March 6, 2006

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Update on MaineCare Crisis
Relations between MaineCare providers and DHHS were strained last week by announcements of further delays in the MECMS system and by concern that the program will run out of funds by the end of the state's fiscal year.
The past week has been a difficult one relative to the MaineCare program.  The Association, along with the Maine Osteopathic Association, held a number of meetings with Commissioners Harvey and Wyke, Deputy Commissioner Hall and the Governor because of what we considered a deterioration of the already tenuous situation.  The precipitating events were:

  • The announcement that the electronic processing of the Part B crossover claims, previously expected to occur in March, would be delayed until July.
  • The continuing delay in the processing of the primary care case management fees, which have not been paid since last April.
  • The acknowledgment that anesthesia claims are not processing correctly because of problems with the modifiers.
  • A letter sent by the State to all MaineCare providers announcing that, immediately, the state would impose a cap on the amount of MaineCare payments sent out each week, because of a shortage of funds.
  • A presentation by state officials before the Legislature's Appropriations Committee which, to some in the audience, sounded like the state was blaming its financial problem on providers who had collected "double payments" by accepting interim payments and then received regular claims payments as well. An undated letter to MaineCare providers mailed around Feb. 23 made the same suggestion.  The state has since apologized for the tone of the letter.

The meetings were respectful but direct.  MMA and MOA representatives expressed that these latest events could be the proverbial straw that breaks the camel's back.  The MECMS problem is now over a year old and Mainecare providers need to know that all available resources are being utilized to fix it.

In order to assist providers on the Part B cross-over claims, the state is preparing to announce this week an expedited process for paper claims.  The state went through the likely elements of this process with us Thursday night and the process as described does seem promising.   It will assist those practices which are not able to wait a few more months for the processing of the Medicare tapes.

On the financial side, the state begins the fourth quarter of the fiscal year on April 1st and is planning to finance the program with an anticipated recovery of $300 million in interim payments.  But because the claims processing is still not at the level of stabilization, many observers do not believe the state will be able to recover nearly that much by July 1, 2006.  MMA and MOA have asked the state to develop a contingency plan for how claims will be paid in the fourth quarter if the recovery of the interim payments comes up short.

Physicians represent a very small piece of the recovery process.  This is not surprising as physician payments make up only about 2.5% of MaineCare.  Most of the $300 million in interim payments was paid out to other types of providers including nursing homes, mental health providers, institutional providers for the mentally retarded, etc.

Any physicians who have been asked to pay back interim payments should be sure to communicate back to the Department regarding the options presented.  And no recovery will be required presently unless claims for the practice are now processing properly.

Watch for further communications from the state this week, and watch for a further update next week in Maine Medicine Weekly Update.

Maine Supreme Judicial Court Strikes Down Portion of Pre-Litigation Screening Panel Law
In a 4-3 decision issued March 1, 2006,  the Supreme Judicial Court of Maine invalidated as unconstitutional an element of the pre-litigation screening panel system.  The panel system, a linchpin of the Association's tort reform efforts of the past twenty-five years, has been widely heralded as being successful in keeping Maine's liability premiums below the national average.  The panel system was adopted by New Hampshire's legislature last year after a two-year effort by that state's physicians.

In Smith v. Hawthorne, a bare majority of the court determined that more information should have been disclosed to the jury about the panel's decision in a case where the panel unanimously found for the patient on the issue of negligence but found for the defendent physician on the issue of causation.  For the 17 years the panels have operated, in such a situation, the finding on causation would be admitted as evidence to the jury, but not the finding on the negligence issue.  The reason for the dichotomy is a very simple one.  The legislature in designing the panel system in l987 intended to replicate the process that happens in court; i.e., a plaintiff must prevail on both the issue of negligence AND the issue of causation in order to achieve a recovery.

The Association, Medical Mutual Insurance Co. of Maine and other interested parties will review the decision carefully and make a decision as to whether a legislative fix is required or whether the number of cases where these circumstances exist is small enough to leave it well enough alone.  Presumably,  judges will now simply allow the introduction of the panel's decision on both questions.

The dissenting decision, written by Justice Jon D. Levy, and joined in by Chief Justice Leigh Saufley and Robert Clifford, was very supportive of the panel system.  Levy warned that the majority opinion "invalidates" a key provision of the act that establishes the review panel process.  It also undermines the inducement to settle non meritorious medical malpractice claims that the statute was intended to achieve," he wrote.

"The court's analysis...occurs in a vacuum, divorced from any consideration of the statute's legislative purpose," Levy added.  He continued in strong language, "This approach is perilous...We risk overstepping our institutional bounds as a coordinate branch of government when we invalidate an act of the Legislature without having weighed and accounted for the public policy the Legislature has sought to advance."

In a Bangor Daily News article on the decision last Friday, the News noted that the case was argued twice before the law court and speculated that it was most likely reheard to allow the newest Justice, Warren Silver, of Bangor, to break the 3-3 deadlock.  Justice Silver replaced Paul Rudman on the court last Fall.  Silver was a well respected and prominent Bangor attorney who served a term as President of the Maine Trial Lawyers Association.  He was a sharp critic of the MMA's liability reform efforts and was involved in the MTLA's efforts in the legislature.

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MMA Executive Committee Approves Practice Self-Assessment Project
At its meeting last week, the MMA Executive Committee approved a proposal to be presented by MMA and the Maine Osteopathic Association to the Maine Quality Forum involving practice self-assessments.  The self-assessments would be offered initially to primary care practices and the assessments would be conducted by a nurse reviewer or other health professional who would utilize a quality-assessment tool to be developed as part of the project.

Because of the statutory protection of confidentiality of internal quality improvement data if collected under the auspices of a professional association, the Forum is likely to do a sole-source contract with MMA and MOA in order to sponsor the project.  It is hoped that between 50 and 75 assessments can be done in a 12-month period.

Both associations are already soliciting practices willing to have the self-assessment done.  The results of the assessment would be provided only to the practice.  There would be no charge for  participation in the project.  Primary care practices interested in participating should contact Gordon Smith at [return to top]

New Website Feature Making it Easier for You
MMA members can now pay their MMA membership dues on-line!  As part of our redesign of the MMA website to make it easier and more beneficial for our members, we are now accepting payments on-line.  We accept MasterCard and Visa and it is a secure process.  The secure form can be found in two locations on the home page index for the site - under "Member Services" or "About."  Just enter the requested information, press submit, and that is all there is to it!  You will receive an emailed receipt showing that your payment has been received.  If members have questions regarding the amount they owe, they should contact Lisa Martin at 622-3374 ext: 221 or

In addition to being able to pay your membership dues on-line, you can also make your Maine Political Action Fund (MPAF) contributions on-line.  This secure form can be found on the home page index under "Maine Physicians Action Fund." [return to top]

Penobscot Community Health Center Seeks CMO

Dynamic Federally Qualified Health Center with over 70 full and part-time providers and rapidly growing, seeks CMO to provide overall clinical leadership, working with a team of exceptionally talented and dedicated clinical and administrative leaders and providers in Family Medicine, Pediatrics, Internal Medicine, Psychiatry, Oral Health, Specialist Medicine, Services for Persons who are Homeless, Public Health, Pharmacy, Lab, X-Ray and other services. Candidates must be passionate about integrated health care services, public health, the vision that health care is a right, and building a model system focused on the patient and family.

We are looking for a physician with exceptional skills in collaborative leadership, collegial team-building, written and verbal communication, systems-building, conflict resolution, and public speaking. Must be willing to work long hours to build a better health care system of quality, integrated, comprehensive community health care. This is an opportunity to make a significant difference in Maine and nationally. Five day a week position, with clinical practice around two days. Prefer experience in quality assurance/performance improvement, prevention and care model programs, provider compensation plans, and evidence-based programs. Extraordinary opportunity to think globally and act locally. Please send cover letter and resume to Ken Schmidt, MPA, Chief Executive Officer, Penobscot Community Health Center, 1048 Union St., Suite 5, Bangor, ME 04401 or [return to top]

The Coding Center's Coding Tip of the Week
Modifier 25:Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

  • A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see E/M guidelines for instructions on determining level of E/M service).In other words—a SOAP note.

  • Examples:

    • The patient presents for a planned procedure and has different problem that requires an E/M service
      (Two different diagnoses would be used)

    • The patient presents with a problem and after evaluation the decision is made to perform a “minor” procedure. “Minor” means that the post-operative period (if any) is less than 90 days.
      (The primary diagnosis can be the same)

    • In both of these cases, it would be appropriate to bill the E/M service with a 25 modifier and the procedure performed on the same day

Questions? Call the Coding Center: 1-888-889-6597. [return to top]

New England Council Seminar on HealthCare IT Attracts 150 Attendees
The Augusta Civic Center was the site of a HealthCare IT conference last Tuesday, sponsored by The New England Council and co-sponsored by MMA, Martin's Point and the Maine Primary Care Association.  Governor Baldacci presented the keynote address and spoke to the importance of technology to his Dirigo Health initiatives.

The major focus of the morning program was the Maine Health Information Technology (MHINT) project which is beginning its Phase II implementation phase.  The MHINT network will collect patient medical information in a central on-line depository and make it available to project participants including physicians, hospitals, nursing homes, pharmacies, labs, etc.

Karen Bell, M.D., Director of the Office of Health IT Adoption at the Office of the National Coordinator for Health Information Technology at DHHS was the other featured presenter and provided an update on the Office's activities.  Dr. Bell had served as Medical Director for Anthem Blue Cross Blue Shield of Maine before leaving Maine to take a position at BCBS of Rhode Island.

More information on the MHINT project is available online at [return to top]

MMA Wants Your Vote!
The MMA website ( has a weekly members-only poll question featured on a monthly basis.  This is a way for us to get your opinion on a particular issue.  In order for us to get a true reflection of where MMA membership stands on a particular issue, we are asking that you please take a moment each month to place your vote.  It's simple.   All you need to do is toggle on a button indicating your vote and then press submit.  The poll question is located at the bottom of the MMA website home page.

You do need to be registered as a member to do this, as you will be asked for a username and password.  If you have not yet registered for our members-only portion of the website, the process is as follows:  In the upper right hand corner of our home page you will see a gray box that says "Register," click on this and it will bring you to a registration form.  You then need to agree to the terms (box to check off) and then fill in the bottom of the form with your full name, email address, desired username, desired password, and you need to confirm the password. Then press submit.  Once this is completed, you will have full access to the members-only portion of the site.  Whenever you go into a members-only area, you will be asked for your username and password.  Should you have any questions or problems registering, please contact Shirley Goggin at or call her at 207-445-2260.

Website poll questions will be changed the beginning of each month, so please take a moment monthly to place your vote. [return to top]

Save the Date: Wednesday June 7 for Annual MMA Corporate Affiliate Breakfast
The Fifth MMA Annual Corporate Affiliate Breakfast will be held this year on Wednesday, June 7 at the Haraseeket Inn in Freeport.  Registration will begin at 7:30am and the breakfast will conclude by 9:30am.  Invitations will be sent to each MMA Corporate Affiliate soon.  There is no charge for the event.

MMA has nearly 90 corporate affiliates who provide various goods  and services to MMA members and their practices through a variety of programs.  Among the benefits of affiliation are a link from the MMA website and discounted exhibit space at MMA seminars and at the Annual Meeting.

Questions about the event may be directed to Lisa Martin, the Association's Membership Coordinator at [return to top]

John C. Dalco, M.D., 1934-2006; First Director of Physician Health Program
The Maine Medical Association was saddened last week to learn of the death of John C. Dalco, M.D. on Feb. 8, 2006 at the age of 72.  Dr. Dalco was the first Director of MMA's Physician Health Program and served in that capacity for some 15 years before retiring and passing on the torch to David Simmons, M.D. who had served as Assistant Director of the program during the last two year's of Dr. Dalco's directorship.

It is not an overstatement to say that Dr. Dalco founded the Physician Health Program in Maine and made it a model for the country.  He was a frequent lecturer across the country on physician health and addiction issues and was active in the Federation of State Physician Health Programs. He was a member of the AMA, the Massachusetts Medical Society, MMA and the American Society of Addiction Medicine.  He also practiced as an internist in Scituate, MA for 35 years.

In his years serving Maine physicians, John helped dozens of physicians with their recovery from addiction and he will be sadly missed.  Our condolences to his wife of 40 years, Claire and his son, John C. Dalco, Jr. and his wife Theresa.  Contributions in John's name may be made to the American Cancer Society, 30 Speen St., Framingham, MA 01701.

Condolences may be sent to Claire Dalco at 7 Rocky Hill Circle, Scituate, MA 02066.  The MMA Committee on Physician Health will determine an appropriate way to recognize Dr. Dalco's contribution to the program and members will be informed of what that recognition will be. [return to top]

Medicare Payment Advisory Commission Issues Report on Medicare Physician Payments
On May 1, 2006, the Medicare Payment Advisory Commission (MedPAC) released a report recommending a 2.8% increase in Medicare's physician conversion factor next year.  It makes a number of recommendations regarding the five-year review of the work component of Medicare's Resource-Based Relative Value Scale as well.

The report, which also contains recommended 2007 updates for other Medicare providers, was the subject of a hearing before the House Ways and Means Health Subcommittee.  Submitted testimony from the AMA endorsed the Commission's recommendations for the 2.8% update in lieu of the 4.6% cut that CMS is now predicting based on the existing formula, but questioned the Commission's expectations regarding increased physician productivity.

To reach a conclusion regarding payment updates, MedPAC attempts to evaluate the adequacy of current Medicare payments as well as beneficiaries" access to care.  This year's report concludes that the volume of physician services "continues to show significant growth" and "the large majority of beneficiaries are able to obtain physician care."  However, the report also indicates that some volume growth may be associated with "small improvements" in the quality of care and that the increased use of physician services has in some instances led to reductions in "potentially avoidable hospitalizations."  It further observes that "some subpopulations of beneficiaries may be experiencing more difficulty accessing primary care physicians in recent years."

While none of the physician and patient surveys examines by MedPAC indicated significant access problems, Commissioners expressed concern over the multi-year payment cuts that are projected under the SGR and cautioned that"consecutive, annual cuts would threaten access to physician services over time."  As a result, the report calls for a 2007 update based on inflation in physicians' practice costs (estimated to be 3.7%).  But it also makes a negative adjustment to reflect productivity improvements that physicians are expected to make to offset increased costs of practice, resulting in a recommended update of 2.8%.

The 0.9% productivity adjustment to physicians' update is twice as high as the productivity adjustment the Commission recommended for inpatient and outpatient hospital updates.  In addition, while hospitals' 3.55% update would be fully funded, the Commission's cost estimate assume that for physicians, Congress ill enact another unfunded payment fix where the cost of the update is not built into the SGT target, effectively requiring physicians to cover the cost through additional years of pay cuts in the future.

This prompted the AMA in its testimony to the Ways and Means subcommittee to object to disparities between MedPac's hospital and physician payment recommendations.  Because physicians are already at full capacity seeing patients and complying with layer upon layer of administrative paperwork burden, there is simply no reason to suggest greater productivity by physicians than hospitals, the AMA said.  Further, with the latest CMS estimates already predicting nine year of cuts totaling 34%, Congress really must find the money to fund positive updates because each "temporary fix merely digs the physician payment system deeper into a hole that, each year, becomes more costly for Congress to fix and increases the risk of a meltdown in Medicare patient's access to care."

Due in part to its perception that Medicare cuts "may disproportionately affect primary care providers" and contribute to potential shortages of these physicians, the Commission also made several recommendations that affect the five-year of physician work values and the deliberations of the AMA/Specialty Society RVS Update Committee (RUC).  The report commends the RUC for its work.  However, it also expresses concern that the physician community does not do an adequate job of identifying overvalued services and recommends the creation of an "expert panel" to help Medicare officials identify "potentially overvalued services" for review by the RUC.  The RUC has also acknowledged the need to identify potentially mis-valued services and created a new subcommittee to deal with this issue. [return to top]

New Fact Sheet for Physicians on Part D Transition Policy and Exceptions and Appeals
On Feb. 24, 2006, the Centers for Medicare & Medicaid Services (CMS) released a fact sheet for physicians and other prescribers that explains the new transition policy, as well as the exceptions and appeals process for the Medicare Prescription Drug Benefit.  This resource is designed to provide ready-links to tools that will streamline the prescribing process under the new benefit.  CMS continues to work with groups representing physicians, pharmacists, patients and Part D plans to simplify and standardize the information that physicians need to provide to plans.

A number of resources for physicians are listed on the provider section of the CMS website at where physician offices will find phone numbers to the plan's coverage determination telephone lines, as well as copies of model forms that will help streamline and expedite the process.  In addition, this information is available through Medicare Learning Network at [return to top]

MMA & MOA Host Successful Physicians' Day at the Legislature
On Thursday, March 2, 2006, the MMA and the Maine Osteopathic Association sponsored a second Physicians' Day at the Legislature for the 122nd Maine Legislature.  During the first session, Physicians' Day focused on the medical liability reform effort and L.D. 1378.  This year, the organizations' chose to highlight physician efforts to improve the quality of health care in Maine.  Beginning with a welcome by Governor John Baldacci and the two physicians in the Maine legislature, Rep. Tom Shields, M.D. (R-Auburn) and Rep. Lisa Marrache, M.D. (D-Waterville), the day then gave participants an opportunity to mingle with legislators informally over coffee in the State House Hall of Flags, to observe proceedings in the House and the Senate chambers, and to follow committee action in the afternoon. 

For more on this event and other legislative concerns, read the MMA's weekly Political Pulse. [return to top]

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