June 4, 2007

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Maine Supreme Court Decision Supports Dirigo Funding

The Supreme Judicial Court of Maine issued a 5 to 1 decision this past week affirming a superior court decision supporting the work of the Dirigo Health Agency and the Bureau of Insurance in determining savings from the Dirigo Program in establishing the controversial "Savings Offset Payment" which provides the bulk of the funding for the program.  Governor Baldacci said he hopes the ruling will "put an end to all these lawsuits and all the parties can get back to the original intent of Dirigo Health."

In the ruling, the court sided with the Baldacci administration while acknowledging that the statute was vague and ambiguous.  Because of the ambiguity, the court gave deference to the Insurance Superintendent's "reasonable interpretation of an ambigous statute."

The cost savings component of Dirigo to be passed on to insurers was supposed to be based upon the savings from reduced charity care and bad debt.   But the Maine Association of Health Plans and two other business organizations sued over the $44 million figure established by the Bureau of Insurance during the first year of the program, claiming that the Dirigo panel included additional categories of savings not envisioned by state lawmakers.  One of the savings attributed to the program was the  increase in MaineCare payments to physicians, for instance. Another major item was the savings attributed to the hospitals holding to the voluntary limits on net operating margins.

The state argued that the Dirigo Board and the Insurance Superintendent had the expertise to interpret and apply the state law and that their determinations were reasonable.

The "Savings Offset Payment" is likely to be replaced this session through legislative action, but no agreement has yet been reached by legislators on an alternative.  Members of the Legislature's Insurance and Financial Services Committee resume deliberations today (Monday) on the issue.

"MMA representatives attended each of the work sessions this past week as the IFS committee struggled with the Dirigo issues and worked on reforming the health insurance market," noted MMA lobbyist Andrew MacLean, Esq.  "These are very complex issues and there are no simple solutions", he noted.

MaineCare MECMS "Visioning" Session Set for Thursday, June 7

MaineCare officials have scheduled a facilitated "visioning" session for providers on this coming Thursday, June 7 from 10:00am to noon at the offices of MaineCare on Civic Center Drive in Augusta.  MMA staff will attend the meeting and provide input but any MMA member or staff that would like to provide input through MMA should contact MMA EVP Gordon Smith via e-mail to gsmith@mainemed.com

The primary purpose of the session is to hear from providers regarding their needs for claims processing as a new MMIS system is purchased through an outside vendor (fiscal agent).  The Office of MaineCare Services intends to issue an RFP for the new system by the end of the calender year.  It is likely to be two to three years from now before a full transition to the new system can occur.

"This session is intended to provide physician offices and other MaineCare providers with an opportunity, in a facilitated session, to provide OMS officials with input on what a new system should look like, what features it should have," noted Smith.  "One place to look for possible suggestions would be the private health plans.  While they are not always exemplary in their performance, generally we don't receive as much criticism from our members of those plans as we do about the poor operations at MaineCare."

The Thursday session will be preceded at 9:00am by a regular meeting of the Governor's MECMS Provider Advisory Group.  "Had you told me two years ago that we would still be meeting as the PAG in June of 2007, I would have told you to have your head examined." said Smith this past week.  "But, unfortunately, I was wrong.  This nightmare known as MECMS still goes on and for many providers has become the proverbial straw that has broken the camel's back.  I learned of yet another medical practice shutting down this week with the physician leaving the state primarily because of MaineCare.  The problem has gone on for far too long and another two to three years for a full transition is unacceptable." [return to top]

Medicare Fee Fix Increasingly Looking Like a Two-Year Deal

Armed with new legislative options for short-term and long-term solutions to the Medicare Sustainable Growth Rate formula, the AMA and key members of an 86 group coalition met this past week with Senate Finance Committee staff to discuss a fix to the formula which, without a change, will lead to a 10% reduction in physician reimbursement effective Jan. 1, 2008. 

The coalition made the case for a minimum two-year fix for the short-term, with repeal of the formula itself in the long-term.  Staff representing Chairman Max Baucus (D-Montana) and Sen. Charles Grassley (R-Iowa) reiterated their intent to continue the new Medicare Physician Quality Reporting Initiative (PQRI) as a voluntary program with positive incentives, indicating that there could be no SGR fix without it.

Maine first district Congressman Tom Allen also met with MMA staff this weekend and indicated that he thought a two-year fix was now likely.  Congressman Allen is a member of the Health Subcommittee of the House Energy and Commerce Committee which shares jurisdiction over the Medicare Program with the House Ways and Means Committee. [return to top]

MMA Executive Committee to Meet on Wednesday, June 6

The 28-member Executive Committee of the Maine Medical Association will meet on this coming Wednesday at the Frank O. Stred building in Manchester.  On the agenda is final adoption of a new mission statement and further deliberations on L.D. 4 and the AMA's Prescribing Data Restriction Program (PDRP).  The Legislature appears poised to enact legislation implementing a state specific approach to the prescribing data issue, allowing any prescriber to opt out of the sharing of their individual data through completion of a form to be sent to them by their state licensing board.

Other major items on the agenda include preparation for the Annual Meeting to be held Sept. 7-9 at the Harborside Hotel and Marina in Bar Harbor, collaboration with the Dan Hanley Center for Health Leadership on two projects, and the Association's Professionalism Initiative, championed by President-elect William Strassberg.

The Executive Committee is chaired by Bangor neurologist Stephanie Lash, M.D. [return to top]

Roderick Prior, M.D. Named Medical Director of MaineCare

MMA was pleased to learn this week of the appointment of Roderick Prior, MD. of Farmington as Medical Director of MaineCare.  Dr. Prior comes to the Office of MaineCare Services after 31 years at Franklin Memorial Hospital.  His background includes the practice of internal medicine, occupational health and hospital medicine.  He also has administrative experience as an HMO medical director and as hospital medical director. 

Dr. Prior also has a background in information technology and served as Chief Information Officer at Franklin Memorial for 9 years.

Dr. Prior is a long-time MMA member and we look forward to working with him in his new position.  In joining new MaineCare Tony Marple, a former hospital CFO, he helps form a new leadership team at OMS that hopefully will move things in a positive direction.  [return to top]

Aetna To Buy Schaller Anderson

From The Arizona Republic, May 25, 2007
Aetna, Inc.'s managed-care Medicaid business is growing through the acquisition of Schaller Anderson, Inc., a Phoenix-based company that helps states manage medical costs for those covered by Medicaid. Schaller Anderson specializes in assisting states control costs of state Medicaid programs. Aetna and Schaller Anderson intend for Phoenix to become the base of Aetna 's national efforts to expand into the Medicaid business. Aetna follows in the steps of other large insurers, such as UnitedHealthcare which acquired PacifiCare in 2005, that are expanding their Medicaid business.

Schaller Anderson has the existing contract with MaineCare to manage the care of 300 individuals in the program.  Following this small pilot, the firm is expected to assist with thousands of MaineCare patients in an effort to save nearly $100 million in the $2.4 billion MaineCare program.  Schaller Anderson set up an office in Portland a few months ago. [return to top]

House Scheduled to Debate Biennial Budget Monday Evening

The 824-page Committee Amendment to L.D. 499, the FY 2008-2009 biennial budget, voted unanimously out of the Appropriations Committee last week became available to the public today.  The legislature's leadership has given House members until 5 p.m. this evening to submit proposed floor amendments and the House likely will debate the bill tonight. 

Of particular interest to the physician community, the $3 million MaineCare physician fee increase in FY 2009 is in this final version of the bill on page 400.  Thanks to all of you who helped get the fee increase to this point.

The Committee Amendment to L.D. 499 reflects total appropriations of approximately $3.1 billion in FY 2008 and $3.2 billion in FY 2009.  The estimated structural gap for the biennium, excluding the FY 2007 ending balance, is approximately $400 million or 6% of projected appropriations.

The budget document includes the following savings in the DHHS, Medical Care - Payment to Providers (MAP) Account: 

  • It includes net deappropriations of $48.1 million in FY 08 & $62.1 million in FY 09, including:
  • $22.96 M in FY 08 & $30.5 M in FY 09 in savings from clinical management of MaineCare members;
  • $9.1 M in each year in savings from implementation of enhanced third-party recovery efforts;
  • $5 M in each year in savings from capping the non-categorical waiver at $90 M;
  • $2 M in each year in savings from prescription drug initiatives;
  • $1.9 M in FY 08 & $4.4 M in FY 09 in savings from an expanded MaineCare private health insurance premium program;
  • $1 M in each year in savings from implementing prior authorization  for radiology services;
  • $0.3 M in FY 08 & $2.2 M in FY 09 in savings from increased MaineCare provider reviews and investigations;
  • $1.3 M in FY 08 & $6.1 M in FY 09 as a result of increased federal matching rates for MaineCare.

The budget document includes the following  adjustments in mental health spending:

  • Part CC deappropriates $6 M in FY 08 & $8.5 M in FY 09 as a result of savings anticipated from implementing a managed care effort for behavioral health services;
  • Part AAAA deappropriates $5 M in FY 08 & $14 M in FY 09 in savings to be achieved by adjusting mental health provider rates, including adjustments resulting from reducing administrative burden, & by redesigning services & other measures that the department may take as specified in the bill.

The budget document includes the following provisions that may interest physicians:

  • Part GG is language relating to the transition from the MECMS to a fiscal agent;
  • Part MM is language relating to the transfer of up to $107.5 M from the General Fund unappropriated surplus to the MAP account for payment of hospital interim payments & settlements;
  • Part GGG increases MaineCare co-payments from $2.50 to $3 per prescription & increases the pmpm cap on total co-payments from $25 to $30;
  • Part LLL sweeps surplus funds from DPFR accounts, including the physician licensing boards, to the General Fund;
  • Part WWW directs DHHS to develop rules to implement the radiology services prior authorization initiative (the MMA will work with the Maine Radiological Society & Spectrum Medical Group to protect the interests of radiologists in this process).

You will find a detailed summary of the budget prepared by the Office of Fiscal & Program Review, the non-partisan staff to the Appropriations Committee, on the web at:  http://www.maine.gov/legis/ofpr/2008-2009_Biennial_Budget_Summary_AFA.pdf.

[return to top]

Legislative Committees Finalize 3 Bills on Patients with Mental Illness Who Pose a Danger

During this session, the legislature has considered several bills generated by highly-publicized incidents of individuals with mental illness causing harm to family members.  The Judiciary Committee has unanimously recommended passage of L.D. 1119, An Act to Permit Mental Health Professionals to Disclose Risks to People Likely to be Harmed by a Patient.  The bill amends the confidentiality provisions of Title 34-B, the section of Maine statutes governing the behavioral health system, to authorize the disclosure of danger. 

This provision provides that "a licensed mental health professional may disclose protected health information that the professional believes is necessary to avert a serious and imminent threat to health or safety when the disclosure is made in good faith to any person, including a target of the threat, who is reasonably able to prevent or minimize the threat."

At a work session last Thursday afternoon, the HHS Committee unanimously recommended passage of L.D. 1033, An Act Regarding the Mandatory Administration of Medication in Hospitals Serving Psychiatric Patients and L.D. 1855, An Act to Clarify Involuntary Admissions for Psychiatric Hospitalizations.  L.D. 1855 is a largely technical bill regarding the involuntary commitment statutes, submitted by the Department.  L.D. 1033 establishes a process for a court to approve involuntary treatment of a psychiatric patient for up to 120 days.  The proposed Committee Amendment to L.D. 1033 is the result of extensive negotiations among interested parties, including the Maine Association of Psychiatric Physicians, coordinated by Senator John Nutting (D-Androscoggin).
[return to top]

MaineCare Pharmacy Budget Initiatives Include Atypical PDL & Brand Name Drug Limit

Late in the biennial budget negotiations last week, the Appropriations Committee adopted 2 new MaineCare drug management initiatives each to save $1 million per year.  First, DHHS will expand the application of the MaineCare PDL to atypical antipsychotic medications.  Currently, the PDL addresses only high doses and duplicate therapy.  The proposed PA process will follow National Association of State Mental Health Directors Guidelines, will not affect established users, and will affect only "new starters."  The Department's psychiatric work group was involved in the development of this proposal.  Second, the Department will institute a 4 brand name drug per month limit with some exceptions.  The MaineCare DUR Committee will discuss these proposals during a meeting at the Office of MaineCare Services, 442 Civic Center Drive tonight from 6 - 8 p.m.  You can view a Powerpoint presentation on these initiatives provided to the HHS Committee last Thursday on the web at:  http://www.mainecarepdl.org/index.pl/home/sfy-08--09-pharmacy-budget-initiatives.

[return to top]

Dr. William Kassler Named New Chief Medical Officer of CMS Region 1

Dr. William (Bill) Kassler has been named the Chief Medical Officer of CMS Region 1.

Dr. Kassler joins CMS after serving 17 years as an officer in the U.S. Public Health Service at the Centers for Disease Control and Prevention (CDC). For the past 2 years Dr Kassler has been a Senior Advisor in the CDC/Washington Office, working on Pandemic Influenza planning, medical informatics, health care policy and fostering collaboration between the public health and health care systems.

Prior to this position, Dr. Kassler served for seven years as State Medical Director for the New Hampshire Department of Health and Human Services.  As chief health official, his responsibilities included both public health and Medicaid, and his priorities were strengthening the system of community safety net providers, and integrating population-based public health strategies and preventive services into clinical care through programmatic collaboration between public health and Medicaid.  He started his career at CDC in Atlanta, where he served as an EIS officer, as a medical epidemiologist in HIV Prevention and later as Chief of Health Services Research and Evaluation in the Division of Sexually Transmitted Diseases Prevention.

Dr. Kassler received his M.D. from the University of Massachusetts Medical School, completed a primary care internal medicine residency at the Rhode Island Hospital in 1988, and is board certified in internal medicine. He was a Robert Wood Johnson Clinical Scholar in health services research at the University of California, San Francisco. He received an M.S. in nutrition from Case Western Reserve University, and an M.P.H. from Berkeley.

Dr. Kassler will join MMA at the annual Practice Education Seminar on June 20th in Auburn to discuss the Physician Quality Reporting Initiative.
He is still a practicing internist at a primary clinic in NH on Fridays. He may be reached at 617-565-1319 or by email: william.kassler@cms.hhs.gov. [return to top]

Maine Hospice Council and Center for End-of-Life Care Annual Meeting and Fundraiser, June 21

You are cordially invited to join us for an afternoon of outdoor activities followed by dinner, awards, and a presentation, "Reflections on Iraq" by Bill Nemitz, Portland Press Herald columnist, on Thursday, June 21, 2007, Sebasco Harbor Resort, Sebasco Estates.  The event will be from 1:00 pm to 8:30 pm, and the registration fee will be $45/person.

The agenda appears below:

1:00 p.m.  Afternoon Activities

  • 9-hole Golf Scramble  ($40 additional)
  • Harbor Cruise ($15 additional)
  • SeaSpray Ocean Kayaking ($55 additional)
  • Beach Walks
  • Canoeing
  • Tennis
  • Horseshoes
  • and other outdoor activities!

4:30 p.m.  Business Meeting
5:30 p.m.  Social Hour
6:15 p.m.  Dinner
7:00 p.m.  Awards presentation
7:30 p.m.  Bill Nemitz "Reflections on Iraq"

Please register by June 15, 2007: 1-800-438-5963   www.MaineHospiceCouncil.org

Proceeds from this event will support the Hospice/Veterans Partnership and other programs of the Maine Hospice Council and Center for End-of-Life Care. [return to top]

Still Room for a Few Enterprising Teams for MMA Golf Tourney, June 18

The tournament will be held on Monday, June 18, 2007 at the Augusta Country Club, a superb Donald Ross designed course that is considered one of the best in Maine. The event will begin with registration and lunch at 11:00 a.m. followed by a shotgun start at noon. An awards program will conclude the day’s events.

The format for the Tournament will be an 18 hole, four person traditional scramble. More detailed rules will be distributed on the day of the tournament.

A generous number of prizes will be awarded to both net and gross winners, as well as for longest drive and closest to the pin.

Register Online [return to top]

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