Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 505 - APPROPRIATENESS REVIEW PROCEDURES AND CRITERIA
Appendix 144-505-A - Information Guidelines With Respect to Appropriateness Reviews
Universal Citation: 10 ME Code Rules ยง 144-505-A
Current through 2024-38, September 18, 2024
The following Guidelines are to be used as the framework for task forces. Plan Development committee and Bureau of Health Planning and Development use in the development of specific criteria, standards and a data questionnaire related to the specific institutional health service under review.
A. Document the need which the population served, including low income persons, racial and ethnic minorities, women, handicapped persons and other historically underserved groups, have for the existing institutional health service subject to review. To assist in making this determination the following information may be requested:
1. A description of the community or service
area served by the existing institutional health service. The information
required may include a description of the geographic area served and the
population characteristics of the population residing within the area as well
as, to the extent practicable, the characteristics of any unique group, such as
the elderly, residing in the service area which the particular service under
review is intended to serve. Patient origin studies may be necessary to
adequately document the historical service area of the service under review.
Release of specific data, such as that stored by the Maine Health Data Service
or the Maine Health Information center, may be required.
2. Historical utilization information,
preferably statistical in nature, for the three most recent calendar years (or
such other periods as may be prescribed by the Maine Health Systems Agency,
Inc. and/or the Bureau of Health Planning and Development) of operation of the
existing institutional health service. Such historical utilization data should
be reconciled or reconcilable to the service area/patient origin data described
above. The Maine Health Systems Agency, Inc. (MHSA) and/or the Bureau of Health
Planning and Development (the Bureau) may require that the historical
utilization data be presented on a monthly, quarterly or semi-annual basis.
Releases of specific utilization data, such as that stored by the Maine Health
Data Service or the Maine Health Information Center, may be required.
3. Documentation that the historical
utilization of the existing health service subject to review has been
appropriate, necessary and of high quality. The MHSA and/or the Bureau may
require the facility to provide evidence, including that provided by special
studies, from the Pine Tree Organization for Professional Standards Review or
any other competent organization, including the Medicare or Medicaid fiscal
intermediary, that the level of historical utilization of the existing health
service subject to review has been appropriate, necessary, and of high
quality.
4. A three year projection
of expected future need and demand for the existing health service. The
projection should take into consideration the historical utilization patterns
of the existing health service, expected changes in the population served,
expected changes in the facility's share of the market, expected changes in
other relevant components of the health care system, including expected changes
in other similar existing institutional health services. All assumptions and
sources of data should be disclosed. The facility should also fully disclose
how the projections relating to the service subject to review relate to the
long-range development plans of the institution.
5. A description of the accessibility of the
community or defined service area to the existing institutional health service
subject to review. The description should address the geographic accessibility
of the service, the availability of adequate transportation services to assure
the accessibility of the service and should contain an analysis of the
contribution of the existing institutional health service, if any, in meeting
the health related needs of the members of any medically underserved groups and
groups which have traditionally experienced difficulties in obtaining equal
access to health services (for example, low income persons, racial and ethnic
minorities, women, and handicapped persons) particularly those needs identified
in the applicable health systems plan, annual implementation plan and State
health plan as deserving priority.
6. An analysis of the relationship between
the existing health service being reviewed and the existing health care system
of the area in which the service is provided. The facility should discuss how
the existing relationship is expected to change as it implements its long-range
development plans. The facility should also disclose which alternatives, if
any, might, in its opinion, be more effective and/or less costly in meeting the
need addressed by the existing institutional health service subject to review
and indicate if such alternatives are available and, if not, what barriers
exist which result in such alternatives not being readily available.
7. A description of how the existing
institutional health services subject to review relate to the applicable health
systems plan, annual implementation plan and State health plan, and
8. If applicable, a description as to how the
existing institutional health service subject to review relates to the:
a. special needs and circumstances of
entities which provide a substantial portion of their services or resources or
both to individuals not residing in the health service area in which the
entities are located or in adjacent health service areas. These entities may
include medical and other health professions schools,, multidisciplinary
clinics, specialty centers and facilities which must respond to significant
seasonal population variations, particularly those associated with tourism.
Such entities should be required to provide documentation of the effect of such
special circumstances.
b. special
needs and circumstances of biomedical and behavioral research projects which
are designed to meet a national need for which local conditions offer special
advantages, and
c. the special
needs and circumstances of HMO's. In the case of areawide reviews which result
in institution-specific findings regarding services provided by or through an
HMO, the special needs and circumstances of the HMO shall be limited to:
1 The needs of enrolled members and
reasonably anticipated new members of the HMO for the existing institutional
health services provided by the organization.
2 Whether the services could be obtained from
non-HMO, or other HMO providers, in a reasonable and cost-effective manner
which is consistent with the basic method of operation of the HMO.
B. Document the cost-effectiveness of the existing institutional health service subject to review. In addition to the information provided in response to Question A (particularly that relating to the need for and quality of the service), the following information may be requested to assist in making the determination:
1. Documentation of the availability of
sufficient human resources (health manpower and management personnel) to
operate the existing institutional health service subject to review at an
acceptable level of care. Where specialized medical personnel (such as
radiation therapists) or personnel with special training are required to
provide the service at an acceptable level of care, the facility should be
required to document the availability of such personnel. The facility should be
required to document substantial compliance with any applicable minimum
staffing requirements of the Department of Human Services.
2. Documentation of the availability of
sufficient funds. for capital and operating needs to operate the existing
institutional health service subject to review at an acceptable level of care.
The facility should be required to provide audited financial statements and/or
cost reports prepared for reimbursement under Titles XVIII or XIX for the three
most recent fiscal years (or period which corresponds with the information
requested in Question A 2) as well as corresponding financial information for
the most current budget year as prepared for the Voluntary Budget Review
Organization or the Health Facilities Cost Review Board with respect to the
service under review.
3. Disclosure
of the annual operating cost savings which would reasonably be expected to
result from the discontinuance or reduction of an existing institutional health
service which is inconsistent with the applicable health systems plan, annual
implementation plan, or State health plan as disclosed in response to Question
A 7.
4. An analysis of the
availability of resources employed in the provision of the existing
institutional health services subject to review for the provision of other
needed health services, including less costly or more effective alternative
methods, if any, of providing the service disclosed in response to Question A
6, and
5. Documentation that the
existing facility complies with applicable fire, life-safety and licensure
standards. facilities which are at variance with such standards, including
those for which waivers have been granted, should detail the extent of such
variance and provide a reliable estimate of the cost of bringing the facility
into compliance with such standards.
6. If applicable, a description as to how the
existing institutional health service subject to review responds to:
a. the special circumstances of health
service institutions with respect to the need to conserve energy. The
institution may be required to demonstrate such energy conservation with
resultant savings,
b. the lowering
of system-wide health care costs or improvements in the allocation of health
services through the effect of competition on the supply of the health care
services being reviewed. Documentation of such reduction of system-wide health
care costs or improvements in the allocation of health services may be
required, and
c. improvements or
innovations in the financing and delivery of health services which foster
competition resulting in lower system-wide health care costs, improvements in
the allocation of health services or the promotion of quality assurance and
cost effectiveness. Documentation of such improvements may be required. Basis
Statement:
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