July 20, 2009

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MMA Executive Committee Reaffirms Position on Health System Reform; Supports Public Option with Qualifications

The MMA Executive Committee met this past week at the home of President Stephanie Lash, M.D. in Orrington and voted to reaffirm the principles set forth in the 2003 White Paper entitled, Providing Coverage to All,  MMA's White Paper on Healthcare Reform in Maine.  The Committee also adopted a statement supporting a "public option" in the current national health care reform debate, so long as any such public plan met the priniciples expressed in the MMA White Paper.

The adopted statement on the public option reads as follows:

        In an effort to provide coverage to all persons, MMA supports a public option in the health insurance market so long as the plan meets the principles of the MMA White Paper on Health System Reform dated May 2003 and re-affirmed July 15, 2009.

Although the White Paper was drafted and its principles adopted more than six years ago, the eight page document is as relevant today in the context of national health system reform as it was when adopted just prior to the enactment by the Maine Legislature of Governor Baldacci's Dirigo Health legislation.  It supports the concepts of universal coverage through an individual health insurance mandate, similar to the Massachusetts law which has since been enacted. 

The White Paper lays out several strategies for dealing with coverage and access, cost, and quality, but recommends achieving universal access by building upon the existing system of public and private payors.  But, the document also states that private health insurance must be reformed in order to lower premiums and to offer products which are both affordable and attractive to individuals and families currently uninsured. 

The idea of a government-supported public plan to compete with private health insurance plans has been one of the most difficult issues that the Congress has dealt with in its current work to reform the way health care is currently delivered and paid for in the country.  Maine's senior U.S. Senator Olympia Snowe, a member of the Senate Finance Committee drafting one of the proposals to be considered by the full Senate, was the only Republican on the Committee to not sign a letter to the Committee Chair (Max Baucus, D-MT) opposing a public option.  But, Senator Snowe has been suggesting a proposal whereby such an option would only be triggered if the private plans were not competitive.

"A public option could be utilized to put some pressure on the private plans, but would need to be structured as to compete fairly," noted Gordon Smith, Esq., MMA EVP following the Executive Committee meeting.  "Such a plan would also need to pay providers adequately for their services, in order not to exacerbate the current cost shift."

The MMA White Paper can be viewed in its entirety on the MMA Website at www.mainemed.com.  Or, you may call the MMA office at 622-3374, ext. 219 and a copy will be mailed to you.


Maine CDC Makes Plans for H1N1

On Thursday, July 9, the Maine Center for Disease Control and Prevention gathered several stakeholders, including MMA, to discuss plans for the remainder of the year relative to the H1N1 flu.  On Friday, Health and Human Services Secretary Kathleen Sebelius announced that Maine would receive more than $1.5 million in federal grants to prepare for the fall flu season and a possible vaccination campaign targeted at the H1N1 virus.  Secretary Sebelius said that no final decision has been made about whether or not to have an H1N1 vaccination program this fall, "but we're taking all the steps to be prepared for one, feeling that that's the likely recommendation of the scientists."

As of Thursday, 168 persons in Maine had tested positively for the H1N1 flu, with 9 hospitalizations and no deaths.  But it is estimated that at least ten times that number have been infected.  The priority over the past month for the Center has been the summer youth camps, which have been hard hit, and other institutional settings.  Surveillance is also focused on high-risk individuals such as pregnant women.  Preliminary data in the U.S. (and Maine data are consistent with this) indicate that young adults and children with underlying conditions and pregnant women are disproportionately affected with much higher hospitalization and death rates than with seasonal flu.

Mitigation strategies are focused on:

  • Prevention (respiratory etiquette - covering coughs, washing hands, staying home if ill)

  • Screening (of fever with respiratory symptoms for early detection of H1N1)

  • Isolation (people with symptoms need to stay home for at least 7 days)

  • Antiviral Medications (Tamiflu ad Relenza) especially for those at high risk for complications.

Priority settings for Mitigation Educational Efforts in Maine include youth camps, jails and prisons, day care centers, shelters, pregnant women, long-term care facilities, employment settings, schools, and persons with underlying medical conditions.

Much of the discussion on Thursday focused on the plans for vaccination clinics in the fall.  Clinics will be conducted for the seasonal flu, which will not protect against H1N1 but will protect overall health.  The Maine CDC/HHS is using federal stimulus finds and the Fund for a Healthy Maine to purchase 180,000 pediatric and 100,000 adult doses of seasonal influenza vaccine which will be offered to any interested school, with private-sector health care providers partnering to administer the vaccine.

The possibility of an H1N1 vaccine certainly exists, but it is still in the early manufacturing stages.  Such a vaccine could be available in the October/November timeframe.  Currently, it is anticipated that two doses per individual, given one month apart, would be required.  The federal CDC would make the vaccine free to all states with the Maine CDC planning for distribution and administration of the vaccine.  Because of federal requirement, and the need for refrigeration, all health care practices wishing to receive the vaccine may need to register as Maine Immunization program (MIP) providers.  MMA is advocating for a significant change in the application form currently utilized in the MIP, in order to encourage more practices to participate.

Reimbursement issues and payment of an administration fee for administering the vaccine are yet to be worked out.

MMA will continue to provide updates on this important public health issue through the Weekly Update and the bi-monthly Maine Medicine


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Looking for a Few Medical Supplies for Clinic in Nepal

A former MMA employee, now studying nursing in the Boston area, will be heading to Kathmandu, Nepal the end of this month to perform voluntary work at Pokhara Clinic of Chitwan, a rural heatlhcare clinic.  She would like to take one suitcase full of medical supplies that would be of use at the Clinic.  If you or your office have some usable supplies that could travel well, please contact Gordon Smith at the MMA office at gsmith@mainemed.com. [return to top]

Health Care Reform Debate Continues in D.C. as Congressional Committees Seek Progress Before August Recess

As indicated in last week's Maine Medicine Weekly Update, the MMA will continue to inform its members and their staffs of these efforts, and their potential impact on medical practices in Maine, through regular reports in this Weekly Update and in the bi-monthly Maine Medicine.  Our reports are drawn from several sources, including the AMA, national specialty societies, the media, and conversations with members of Maine's Congressional delegation and their staffs.

Last Friday, July 17th, the House Ways & Means Committee voted 23-18 in favor of H.R. 3200, the America's Affordable Health Choices Act of 2009.  Three conservative Democrats joined all committee Republicans in opposing the bill.  The American Medical Association (AMA) endorsed the bill. You can find the AMA's statements on this bill and other aspects of the health care reform debate in Washington on the AMA's web site at:  http://www.ama-assn.org/ama/pub/advocacy/current-topics-advocacy/health-system-reform/hsr-news-statements.shtml.

In a memo to state and other medical societies dated July 16, 2009, the AMA's leadership outlined the AMA's views on H.R. 3200 as follows:

The AMA Board of Trustees believes that physicians and patients are not well served by the status quo and is committed to advancing long overdue health system reforms.

At the 2009 AMA Annual Meeting, we outlined the following definitions of success for health system reform legislation:

  • Expand affordable coverage
  • Permanent repeal of the SGR
  • Quality improvement vs. profiling
  • Adequate physician payment
  • Administrative simplification
  • Medical liability reforms
  • Empower physician practices with antitrust relief and breaking down existing silos

The AMA House of Delegates also adopted new policy to "support health system reform alternatives that are consistent with the principles of pluralism, freedom of choice, freedom of practice, and universal access for patients."

Based on that guidance, the AMA Board of Trustees reviewed H.R. 3200, the America's Affordable Health Choices Act of 2009.  The AMA Board determined that H.R. 3200 was consistent with AMA policy in the following respects:

  • According to the non-partisan Congressional Budget Office, it would provide health insurance coverage for nearly 97% of legal non-elderly U.S. residents.
  • It includes essential health insurance market reforms such as eliminating coverage denials for pre-existing conditions.
  • Medicaid eligibility would be expanded to all non-elderly adults and families up to 133% of the federal poverty level and payments for primary care services would be increased.
  • A health insurance exchange would be established to provide choice of plans to uninsured, self-insured, and small business employees.
  • Coverage for preventive services would be improved.
  • It erases the SGR debt and substitutes more favorable expenditure targets for Medicare physician updates.
  • Medicare primary care payments would be increased, without offsetting cuts in reimbursement for other physician services.
  • Workforce investments would be made to address primary care shortages.
  • Efficiency bonus payments would be provided for physicians in low-cost localities.
  • Administrative simplifications would be implemented to reduce costs and hassle factors for physicians and patients.

Further, H.R. 3200 provides substantial funding for the physician community in a difficult economic environment.  The CBO estimated that the bill includes more than $230 billion in positive investments for physicians with a breakdown as follows:

  • $228.5 billion to eliminate the accumulated SGR cuts
  • $1.6 billion for PQRI quality reporting changes (bonus payments only, no penalties for non-reporting)
  • $5 billion for the primary care bonus
  • $1.8 billion for the medical home pilot
  • $1.3 billion to extend the floor on Medicare's geographic adjustment for physician work

Although the bill as introduced does not include any medical liability reform, the AMA is working with a member of the Energy & Commerce Committee on a possible amendment to pilot alternative reforms such as health courts and safe harbors for physicians who adhere to best practice guidelines.

The Senate Health, Education, Labor & Pensions (HELP) Committee completed its mark-up on legislation that addresses many key issues.  However, that Committee does not have jurisdiction over Medicare, Medicaid or revenue authority.  The Senate Finance Committee is expected to publicly release a different framework for health reform legislation very soon.  

The Senate Finance Committee framework is expected to include some of the elements mentioned above but is also expected to differ in key aspects.  Additional changes will be considered during Senate floor debate.

H.R. 3200 could move to the House floor this week.   The bill would subsidize those who are unable to afford coverage earning up to 400% of the FPL ($43,000 for individuals and $88,000 for a family of four).  The individual mandate in the bill would penalize those who fail to obtain "adequate" coverage an amount equal to 2.5% of the excess of a taxpayer's adjusted gross income for the tax year.  The CBO estimates these penalties to amount to $29 billion over 10 years.  It also includes an employer mandate, subjecting employers who do not offer health coverage to an assessment up to 8% of its payroll.  The CBO estimates these penalties could amount to $163 billion over 10 years.

On July 15th, the Senate HELP Committee voted 13-10 to report out its version of the Affordable Health Choices bill including both an employer mandate and a public insurance option.

In recent appearances before both the Senate Budget Committee and the House Ways & Means Committee, CBO Director Douglas Elmendorf told legislators that the current direction of the health care reform debate was unlikely to reduce costs to the federal government or to lower premiums for individuals.


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Coding Center to Offer CPC Coding Course in Lewiston

The Coding Center, a subsidiary of the Maine Medical Association, will present a eighteen-week coding course, qualifying a student to then sit for the AAPC exam, beginning in Lewiston in August.  The classes will be held at Central Maine Medical Center's Conference Room and will be taught by Gina Hobert, CPC-I, CPC, CPC-H.

This 18-week course, developed by the American Academy of Professional Coders (AAPC), will take students through the 2009 Current Procedural Terminology (CPT), International Classification of Disease (ICD-9), and HCPCS books to address proper coding in physician practices. This class is intended to educate students on proper techniques and rules of coding and will also prepare them to sit for the AAPC Certified Professional Coder (CPC) exam.

The Program includes the following:
- One year membership in the  AAPC
- Student workbooks
- CPC exam
- Group discussion and networking opportunities

Prerequisites: Two years coding experience, understanding of anatomy and medical terminology is strongly recommended

Course Requirements:
- 2009 Current Procedural Terminology (CPT) Book  (Professional Edition strongly recommended)
- 2009 ICD-9-CM Book
- 2009 HCPCS Book

$1650 MMA members & affiliates
$1750 non-MMA members

For more information on the course, please contact Maureen Elwell at 622-3374, ext. 219 or via e-mail to melwell@mainemed.com, or click here for a registration form .[pdf] [ [return to top]

Make Plans Now to Attend 156th Annual Session, September 11-13 in Bar Harbor

Your May-June issue of Maine Medicine contained a brochure with registration materials for the Association's Annual Meeting being held this year at the Harborside Hotel & Marina in Bar Harbor.  Friday's educational program and opening night reception will be held at the Jackson Laboratory also in Bar Harbor.  The theme of this year's meeting is Personalized Medicine, Translating Science to Clinical Practice, with clinical researchers from the Jackson Laboratory being paired with practicing clinicians in each field to present one of our strongest educational programs.

The meeting begins at 2:30 pm on Friday, September 11th with a keynote presentation by Richard P. Woychik, Ph.D., President and CEO of the Jackson Laboratory.  The presentation will be in the auditorium at the Laboratory's facilities.  A world-renowned geneticist with a background in both academia and industry, Dr. Woychik came to the Jackson Laboratory in 2002.  Dr. Woychik's wide-ranging interests include the molecular genetics of obesity and insulin-dependent diabetes, hearing loss, and polycystic kidney disease.

If you are interested in attending and cannot find the brochure, either give the office a call at 622-3374 or register on-line on the MMA website at www.mainemed.com[return to top]

MMA and MaineCare Launch Academic Detailing Program (MICIS)

The Maine Medical Association has received a state contract to develop and implement an academic detailing program designed to provide independent clinical information to Maine physicians and other prescribers of medication.  By aligning prescribing practices with the best scientific evidence on the treatment of common clinical problems, it is hoped that patient outcomes can be improved.  And while the primary goal of the program is to improve quality, the experience in other states has demonstrated that academic detailing also helps to control costs, which obviously has important implications for access to care.  The program has been named the Maine Independent Clinical Information Service or MICIS.

Academic detailing focuses on clinical topics where there are gaps between evidence-based guidelines and typical practice patterns.  Educational modules are developed after synthesizing the findings of the best available studies into key messages for practicing clinicians.  These training materials, developed by physicians associated with Harvard Medical School, form the basis of face-to-face discussions between the academic detailers and physicians.

MICIS was mandated by the Maine Legislature and is funded by fees collected from pharmaceutical companies as a cost of doing business in the state.  The Legislature wanted to create a mechanism where physicians and other providers could be exposed to clinical content created by an independent group of experts not swayed by financial concerns.  The Program is overseen by an advisory committee chaired by family physician Noah Nesin, M.D. of Lincoln.  MMA is represented on the Academic Detailing Advisory Committee (ADAC)  by Kellie Miller, M.S.and Gordon Smith, Esq.  Other participants include representatives of Goold Health System, MaineCare, pharmacists, physicians, and consumers.  Two physician assistants have been trained to conduct the detailing presentations.  Noel Genova, PA-C of Portland has practiced primary care in Portland, in Kentucky, and in Birmingham, England and also provides consultations on prescribing for chronic pain funded by the Board of Licensure in Medicine and provided through MMA.  Erika Pierce, PA-C is a native of Central Maine and has practiced in primary care settings in the Central Maine area since 2005.

The first two modules prepared deal with the clinical topics of anti-coagulants and Type II Diabetes.  Detailing visits will begin by early fall.  To schedule a visit to your practice, contact Noel Genova directly at noelpac@aol.com or 207-671-9076 or Kellie Miller at kmiller@mainemed.com or 622-3374, ext. 229.

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Board of Licensure in Medicine to Develop Clinical Protocols for Prescribing of Narcotics

As a result of legislation filed by Senator Peter Mills, the Board of Licensure in Medicine has invited a group of stakeholders to meet at 10:00 am on July 21st in Augusta to begin work on a set of common protocols for the use and administration of controlled substances for use by licensed prescribers.  The protocol must be developed by February 1, 2010.   

L.D. 1193, An Act to Establish Uniform Protocols for the Use of Controlled Substances  was considered this past session by the Committee on Business, Research & Economic Development.  As originally presented, the proposal would have prohibited any narcotic from being prescribed beyond thirty days for the treatment of chronic pain arising from a noncancerous or nonterminal condition except by a prescriber with specialized training and expertise in managing a patient suffering from chronic pain.  It proposed additional restrictions on such patients as well, such as restricting them to one prescriber and one pharmacist.

Following a public hearing at which MMA and other organizations opposed the restrictions without further consideration of the consequences, the Committee eventually recommended that the legislature pass the following Resolve, in lieu of the bill.

                   Resolve, To Establish Uniform Protocols for the Use of Controlled Substances

          Board of Licensure in Medicine to convene stakeholders to develop common protocols for the use and administration of controlled substances.  Resolved:  That the Board of Licensure in Medicine shall convene a group of stakeholders, including but not limited to representatives from the State Board of Nursing, the Board of Osteopathic Licensure, the Board of Dental Examiners, the Maine Board of Pharmacy, the State Board of Veterinary Medicine and the Board of Licensure in Podiatric Medicine and the Director of Substance Abuse within the Department of Health and Human Services, to develop common protocols for the use and administration of controlled substances, as defined in the Maine Revised Statutes, Title 22, section 7246, for use by licensed prescribers.  The protocol must be developed no later than Feb. 1, 2010.  The Board of Licensure in Medicine shall notify the Joint Standing Committee on Business, Research and Economic Development of the protocol.  The joint standing committee is authorized to submit legislation regarding the protocol to the Second Regular Session of the 124th Legislature.

        The Legislature enacted the Resolve and the July 21st meeting is the beginning of the process.  MMA representatives and interested physicians will attend the meeting and provide input, along with representatives of hospice care and other interested parties.  Any MMA member or specialty society wishing to provide input through MMA should direct comments to EVP Gordon Smith, Esq. via e-mail to gsmith@mainemed.com. [return to top]

MMA/Quality Counts Partner to Make Docsite Licenses Available at No Charge for PQRI Reporting

Ever thought about participating in the CMS Physician Quality Reporting Initiative (PQRI) but didn't know where to begin?  MMA has partnered with Quality Counts to offer practices a new option for participating in PQRI by using the alternative reporting allowed through the DocSite reporting tool, available at no cost through a grant from the Physicians Foundation.  Interested practices can use the PQRI "Alternative Reporting Methods and Criteria," which allows physicians to track and report data for 30 consecutive patients with one of seven conditions, including Diabetes, Back Pain, Prevention, Chronic Kidney Disease, and Rheumatoid Arthritis.

Successful reporting to PQRI makes the practice available for bonus Medicare payments based upon the total Medicare reimbursement received by a practice during 2009.

Both primary care practices and specialty practices are eligible to receive the coupons, so long as they treat one or more of the seven conditions.  But there are only 75 coupons available, and each physician in the practice needs one to report, so don't delay.  MMA is making the coupons available to members on a first-come, first-serve basis.

To order your coupon number contact Warene Eldridge at weldridge@mainemed.com or via phone to 622-3374, ext. 227.  For further information, see http://www.mainequalitycounts.org/library/2009-6216005705.pdf.

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Workers' Comp. Board Proposes Rule with Increase in IME Fees

In late June, the Maine Worker's Compensation Board published amendments to its Rule Chapter 4, Independent Medical Examiner to increase the mileage, lodging, and meal reimbursement for claimants attending an independent medical examination.  The proposed amendment also increases the permitted hourly charge for physicians performing IMEs from $200 per hour to $300 per hour and the maximum billable time for the IME from four hours to five hours.

The Workers' Compensation Board and staff have been trying to encourage more physicians to participate in IMEs and the MMA has pledged to assist them with this effort.  This proposed amendment certainly is an indication of good faith in this effort. 

The Board has scheduled a public hearing on the proposed amendments to Chapter 4 for Monday, July 27, 2009 at 9:00 a.m. in Room 170 at the WCB Central Office, AMHI Complex, Deering Building, 90 Blossom Lane, Augusta, Maine.  The deadline for written comments is 5:00 p.m. on Thursday, August 6, 2009.  Written comments should be directed to John C. Rohde, General Counsel, WCB, State House Station 27, Augusta, Maine 04333-0027.

If you would like to offer your comments through the MMA, please contact Andrew MacLean, Deputy EVP, at amaclean@mainemed.com or 622-3374, ext. 214. [return to top]

CMS Publishes 2010 Medicare Physician Fee Schedule; Removes Office Drugs from Formula

The Centers for Medicare & Medicaid Services (CMS) published the 2010 physician fee schedule in the Federal Register on July 13th:  http://edocket.access.gpo.gov/2009/pdf/E9-15835.pdf.

CMS published a correction to this notice on the same date:  http://edocket.access.gpo.gov/2009/pdf/E9-16507.pdf.

The proposed fee schedule would remove office-administered Part B drugs from the calculation of the fee schedule, a move applauded by organized medicine.  However, the proposal still includes the SGR methodology, meaning that Medicare physician payments would be cut by 21.5% unless Congress acts before January 1, 2010 through health care reform initiatives or otherwise.

The proposal also would:

  • substitute E&M service codes for consultation codes, which are billed by specialists and are paid at a higher rate than E&M services, and redistribute the savings:
  • increase the practice expense units for imaging to reflect a higher utilization rate than the current rate which assumes that a physician who owns the equipment will use it about 50% of the time;
  • implement a requirement in the Medicare Improvements for Patients & Providers Act that suppliers of the technical component of advanced imaging services be accredited beginning in 2012;
  • add more measures and measure groups for eligible professionals to report under the PQRI to provide a mechanism for participants to submit data from EHRs and to create a process for group practices to use for reporting the quality measures;
  • add an EHR-based reporting mechanism to allow CMS to begin accepting data from qualified EHR products on 10 proposed individual PQRI measures and allow eligible professionals to count their submission of EHR-based measures toward their eligibility for a PQRI incentive payment.

The proposal also includes an update to the practice expense component of the fees by including data from the AMA's survey, the Physician Practice Information Survey.

CMS is accepting comments until August 1st and is expected to publish a final rule by November 1st. [return to top]

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