Maine Healthcare Data Organization Reporting Requirements Update
The proposed rulemaking by the Maine Healthcare Data Organization (MHDO) focuses on implementing a uniform reporting system for prescription drug price data sets and collecting non-claims-based primary care provider payments. The timeline for this update includes public hearings and board reviews to ensure adherence to legislative requirements. Currently, registration status shows a significant percentage of entities have completed the registration process, indicating progress towards enhanced data reporting in the healthcare sector.
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Content Content 1. Proposed Rulemaking 2. Enforcement Action 3. CompareMaine Version 9.0 4. Public Law Chapter 668, An Act To Protect Consumers from Surprise Emergency Medical Bills & Impact on MHDO 5. Key Project for next 12 Months 6. Maine Quality Forum Update HAI External Validation Primary Care Spending in State of Maine, 2021 Report Page 1 MHDO BOARD MEETING JUNE 4, 2020
Proposed Rulemaking Chapter 570: Uniform Reporting System for Prescription Drug Price Data Sets Clarifications to definitions and sections 2(B) and 2(C); consolidation of two manufacturer reporting templates [Sections 2(J)(1) and 2(J)(2)] into one to allow more effective reporting of not only new drugs and price increases, but also pricing component data; and clarifications and revisions (mostly based on feedback from the reporting entities) to some of the labeling and language in the reporting templates. (major substantive rule) New Rule for collecting non-claims based Primary Care Provider Payments Develop proposed rule to collect non-claims based payments from payers specifically those payments made to/for primary care. Identified Use Case: State s annual report on Primary Care Spending in State of Maine (as required by Public Law Chapter 244) Leverage the structure(s) that currently exists in other states (MA, OR, CO, RI, VT) for the collection of non-claims based payments Chapter 243: Uniform Reporting System for Health Care Claims Data Sets Add in and out of network provider designation to support reporting requirements in Public Law 668; update definition of pharmacy benefit manager (Note: the Common Data Layout (CDL) includes in and out of network data fields in both the medical and pharmacy claims data files) 2 MHDO BOARD MEETING JUNE 4, 2020
Proposed Rulemaking Timeline June 4, 2020 MHDO Board Considers Initiating Rulemaking Early August, 2020-Proposed Final Draft Rules September 3, 2020 Public Hearings October 1, 2020 MHDO Board reviews public comments and agency responses. Board considers adoption of proposed rule changes for APM s and Chapter 243. Chapter 570 will be submitted to the legislature. 3 MHDO BOARD MEETING JUNE 4, 2020
MHDO Reporting Requirement Rule Chapter 570, Uniform Reporting System for Prescription Drug Price Data Sets, Registration Requirement: Section 2. A. Registration. Each entity required to report shall complete an online registration form, or update an existing one, via the MHDO Prescription Drug Price Data Portal web interface by January 30th of each year. It is the responsibility of the reporting entity to complete, as needed, all company and contact information. 4 MHDO BOARD MEETING JUNE 4, 2020
Chapter 570 Registration Status Organization Type Total Registered Percentage Manufacturer 349 279 79.9% Wholesale Distributer 328 202 61.6% Pharmacy Benefit Manager 34 28 82.4% Unique Entities Total: 664 Unique Entities Registered: 475 % Unique Entities Registered: 71.5% 5 MHDO BOARD MEETING JUNE 4, 2020
Enforcement Action MHDO Rule Chapter 100, Enforcement Procedures, Section 3.Penalties; fines. 3. E. A prescription drug manufacturer, wholesale drug distributor or PBM that fails to file prescription drug price data and/or to meet the standards for data and the provisions for compliance as set forth in 90-590 C.M.R Chapter 570 Section 2 is considered in civil violation under 22 M.R.S. 8705-A for which fines may be adjudged as follows: 1. $100 per day for the first week of non-compliance; 2. $250 per day for the second week of non-compliance; 3. $500 per day for the third week of non-compliance; and 4. $1,000 per day for the fourth week of non-compliance and each week thereafter, not to exceed a maximum of $25,000 per any one occurrence. Staff Recommendation: Board authorizes the MHDO to notify the reporting entities that have not registered as required in Rule chapter 570, that the board has authorized the MHDO to move forward with imposing the financial penalties as described in Rule Chapter 100, Section 3. E. effective July 13, 2020. 6 MHDO BOARD MEETING JUNE 4, 2020
CompareMaine CompareMaine 2020 Report Card on State Price Transparency (developed by the Catalyst for Payment Reform and the Source on Healthcare Price and Competition, at the University of California Hastings College of Law) ranked Maine and New Hampshire with an A grade. States that scored high in this year s report are those with robust price transparency laws and useful resources for consumers, such as mandatory websites that display price information at no charge and in a consumer-friendly format. Page 7 MHDO BOARD MEETING JUNE 4, 2020
CompareMaine CompareMaine October 1, 2015-April 30, 2020: Approx. 111,000 Sessions and 604,000 pageviews Top 10 Procedures Searched on CompareMaine 1. Colonoscopy with Biopsy for Noncancerous Growth 2. Vaginal Delivery 3. Knee Replacement 4. Colonoscopy Without Biopsy for Encounter for Preventative Health Services 5. Hip Replacement 6. Gallbladder Removal 7. MRI Scan of Brain 8. C-section (Cesarean Delivery) 9. MRI Scan of Leg Joint 10. MRI Scan of Lower Spinal Canal Page 8 MHDO BOARD MEETING JUNE 4, 2020
CompareMaine CompareMaine Reporting Goals Established by Board in 2018: Target 80% of commercial payments Don t limit the addition of procedures to shoppable ; review the commercial claims data and look for most costly, most common and high variation (at least 5 providers performing the service with variation in payments) Page 9 MHDO BOARD MEETING JUNE 4, 2020
CompareMaine 9.0 CompareMaine 9.0 Scheduled to launch December 2020 (claims represent period April 1, 2019 March 31, 2020); Adding 27 new procedures CM 9.0 payments will represent over 63% of total commercial payments reported in the APCD Adding 32 new facilities (defined as an organization that provides healthcare services and procedures. This includes hospitals, surgical centers, diagnostic imaging centers, health centers, laboratories, and clinics.) Page 10 MHDO BOARD MEETING JUNE 4, 2020
% Total Paid on CM compared to same categories in APCD (commercial only) # CPT Codes on CM vs. AMA Category Cardiology 73% 6 / 47 Procedure Procedure Categories on Categories on CompareMaine CompareMaine Deliveries 100% 12 / 12 Emergency Department 30% 3 / 5 Integrative Medicine 84% 12 / 16 Laboratory 58% 98 / 1,433 Mental & Behavioral Health 97% 14 / 36 OB/GYN 66% 10 / 263 Office Visits 99% 27 / 73 Outpatient Procedures 41% 21 / 744 PT & OT 99% 24 /41 Radiology & Imaging 71% 41 / 554 Surgical Procedures 15% 50 / 5,383 Total 63% 318 / 8,607 Page 11 MHDO BOARD MEETING JUNE 4, 2020
Category Integrative Medicine Unique Claim Count Total Paid 14,759,904.24 17,628,591.39 CompareMaine APCD Percent CompareMaine APCD Percent 323,703 369,107 87.7 885,912 1,203,525 73.61 316,698 330,881 95.71 2,890 2,890 $ $ 83.73 Laboratory $ $ 44,594,164.52 76,544,778.22 CompareMaine CompareMaine in Relation to the in Relation to the Commercial Commercial Claims in the Claims in the APCD APCD 58.26 Mental & Behavioral Health CompareMaine $ $ 30,382,493.57 31,251,642.37 APCD Percent CompareMaine APCD Percent CompareMaine APCD Percent CompareMaine APCD Percent CompareMaine APCD Percent CompareMaine APCD Percent CompareMaine APCD Percent CompareMaine APCD Percent CompareMaine APCD Percent CompareMaine APCD Percent CompareMaine APCD Percent 97.22 Deliveries $ $ 8,111,097.89 8,111,097.89 100 100 Ob/Gyn 166,619 184,737 90.19 36,794 530,113 6.94 1,001,426 1,010,217 99.13 528,719 532,318 99.32 183,090 305,494 59.93 40,775 42,045 96.98 38,913 82,426 47.21 17,646 145,981 12.09 3,543,185 4,739,734 74.75 $ $ 29,590,753.27 44,817,641.81 66.02 Outpatient Procedures $ $ 31,068,566.67 75,124,248.87 41.36 Office Visits 138,885,272.43 $ 140,193,492.43 $ 99.07 PT & OT $ $ 34,926,931.76 35,010,240.41 99.76 Radiology and Imaging $ $ 63,837,280.55 90,177,114.94 70.79 Cardiology $ $ 10,568,685.06 14,523,888.30 72.77 Emergency Dept Visits $ $ 11,600,399.40 38,777,560.36 29.92 Surgical Procedures 19,340,575.66 125,940,934.85 $ $ 15.36 Totals 441,056,495.43 $ 698,101,231.84 $ 63.18 Page 12 NOTE: APCD TOTAL PAID REPRESENTS TOTAL PAYMENTS FOR THE COMMERCIAL CLAIMS DATA
Category CPT Code Procedure/Service Item Origin 29827 Shoulder Arthroscopy Surgery - Repair of shoulder rotator cuff using an endoscope Removal of tonsils and adenoid glands patient younger than age 12 Consumers and Harvard Pilgrim Surgical Procedures Surgical Procedures Outpatient Diagnostic Tests and Procedures 42820 45385 CMS Shoppable Service Harvard Pilgrim Removal of polyps or growths of large bowel using an endoscope Repair of groin hernia patient age 5 years or older 49505 Harvard Pilgrim CMS Shoppable Service Harvard Pilgrim Harvard Pilgrim CMS Shoppable Service FirstMRI Harvard Pilgrim Surgical Procedures Radiology and Imaging Radiology and Imaging Radiology and Imaging Radiology and Imaging Radiology and Imaging 70496 71275 72110 72197 74183 CT scan of blood vessel of head with contrast CT scan of blood vessels in chest with contrast X-Ray, lower back, minimum four views MRI scan of pelvis before and after contrast MRI scan of abdomen before and after contrast Ultrasound 14 Weeks Single Gestation - Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus Ultrasound of pregnant uterus, 1 or more fetus(es) Vaginal ultrasound of pregnant uterus Ultrasound of fetus 3D Mammogram - Screening digital tomography of both breasts Adding 27 New Adding 27 New Procedures to Procedures to CompareMaine CompareMaine 9.0 9.0 76801 Coastal Womens Healthcare Ob/Gyn 76805 76815 76817 76819 77063 CMS Shoppable Service Coastal Womens Healthcare Coastal Womens Healthcare Coastal Womens Healthcare Legislative Session Harvard Pilgrim CMS Shoppable Service CMS Shoppable Service CMS Shoppable Service Ob/Gyn Ob/Gyn Ob/Gyn Ob/Gyn Ob/Gyn 80048 80055 85730 Blood test, basic group of blood chemicals Obstetric blood test panel Coagulation assessment blood test Laboratory Services Laboratory Services Laboratory Services Outpatient Diagnostic Tests and Procedures Outpatient Diagnostic Tests and Procedures Outpatient Diagnostic Tests and Procedures Outpatient Diagnostic Tests and Procedures Outpatient Diagnostic Tests and Procedures Unassigned Unassigned 93000 Electrocardiogram, routine, with interpretation and report Exercise or drug-induced heart and blood vessel stress test with EKG tracing and monitoring Ultrasound scan of veins of one arm or leg or limited including assessment of compression and functional maneuvers CMS Shoppable Service 93017 Harvard Pilgrim 93971 Harvard Pilgrim Harvard Pilgrim CMS Shoppable Service 95810 Sleep monitoring of patient (6 years or older) in sleep lab Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube Harvard Pilgrim Emergency department visit, very minor Emergency department visit, low complexity 95811 99281 99282 Consumers Consumers, Harvard Pilgrim TopCostUtilization, Consumers, Harvard Pilgrim TopCostUtilization, Harvard Pilgrim 99283 Emergency department visit, moderate severity Unassigned J3010 Fentanyl citrate injection Infusion Therapy Page 13 MHDO BOARD MEETING JUNE 4, 2020
CompareMaine 9.0 Adding 32 entities that have 4-6 of the top procedure categories on CompareMaine AMERICAN CURRENT CARE PA BE WELL MY FRIEND LLC CENTRAL MAINE CLINICAL ASSOCIATES CORPORATION CONVENIENTMD LLC FAMILY FOCUSED HEALTHCARE PLLC FREEPORT MEDICAL CENTER PA HALLOWELL FAMILY PRACTICE LLC HOPE HEALTH PC ISLANDS COMMUNITY MEDICAL SERVICES INC KENNEBEC MEDICAL CONSULTANTS MABEL WADSWORTH WOMEN'S HEALTH CENTER MAINE CENTER FOR CANCER MEDICINE & BLOOD DISORDERS, P.A. MAINE CENTERS FOR HEALTHCARE PA MAINE HEART CENTER MAINE URGENT CARE, LLC MEDOMAK FAMILY MEDICINE LLC MIDCOAST PEDIATRICS PENBAY NEUROLOGY, P.A. PENOBSCOT VALLEY DERMATOLOGY, P.A. PORTLAND WEST FAMILY PRACTICE, LLC RAYMOND REDICARE PC ROYAL RIVER FAMILY CARE, PA RUMFORD COMMUNITY FAMILY HEALTH CENTER, INC. SEBASTICOOK VALLEY HEALTH THOMAS R. MAYCOCK TWIN CITY FAMILY MEDICINE PA WATERBORO VILLAGE PEDIATRICS LLC PA WATERVILLE PEDIATRICS WATERVILLE WOMENS CARE INC WEBBER HOSPITAL ASSOCIATION WELLS FAMILY PRACTICE LLC WISCASSET FAMILY HEALTH Also Adding 42 new NPIs at 15 facilities already reported on CompareMaine
Public Law Chapter 668 (LD 2105) An Act To Protect Consumers from Surprise Emergency Medical Bills-Impact on MHDO 2. Requirements. With respect to a surprise bill or a bill for covered emergency services rendered by an out-of-network provider: B. Except as provided for ambulance services in paragraph D, unless the carrier and out-of- network provider agree otherwise, a carrier shall reimburse the out-of network provider or enrollee, as applicable, for health care services rendered at the average network rate under the enrollee's health care plan as payment in full, unless the carrier and out-of-network provider agree otherwise; and greater of: (1) The carrier's median network rate paid for that health care service by a similar provider in the enrollee's geographic area; and (2) The median network rate paid by all carriers for that health care service by a similar provider in the enrollee's geographic area as determined by the all-payer claims database maintained by the Maine Health Data Organization or, if Maine Health Data Organization claims data is insufficient or otherwise inapplicable,another independent medical claims database; 15 MHDO BOARD MEETING JUNE 4, 2020
Public Law Chapter 668 (LD 2105) An Act To Protect Consumers from Surprise Emergency Medical Bills-Impact on MHDO 4303-E. Dispute resolution process for surprise bills and bills for out-of-network emergency services 1. Independent dispute resolution process 1. C. In determining a reasonable fee for the health care services rendered, an independent dispute resolution entity shall select either the carrier's payment or the out-of-network provider's fee. The independent dispute resolution entity shall determine which amount to select based upon the conditions and factors set forth in this paragraph. In determining the reasonable fee for a health care service, an independent dispute resolution entity shall consider all relevant factors, including: 1.C.(3) The median network rate for the particular health care service performed by a provider in the same or similar specialty, as determined by the all-payer claims database maintained by the Maine Health Data Organization or, if Maine Health Data Organization claims data is insufficient or otherwise inapplicable, another independent medical claims database. If authorized by rule, the superintendent may enter into an agreement to obtain data from an independent medical claims database to carry out the functions of this subparagraph. 16 MHDO BOARD MEETING JUNE 4, 2020
Public Law Chapter 668 (LD 2105) An Act To Protect Consumers from Surprise Emergency Medical Bills-Impact on MHDO Next Steps: MHDO had an initial meeting with Bureau of Insurance to discuss requirements and implementation. Ongoing discussions with the BOI will continue. 17 MHDO BOARD MEETING JUNE 4, 2020
Key Projects for the Next 12 Months Key Projects for the Next 12 Months Develop first annual Pharmacy Report as required by Public Law 470, An Act To Further Expand Drug Price Transparency (Due November 1, 2020) Launch new MHDO website Develop provider database leveraging existing provider data collected Rulemaking Finalize data delivery model improvements (member and provider 2.0) Page 18 MHDO BOARD MEETING JUNE 4, 2020
Key Projects for the Next 12 Key Projects for the Next 12- -18 Months 18 Months Implement new requirements as defined in PL Chapter 668. Anticipating passage of LD 30, An Act To Improve Health Care Data Analysis and LD 2110: An Act To Lower Health Care Costs Draft RFP for competitive bid for MHDO Data Collection, Processing, Storage, Release, Analytics and Other Related Services. Estimated Key Dates and Deliverables : Finalize draft RFP & send to purchases for approval 11/1/2021 Release RFP to field end of January 2022 Bidders Conference February 2022 Proposals due April 2020 Contract award June 2020 Finalize Contract September 2020 Page 19 MHDO BOARD MEETING JUNE 4, 2020
1. Update on external validation of HAI data reported to MHDO via Rule Chapter 270, Uniform Reporting System for Health Care Quality Data Sets, Section 2.I. The MQF and Maine CDC shall develop and implement an external validation process to assure the accuracy of healthcare associated infection data submitted to the NHSN. Each hospital selected to participate in a State external validation study shall cooperate with the State s third-party external validation contractor and provide any hospital medical records or data required to complete the study. 2. Update on 2021 Annual Report: Primary Care Spending in State of Maine (PL Chapter 244) Based on feedback from the Primary Care Advisory Group to leverage regional/national definitions, MQF is working with the New England States Consortium Systems Organization (NESCSO) who has contracted with Onpoint Health Data to develop a multi- state report on primary care investments. A core objective of the initiative is to develop a standardized methodology to report the percent of primary care investments relative to total healthcare spending in six New England states Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, and Vermont. NESCSO will release its report later this fall and will present the project at NESCSO s 2020 annual meeting. Timeline for development of MQF s 2021 annual report: September/October-Convene Primary Care Advisory Group. Early December-MQF finalizes draft report and releases to Primary Care Advisory Group for feedback January 15th- MQF submits final report to the Joint Standing Committee on Health Coverage, Insurance and Financial Services and Commissioner Lambrew, Department of Health and Human Services 20 MHDO BOARD MEETING JUNE 4, 2020
