of the prior statute suggested that the wording of the law required certifications to be written for a full year. In addition, the legislature this year changed the law to allow nurse practitioners to issue medical marijuana certificates in addition to physicians. The changes are effective August 1, 2014.  The full text of LD 1739 can be found here. For more information on Maine's Medical Marijuana program, visit: http://www.maine.gov/dhhs/dlrs/mmm/ 

With any questions or concerns, please contact MMA Attorneys Gordon Smith, Andrew MacLean or Jessa Barnard via email or at 622-3374.   [return to top]

Featured MICIS Module: Obesity Management in Primary Care

The Maine Independent Clinical Information Service (MICIS), the academic detailing program of the Maine Medical Association, has been helping busy physicians keep up with medical literature since 2009.  MICIS provides high-quality, rigorous, independent modules presented to you by trained clinicians at your work site, at no cost. CME is available.  Currently available topics are: Obesity Management, Antibiotic Stewardship and COPD.

The Obesity Management module includes:

• The definition, causes, prevalence and risks associated with obesity
• Counseling on lifestyle modification for diet, exercise and behavioral changes as first line approaches
• The relative risks and benefits of drug therapy including phentermine, orlistat, phentermine/topiramte and lorcaserin
• Findings from the Look Ahead and POWER-UP clinical trials on multi-component primary care-based interventions
• The relative risks and benefits of weight loss surgery

Please contact Program Manager Jennifer Reck at jreck@mainemed.com for more information or to schedule a visit at your practice site.

Funds Available for 2014 Patient Experience Surveys

The DHA ‐Maine Quality Forum (MQF) is delighted to announce that it will support the administration of another round of CG‐CAHPS surveys to patients served by primary and specialty practices in Maine. As in 2012, MQF will pay subsidies of up to 90 percent of survey costs to practices that contract with a MQF‐qualified vendor, use an allowable version of CAHPS, and agree to have their survey results publicly reported.

There are two new features to the 2014 initiative that provide greater flexibility to practice sites:

• Multiple versions of CG‐CAHPS will be supported, including the CG‐CAHPS and the PCMH‐ CAHPS.  
• Practices may choose to conduct a continuous survey throughout the measurement period or a one‐time survey at the end of the measurement period.

DHA‐MQF is currently accepting applications from survey vendors seeking approval as a Qualified Vendor under this initiative. The list of approved Qualified Vendors will be announced in early July, 2014.  Practices wishing to participate will be required to register in advance. Registrations will be accepted between July 15 ‐ August 15, 2014 at: http://www.mainepatientexperiencematters.org/register.php  

Join DHA‐MQF in a webinar to discuss the Patient Experience Matters initiative and how your practice can participate.  

Monday, June 23, 2014
2:00 pm ‐ 3:00 pm
This session will use Adobe Connect and also a phone connection for the best audio.
Here are the login details:

1. Connect to the webinar by going to:   https://msps.adobeconnect.com/pem/    
2. Sign in as a guest and when prompted, please use your full name.  
3. You then will be asked to enter your phone number to have the webinar call you back.  
4. If that does not work then please call directly into the webinar by dialing 1‐888‐394‐8197; Participant Code: 778510 

Jackson Lab and MMA Looking for Primary Care Physicians Interested in Learning about Genetic Testing

Jackson Lab has received a grant from the Maine Cancer Foundation to develop and present educational modules (on-line) that will be used to educate primary care physicians on the information they need to know to advise patients about screening for genetic factors for cancer.  At this point, MMA is working with Jackson Lab to implement the program and we need a small number of physicians to be interviewed for 30 minutes and asked a series of questions about this topic.  The interviews would be by telephone and physicians would be paid $200 for their time.  Interviews would be scheduled for June but could be done in the evening if necessary.

Any primary care physician interested in being interviewed should communicate with Gail Begin at MMA (gbegin@mainemed.com). [return to top]

Most HIPAA Violations Still Due to Theft of Laptops, Mobile Devices

Health data breaches in 2011 and 2012 were largely due to theft of devices on which protected health information (PHI) was stored, according to one of two reports sent June 11 to Congress by the Office for Civic Rights within the Department of Health and Human Services.  An additional report contained information about the continuing efforts to enforce the HIPAA privacy and security rules.

Among the interesting findings in the report:

• The OCR received 236 reports in 2011 of data beaches affecting 500 or more individuals.  In 2012, 222 such reports were received.  The total number of individuals affected by the breaches in 2011 was more than 11.4 million and in 2012 was more than 3.3 million.
• Theft of devices has been the single biggest reason breaches occur, making up about half of all breach incidences reported in one year.  Other leading causes of breaches of PHI include unauthorized access to or disclosure of PHI and loss of data.
• While most of the reports of breaches are by providers, in 2011 breaches by Business Associates were responsible for breaches affecting the largest number of individuals.  For instance, the largest breach in 2011 affecting 4.9 million individuals involved the theft of unencrypted backup tapes from a Business Associate.
• Thirty percent of all large breaches in 2011 involved paper records.
• From April, 2003 until Dec. 2012, OCR received 77,190 complaints of privacy and security rule violations.  More than 90 percent of these complaints have been resolved, with most of them addressed within a year of receipt of the complaint.  More than one-half of the complaints did not present an eligible case for enforcement of the HIPAA rules.
• A majority of the cases investigated were resolved by the OCR providing technical assistance to the covered entities or by the OCR requiring the covered entities to develop corrective action plans.  In an additional 9,000 cases, no violation was ultimately found to have taken place.

The OCR data breach report can be found here.

The report on HIPAA privacy and security rule compliance is available here. [return to top]

MACPAC Recommends Extending CHIP Program for Additional Two Years

The Medicaid and CHIP Payment and Access Commission on June 13 recommended to Congress that it extend federal funding for the Children's Health Insurance Program for an additional two years.  In its June report to Congress, MACPAC stated that unless CHIP funding is extended, there is a risk that many children might become uninsured, unable to access either employer-sponsored insurance or coverages under the Affordable Care Act (ACA).

CHIP funding is currently scheduled to terminate after the federal fiscal year 2015. [return to top]

MMA Announces Departure of Associate General Counsel, Jessa Barnard

It is with great regret that the Maine Medical Association shares the news with members and colleagues that Jessa Barnard, Esq., who served as MMA's Director of Public Health Policy from 2010-2012 and Associate General Counsel since 2012, will be leaving the Association at the end of the month. 

Ms. Barnard has provided government relations and legal support to the Association and has led Association public health and health care reform education efforts.  "I would to thank my coworkers at the MMA, MMA Board members, all of our coalition partners and the many physicians and office staff with whom I have worked for making the past four years of my career so rewarding," Ms Barnard said of her departure.  MMA EVP Gordon Smith praised Ms. Barnard's contributions to the MMA's advocacy work stating, "She is a very talented attorney and advocate and we have been very fortunate to have had Jessa as part of the MMA team for the past four years."  Mr. Smith continued, "We wish Jessa and her family well in the return to Vermont and all the best in her future career."  

She will be moving to her home state of Vermont to be closer to family and will be taking time off to care for her children before looking for opportunities to return to practicing health law and policy.  Her last day in the office will be June 25th. 

After her departure, you can contact Andrew MacLean at amaclean@mainemed.com or 622-3374 x 214 for assistance with issues you would have directed to Jessa.   [return to top]

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