November 24, 2008

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July 1, 2008 MaineCare Fee Increase Coming January 1, 2009

The physician fee increase enacted in 2007, retained in 2008 and expected July 1, 2008 is currently the subject of emergency rulemaking that will permit the fee increase to be incorporated into MaineCare payments beginning on January 1, 2009.  The increase will eventually be retroactive to July 1, 2008, but technical issues are delaying the payment.

MaineCare Director Tony Marple informed MMA staff this week that a request by MMA to have the rulemaking be done on an emergency basis has been accepted and that the expedited process will mean the increase will become effective on January 1, 2009.  Exactly when a check for the difference between the old fees and the new fees will be paid for the retroactive portion is still uncertain.  Department lawyers will be examining whether the emergency rule can be applied retroactively.

In 2007, the legislature approved a $3 million appropriation to increase physician fees which combined with the federal match will increase payments by more than $8 million.

1st Circuit Court of Appeals Finds NH Ban on Prescription Data Mining Constitutional

In a ruling that is likely to affect Maine's law allowing physicians and other prescribers to "opt out" of prescription data mining activities, the 1st Circuit Court of Appeals in Boston ruled last Tuesday that the New Hampshire law banning such activity is constitutional.  The ruling overturns a decision last year in the federal district court in New Hampshire finding that the law infringed on free speech and was therefore unconstitutional.  Maine's more modest law also had been struck down last December by federal district court Judge John Woodcock, who relied heavily on the New Hampshire decision in writing his opinion.

The Appeals Court found that the law did not impinge on free speech, but even if it did, concluded that it would still be lawful given the appropriate balancing of interests.  The appeals court concluded that New Hampshire legislators enacted the law as part of a legitimate attempt to promote the delivery of cost-effective health care.

The New Hampshire law, the first of its kind in the country, prohibits pharmacies from selling physician prescribing data to companies such as IMS Health Inc. and Verispan, LLC.  IMS and Verispan are two of the major "data-mining" companies who purchase the data, repackage it, and sell the information to the pharmaceutical manufacturers who then use it in their marketing strategies.  No information that personally identifies patients is released, but the identity of prescribers is not protected.  The New Hampshire law prohibited the sale of such data.  Maine's law is not as strong, but does allow physicians and other prescribers to make an election through their licensing boards to prohibit the sale of their data.  Vermont's law is between the two approaches, allowing the data to be sold only if a prescriber "opts in."  Both the Vermont law and the Maine law are currently on hold pending a decision of the appeals court.

The AMA also has a voluntary program, called the Prescription Data Restriction Program (PDRP), that allows physicians (whether AMA members or not) to prohibit the release of their individual data from the AMA database which is also used by the data mining companies.  Eighty seven (87) Maine physicians have taken advantage of this option.

In 2008, legislatures in Arizona, Illinois, Maryland, Minnesota, Washington, and West Virginia also considered similar legislation, but no bills made it out of committee.  More state legislatures probably will take up the issue in 2009.  The Maine law is likely to go forward, but is still on hold for the time being.  Watch for additional information in the Maine Medicine Weekly Update and in Maine Medicine as this issue continues to be in the news.

 The case, IMS Health Inc. v. Ayotte, 1st Cir., No. 07-1945, 11/18/08 may be found on the web at:

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CON Capital Investment Fund Public Hearing on December 11, 2008

A public hearing will be held on December 11, 2008 on amendments to the current state rule establishing the Capital Investment Fund (CIF), the limit on amounts hospitals and other providers may spend on capital investments through the certificate of need (CON) process.  The proposed rule amends the CIF cycle from one year to three with a one year transition.  Certificates of need would remain on an annual cycle.  The amount of the CIF will remain similar to previous years.

The hearing will be held at 2:00 pm in Conference Room C, 35 Anthony Ave., Augusta (in the Augusta Business Park).  The deadline for providing written comment on the rule is Monday, December 22, 2008.  Written comments may be directed to Peter Kraut, Health Policy Analyst, Governor's Office of Health Policy and Finance, 15 State House Station, Augusta, 04333 or email Peter.Kraut@Maine.Gov.


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Aligning Forces 4 Quality Steering Committee to Meet on Tuesday

The Aligning Forces 4 Quality (AF4Q) Steering Committee will meet at the offices of MMA on Tuesday, November 25th.  The AF4Q project is funded by the Robert Wood Johnson Foundation (RWJF) and Maine is one of fourteen AF4Q sites across the country.  The project focuses on measuring performance, reporting performance publicly, and consumer engagement.  The work is to be accomplished over a three year period.  In Maine, the grantee is Quality Counts! and the Project Director is Ted Rooney, R.N.

At Tuesday's meeting, the Steering Committee will be asked to review/edit/endorse the RWJF operational work plan that must be finalized and submitted to the Foundation following the January 7, 2009 Executive Leadership Team meeting.  The Committee will also discuss whether the project should link with the National Priorities Partnership and if so, how.

The National Priorities Partnership consists of 28 key health care stakeholders, including consumer groups, employers, government, health plans, health care alliances, health care professionals, scientists, accrediting and certifying bodies, and quality alliances.  The Partners are leading a national movement to create a higher-performing, more affordable, and more equitable health care system.

The goals of the National Partnership are in many ways similar to the goals of AF4Q, including action in the areas of public reporting, quality improvement, and consumer engagement.  More specifically, the National Partnership seeks to eliminate harm, eradicate disparities, reduce disease burden, and remove waste to provide world-class, patient-centered, affordable health care through:

  • Patient and Family Engagement, to provide patient-centered, effective care;

  • A Healthy Population, to bring greater focus on wellness and prevention;

  • Safety of the System, to improve reliability and eliminate errors wherever and whenever possible;

  • Care Coordination, to provide patient-centered, high-value care;

  • Palliative and End-of-Life Care, to guarantee appropriate and compassionate care for patients with advanced illnesses; and

  • Eliminating Overuse, to remove waste and achieve effective, affordable care.


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MaineCare Moves Out-of-State Prior Authorization Process to Schaller Anderson

Effective December 1, 2008, out-of-state prior authorization requests for hosital-based inpatient and outpatient services are to be sent to Schaller Anderson Medical Administrators, Inc. at the following fax number:  1-877-861-2615, rather than the MaineCare Prior Authorization Unit.

More details on the change can be found at:  Questions may be directed to the Office of MaineCare Services, Prior Authorization Unit at 207-287-2033 or 1-866-796-2463. [return to top]

Specialties and Primary Care Groups Invited to MMA on December 16 to Discuss Patient Centered Medical Home

State specialty society leaders and the officers of the major primary care organizations have been invited to attend a meeting on Tuesday night, December 16 at the MMA offices in Manchester to learn more about the concept of the Patient Centered Medical Home (PCMH) and efforts in Maine to implement a pilot project demonstrating the efficacy of the concept.  Dinner will be available at 5:30 pm with the meeting beginning at 6:00 pm.

The invitation was sent by Lisa Letourneau, M.D., MPH, Executive Director of Quality Counts!, Elisabeth Mock, D.O., MPH, Chair, Coalition for the Advancement of Primary Care, and Gordon Smith, Esq., EVP of MMA.

The principles of the PCMH, originally established and adopted by the four primary care associations representing family physicians, internists, pediatricians, and osteopathic physicians recently have been adopted as well by the AMA.

In addition to hearing about the concept, attendees will also be asked to provide feedback on efforts in Maine to establish a Multi-Payer Pilot of the PCMH model that will likely include 10 to 20 primary care medical practices using a new reimbursement system for primary care.  The effort to launch this pilot is being led by the Maine Quality Forum, Quality Counts, and the Maine Health Management Coalition, and is being overseen by a multi-stakeholder steering group, called the Coalition for the Advancement of Primary Care.  There are currently several related work groups in the state meeting regularly to develop the pilot, and to design a new physician payment methodology for the PCMH model.  More information about the model and the pilot can be found under the "Resource Library" section of the Quality Counts! website at

As is stated in the invitation, "Those of us involved in developing the PCMH Pilot recognize that it will only be successful if we recognize the value of specialty care, and foster a collaborative approach between primary care and specialty physicians to improve care.  We are proposing this meeting to inform the non-primary care specialties of the principles of the PCMH model, and to discuss how the PCMH may impact specialists.  Following a presentation organized by the primary care specialties, we would like to invite your thoughts on creating a collaborative approach, and your feedback on the information presented."

In addition to specialty society leaders, any physician or other interested person is welcome to attend, but do RSVP to Diane McMahon at MMA at or by phone at 622-3374, ext. 216.  Directions to the office are available on the MMA website at [return to top]

Shaken Baby Prevention Program Now Available

As many of you are aware, Shaken Baby Syndrome or Abusive Head Trauma is a devastating form of child abuse and the leading cause of serious head trauma in infants under the age of 24 months.  The annual incidence for children under the age of 12 months hospitalized with abusive head trauma worldwide and in Maine is 30-40/100,000 live births.  This translates in Maine, with approximately 15,000 births/year, to 5-6 cases/year.  In our tracking of cases over the years, the number of children hospitalized in Maine has varied annually from a low of 2 to a high of 10!  Approximately 30% of these children die while 40-50% suffer permanent brain damage in the form of paralysis, blindness, and mental retardation.  Few survivors if any emerge unscathed.  Recent long term follow up of the apparently well survivors has shown that most have developmental and learning problems later in life.  The cost to Maine society is estimated at $1,000,000 per baby.  According to parent surveys done in North Carolina for every baby hospitalized with Abusive Head Trauma, 35-50 are shaken to quiet the infant and not hospitalized!

A large group of Maine professionals have been meeting over the past year to develop a prevention program that is evidence based and well researched.  These meetings have included representatives from medical, public health, child welfare, and community based agencies.  Participants have come from Maine CDC, DHHS, Public Health Nursing, Home Visitor Programs, Medical Providers from MMC, EMMC, CMMC and Maine General Medical Center, and others.  The group has analyzed and discussed a number of prevention programs and has decided to implement The Period of PURPLE Crying in Maine.

This program developed by the National Center on Shaken Baby Program in Salt Lake City in cooperation with the University of British Columbia in Vancouver has been tested on a large number of parent groups and is undergoing a large multiyear CDC study in North Carolina.  It has been implemented in Utah and British Columbia as well.

The program has several basic premises:
1. Crying is normal as evidenced by the normal crying curve research by Dr. T. Berry Brazelton.
2. The only adverse consequence of crying is Shaken Baby Syndrome.
3. The incidence curve of Shaken Baby is the same as the normal crying curve with the peak Shaken Baby incidence occurring at 2 months!
4. There are steps that parents can take to reduce normal crying.
5. Even in the best of circumstances crying may be inconsolable.
6. It is ok to put the baby down in a safe place and take a break.
7. The critical time for education is at the birth of the baby.
8. All caretakers should be educated.
9. These messages should be reinforced by primary care providers and others including home visitors.
10. There should be a public education program to further reinforce the message.

PURPLE includes a 10 Minute DVD given to and watched by each family at the time of birth, a 3 minute educational script provided by the perinatal nurses to the family, and an educational booklet for families. Families are encouraged to share this information with anyone with carrying for their babies.  The program can be viewed at  The training module can be viewed at  To sign in and view the entire program username mainePURPLE and password mainePURPLE.

Coordination of the program will be through the Maine Children’s Trust. [return to top]

CMS Selects NHIC to Administer Claims Payment Across New England

The Centers for Medicare & Medicaid Services (CMS) today announced that National Heritage Insurance Corporation (NHIC) has been awarded a contract of up to five years for the combined administration of Part A and Part B Medicare claims payment in Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont.
"With this award, CMS continues its progress in reengineering the way in which the government contracts for claims administration for the largest part of the Medicare program.  CMS is seeking the best value, from a cost and technical perspective for this critical function," said Acting CMS Administrator Kerry Weems. "This is another step toward improving services to beneficiaries and providers who are in the Medicare fee-for-service benefit plan."  
NHIC will serve as the first point of contact for the processing and payment of Medicare fee-for-service claims from hospitals, skilled nursing facilities, physicians, and other health care practitioners in Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont.  The new Part A/Part B Medicare Administrative Contractor (A/B MAC) was selected using competitive procedures in accordance with federal procurement rules.
The new contractor will take claims payment work now performed by three fiscal intermediaries and two carriers in Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont.  The A/B MAC contract, which has an approximate value of $176 million over five years, will fulfill the requirements of the Medicare Modernization Act's (MMA) contracting reform provisions. [return to top]

Apply for the 2009-2010 Hanley Fellows Program


Apply Today!

2009-2010 Hanley Fellows Program

Are you ready to make a difference by leading change at the health and health care systems level?
If so, the Hanley Fellows program may be right for you!
This winter the Daniel Hanley Center for Health Leadership will select up to five leaders for the Center's 18-month Hanley Fellows program.
Based on a personal mentorship approach, the Hanley Fellows program is designed to prepare a small cadre of highly experienced leaders to lead change at the health and health care systems levels here in Maine.
Follow in the distinguished footsteps on the Center's first class of Hanley Fellows:  Dr. Ned Claxton of Central Maine Medical Center's Family Practice Residency; Maureen Kenney, MSSW of Hannaford Brothers; and Dr. Lisa Letourneau of Quality Counts!
Over the course of an 18-month period, each Fellow will be paired with an experienced Mentor who together will take part in an intensive leadership retreat.  Fellows and Mentors will then meet for quarterly breakfast meetings and monthly meetings and conference calls. 

Mentors will  provide each Fellow with keen insight into what it takes to be an effective leader in today's complex, dynamic and demanding health and health care environment. The Mentor will draw upon their own experience to help the Fellow address specific needs and interests.   
Mentors for the inaugural class of Hanley Fellows (2006-2008) included State Senator Libby Mitchell, Greater Portland United Way President Meg Baxter and the head of the Maine Medical Association, Gordon Smith. 
Mentors for the new class of Hanley Fellows will be selected from a pool of distinguished leaders from Maine's health and health care community as well as from other sectors such as business, government and academia.   
Want to learn more? Visit or email Jim Harnar at  
Application deadline is December 12.
Click here to review Fellows Prospectus, Q & A and Application. [return to top]

AMA Offers PQRI 2009 Webinar

Get up to speed right now!

Physicians   ▪   CPT advisors     Practice managers and coders

Sign up for this timely PQRI 2009 webinar today!

Wednesday, December 17, 2008

1 – 2:30 p.m. EST

Changes in the Centers for Medicare and Medicaid Services (CMS) 2009 Physician Quality Reporting Initiative (PQRI) program will become effective on January 1. Be informed by attending this timely webinar, hosted by the American Medical Association (AMA)—convener of the Physician Consortium for Performance Improvement®, the measure developer of 112 of the 153 measures in PQRI 2009. Don’t miss this important opportunity to learn about the measures included in the 2009 PQRI program and how your practice can prepare to report through claims for the 2009 reporting year. 

Hear from leading experts

Susan Nedza, MD, MBA, Vice President, Clinical Quality and Patient Safety, AMA

Dr. Nedza brings the experience she gained during her work at CMS on the PQRI program together with her knowledge of the performance measures and CPT Category II Coding. 

Kendra Hanley, MS, Senior Policy Analyst, Clinical Performance Evaluation, AMA

Ms. Hanley leads the development and maintenance of the PCPI measure specifications, including the PQRI program, and advises on CPT Category II code development for clinical performance measures.   

Samantha Tierney, MPH, Senior Policy Analyst, Clinical Performance Evaluation, AMA

Ms. Tierney leads the development of the AMA-developed PQRI tools for individual performance measures and measures groups.

Learn the latest developments

  • New options for claims reporting in 2009—individual measures or measures groups
  • How to determine which measures apply to your practice
  • Key elements of 2009 PQRI performance measures and specifications—what has changed and what is new
  • Tips to facilitate more accurate reporting
  • New implementation tools developed by the American Medical Association for PQRI 2009, including tools for reporting measures groups

Don’t miss this important opportunity. If you submit Medicare Part B claims and plan to participate in the 2009 PQRI program, you should register today.

Registration fee, $160-AMA Members; $185 Non-members


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Study on Physician Participation in Medicaid Cites Slow Payment as Major Obstacle

A study by the Center For Studying Health System Change published on November 18, 2008 on the Health Affairs web site finds that slow reimbursement by state Medicaid programs is associated with lower rates of participation.  The Center's previous research indicates that about 50% of physicians accept all new Medicaid patients while 70% accept all new Medicare or privately insured patients.  

The study found the following relationships:

  • High payments/fast reimbursement:  64% of physicians in states with Medicaid programs meeting these standards accepted all new Medicaid patients;
  • High payments/slow reimbursement:  50.9% of physicians in these states accepted all new Medicaid patients;
  • Low payments/fast reimbursement:  48.4% of physicians in these states accepted all new Medicaid patients;
  • Low payments/slow reimbursement:  43.2% of physicians in these states accepted all new Medicaid patients.

The study also found greater variability in reimbursement time in Medicaid programs than in the private insurance market with a low of 36.9 days in Kansas to a high of 114.6 days in Pennsylvania.

You can find a copy of the study, Do Reimbursement Delays Discourage Medicaid Participation by Physicians? on the web at: [return to top]

HHS Lists Quality Measures Used by Federal Agencies

On November 13, 2008, the U.S. Department of Health & Human Services (DHHS) announced a list of quality measures that will be used by federal agencies for reporting, payment, or quality improvement.  The agency has done this to "advance collaboration within the quality measurement community and to synchronize measurement."  You can find the new list on the web at: [return to top]

Obama Selects Daschle as DHHS Secretary; Congress Begins Health Care Reform Discussions

On November 19, 2008, the Obama transition team announced that the President-elect has selected former Senate Majority Leader Tom Daschle (D-SD) to be not only Secretary of the Department of Health & Human Services, but also the White House health "czar" to help develop and carry out Obama's health care reform agenda.  Most observers have praised the choice of Daschle who certainly knows his way around Capitol Hill and has spent time studying health policy since his departure from Congress.  Senator Daschle recently has been an adviser to the Alston & Bird law firm and is a Distinguished Fellow at the Center for American Progress.  In 2008, he published Critical:  What We Can Do About the Health-Care Crisis.

Also on November 19, 2008 a bipartisan group of Senators from two key committees with health policy jurisdiction (Finance and Health, Education, Labor & Pensions) met to discuss how they could work together on health care reform initiatives to take advantage of current momentum on these issues.  Last week, the MMA reported on Finance Committee Chairman Max Baucus' (D-MT) White Paper on health care reform.  The Senate HELP Committee Chairman Edward M. Kennedy (D-MA) also announced last week that he had created 3 committee working groups to help develop health care reform legislation.  The 3 groups are:

  • a committee focused on prevention and public health chaired by Sen. Tom Harkin (D-IA);
  • a committee focused on health care quality chaired by Sen. Barbara A. Mikulski (D-MD); and
  • a committee focused on insurance coverage chaired by Sen. Hilary Rodham Clinton (D-NY). 
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