The MaineMDA is actively involved with the Maine collaborative to improve dementia care, alongside the MHCA and the state ombudsman to reduce the unnecessary use of antipsychotics in dementia patients. Our organization work extends beyond the CMS initiative in that it calls for reducing and eliminating all unnecessary use of psychotropics (not just Antipsychotics), in dementia patients, while at the same time preserving the purgatives of licensed physicians and midlevel providers to use these drugs for symptom management in rare cases where there is true psychosis or temporary psychosis due to delirium or severe depression, etc. Our current goal is to reduce use of antipsychotics to below 5% which is more stringent that the state and national goal of 15%, The current rate of use is 17-19%.

We advocate for better Geriatric reimbursement while at the same time educating our members about the MIPS program which currently caps pay raises for physicians at 2% and later at 5%. we believe that CMS needs to recognize that Geriatricians are instrumental in keeping cost down in the top complexity patients and that their efforts should e measured taking into account their skewed statistics. We also want CMS to stop designating Geriatric practices with midlevel providers as multispecialty groups. This is resulting in an Apples and Oranges data comparisons and is negatively impacting Geriatric practices.

Last but not least, we advocate for a primary Geriatric bonus for providing primary care to geriatric patients which is erroneously seen by CMS  as no different than family practice or Internal Medicine.

in 2017 the state of Maine passed legislation to mandate E-prescribing and PMP checks. the MaineMDA worked with the MMA to include language in the statute that exempts care settings where medication management is done by professionals and patients don't have possession of medication. We argued that doctor shopping and duplicate prescription is not applicable to a situation where nurses are taking direct orders from doctors and patients are not taking possession of medications.

With regards to e-prescribing there was language included to exempt providers practicing outside of their office, such as nursing homes. This definition applies to all providers in the nursing homes unless their physical office is location in the nursing home.  Considering that most nursing home providers are also small practices e-prescribing can be disproportionally expensive to purchase. Last but not least, nursing home, assisted living, and independent living settings have chronic EMR integration issues which makes it hard for providers to E-prescribe.  

Currently the state still requires nursing home geriatric providers to submit an annual request of E-Prescribing  exemption, but since all nursing home providers meet the statutory requirement for exemptions, they are all approved without exception. .

Way back in 2013, in collaboration with the ombudsman and MHCA, we pushed for the restoration of the MaineCare bed hold in long-term care.

Our team also supported legislation brought on by one of their officers to put emphasis on the patient’s choice during hospital transfers to SNF facilities. We also advocate for better DEA regulations in nursing homes and assisted livings to reduce paperwork and barriers to care while at the same time reducing waste and drug diversion.

http://legislature.maine.gov/legis/bills/display_ps.asp?paper=SP0179&snum=126

Changes in healthcare system has resulted in the inadvertent erosion of patient choice during transition of care from hospitals to SNF and LTC facilities.

In some extreme cases patient referrals are treated like a healthcare commodity and since the advent of ACOs the government regulators treated closed networks as a legitimate business model.

For small nursing homes and rehab facilities, especially in rural areas this has meant the loss of the two or three hospital referals a month as these patients were instead refereed to facilities affiliated with the hospitals.

A patient from Pittsfield Maine undergoing surgery in Waterville did not go to the small Pitssfield SNF facility for rehab even though the patient and their family would have preferred that if they had a choice.

unfortuantly due to lack of enforecement through the survey process, there has been no instances of citation for hospitals for stearing patients to their affiliates. The pitssfield facility along with some other rurual SNF and LTC facilities are now closed. With the loss of SNF rehab the communities also lost the LTC (long term care), as a result elderly in need of LTC in those closure areas need to be moved away from their communities to facilities far away.

The law also applied to physician choice but there has never been a state citations for hospitals or SNF facilities since its inception.

With the advent of ACOs, hospitals began including SNF and Nursing Homes into their network of affiliations. The initial stated drive was maintaining quality, but in practice that has meant the use of patient referrals as a bargaining chip that disadvantaged small practices in favor of hospital employed physicians who served as medical directors. Facilities gravitated to using hospital based providers as medical directors for the promise of more referrals, for the same reason that, decades ago, they used to employee multiple physicians as medical directors to get more referrals. This practice was a major impetus for STARK laws that restricted compensation for medical directors to services provided, not the promise of referrals.

Federal role in the future:

The STARK laws don't cover this issue and are outdated when it comes to nursing home and SNF referrals, since physicians are no longer the referral source for nursing homes, the hospitals are.

We see an eventual necessity for a Hospital STARK laws to cover Hospital referral conflicts of interests with SNF, LTC, hospital owned home health, and acute rehabs.