Maryland’s Multi-payer Patients Centered Medical Home Program

As the result of legislation, insurance carriers required to participate are the following Aetna, CareFirst, BlueCross, BlueShield, CIGNA, United Healthcare, and Coventry. Carriers who gross more than 90 billion are required participators

The Centers for Medicare and Medicaid Services announced a pilot project so that any state-sponsored programs may participate.

The program requires that all participating practices apply for NCQA’s recognition program for level 1+ or higher within 6 months. By December 2011 and level 2+ within 18 months of implementation. The practices must pass categories within each of the nine NCQA domains. The elements are strongly linked to potential cost savings to purchasers, and patients. 

  

Selection criteria including primary care physicians, and nurse practitioners. Geographic diversity, practice size, and ownership type are a part of the criteria selection too.

According to the NCQA recognition requirement nurse practitioners are not recognized however, NCQA will review applications and forward the details to the MHCC, if they meet level 1+ and level 2+ requirements. The caveat is they will not be recognized by NCQA.

Practices may participate in Maryland’s MHCC program and single payer programs, such as CareFirst if the program is site specific, using NCQA requirements; CareFirst is enrolling practices at the organization level. Participation with both programs requires following patient participation rules, payment methodologies, and quality reporting according to both programs. In other words not combining information into one report if variances between the reporting requirements differ.  CareFirst may supplement MHCC payment system consistent with Care First’s for the practice using both payment systems. Other practice locations not in the MMPP will follow the CareFirst conventions.

In order for cost-effectiveness for the practice, the practice needs to participate with 2-5 of the required carriers.

Patient participation includes an op-out option. The payment for those patients opting out who opt-out are excluded from the payment and quality measures.

Every six months patients joining and leaving the practice will be added to the payment program. The quality measure includes providing a list of patients and their insurer to MHCC. The information is matched against enrollment records and claims histories. The patient according to where most primary services received using E&M codes for the prior two years are matched to the primary provider. If the patient has not received services within the window, the patients are evaluated with pharmacy claims. Those patients who have changed carriers within the window are in the process of determining verification.

Do I want the government knowing what I am being treated for and how is that information used? What other entities have access to the information.

It is irrelevant the number of locations within the practice, all locations is included in the payment system.

Practices performance measures for monitoring are at least one disease including diabetes, heart/stroke management, and asthma control. These measures align with Medicare and Medicaid’s EHR meaningful use definition for bonus payments and Medicare’s PQRI standards. Incentive payment guidelines including meeting thresholds in reduction.

The payment structure is different from managed care capitation. PCMH offers a fixed and incentive payment in addition to the fee-for-service payment. The fixed and incentive payments differ for treatment services.

Payment includes two types of reimbursement. Practices will receive per patient monthly payment for those patients participating with the program. This is to cover the cost related to the program. This payment is semiannual. Adjustments include the number of patients, payer category, and NCQA recognition standards. Practices that decrease emergency department visits and hospital utilization are included in payment as well. Fixed payments begin April 1, 2011. The semiannual payment is retrospective and depends upon meeting quality thresholds.

How much is per patient, is the carrier required to report this information to MHCC? How does it benefit the carriers who pay the fixed payment?  If the practice receives bonuses for decreasing hospital services and ER services then how is that a savings for the state? What is the projected savings with and without using this incentive?

  

If the practice receives subsidy from a private carrier for house bill 706 and participate in the program the subsidy payment will be a countable cost in shared savings computation.  The example provided is if a practice location receives $15,000.00 in HER subsidies in 2011, those payments will be counted as expenses to the practice when the shared savings are calculated. The treatment of the subsidy is identical to the fixed payments are considered in the share savings computation.

Reducing Readmission Rates Part III

            Starting October 2012 Medicare begins penalties for facilities for readmissions within 30 days of discharge. Late last year Dartmouth Institute for Health Policy and Clinical Practice and Robert Wood Johnson Foundation announced little progress was made during a study from 2003-2009. The report found 1 in 6 Medicare patients were readmitted within 1 month of discharge. A staggering 60% Medicare patients did not follow-up after discharge as a factor.

            Hospitals have until October to make systemic changes to coordinate care across the health care continuum. Systemic changes will include ancillary service coordination. 

Medicare will start a 1% reduction in payments to facilities not reducing the readmission rate for patients with specific diagnoses including pneumonia, heart attack, or heart failure.

The National Committee for Quality Assurance implemented 9 practice standards that align with the Joint Principles of Patient Centered Medical Home including Access and Communication, Patient Tracking and Registry Functions, Care Management, Patient Self-Management Support, Electronic Prescribing, Test Tracking, Referral Tracking,

Performance Reporting and Improvement, and Advanced Electronic Communications.

             Group Health Cooperative published a study after one year of using the model emergency room visits saw a 29% reduction rate. Hospitalizations decreased 11%. The medical home visits decreased 6%. The caveat is the model administrative cost increased $ 53 per patient. The emergency room savings saw a decrease of $ 54 per patient.

           CMS Partnership for Patients initiatives is to improve the quality, safety, and affordability of health care not exclusive for the Medicare population, rather for all. The partnership has nine core areas to improve hospital readmission rates by 20% by 2013. The elements include adverse drug events, catheter-associated Urinary Tract Infection, Central Line-associated bloodstream infection, Injuries from Falls, and Immobility, Obstetrical adverse events, pressure ulcers, surgical site infections, Venous thromboembolism, Ventilator-associated Pneumonia, preventable readmissions.

            Higher Volume of Post-acute Care Patients Associated With a Lower Rehospitalizations Rate in Skilled Nursing Facilities by Li Y (at el,) says yes. The study found a 15% reduction in readmission rates within 30 days of discharge. Patients that transfer to step down care requiring skilled nursing care supports the need for improved care coordination.

Maryland Physicians Review Board

Maryland Physicians Review Board 
The mission of the Maryland Physicians Review Board for the state of Maryland protects the welfare of health consumers. The Board monitors the licensing of many clinical practitioners. The Medical Protection Act gives authority to the Maryland Board of Physicians investigative, and discipline physicians with strong sanctions for serious offenses. The board provides to the public licensing information related to sanctions, and licensing. 
Complaints 
Complaint means a written allegation that a physician committed a prohibited act. Complaints listed in the Medical Protection Act (a) Malpractice, (b) Report from a hospital or institution alleging violations of the Health Occupations Article (c) Malpractice insurance report (d) Law enforcement report (e) Report from anther country, state, or jurisdiction or the armed services (f) Consumer Complaints (g) Telephone directory (h) Advertisement (i) News article (j) media tape and (k) other. Serious offense complaints are misuse of alcohol and/or drugs leading to impaired judgment on the job (Maryland Medical Practice Act, 2002). Sexual contact with patients is a serious offense with separate policy for complaint processes. Any clinician convicted of a criminal nature results in discipline. Clinicians may not prescribe narcotics without a “bona fide” indication of need. Kickbacks of money or other for referral of patients, is a serious offense to providing quality care. No physician may practice without a license, or aiding others. Clinicians’ providing substandard care is the last serious complaint that results in investigation. 
Minor complaints generally take a few weeks informally to investigate, and resolve. A disciplinary result for minor complaints is a letter of advisory “which informs, educates, or admonishes a health care provider in regard to the practice of medicine under (What is the Maryland board of physicians? 2003). Serious offenses resulting in investigation can take up to 18 months to complete. Cases involving standards of quality care go through peer review. 
Breach 
The board must show evidence to justify the breach of the Maryland Medical Protection Act. Complaint determination follows several steps. First, dismissal of charges occur when the claim lacks evidence If the evidence supports the claim the board makes a determination to take informal action, by first issuing the advisory letter. 
In the letter, the board could request the respondent to enter into a disposition agreement with the board. The board can issue a cease and desist order regarding the complaint. The board can deny licensure, reinstatement, and accept surrender. 
For serious complaints, the board can vote to charge the physician with violation of the Medical Protection Act. The board forwards the information for prosecutorial action. The prosecutor may send the case back based on the evidence. If the board issues charges or a notice of intent to deny licensure the board will offer the opportunity for the alleged offender to request a Case Resolution Conference unless a lack of response or intent to deny. 
The Case Resolution Conference is voluntary, informal, and confidential. If both parties are unable to reach, an agreement the case proceeds to a hearing. The alleged offender can request a conference to issue formal charges. 
The Administrative Procedure Act governs hearings of the board (Maryland Medical Protection Act, 2002). Due process allows the accused to defend himself before an administrative law judge in a formal administrative hearing. The complainant is a witness in formal proceedings. Sensitive cases allow the witness identity to remain confidential. After the hearing confirms breach, disciplinary actions follow concluding the Case Resolution Conference. 
Disciplinary Action 
The board allows disciplinary penalty appropriate to the complaint. This includes “retraining, a course in ethics, psychiatric treatment community services, in addition to or in lieu of suspension or revocation” (Maryland Medical Protection Act, 2002). Board has authority to reprimand, suspend, deny or surrender license, dismiss the charges. Factors taken in consideration include financial benefits from the conduct, willfulness of improper conduct, extent of actual, or potential harm caused to the public, The Maryland Medical Protection Act lists the following penalties: First time offender’s penalties are between (a) $1000.00 and not more than $30,000.00. The second offense, the penalty is (b) less than $10,000.00 and up to $40,000.00, the third offense minimum is (c) $15,000.00 and maximum of $50,000.00 (2002). 
Example 
According to Barrett, Neil Solomon the former Maryland Secretary of Health surrendered his medical license (2005). The letter was an admission to his misconduct (Appendix 1). While working at a weight-loss center the physician had sexual relationships with eight female patients. This former physician did not do this to the staff, but rather the patients. The women sued for $160 million forcing the physician into bankruptcy. He paid a total of $45,000.00. Part of the surrender process is admission of misconduct. The Maryland Board of Physicians according to Barrett, The board warned if he denied any details, the board would release the details of the investigation (2005). 
Conclusion 
Board cannot order compensation to an individual harmed by a physician civil matter. Findings from the board are inadmissible in civil actions. The civil action may not include information related to the criminal case. The act of the suit requires examination. The information within the Case Resolution Conference is inadmissible unless the information comes from another source. A motion for reconsideration is at the discretion of the board. The board does not automatically give a right to reconsideration. A judicial review of the board’s decision is an option the physician can pursue. If the board denies reinstatement, the physician has the option for appealing the decision in a judicial review as well. 

References 

Maryland Medical Practice Act (2002) Code of Maryland Regulations, and Register: 10.32.02.02 of Maryland Retrieved on February 14, 2010 from Division of State Documents: http://www.dsd.state.md.us/comar/comarhtml/10/10.32.02.02.htm 
What is the Maryland Board of Physicians? (2003) Board of Physicians, Maryland Department of Health And Human and Mental Hygiene Retrieved on February 14, 2010 from http://www.mbp.state.md.us/pages/whatis.html 
Barrett, Stephen (2005). Former Maryland Secretary of Health Surrenders Medical License. Retrieved on February 14, 2010 from Casewatch.org http://www.casewatch.org/board/med/solomon.shtml 

Appendix 1 

NEIL SOLOMON, M.D. 
901 Dulaney Valley Road 
Dulaney Center 2 
Towson, Maryland 21204 
October 27, 1993 
State of Maryland Board of Physician Quality Assurance 
4201 Patterson Avenue 
P.O. Box 2571 
Baltimore, Maryland 21215-0095 
Re: Surrender of Medical License of Neil Solomon, M.D. 
License Number: D 12963 
Case Number: 94-0104, 94-0105 
Dear Mr. Gunther and Members of the Board: 
Please be advised that I have decided to surrender my license to practice medicine in the State of Maryland, License Number D12963. I understand that I may not give medical advice or treatment to any individual, with or without compensation, cannot prescribe medications, or otherwise engage in the practice of medicine as it is defined in Md. Health Occ. Code Ann. §14-101 (1991 Replacement Volume). In other words, I understand that surrender of my license means that I am in the same position as an unlicensed individual. 
I understand that this letter of surrender shall be considered a PUBLIC document immediately upon its acceptance by the Board of Physician Quality Assurance (the "Board”). I also understand that this surrender of my medical license is and shall be considered IRREVOCABLE. 
My decision to surrender my license to practice medicine has been prompted by an investigation of my practice by the Board. The Board initiated this investigation after it received several complaints, and after it became aware of several civil actions filed against me by former patients, all of which alleged that I instigated improper sexual contact with patients during the physician/patient relationship. 
I admit that for at least the past 20 years, I have used my position as a physician to instigate a wide range of sexual relations with at least eight women patients. This conduct included acts of sexual intercourse, as well as other explicit sex acts. These activities took place in my medical office during patient visits, as well as in other locations. I admit that I engaged in sexual misconduct with my patients during the physician/patient relationship. I admit that I engaged in this conduct with multiple patients over the same time period. I recognize that these patients developed a sense of trust, confidence, and dependence through the physician/patient relationship, and that I misused my influence as a physician and the trust my patients placed in me for my own sexual gratification. 
I admit that it was improper to engage in any sexual relationship with any patient. 
The Board's investigation resulted in charges under the Maryland Medical Practice Act (the "Act"). Specifically, the Board, on October 13, 1993, voted to charge me with the commission of certain prohibited acts under Md. Health Occ. Code Ann. ("H.O") §14-404, including the following: 
Subject to the hearing provisions of §14-405 of this subtitle, the Board, on the affirmative vote of a majority of its full authorized membership, may reprimand and licensee, place a licensee on probation, or suspend or revoke a license if the licensee: l a guilty of immoral or unprofessional conduct in the practice of medicine; [H.O. §14-404(a) (3) I. 
Furthermore, pursuant to State Gov't Code Ann. §10-226, the Board, on October 13, 1993, voted to consider SUMMARILY SUSPENDING my license to practice medicine in the State of Maryland. 
On October 20, 1993, my attorney was personally served with an unexecuted copy of a proposed Order for Summary Suspension of my medical license, issued by the Board, which specified the charges in particularized detail. I affirm that I have received a copy of the unexecuted Order for Summary Suspension, and have otherwise been advised of the Board's actions through, communications between representatives of the Office of the Attorney General and my legal counsel. 
I have decided to surrender my license to practice medicine in the State of Maryland and in all other states where I maintain a license in lieu of summary suspension and revocation of my license by the Board. 
I understand that pursuant to its authority under Md. Health Occ. Code Ann. §14-403, the Board has the authority to set conditions on its agreement to accept the surrender of my medical license. In addition to the above, I understand that as a condition of the Board's acceptance of this Letter of Surrender, I agree to the following: 
1. Within seven days of the acceptance of this Letter of Surrender by the Board, I will submit irrevocable letters of surrender of my medical license to any other states, jurisdictions, or countries where I have a medical license, or have any applications for licensure pending. In these irrevocable Letters of Surrender, I will fully advise the respective medical boards of the actions taken by the State of Maryland, and the basis of those actions. I agree to attach to those letters this Letter of Surrender. I agree to submit to the Board within thirty (30) days of the acceptance of this Letter of Surrender, proof it deems satisfactory that I have complied with this condition; 
2. I will not under any circumstances apply for a medical license or a reinstatement of my medical license in the State of Maryland or in any other state, jurisdiction, or country; 
3. In the event that I apply for reinstatement of my medical license in Maryland or in any other state, jurisdiction, or country, the Board, in its sole discretion, may publicly release any and all information regarding the findings of its investigation into my conduct as a physician and my medical practice that would otherwise be confidential under applicable laws, including, but not limited to the unexecuted Order for Summary Suspension; 
4. In the event that I make any public statements denying my unprofessional sexual misconduct with my patients, the Board, in its sole discretion, may publicly release any and all information regarding the findings of its investigation into my conduct as a physician and my medical practice that would otherwise be confidential under applicable laws, including, but not limited to the unexecuted Order for Summary Suspension. 
I understand and agree that the Board will advise the Federation of State Medical Boards and the National Practitioners Data Bank of this Letter of Surrender, and that1 surrendered by medical licensee in lieu of a summary suspension and a revocation of my medical licensure by the Board. I affirm that I am also currently licensed to practice medicine in the District of Columbia, and in the States of New York and Ohio. I acknowledge that on the date Board accepts this Letter of Surrender, the Board Mr. Gunther and Members of the Board will send copies of this document to the respective medical boards of those jurisdictions.I affirm that I have a current Maryland Controlled Dangerous Substances Registration Certificate M07437 issued by the Maryland Division of Drug Control; and that I have a current United States Drug Enforcement Administration ("DEA") Certificate for the State of Maryland, Certificate AS2376689, issued by the DEA.I acknowledge that, on the date the Board accepts this Letter of Surrender, I must present to the Board: 
1. Maryland License D12963, including any renewal certificates and wallet-sized renewal cards; 
2. Maryland Controlled Dangerous Substances Certificate Number M07437 including any prescription pads bearing my name and any prescription ordering forms in my possession or under my control; and
3. United States DEA registration Certificate AS2376689 I acknowledge that on the date that the Board accepts this Letter of Surrender, the Board will send a copy of this Letter of Surrender to both the State of Maryland Division of Drug Control and the United States DEA, attesting that I am surrendering my privilege to prescribe controlled dangerous substances in the State of Maryland. I further acknowledge that I will submit a signed, executed copy of DEA form 104, Voluntary Surrender of Controlled Substances Privileges, which will be forwarded to the United States DEA. 
Finally, I wish to make clear that I have consulted with an attorney before signing this letter IRREVOCABLY SURRENDERING my license to practice medicine in the State of Maryland. I understand both the nature of the Board's actions and this Letter of Surrender fully. I make this decision knowingly and voluntarily. 
Sincerely, 
_______________________ 
Neil Solomon, M.D. 
VERIFICATION 
I HEREBY CERTIFY that on this day of, 1993. before me, a Notary Public of the State of and City/County aforesaid, personally appeared Neil Solomon, M.D., and declared and affirmed under the penalties of perjury that signing the aforegoing Irrevocable Letter of Surrender was his voluntary act and deed. 
Notary Public 
My Commission Expires: 8/1/94 
On behalf of the Boar of Physician Quality Assurance, on this 27th day of October 1993, I accept Neil Solomon, M.D.'s PUBLIC IRREVOCABLE surrender of his license to practice medicine in the State of Maryland. 
_______________________ 
Frank A. Gunther, Jr., Vice Chair 
Board of Physician Quality Assurance