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Maine's universal coverage plan could burden state physicians.

A universal health care plan that promises to cover Maine's uninsured in 5 years could bring added hassles to that state's physicians.

They'll have to be more prudent about their medical records, disclosing charges to patients, and submitting claims under this ambitious program, Gordon Smith, executive vice president of the Maine Medical Association, told this newspaper.

The Maine legislature in June approved the nation's first universal health plan with a goal to cover the state's 180,000 uninsured citizens by 2009. The public-private insurance program, known as "Dirigo Health," will offer low-cost health plans to individuals, small businesses, and the self-employed through private insurance carriers. "Dirigo," part of Maine's motto, means "I direct" in Latin.

MaineCare, the state's Medicaid program, will be expanded to cover more low-income adults and children. Those with incomes below 300% of the federal poverty level are eligible for health care subsidies on a sliding scale based on ability to pay. The program would be supplemented by federal grants, federal Medicaid funds, and payments by subscribers and participating businesses. The state also expects to save $80 million annually by eliminating unreimbursed care for the uninsured.

While the new plan isn't with out its perks--it includes $500,000 to increase the physician incentive program within MaineCare--some provisions of the law have physicians worried, Mr. Smith said.

One provision requires physicians to submit claims electronically through the use of standardized forms.

It also allows carriers to reject claims that are not submitted electronically.

This isn't comforting news for physicians who operate one-person offices, live in remote, rural areas, or have no computer, Mr. Smith said. These requirements "could put them out of practice." However, the law does contain waivers and exceptions for offices with fewer than 10 staff, something that could soften the blow for rural offices that don't have ready access

Physicians are especially nervous about a provision that allows the Maine Health Data Organization to collect quality data from their offices--something that's never been permitted before. There are concerns about the onerous administrative burdens and potential costs that are associated with this audit.

"Doctors' offices that don't have electronic records may have to hire a new person to pull out each record and assess what the data organization is looking for," Mr. Smith said.

It's also unknown what type of data the organization will be looking for--and whether the data might get published somewhere.

If the patient requests it, health care practitioners will also be required to notify patients in writing of charges for commonly offered health care services and to assist the patient in calculating the amount of his or her copay. While this could be a hassle, it has a trade-off: The patient won't be as isolated from the cost and value of these services, Mr. Smith said.

The hope is that this will produce more educated health care consumers.

As a cost-containment issue, physician practices were asked to voluntarily hold their annual increases in profit to 3%, but this is not expected to have much of an impact, "since physician revenues and salaries have been flat for several years," Mr. Smith commented.

Cardiologists, orthopedic surgeons, and other surgical specialties face their own setbacks under the new law.

Dirigo Health specifically places limitations on physicians who want to build specialty hospitals.

Previously, physicians could pull out of a hospital and build their own surgical center of any size or for any amount of money without having to go through any specific process.

Now they do, said Dr. Maroulla Gleaton, president-elect of the Maine Medical Association. A "certificate of need," or CON, is required before construction of any surgical facility that costs more than $1.2 million and results in capital expenditures of more than $2.4 million.

"In order to get their arms around allocation management, the state needed to have control over what's being built here," since new surgical facilities increase utilization, and "utilization is a big cost driver," Dr. Gleaton said.

This comes as good news to hospitals that were unhappy about the competition from physician-funded ambulatory care centers, Dr. Gleaton added. While the hospitals are subjected to the same CON requirements, this new provision puts physician specialty hospitals on the same playing field as regular hospitals, she said.

The one bright piece of news for physicians is the way in which the investment pools have been set up to determine how much money will be used on an annual basis to build these facilities.

There will be a separate pool for physicians and hospitals, with a condition that the physician pool gets at least 12% of the investment money in any given year.

At the very least, this ensures that physicians won't be left high and dry, Dr. Gleaton said.
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Title Annotation:Electronic Claims Required
Author:Silverman, Jennifer
Publication:OB GYN News
Date:Aug 1, 2003
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