Appendix 144-505-A - Information Guidelines With Respect to Appropriateness ReviewsThe 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, and8. 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, andc. 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, and5. 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, andc. 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: C.M.R. 10, 144, ch. 505, app 144-505-A