August 16, 2004

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MMA Continues Work on Prior Authorization Improvements
MMA staff continues to receive more feedback from members on MaineCare's prescription drug prior authorization program than any other single issue. MMA continues to pursue a dialogue with DHHS staff on ways to improve the program and to minimize the harm to patients.
The Prior Authorization Subcommittee of the Medicaid Advisory Committee is pushing ahead on its review of the PA process. Several pages of questions were submitted to the Bureau of Medical Services for its review and response, helping the subcommittee focus its work. Susan Chisholm from Maine Things Considered on Maine Public Radio is attending the September 7 meeting with the purpose of learning more about the issue and giving it some airtime. She envisions an introductory piece now with a follow-up when the subcommittee issues their report. The subcommittee is looking at Vermont law, which allows a physician to determine a PA request to be final and medically necessary so it will be automatically approved. While the Vermont law has had some trouble, the subcommittee hopes to learn from its experience and perhaps incorporate some of the laws more salient pieces.

Nearly one year ago, in a meeting with the acting DHS Commissioner and Dr. Timothy Clifford, MMA staff suggested that if a physician took the time to complete the prior authorization request, the request should be granted.  This recommendation was premised upon the fact that the physician had personally examined the patient, had a history with the patient, and was certainly in a better position to know what drug would be better for this particular patient.  Unfortunately, MMA's suggestion was quickly rejected, but it is good to see the issue surfacing again at the Medicaid Advisory Committee.

MMA members having problems with the process should notify MMA so that we can monitor the program more effectively and be more aggressive in our advocacy for members and their patients.  PA issues can be brought to the attention of either Mr. Smith, Mr. MacLean or Ms. Bragdon.  All can be reached at 622-3374 or via e-mail at;;

Maine Quality Forum Meets
The Maine Quality Forum held its monthly meeting last Friday, during which time they received an update on Dirigo, as well as the Technology Subcommittee, which is looking at EMRs as well as nurse staffing ratios. The most interesting part of the meeting was the release of a draft website which the Forum intends to be used by the public to research health care information. The public would eventually access rating information on physicians as well as data on frequency and outcomes of surgery and medical admissions.  Dennis Shubert, MD, the executive director of the Forum, welcomes comments. For a copy of the draft, which can be emailed to you, please contact Diane McMahon at

Dr. Shubert has solicited input from both the Maine Medical Association and the Maine Hospital Association on the types of data that would be available on the website.  A great deal of data on geographic variations in surgery and medical admissions is available from the Maine Health Data Organization (MHDO) and would be put on the website.  Links to a great deal of of other sites would be included as well, including, for instance, a link to the Maine Health Management Coalition at

While data on individual physicians could not be included without a change in the MHDO rules, data on physicians is available at the individual health plan level, at Medicaid and at Medicare.  It is also likely that a rule change will be sought to allow the disclosure of some types of data on individual physicians.  Watch the pages of Maine Medicine Weekly Update for continuing information regarding this important topic. [return to top]

Legislature Returns for Confirmation Day
The Maine State Legislature will return to Augusta for one day for what's called Confirmation Day on Wednesday, August 25. The legislators will come in only to act on the Governor's pending nominations. Although there had been some hope that the legislature would address the outstanding bond issues (i.e. Land for Maine's Future), it appears unlikely that an agreement between the Democrats and the Republicans can be reached beforehand. No other substantive work is expected to be done.

MMA representatives will attend the session to talk with legislators about the upcoming election and to discuss pending healthcare issues expected to be addressed in January. [return to top]

DEA Releases New Pain Management Guidelines
On August 11, 2004, the U.S. Drug Enforcement Administration (DEA) released new pain management guidelines designed to address the "aura of fear" among physicians in prescribing pain medication.  The guidelines are a list of 29 questions and answers (FAQs) developed with input from medical experts.  The DEA made 50 arrests of physicians for alleged improper prescribing practices.  The trend is toward fewer arrests with the number averaging 70-80 during the past decade.  The Portland Press Herald  on Monday (8/16) editorialized in favor of the new guidelines, noting that the new guidelines have a good chance of helping the 40 percent of patients who, "are suffering needlessly with severe pain." 

Generally, the rules spell out the steps physicians must take to prescribe adequate pain medication without attracting scrutiny from the DEA or other state and federal agencies.  The guidelines are consistent with the rules issued by Maine's Board of Licensure in Medicine and the osteopathic board  three years ago  on the same subject.. 

The new guidelines are available on the internet at: [return to top]

Global Budgeting the Subject of Hospital Commission Meeting
The Hospital Study Commission on Monday (8/16)  heard a presentation by Albert Charbonneau, a former hospital administrator and CEO.  Charbonneau worked for years in Rochester, NY with the Rochester Area Hospital Commission on cost containment.  They convened meetings of all nine area hospital CEOs every Friday for 10 years, with a state and federal anti-trust exemption to achieve cost savings and quality improvement.  They agreed to a set revenue level and created incentives to reduce inpatient utilization and increase outpatient utilization.  They also had a regional contingency fund of 1% of the total payment base which they used to support increased costs and CON.  Formed from instability in the reimbursement arena, the Commission lasted for 10 years before it fell apart.  Another group was then created in response to healthcare costs rising, in which they brought in business, consumer and providers to create independent objective data, linking quality and cost.  At the request of the medical association, the new group created community-wide clinical guidelines, standardized onto one page.

After the presentation, the group discussed many of the ideas brought up and expressed interest in pursuing some of the same processes.  The commission has a deadline of November 1 to release its report but is considering a two-week delay so that they will get more press (November 2 is Election Day).  Apparently, eight sections of the report have been drafted but only released to Commission members. [return to top]

"Dirigo" Physicians to Meet with MMA Committee August 31
Physicians serving on any Dirigo Health Board or Commission have been invited to meet with MMA's ad hoc Committee on Health System Reform in order to exchange ideas and to help ensure that the pieces of Dirigo are communicating with one another. The meeting will be held on Tuesday evening, August 31, 2004 at the offices of the Maine Medical Association in Manchester at 6:00pm.  Dinner will be available.

Last year, the Association's ad hoc committee issued a white paper on health system reform that called for universal coverage to be achieved through compulsory health insurance.  The Committee is chaired by MMA President Maroulla Gleaton, M.D., a practicing ophthalmologist from Augusta. [return to top]

Penobscot County Medical Society Celebrates in Orono September 18th
The Maine Center for the Arts on the University of Maine campus in Orono will be the site of an important anniversary celebration on Saturday evening, Sept. 18.  The Society was organized on Feb. 15, 1854 at the home of Dr. Hosea Rich of Bangor, making it the oldest county medical society in the state.  On the 18th, MMA and the county society will join together to host an anniversary gala featuring a program highlighting many of the events in medicine in Maine over the past one-hundred fifty years.  A special video is being prepared for the occasion.

Invitations should have been received by every Penobscot County physician and by every MMA member in the counties of Hancock, Washington, Aroostook and Piscataquis counties.  The event begins with a reception in the lobby of the Maine Center for the Arts at 5:30pm with a dinner at 7:00pm followed by the program at 8:00pm.  While invitations have been sent to the group noted above, the 8:00pm program will be open to the public.  A special supplement is being published in the Bangor Daily News on Monday, Sept 13 to commemorate the event and the history behind it.

Don't miss this exciting event.  If you haven't returned your RSVP, please do so soon. If you need a ticket, call Chandra Leister at 622-3374 or  All practices in northern and eastern Maine have been asked to participate in the program through attendance and sponsorships.  Hospitals have been invited to participate as well.  For more information on sponsorships, call Gordon Smith at 622-3374 or [return to top]

AMA, ACP Study Distribution of Health Care
Two high-profile papers were recently produced by the AMA and the American College of Physicians defining the roles and ethical responsibilities of physicians, insurers, employers and patients in making health care coverage and resource allocation decisions.  The AMA report was a project of its Ethical Force Program and is set to be published in an upcoming volume of the American Journal of Bioethics.  The ACP paper was produced by its Center for Ethics and Professionalism and appeared in the July 20 issue of the Annals of Internal Medicine.

The AMA report, "Ensuring Fairness in Health Care Coverage Decisions," calls for the processes of designing and administering health benefits to be transparent, participatory, equitable and consistent, sensitive to value and compassionate.

The ACP report, "Ethics in Practice:  Managed Care and the Changing Health Care Environment." is a statement of principles calling for respectful, truthful, fair and compassionate relationships; shared responsibility for stewardship of health care resources; fostering the ethical delivery of effective and efficient care; and informing patients about care and treatment options and the financial issues affecting the provision of care.

Links to the papers are available as follows: [return to top]

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