December 5, 2005

Subscribe to Maine Medicine eNewsletters
Manage Your Subscriptions
Email our Editor...
Maine Medical Association Home Page
. Search back issues
. Plain Text Version
Printer Friendly

Health Plans and State Chamber Appeal Dirigo Savings Offset Payment
In yet another indication of the contentiousness surrounding the various initiatives that make up Dirigo Health, the Maine State Chamber of Commerce, the Maine Association of Health Plans and health plans representing auto dealers and banks filed lawsuits in Augusta and Portland last week asking judges to overturn the decision of the Dirigo Health Agency Board of Directors that would result in $43.7 million of "savings" being recaptured by the state from the health plans.
The Agency's ability to grow the DirigoChoice health plan is largely dependent upon the savings offset payment.  The program now insures about 7,000 people and the additional funds would allow the plan to enroll the 3,000 individuals on a waiting list and a few thousand additional individuals over the course of the next few months. 

Essentially, the lawsuits allege that the savings identified by the Superintendent of Insurance and the Dirigo Health Agency are, in part, speculative and that other savings may be real, but are not attributable to the Dirigo legislation.  On Oct. 29, Insurance Superintendent Alessandro Iuppa issued a decision finding that the savings from the Dirigo initiatives was $43.7 million.   While the staff of the Dirigo Health Agency recommended assessing health plans a smaller amount, on Nov. 22, the directors of the Agency made a decision (4 to 1) to collect the full amount through assessments that will begin in January.

These decisions have implications for Maine physicians inasmuch as the health plans are expected to negotiate in good faith in order to recapture this "savings" from providers, primarily hospitals, although physicians could be impacted as well.  For instance, the $8.5 million increase in MaineCare reimbursement has been included in the savings (only one-half, recognizing that the increase took effect on July 1, 2005) which means that payors may attempt to reduce physicians payments by this amount.  MMA will argue vigorously that any such savings has been more than outweighed by increased physician costs, particularly in liability insurance and also by the increased costs associated with the MaineCare claims management problem. 

MMA will continue to report on the litigation and its impact on Dirigo Health and on Maine physicians in this e-newsletter and in the pages of Maine Medicine.

Health and Human Services Committee Hears Public Comment on Draft State Health Plan
The Legislature's Health and Human Services Committee on Wednesday (Nov. 30) heard testimony from the public on the draft State Health Plan released by the Governor's Office on Health Policy and Finance and the Health Systems Development Advisory Council.  MMA gave testimony the previous week at the series of public hearings held in Brewer, Portland and Lewiston.  The Association's final comments, reviewed by the MMA Legislative Committee on Tuesday evening, were filed with the state on Friday and can be accessed on the MMA website under the "What's New" section at

Among the organizations testifying on Wednesday was the Maine Hospital Association which criticized the draft Plan for its failure to note the MaineCare issues, including the state's failure to pay its bill with hospitals and MaineCare reimbursement policies that erode vital access to physicians and other health care services.  MHA also criticized the draft for its failure to address the inadequate allocation of state resources for community and hospital-based mental health services.  MHA also objected to several of the provisions regarding the state's strict Certificate of Need law, including the Maine Quality Foundation's expanded role in evaluating the need for a project.  The Association also opposed the creation of a working group on rural hospitals and rural health care, a provision that had been supported by the Maine Primary Care Association.

Other members of the public and health care organizations praised the draft for its emphasis on prevention and the management of chronic disease but criticized it for its lack of specificity, its failure to include priorities for medical services and its lack of depth in the mental health and substance abuse section.

Following the receipt of the public comment, the Health and Human Services Committee talked with the chair of the Health System Development Advisory Council and Trish Riley about the concerns raised by the public.  The Advisory Council meets again this coming Friday (Dec. 9) to review the public comments and any recommendations from the Health and Human Services Committee.  A final document is expected early next year. [return to top]

First Fridays CME Programs Continue with Jan. 6, 2006 Program on Medical Practice Compliance
The fourth "First Fridays" presentation was held on Friday, Dec. 2 with about 30 attendees hearing encore presentations from the 2005 Physician Survival Seminars.  Many thanks to the presenters Michael Duddy, Esq., John Gleason, Esq., and Margaret Palmer, PhD., who presented on the topics of managing the unruly patient, employment law, and managing the angry physician respectively.

The next First Friday program will be held on Friday, Jan. 6, 2006 on the issue of Medical Practice Compliance, focusing on the need for a compliance plan in every physician office.  A sample compliance plan will be distributed and practical advice will be offered on how to draft and implement a plan for an office your size.  Speakers will include former U.S. Attorney Jay McCloskey, attorney Kenneth Lehman and an assistant Attorney General.  The program will be held at the MMA offices in Manchester from 9:00am to noon.  The cost is only $60 which includes breakfast and all the course materials.

Watch for an insert in the Nov.-Dec. issue of Maine Medicine which will include the registration material for this program and a list of all the programs offered throughout the year.  More information and registration can also be handled by calling Gail Begin at MMA at 622-3374 (X 210) or via e-mail to

The Association developed the First Friday series of educational programs in response to feedback from members and practice managers who expressed the need for these types of programs in a half-day setting.  Suggesting for future topics can be sent to Gordon Smith at [return to top]

Payor Liaison Committee Seeks Feedback on Tiered Specialty Networks
At the MMA Payor Liaison Committee meeting on Thursday, December 1, 2005, members devoted a substantial portion of a third committee meeting to a discussion of the the "tiered" specialty networks being developed for self-insured clients of Aetna and CIGNA for 2006.  The Committee is very concerned about the selection criteria for development of these networks and about the quality and accuracy of the data on which the plans are making these decisions.  Committee Chair Thomas Hayward, M.D. has asked the MMA staff to track the implementation of these networks and to gather information about physicians included in the networks and appeals by those excluded.  MMA attorneys Gordon Smith and Andrew MacLean are available to help physicians with questions about appeals.  Section 4303 of the Health Plan Improvement Act, part of Maine's managed care patient & provider "bill of rights," may be helpful in preparing your appeal:

Please keep the MMA informed of your experience with these new Aetna and CIGNA networks by contacting Gordon Smith ( or Andrew MacLean ( at the listed email addresses or by phone at 622-3374.  The MMA will ask Aetna and CIGNA representatives to return to the Payor Liaison Committee for further discussion of the "tiered" specialty networks on February 16, 2006.

DHHS Deputy Commissioner J. Michael Hall also spent about an hour with the Committee to update them on the progress of MECMS implementation. [return to top]

MMA Legislative Committee Organizes for Second Legislative Session
The MMA Legislative Committee, chaired by Katherine Pope, M.D., held an organizational meeting for the Second Regular Session of the 122nd Maine Legislature on Tuesday, November 29, 2005.  The group reviewed the list of bills admitted by the Legislative Council for consideration during the second session following an appeal session on Monday, November 28, 2005.  It also reviewed key bills carried over from the first session.  Dr. Dennis Shubert, Executive Director of the Maine Quality Forum, addressed the Committee on the work of the MQF Ad Hoc Committee on Sentinel Event Reporting.  The Governor's Office of Health Policy & Finance has asked Dr. Shubert to report this month on whether to pursue legislation to amend the list of reportable events in the current sentinel event law.

The Committee scheduled meetings for Tuesday, January 10, 2006, February 7, 2006, and March 7, 2006.  Conference calls will take place each Wednesday evening at 7 p.m. beginning January 18, 2005 during weeks in which the Committee does not meet in person.  All members are welcome to participate in the MMA's legislative advocacy work and specialty societies are strongly encouraged to nominate one or more representatives to participate.  Please contact Andrew MacLean ( or Charyl Smith ( for more information.

The meeting agenda follows:




Frank O. Stred Building, Manchester, Maine

November 29, 2005

6 - 9 p.m.





1.          Welcome and introductions (Dr. Pope)


2.         MMA First Session Summary (available) & Second Session Preview (attached) (Dr. Pope)


3.         Maine Quality Forum Ad Hoc Committee on Sentinel Event Reporting

(Ad Hoc Committee November 2005 Report & Preliminary Physician Survey attached) (Mr. MacLean)

        Guests:  Dennis Shubert, M.D., Executive Director, MQF & Mary Mayhew, Vice President of Government Relations, Maine Hospital Association


4.         Update on Dirigo funding mechanism - "Savings Offset Payment"

(Governorís Press Release of 11/22/05 attached) (Mr. MacLean)


5.         Governor's Provider Advisory Group - MECMS (Mr. MacLean)


6.         Key bills carried over from the first session (Mr. MacLean)


        L.D. 17, An Act to Ensure Fair Reimbursement for the Medical Care Provided to State Inmates (MMA supported)

        L.D. 1420, An Act to Establish a Maternal and Infant Death Review Panel (MMA supported)

        L.D. 1631, Resolve, Requiring the State to Reimburse Providers for Costs Incurred Due to MaineCare Reimbursement Delays (MMA supported)

        L.D. 61, An Act to Authorize a Judge to Order Involuntary Commitment of a Person with Mental Illness Not Taking Prescribed Medication (MMA monitored)

        L.D. 151, An Act to Improve the Delivery of Maine's Mental Health Services (MMA monitored)

        L.D. 846, An Act to Prevent Discrimination Against Persons Without Health Insurance (MMA monitored)


7.          Draft State Health Plan:

             (MMAís draft comments attached) (Mr. MacLean)


8.         Quick Updates (Mr. MacLean)

        Blue Ribbon Commission on the Future of MaineCare

        MaineCare Advisory Committee PA subcommittee

        Governor's Drug Importation Task Force

        Maine Coalition on Smoking OR Health

        DNR Orders Working Group

        Coalition for Health Care Access & Liability Reform


9.         Federal budget reconciliation process - Medicare SGR fix (Mr. MacLean)


10.       MHDO Rule Chapter 120, Release of Data to the Public (MMA comments attached) (Mr. Smith) 


11.       Doctor of the Day Program (brochures available) (Dr. Pope)


12.       Physicians' Day at the Legislature:  March 2, 2006


13.       Second session meeting/conference call schedule (Dr. Pope)


14.       Other


15.     Adjourn


  [return to top]

DHHS Officials Outline Plan for MECMS Processing of Crossover Claims
In meetings last week, senior staff of the DHHS briefed representatives of the MMA and Maine Osteopathic Association and the Legislature's Appropriations and HHS Committees on progress in processing Medicare/Medicaid crossover claims through MECMS.  Physicians and other providers have been anxiously awaiting the processing of these crossover claims and the Department recently has begun processing paper crossover claims for those who wish to submit them. 

DHHS expects to achieve Part A and B functionality through MECMS by the end of the year and will then begin user testing.  The Department anticipates that providers will be able to process Part A claims through MECMS some time in January 2006.  Full processing of Part B claims will take place some time after that, depending on the success of the Part A implementation - in late February or early March.

DHHS officials and the State CIO gave their periodic update on the MECMS implementation to the Appropriations and HHS Committees at a joint meeting on Wednesday, November 30, 2005.  The following are key statistics from the briefing:

  • The system is processing fresh claims at an 85% "throughput" rate;
  • The total number of suspended claims is still high at 365,000 with a high number of those claims greater than 90 days in suspense (43%);
  • The number of suspended claims is too high for the State to work down manually given current staffing levels; it likely will take many months to clear the backlog;
  • Interim payments have been reduced to about $5.2 million weekly
  • The Department has identified 9 test sites for the interim payment reconciliation process; it will not now be pursuing reconciliation with providers the State anticipates it owes money;
  • The Department anticipates achieving system stability, including HIPAA compliance by the end of the year.

Today, the HHS Committee unanimously recommended passage of L.D. 1631, Resolve, Requiring the State to Reimburse Providers for Costs Incurred Due to MaineCare Reimbursement Delays (MMA supported).  Last week in outlining his supplemental budget request, DHHS Commissioner Jack Nicholas mentioned that he will include approximately $4 million to reimburse providers for out-of-pocket costs incurred because of the MECMS problems.  The MMA encourages practices to prepare an accounting of these costs, such as interest on lines of credit and additional staff costs, so that you are prepared to submit the accounting in early 2006.  Please keep the MMA informed about the types and magnitude of these out-of-pocket costs by contacting Gordon Smith ( or Andrew MacLean ( [return to top]

Commissioner Nicholas Outlines DHHS Supplemental Budget Request
During the joint meeting of the Appropriations and HHS Committees last week, DHHS Commissioner Jack Nicholas presented an overview of the Department's likely supplemental budget request for the second session.  It will include the following:

  • Compliance with the AMHI Consent Decree:  $1.3 M in FY 06 and $2.9 M in FY 07
  • MECMS implementation costs (Xwave, Deloitte):  $5 M in FY 06
  • MaineCare transformation project:  $2 M in FY 06
  • Transportation costs as result of increased fuel costs:  $862,575 in FY 06 and $1,150,100 in FY 07
  • Consulting costs (actuarial) for behavioral health managed care initiative:  $250,000 in FY 06
  • MaineCare shortfall:  $10-20 M in FY 06 and $10 M in FY 07
  • Audit settlements (school-based rehab):  $3.9 M in FY 06
  • Title IV-E eligibility determinations:  $4.9 M in FY 06
  • Caseworker arbitration settlement:  $1 M in each year
  • Compensation of providers for out-of-pocket costs of MECMS problems:  $4 M in FY 06
  • Medicare Part D "clawback:"  $20-30 M over the biennium
[return to top]

GOHPF Staff Compares State Drug Programs with Medicare Part D
Last week, the Governor's Office of Health Policy & Finance (GOHPF) Pharmacy Manager Jude Walsh made a presentation to the Appropriations and HHS Committees on Medicare Part D, the MaineCare drug program, and the Low-cost Drugs for the Elderly & Disabled Program (DEL).

Ms. Walsh estimates that 239,000 Maine seniors will have drug coverage following the roll out of the Part D benefit.  Approximately 125,000 had no prior drug coverage.

She presented the following summary of the 3 programs:

MaineCare Drug Program

  • Mandatory co-pays $1 - 3 per Rx (current:  voluntary co-pays $2.50/Rx to a maximum of $25/mon.)
  • Fewer drugs covered under Part D

Drugs for the Elderly

  • 42,000 members, 32,000 eligible for Part D, 10,000 remain in DEL (current:  14 classes of drugs - co-pay 20% plus $2/Rx and no asset test, eligible to 185% of FPL)

Part D

  • All drugs covered
  • Eligibles over 150% will pay premiums
  • Asset test - many DEL will be affected
  • >135%:  no premium, must pay $2/generic and $5/brand co-pay, full coverage - no "doughnut hole"
  • >150%:  sliding scale premium, approximately $18/mon., pay 15% after $50 deductible, full coverage - no "doughnut hole"
  • 150% - 185%:  standard plan premiums will vary, likely will be approximately $36/mon., $250 deductible, coverage for first $2250 + 25% co-insurance, subject to "doughnut hole" - no coverage between $2250 and $5100, costs above $5100 - $5 co-insurance or $2-5 co-pay whichever is greater

The GOHPF has planned the following Medicare Part D "Wrap Services" that is planned to be essentially cost neutral - approximately $20 M/year - the same cost as the DEL program.  The scope of wrap services for dual eligibles and DEL members will be similar to the scope of services provided by New York, New Jersey, and Pennsylvania.

  • Co-pays:  50% for brand name with $10 cap
  • Premiums:  100% paid
  • Deductibles:  50% paid
  • "Doughnut Hole:"  80% paid - similar to DEL now
  • Excluded drugs:  6 categories excluded under federal law, including benzodiazepines, will be covered
  • Contract for appeals and exceptions:  the State will conduct a RFP for an external group to manage
  • Outreach:  the State received a $2 M grant from CMS last year to support these efforts and has received a Maine Health Access Foundation grant of $150,000 for this year.
[return to top]

MMA Looking for Nominees for MHINT Governing Board
The Association has been asked to make recommendations for members of the governing board of the new company likely to be formed to operate the Maine Health Information Technology Project  (MHINT) or its successor organization.  Physicians interested should have an interest , and background, in medical technology and medical information systems.

The mission of the Board of Directors of the MHINT NEWCO (as it is called presently) is to establish and sustain a statewide integrated clinical health information sharing infrastructure to improve the quality of health care, enhance patient safety, moderate the growth of costs and make healthcare information available to patients.

The MHINT NEWCO will operate as a non-profit organization responsible for overseeing the implementation and operation of a statewide health information technology network.  MHINT NEWCO will manage all aspects of the governance of the system including the funding and financial management of the organization, hiring and management of an Executive Director, approval of an annual budget and workplan, and promotion of the MHINT statewide and nationally.

The Board of Directors shall have the responsibility for the oversight and control of the property and affairs of MHINT NEWCO.  It will consist of not less than twelve, nor more than 15 persons drawn from geographically diverse regions of the state.

Board members shall be individuals who are recognized high level leaders in their field and who represent major stakeholders.  These individuals must be willing to:

  1.     Assure a high level of commitment and buy-in for the MHINT from their peers
  2.     Provide leadership and opportunities in working with major stakeholders and   potential  funding sources.
  3.     Provide experience and expertise in developing a MHINT business plan
  4.     Provide and/or raise funding to sustain the MHINT
  5.     Participate in discussions regarding the MHINT Technology System based on experience and expertise
  6.     Represent a potential MHINT user or data source
  7.     Represent a consumer as an individual or association

The existing Steering Committee, MHINT staff and a subset of the Governance Committee will serve as the Nominating Committee.  They will contact selected candidates to determine level of interest and a list of candidates for the Board will be presented to the Governance Committee at its next meeting.  The approved list of candidates will be invited to attend a kick-off meeting of the MHINT NEWCO in early January, 2006.

Any MMA member interested in serving on the Board of Directors should contact MMA EVP Gordon Smith at 622-3374 (X-212) or via e-mail to [return to top]

Urge Maine's Congressional Delegation to Fix Medicare Payment Formula
Congress now returns to work in Washington after the Thanksgiving break and will focus on budget reconciliation efforts.  Urgent action on the Medicare SGR formula is necessary as part of this work.  The U.S. Senate has acted to increase Medicare payments to physicians by 1% in 2006, but the House has not yet acted.  If Congress does not act soon, Medicare will cut physician reimbursement by 26% during the next 6 years - including a 4.4% cut on January 1, 2006.  These cuts threaten patients' access to care, as many physicians will be forced to decrease the number of new Medicare beneficiaries they can treat.

Please contact members of Maine's Congressional delegation to urge their support for the Medicare SGR fix.  You can compose an email message on the AMA's Grassroots Action Center website at:

Or, you can call the members' offices at the following numbers:

Senator Olympia Snowe:  202-224-5344

Senator Susan Collins:  202-224-2523

Representative Tom Allen:  202-225-6116

Representative Mike Michaud:  202-225-6306 [return to top]

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