June 22, 2003

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Medicaid to Further Limit Brand-name Drugs
Effective July 1, the state Medicaid program, now called MaineCare, will further limit access to brand-name drugs to the 210,000 MaineCare patients, a move expected to save nearly $100 million over the biennial budget cycle.
The State began an expanded prior authorization program in January 2001, a program which the Maine Medical Association aggressively opposed at the time.   The program, though labor intensive and onerous to the physicians participating in Medicaid, has saved nearly $45 million over the past two and one-half years.  Because of  the current state budget crunch, the program has been directed to further cut projected drug expenses over the next two years by 14%, or nearly 100 million dollars.

While the existing program required prior approval for about 100 different prescription drugs, the new expanded program will rank virtually all drugs based upon cost efficiency and clinical appropriateness.  To receive authority for a patient to receive a non-preferred drug, a physician will have to demonstrate that a patient has not received the necessary therapeutic effect from one of the preferred drugs.  The controversial practice of "step therapy" is also expanded. 

For the first time, off-label usage will be prohibited, although some patients currently benefitting from an off-label use will be grandfathered so that prior authorization is not required.  All other scripts for non-labled use will be subject to a requirement to document the reason for the use and to provide supporting clinical trial evidence.

MMA's major objection to the expanded program is the ethical problem inherent in basing a program for vulnerable patients on cost alone.  The placing of a drug on the preferred list is based not upon the efficacy of the drug, but upon whether the manufacturer has negotiated with the state to provide a supplemental rebate.  While patients with private insurance may have the opportunity to pay privately for a recommended drug, medicaid patients would rarely be able to do so.  The Association will continue its advocacy in relationship to the expanded program in the hopes that physician objections and patient interests can be considered.

Questions concerning submission of a pharmacy claim should be directed to 1-888-420-9711.  Questions about the policy should be directed to MaineCare representatives at 1-800-321-5557.

Governor Baldacci signs Dirigo Health Legislation
On Wednesday, June 18th, Governor John Baldacci signed into law a health reform law that many observers have called landmark legislation that will be looked at by states throughout the Country.  Even the New York Times, in an editorial on June 19th, congratulated the State for taking a new tack toward solving the nation's health care problems.  The editorial stated that, "the plan is notable for its boldness in a period of great budgetary gloom in most state capitals.

The basic thrust of Dirigo Health is an effort to transform the amount of money that hospitals and other health care providers currently lose on bad debt and charity care into a revenue stream to subsidize health insurance coverage for the uninsured.  The plan calls for capturing at least $80 million of the $275 million in bad debt and charity care by insuring many of those patients now receiving free care, reducing provider rates accordingly and charging insurance company (or premium payors) a 4% fee to reflect the savings realized from lower provider charges.

While many observers are skeptical about the ability of the state's Dirigo Health product to attract purchasers, even at subsidized rates, the Governor and the Legislature deserve credit for at least trying.  MMA will work with the state to build the program and to make every reasonable effort in the hopes that it can succeed.

The legislation will take effect in early September.  At that time, a quasi-state agency called Dirigo Heatlh will be formed and overseen by an 8-member board.  The five voting members of the Board will be appointed by the Governor and confirmed by the Legislature.  The three non-voting members are designated members of the Governor's cabinet.  Insurance offered through Dirigo Health would be available no earlier than July, 2004.  The product would be offered initially to uninsured individuals, the self-employed and employees of businesses or municipalities with 50 or fewer employees.  Employers would have to pay up to 55% of the premium with employees under 300% of the federal poverty level receiving subsidies for their share of the premium, based upon a sliding scale depending on income.

Participation in the plan would be voluntary, with employers being eligible if they insure 75% of  eligible employees.  FIrst year enrollment is hoped to reach 31,000 persons, with the first year subsidy being provided largely through federal funds of $53 million.  Following the first year, additional funding would be provided by assessing health insurance premiums in the state, not exceeding 4%.

Part of the legislation expands MaineCare eligibility to several thousand adults.  The MMA objected to this expansion without a commensurate increase in reimbursement.  We were successful in restoring the cuts in provider reimbursement in FY 2004-2005.  Other provisions in the law deal with various cost-containment provisions and the creation of a Maine Quality Forum.  In addition, the Superintendent of Insurance is directed to conduct a study of  medical malpractice cases, awards and the availability and affordability of medical malpractice insurance in the State.

Finally, the Department of Human Services is to conduct a comprehensive review of reimbursement rates in the MaineCare program and report the results to the Legislature in Jan., 2005. [return to top]

Medicare Reform Moves Forward in Congress; Changes to Geographic Practice Cost Index Anticipated
The Senate Finance Committee marked up the "Prescription Drug & Medicare Improvement Act" on June 12th and the  proposal is currently being debated on the Senate floor.  Dr. Bill Frist (R-Tn) has stated that the bill will be the only piece of legislation on the Senate floor this week, until it is finished.  In addition to a prescription drug benefit, the Senate proposal also includes some regulatory relief provisions long fought for by the AMA, including barring retroactive substantive changes in regulations, manual instructions, guidelines, etc.  The bill also limits random audits, specifies response time by contractors and permits physicians to rely on  written guidance provided.  In addition, the bill provides funds for physician education and outreach, and bars recoupment of overpayments until the physician's appeal is decided.

Of particular interest to Maine physicians, the Medicare bill that cleared the Senate Finance Committee includes favorable changes to the Geographic Practice Cost Index (GPCI), increasing Medicare payment to areas such as Maine where physicians recieve less than the national average.  Specifically, the GPCI provision would result in an increase in the work component of the Medicare physician update formula to .98 percent of the national average for 2004.  For 2005 to 2008, all three formula components - work value, practice expense and malpractice expense - would increase.  These changes, pushed by Committee Chair Chuck Grassley of Iowa, have been endorsed by the Geographic Equity Coalition in which MMA participates.

While the Senate bill does not contain any physician payment changes, other than the GPCI provisions noted above, the working drafts of the bills in the two House Committees contain language to provide payment updates to physicians and other healthcare professionals of no less than plus 1.5% in 2004 and 2005 and a change to the underlying formula beginning in 2006.  Without such a change, CMS has predicted a payment cut of 4.2% for physicians in 2004. 

Whatever emerges from the House and Senate will eventually have to worked out by a House/Senate Conference Committee which is expected to meet over the summer.

You can help the cause by calling the AMA's toll-free grassroots hotline at 1-800-833-6354. [return to top]

Stephen C. Shannon, D.O., MPH is First Recipient of Dan Hanley Leadership Award
On Friday, June 20th, nearly one hundred fifty persons gathered at the First Annual Dan Hanley Leadership Award Luncheon at Bowdoin College.  The Annual Dan Hanley Leadership Award was presented to Stephen C. Shannon, D.O., MPH, Dean of the University of New England College of Osteopathic Medicine.   The Award was established to honor the kind of courage, innovation and vision that Dr. Hanley demonstrated during his years of practice and service to Maine.  Other attributes considered were kindness, inclusion  and collaboration and hard work.  Selected from over thrity outstanding nominees for the award, Dr. Shannon was found to have already had a profound effect on the way a generation of medical students has come to understand health care and on the way health care is delivered and will be delivered in Maine.

Dr. Shannon has been at the University for the past 8 years and has quietly transformed the medical school, finding ways to be responsive to the needs of Maine communities, patients and providers while improving student experience and readiness to practice. He developed and personally taught population health; secured funding to support greater integration of behavioral medicine; and built a network of clerkships, internships and residency programs, providing exposure to rural primary care practice while expanding access to care.

In addition to his work at the College, Dr. Shannon has played a leadership role in many other Maine organizations involved in health care, including roles with the Maine Medical Assessment Foundation, The Maine Center for Public Health, the Coastal Healthy Community Coalition, the Biddeford Free Clinic,  the Maine Biological Research Coalition, and the Maine Osteopathic Association.

The Maine Medical Association congratulates Dr. Shannon on his receipt of the FIrst Dan Hanley Leadership Award.  We are proud to  count you among our members. [return to top]

"Preparing Your Practice for Change," Presented Wednesday, June 25th in South Portland
The 12th Annual Physician Survival Seminar, "Preparing Your Practice for Change", will be presented this Wednesday, June 25th, at the Portland Marriott at Sable Oaks, in South Portland.  This popular annual program sponsored by the Maine Medical Association is intended to present physicians and their office staff with the major new laws, rules and market trends affecting Maine medicine.

This year's array of speakers is outstanding, with W. Robert Wright, CEO, StarLight Group and representatives of Maine Employers/Business Community keynoting the Wednesday program.  Frank Johnson,  Director of the State Employee Health Program and Peter Hayes of Hannaford Brothers will represent the business community.

In addition to the scheduled presentations, additional presentations on the Governor's "Dirigo Health" have been added, as well as an explanation of the proposed settlement of the class action suit against Aetna.  Medicaid officials wil also be present to discuss new MaineCare initiatives.

Late registration can be accomodated by calling Susan Feener at the MMA office at 622-3374.  Half day registrations are available.  You may also purchase a set of materials from the conference for $35. [return to top]

New Guidelines for Antibiotics for Earaches
To help reduce antibiotic resistance, the American Academy of Pediatrics and the Centers for Disease Control have developed new guidelines that advise physicians to delay prescription of antibiotics for two to three days for many children with earaches.  Physicians write about 10 million prescriptions for antibiotics each year for children with earaches, which accounts for almost half of all antibiotic use among preschool children.  Most earaches are caused by viral, not bacterial, infections, and 81% heal without medication, according to the Agency for Healthcare Research and Quality.  According to the new guidelines, physicians should:

1.  Wait two to three days before they prescribe antibiotics for children older than six months without certain diagnosis of an ear infection;

2.  Prescribe antibiotics for children older than two years with ear infections for five days, rather than seven to ten days;

3.  Immediately prescribe antibiotics for children younger than six months with earaches;

4.  Immediately prescribe antibiotics for children younger than two years with certain diagnosis of an ear infection;

5.  Immediately prescribe antibiotics to children between six months and two years without certain diagnosis of an ear infection but with a fever higher than 102 degrees or severe ear pain. [return to top]

150th Annual Session to be Held Sept. 5-7th at Balsams Grand Resort Hotel, Dixville Notch, N.H.
Registration materials for the Association's Sesquicentennial Meeting, to be held Sept. 5-7 at the Balsams Grand Resort Hotel in Dixville Notch, N.H., were included in the June issue of Maine Medicine.  If you did not receive a copy for any reason, please call the MMA office at 622-3374 and we will be happy to send you the materials.

In adition to celebrating the history of 150 years of caring for the people of Maine, the meeting will feature talks by Michael LaCombe, M.D. and Beck Weathers, M.D., who will speak of his remarkable survival from his experience on Mount Everest.  The usual recreational offerings of tennis, golf,  hiking and running will also be available.  Specialty society meetings of orthopeadic surgeons, anesthesiologists and urologists will also be held.

The Association held its Annual Session at the Balsams continually from l979 through l995.  While the Meeting is now rotated among several popular locations, the Balsams has become a favorite place for many MMA members.  The staff and officers of MMA hope you will consider joining us this year for our very special anniversary celebration at this very special location. [return to top]

Kennebec County Medical Society to Meet Tuesday, June 24 in Manchester
The Kennebec County Medical Society will meet this Tuesday, June 24th, at the Augusta Country Club.  A social hour will be held from 6:00pm to 7:00pm with dinner being served at 7:00pm.  The meeting will feature presentation of awards to winners of the 7th Annual KCMS High School Essay Contest.

Members interested in attending should contact Anna Marie Maheux at 623-5329. [return to top]

For more information or to contact us directly, please visit www.mainemed.com l ©2003, Maine Medical Association