March 2, 2009

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Health Systems Development Advisory Committee Hears Reports on ER Use and Cost Drivers

The Advisory Council on Health Systems Development met on Friday to hear long-awaited reports on Emergency Department usage in the state and on health care cost drivers in the state.  The reports are available on line from the Governor's Office on Health Policy and Finance.  These reports could result in legislation being introduced this legislative session to address issues identified in the Reports.

The Health Systems Development Advisory Council met on Friday (Feb. 27) and heard two important reports which had been prepared over the past few weeks.  This Council was established in 2003 as part of the Governor's Dirigo Health Program.

The Council heard first from the primary authors of the recent study on emergency care utilization in the state, conducted by the Muskie School of Public Service with funding from the Maine Health Access Foundation.  According to the study, based upon 2006 data, Maine's emergency room usage was 30 percent higher than the national average.  Significantly, use of ER services was three times higher for MaineCare enrollees compared to the rest of the population. The uninsureds made up about nine percent of usage, which would be about in line with their percentage of the population.  The report concluded that a substantial number of ER visits were for conditions that could be treated in a primary care office.

The study was advised by a committee that included several physicians, including MMA Executive Committee member Kenneth Christian, M.D., who is Director of the Emergency Room at Maine Coast Memorial Hospital in Ellsworth.

The second report was on cost drivers and was presented by a representative of Health Dialog which performed the study through a contract with the Maine Quality Forum.  The study concluded that recent health care cost increases were more the result of increases in utilization of services (65%) than increases in price (35%).  Using the definition of unwarranted variation developed by the authors of the Dartmouth Atlas, the study concluded that $284 million dollars of inpatient costs are potentially avoidable.  Another $304.8 million could be saved by eliminating unnecessary outpatient tests. 

The Advisory Council may make its own recommendations to the legislature relative to these reports.  The reports are available online at

Political Pulse: Legislative Highlights of the Week

This week the Appropriations Committee continued public hearings on the Governor's FY 2010-2011 biennial budget, L.D. 353, while the HHS Committee held work sessions on the health care and social services portions of the budget.  The HHS Committee has tabled the cuts to critical access hospitals and hospital-based physicians and has established a subcommittee to review those issues and make a recommendation to the rest of the committee.  The subcommittee, chaired by Representative Anne Perry (D-Calais), is expected to meet next week.  Senator Peter Mills (R-Somerset), Senator Lisa Marrache, M.D. (D-Kennebec), and three other members to be named will complete the subcommittee.

Again this week, your legislative contacts on these budget issues should be focused on the HHS Committee members and your own legislators. 

You can find your own legislators on the web at:

You can find members of the HHS Committee and their contact information on the web at:

You can call toll-free and leave a message at the State House for any legislator as follows:

  • Senators:  1-800-423-6900
  • Representatives:  1-800-423-2900

On Tuesday, February 24, 2009, the MMA testified before the Business, Research & Economic Development Committee in opposition to L.D. 13, An Act to Expand the Diagnostic Functions of Independent Practice Dental Hygienists, a bill that would permit the hygienists to own x-ray equipment and "perform" x-rays.  The Maine Dental Association also opposed the bill which was heard with several other dental bills in a lengthy hearing.  On Thursday afternoon, the BRED Committee gave final approval to two bills supported by the MMA, L.D. 89, An Act to Amend the Laws Concerning Informal Conferences as Part of the Board of Licensure in Medicine's Disciplinary Proceedings and L.D. 94, An Act to Authorize the State Board of Nursing to Request Mental and Physical Examinations and to Establish a Nurse Health Program.

On Wednesday, February 25, 2009, the MMA testified in favor of L.D. 282, An Act Regarding the Requirement that the Treatment of a Gunshot Wound be Reported, sponsored by Representative Paul Davis (R-Sangerville).  Rep. Davis was good enough to check in with Mayo Hospital Emergency Department Director and MMA President-elect David McDermott, M.D., M.P.H. before submitting the bill.  The bill's primary intent is to expand the list of practitioners required to report to include mid-level practitioners.  Rep. Davis submitted the bill at the request of Penobscot and Piscataquis County DA Christopher Almy.  The DA association and the Criminal Law Advisory Committee also supported the bill and there was no opposition.

On Thursday, February 26, 2009, the Judiciary Committee heard L.D. 428, An Act to Amend the Intestate Succession and Wills Laws Concerning Wrongful Death, a bill that would increase the cap on punitive damages in wrongful death actions from $75,000 to $250,000, submitted on behalf of the Maine Trial Lawyers Association.  While punitive damage awards are not common in medical malpractice actions, the MMA, Maine Hospital Association, and Medical Mutual Insurance Company of Maine all expressed concern about the proposed change.

You can find the text of any of these bills and check their status on the web at: [return to top]

Over Fifty Primary Care Sites Apply for Patient Centered Medical Home Pilot

More than fifty primary care sites have applied to participate in the Patient Centered Medical Home (PCMH) Pilot supported by Quality Counts, the Maine Quality Forum and the Maine Health Management Coalition.  A subcommittee of the PCMH Workgroup will now select ten to twenty practices for the three-year pilot.  The deadline for applications was Feb. 28 and practices will be selected within the next couple months.  

"Given that the application process was fairly rigorous and that the practice sites had to commit to achieving level one recognition by NCQA, I am incredibly impressed with the response," noted Gordon Smith, MMA EVP and Vice-Chair of the Quality Counts Board.   "This enthusiastic response is just one more indication of the high level of interest among Maine's medical community in practice transformation, quality improvement and payment reform."

  [return to top]

New Bills for Your Review & Comment/Reminder of Legislative Committee Conference Call

The following are bills of interest to the physician community printed and referred to committees last week for your review and consideration.  Please note that clicking on the highlighted "LD XXX" will take you to a PDF version of the bill.

LD 630, An Act To Update and Streamline State Licensing Laws and Clarify the Process for Appealing Final Decisions of Certain Licensing Entities (monitor)

LD 637, An Act To Ensure Services for Adults with Developmental Disabilities (monitor)

LD 646, An Act To Improve the Water Quality of Maine's Rivers (Public Health Committee; support)

LD 654, Resolve, To Review Statutes, Rules and Policies Regarding Mental Retardation, Pervasive Developmental Disorders and Other Cognitive and Developmental Disorders (monitor)

LD 670, An Act To Make Health Insurance More Affordable (support)

LD 675, An Act To Lower the Cost of State Government in the Departments under the Purview of the Joint Standing Committee on Health and Human Services (monitor)

LD 683, An Act To Promote Cost-effective and Broad-based Vision Care for Maine Citizens by Clarifying the Scope of Prescription Authority by an Optometrist (ophthalmologists; position being determined through negotiations among MSEPS, MMA, and the Maine Optometric Association)

LD 690, An Act Concerning Domestic Violence and Firearms (Public Health Committee; support)

LD 695, An Act To Streamline Health Care Services in Maine by Allowing Certified Nurse Practitioners and Certified Nurse Midwives To Verify Medical Papers and Records (monitor)

LD 701, An Act To Fund the Screening and Early Detection Elements of the Statewide Cancer Plan (Public Health Committee; monitor)

LD 708, An Act To Create a Moratorium on the Open-air Production of Genetically Engineered Pharmaceutical Crops in Maine (Public Health Committee; monitor)

LD 710, An Act To Allow Denturists To Practice to the Level of Their Educational Training (monitor)

LD 721, Resolve, Directing the Department of Health and Human Services To Raise Public Awareness of Reflex Sympathetic Dystrophy Syndrome (monitor)

LD 724, An Act To Provide Transparency Concerning Operating Expenses for Hospitals (monitor)

LD 726, An Act To Improve the Process for Issuing Concealed Weapons Permits (Public Health Committee; support)

LD 729, An Act To Authorize a General Fund Bond Issue To Create a New Health Care Internet Infrastructure (support)

LD 735, An Act To Allow Unimmunized Children to Attend School Upon Parental Waiver (Public Health Committee; pediatricians; oppose)

LD 738, An Act To Require Patients of Opioid Treatment Programs To Release Medical Information to a Designated Primary Care Physician (Public Health Committee; monitor)

LD 752, Resolve, To Require the Department of Health and Human Services To Request a Waiver To Prohibit the Use of Food Stamps for the Purchase of Soft Drinks (Public Health Committee; pediatricians; monitor or support)

LD 753, Resolve, To Require the Department of Health and Human Services To Request a Waiver To Prohibit the Use of Food Stamps for the Purchase of Taxable Food Items (Public Health Committee; pediatricians; monitor or support)

LD 754, An Act Regarding Subrogation of Medical Payments Coverage (monitor or oppose)

LD 757, An Act To Improve the Transparency of Certain Hospitals (monitor)

LD 768, An Act To Improve the Dental Health of Children by Making Fluoride Treatments More Available (Public Health Committee; pediatricians; oppose)

LD 782, An Act To Require Health Insurers To Provide Coverage for Nutritional Wellness and Prevention Measures and Products (oppose)

LD 783, An Act To Protect the Privacy of Consumer Financial Information (monitor)

The next MMA Legislative Committee conference call is scheduled for 8:30 p.m. on Thursday, March 5, 2009.  The conference call number is 800-989-2842 and the access code is 6223374#.  Any MMA member or specialty society representative is welcome to join the discussion of bills listed above and other legislative highlights. [return to top]

AMA Provides Overview of President Obama's First Budget Proposal

In preliminary budget documents released on February 26, the Obama Administration proposes to create a $634 billion “reserve fund” over the next decade to finance expanded health insurance coverage and other health care investments.  Approximately half of the health reform reserve fund would be generated by increasing taxes on couples earning more than $250,000 a year and individuals earning more than $200,000 a year.  The other source of funding would be savings from Medicare and Medicaid.

Of particular importance to physicians, the budget proposal includes $329.6 billion “to account for additional expected Medicare physician payments” over the next 10 years.  The funds are described as the Administration’s “best estimate of what the Congress has done in recent years,” and, if adopted by Congress, would effectively eliminate the enormous deficit and scheduled Medicare physician payment cuts of 40% over the next seven years.  While the full impact is not yet known, this large infusion of funds appears to meet the AMA's repeated call for a realistic budget baseline that assumes Congress will not allow the drastic cuts programmed under the current SGR formula to occur.

The document also signals the Administration’s willingness to consider further modifications in the SGR formula, stating that “as part of health care reform, the Administration would support comprehensive, but fiscally responsible, reforms to the payment formula.”  It adds that “Medicare and the country need to move toward a system in which doctors face better incentives for high-quality care rather than simply more care.”

The President’s decision to propose a more realistic budget baseline for Medicare spending on physician services responds to a long-time advocacy goal shared by the AMA and other medical organizations.  It followed several top-level meetings between AMA and Administration officials, including most recently a meeting with senior officials at the White House Office of Management and Budget and AMA President Nancy Nielsen’s participation in the White House Fiscal Summit on February 23.

Included in the Medicare savings proposals are unspecified restrictions on physician owned hospitals (with negligible savings and no policy explanation), a requirement for the use of radiology benefits managers ($260 million in savings over 10 yrs), and incentives for physicians to administer flu vaccinations (with negligible savings and no policy explanation).

Other Medicare and Medicaid savings provisions in the Obama budget outline include:

  • Competitive bidding for Medicare Advantage plans ($176.6 b)
  • Bundled payments for hospitals and post-acute care services ($17.8 b)
  • Reduce payments for hospital readmissions ($8.4 b)
  • Reduced payments for home health services ($37.1 b)
  • Increased Medicaid drug rebates ($19.6 b)
  • Increased Part D drug premiums for higher income beneficiaries ($8.1 b)
  • Medicare program integrity efforts ($2.0 b)

The AMA issued a statement applauding the President’s decision to include an assumption that the SGR-driven physician pay cuts will not occur and his commitment to expanding health insurance coverage for the uninsured.   As is the case every year, however, the President’s budget proposal is just the first step in a lengthy budget process.  The AMA will be closely analyzing all the health care budget proposals from the Administration and Congress and will work to modify or eliminate objectionable provisions (such as restrictions on physician owned hospitals) while continuing to strongly advocate for appropriate funding of Medicare physician services and expansion of coverage for the uninsured.  

The full budget document, entitled “A New Era of Responsibility,” can be accessed on the Office of Management and Budget web site, at . [return to top]

DHHS Announces Emergency Rulemaking on Hospital-Based Physician Reimbursement

An emergency rule, MaineCare Benefits Manual, Chapter III, Section 45, Hospital Services, was adopted February 1, 2009 and was repealed on February 21, 2009.  A new emergency rule replaced it effective February 21, 2009.  This is notice of the new emergency rule. 

The U.S. Centers for Medicare and Medicaid Services’ (CMS) approval is required before this rule can be permanently adopted. 

AGENCY:  Department of Health and Human Services, Office of MaineCare Services

CHAPTER NUMBER AND TITLE:  MaineCare Benefits Manual, Chapter III, Section 45, Hospital Service


CONCISE SUMMARY:  The Fiscal Year 2009 Emergency Supplemental Budget, deappropriated funds to reduce MaineCare reimbursement for hospital-based physician services to provide for a rate as close to 70% of the Medicare reimbursement rate as the Department determines can be funded with the resources used for physician reimbursement, as adjusted by the Supplemental Budget, which reduced the reimbursement by $1,947,490 state dollars, effective February 1, 2009.  P.L. 2009, ch. 1.

On February 1, 2009, the Department adopted emergency rules which reduced reimbursement for both hospital-based inpatient and outpatient physicians.  Since February 1, 2009, the Department has determined that the February 1st emergency rule must be repealed because upon further review, the Department determined that it would be less administratively burdensome on hospitals to limit the impact to non-emergency hospital-based outpatient physician services only, rather than to all hospital-based physicians, within the required savings of $1,947,490 state dollars.  Accordingly, the Department is repealing the February 1, 2009 emergency rules and will be adopting, simultaneously, these emergency rules, which are being adopted effective February 21, 2009. 

Hence, in accordance with P.L. 2009, ch. 1, the Department is adopting these emergency regulations, with an effective date of February 21, 2009, which will reduce reimbursement for hospital-based physician services as follows:  non-emergency hospital-based outpatient physician rates at acute care non-critical access hospitals, acute care critical access hospitals and hospitals reclassified to a wage area outside Maine, will be reduced to 46.21% of non-emergency hospital-based outpatient physician costs.  The rate of 46.21% is the closest to 70% of the Medicare reimbursement rate that the Department could fund with the resources used for physician reimbursement, as adjusted by the Supplemental Budget, which reduced the reimbursement by  $1,947,490 of state dollars.  Prospective Interim Payments (PIPs) will be lowered in an amount corresponding to the anticipated non-emergency hospital-based outpatient physician payment reductions. 

See for rules and related rulemaking documents.

EFFECTIVE DATE:                       February 21, 2009
AGENCY CONTACT PERSON:  Bob Kohl, Health Planner
AGENCY NAME:                          Division of Policy and Performance
ADDRESS:                                   442 Civic Center Drive
                                                      11 State House Station
                                                      Augusta, Maine 04333-0011
TELEPHONE:                              (207)-287-6124   FAX: (207) 287-9369
                                                      TTY: 1-800-423-4331 or 207-287-1828 (Deaf/Hard of Hearing) [return to top]

Maine Health Information Center Receives Contract to Build All-Payor Claims Data Base in Minnesota

The Minnesota Department of Health has selected the Maine Health Information Center (MHIC) to develop a statewide comprehensive claims database, a key component of the state’s new healthcare reform initiative.

Under the two-year contract, the MHIC will facilitate development of data collection rules; design and build the claims database; collect, process, and validate the data; extract data to inform comparisons of healthcare utilization, cost, and quality; and work with health plans to ensure patient privacy, timely and secure data collection, and compliance with state rules.

The MHIC’s selection follows a highly competitive bidding process. Key to its win is the MHIC’s reputation as a reliable partner in providing similar services to four states—Maine, Massachusetts, New Hampshire, and Vermont—notes Katie Burns, director of Quality Measurement, Transparency, and Payment Reform Initiatives at the Minnesota Department of Health.

“The fact that the MHIC has experience in actually doing this work for other states came through loud and clear” in their proposal, says Burns.

MHIC president and CEO James Harrison credits his organization’s public/private partnership with the State of Maine, the Maine Health Data Processing Center, for enabling the MHIC to deliver a state-of-the-art solution in a cost effective manner to Minnesota and other states. “We have enhanced our data management systems and expertise through this collaboration in Maine, the first state in the country to develop a comprehensive claims database. As our system improves,” Harrison notes, “everyone benefits.”

For more information about the MHIC, visit For more information about Minnesota’s Health Reform Initiative, including specifics about the MHIC’s project, visit [return to top]

Secretary of State Denies Ballot Certification to Conservative Health Reform Initiative

The Secretary of State's Office announced last week that while four voter-initiated measures will appear on the November 2009 ballot, the measure that would have significantly changed the way health insurance is regulated in the state was not certified as eligible.  While more than the required number of signatures were filed, thousands of signatures were found invalid for a variety of reasons and most of the remainder were thrown out because the pages of the proposal attached to the signatures were not in the order required by the law.

Most of the preparation of the measure has been done by the Maine Heritage Policy Center, a conservative think tank.  One of the provisions would have allowed Maine citizens to purchase health insurance across state lines, but limited to the other New England states.

One of the four questions certified for the ballot would revise the medical marijuana law to create nonprofit drug dispensaries and a statewide ID card system to protect patients from arrest.  The other three ballot questions involve a tax cap and two excise tax initiatives.

The questions now go before the legislature which must either enact them as drafted, or let them go on the ballot. [return to top]

Autism: Bridging the Gap Between Knowledge and Practice for Clinicians

Are you a health care professional who is confused by all the information swirling around you about Autism?  Are you challenged by the struggles and frustrations that children with autism and their parents bring to you?  CDC/ encourages clinicians to consider attending a one-day conference sponsored by the Maine CDC/ on Autism on Tuesday May 12th at the Augusta Civic Center.  Cosponsored by the Maine Medical Association, the Maine Osteopathic Association, the Maine Chapter of the American Academy of Pediatrics, Maine Emergency Medical Services, Downeast Association of Physician Assistants, and the Autism Society of Maine.  The department is applying for 7.0 hours of CMEs/CEUs for physicians, nurses, nurse practitioners, physician assistants, and EMS providers.  

This conference features a cadre of Maine’s developmental pediatricians and several nationally-known speakers.  Developmental pediatricians Victoria Dalzell, MD, from MMC, Mary Ellen Gellerstedt, MD, from EMMC, Carol Hubbard, MD, from MMC and immediate past president of the Maine Chapter of AAP Don Burgess, MD, will start the day with an Autism 101 from a medical standpoint.  Tim Buie, MD, pediatric gastroenterologist from Massachusetts General Hospital and Harvard Medical School will review medical co-morbidities, including the role of diet and supplements.  Martha Herbert, MD, PhD pediatric neurologist from Massachusetts General Hospital and Harvard Medical School will review genetic and environmental theories on the causes of autism.  Jon Poling, MD, PhD, adult neurologist from Georgia, whose daughter with autism made national news last year when her parents successfully sued the US DHHS for compensation under the Vaccine Injury Compensation Program, will share his views about vaccines and autism.  All keynotes will include a question and answer session with the audience. 

Are you interested in the conference but can’t make it?  It will be available as a webcast a few days after the conference, and CDC/ will be making some DVDs available to parent groups. 

Online Registration, a full conference brochure is available at both the following websites: 

Maine CDC’s homepage (upper right hand corner under “Hot Topics”)

 Autism:  Bridging the Gap Between Knowledge and Practice for Clinicians Conference site [return to top]

Kansas Governor Kathleen Sebelius to be Nominated as HHS Secretary

Kansas Governor Kathleen Sebelius is expected today to be nominated as President Obama's Secretary of Health and Human Services.   Sebelius, 60, is a former state insurance commissioner and is serving her second four-year term as Governor.  While she is expected to take over the huge HHS Department, she will not take on the While House health care position as Tom Daschle was expected to before he withdrew.  President Obama now expects to name a different person for the White House health care position.

The Sebelius nomination comes none too soon, as later this week the President is hosting lawmakers and representatives of major interest groups at a White House summit on health care reform.

The President opened the healthcare reform debate last week in his budget address.  He has proposed a budget that sets aside $634 billion over ten years as a down payment on coverage for all, a goal that could ultimately cost  more than $1 trillion.  The President has previously expressed his support for preserving the employer role in providing health insurance, but supplementing that role with options for public coverage that would allow all citizens to be covered with an appropriate option eventually.

It will be up to the Congress to take these general ideas and develop comprehensive legislation.  Two of the major players, Sen. Max Baucus (D-Montana) and Sen. Edward Kennedy (D-Massachusetts) expect to have legislation drafted by the summer of this year. [return to top]

Legislative Proposals to Target Obesity

The Maine Medical Association, along with a coalition of legislators and health advocates seek to advance three new policies aimed at curbing obesity in Maine.


With obesity rates continuing to move upward in Maine, a group of legislators announced a package of legislation at a press conference last week, aimed at helping to trim those numbers.  The lawmakers were joined by the Maine Medical Association and the National Heart Association in calling for greater access to nutrition information for restaurant-goers, increased collection of certain health data and for more physical education at Maine’s schools as part of a comprehensive approach to fighting obesity.


Speaker of the House, Hannah Pingree has submitted legislation that would require chain restaurants with more than 15 establishments nationally to post caloric information on their menus and menu boards.  This proposal aims to provide caloric information at the point of purchase.  New York City, Philadelphia, Portland, Oregon and the state of California have all enacted similar policies.  In New York City, where the policy has been most widely implemented to this date, the response from consumers has been positive.  A recent poll showed that 90 percent of restaurant-goers claimed the calorie content of their order was higher than they would have expected and that 82 percent said the information is affecting what they order.


Rep. Helen Rankin (D-Hiram) is sponsoring another initiative to aid in the fight against obesity.  Rankin is proposing that the Maine Center for Disease Control work with local schools to collect body mass index (BMI) data on Maine’s children.  Rankin’s bill would keep the BMI data confidential and would be used for surveillance purposes to track the obesity epidemic among our youth.  This bill would create a protocol for all school nurses to follow in the collection of body mass index data from children and provide a method for uniform reporting to the Department of Health and Human Services, Maine Center for Disease Control and Prevention.


LD 319, An Act to Track the Prevalence of Childhood Obesity in Maine, will be heard tomorrow, Tuesday, March 3rd at 1:00 pm in the Health and Human Services Committee.  MMA Public Health Committee Chair, Charles Danielson, MD will be testifying in support, along with the Health Policy Partners of Maine (over 50 organizations and individuals working together to improve the health of Maine people), the Maine Chapter of the American Academy of Pediatrics, and The Maine Dietetic Association. 


This approach of enacting comprehensive “healthy weight” policy initiatives also includes Rep. Lisa Miller’s (D-Somerville), PE4ME initiative, which was recommended for implementation after a study issued to the Legislature late last year.  PE4ME would require all K-8 students in all Maine schools receive at least 30 minutes per day of moderate-to-vigorous physical activity and at least 150 minutes per week of physical education that is evidence-based, health-related, and teaches students the motor and behavioral skills needed to develop an active, physically fit lifestyle.  Budgetary constraints have led to a substantial reduction in the time available for PE, yet there is evidence that school-based physical activity programs do not adversely impact academic performance and that regular exercise improves students’ concentration and cognitive functioning. [return to top]

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