October 5, 2009

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Senate Finance Committee Completes Mark Up of Reform Bill; Sen. Snowe Uncommitted

The Senate Finance Committee completed its work on Chairman Baucus' draft health care reform bill on Friday morning around 2:00 am.  A final vote is expected this coming week following the delivery of some more cost estimates from the Congressional Budget Office.  The 10-year, $900 billion proposal would significantly expand access but would be financed by cuts to Medicare and Medicaid, as well as new taxes and fees.  The bill is expected to pass in the Committee this coming week and the Senate Democratic leaders will then work to meld the bill with the proposal previously passed in the Senate Health, Education, Labor & Pensions (HELP) Committee.  A Senate debate on the bill could then begin before the end of October.  Maine's Senior Senator Olympia Snowe has not yet indicated whether she will vote for the Senate Finance Committee proposal.

This morning in Washington, Richard Evans, M.D., a general surgeon practicing in Dover-Foxcroft and one of Maine's two AMA delegates, participated in a health system reform event in the White House Rose Garden with President Obama and other physicians across the country, including AMA Board Chair Rebecca Patchin, M.D.  Watch the MMA website, www.mainemed.com, for photos and reports on the event.

From the point of view of physicians, two of the troubling provisions in the Senate Finance Committee (SFC) proposal involve the creation of an independent Medicare Advisory Commission and unfavorable changes to the Medicare PQRI program.

The Independent Medicare Advisory Commission is tasked with reducing Medicare costs by $12 billion over five years.  Hospitals would be exempt from the cuts because of the previous agreement with the White House that hospitals would reduce expenses by $150 billion over ten years from what would otherwise be expected to be spent.  The Commission would be required to reduce provider payment rates if the target for reduction was not met.  Congress would have 30 days to stop implementation of the reductions, but could only do so with a two-thirds vote.

Relative to the existing Medicare Physician Quality Reporting Initiative (PQRI), the SFC proposal makes some improvements regarding feedback to the physician, but it also reduces the current 2010 2% bonus to 1% and reduces the bonus to 0.5% in 2011.  It also begins to impose penalties on eligible physicians who do not participate beginning in 2012.

On the other hand, as the AMA President James Rohack, M.D. noted in a conference call at 1:00 pm today, there are many aspects of the SFC proposal that are very positive and consistent with AMA policy.  These aspects include:

  •          Expansions of coverage for millions of Americans currently without insurance;

  •          Reductions in administrative waste and burden;

  •          Insurance reforms to prevent health plans from denying coverage for pre-existing conditions; and

  •          Expansion of coverage by providing tax credits, part of the AMA's plan for expanding coverage.

The bill also fixes the sustainable growth rate problem, but only for one year, replacing the scheduled 21.5% cut with a 0.5% update.  The House bill, H.R. 3200, proposed a permanent fix over ten years at a cost of $230 billion.

The AMA and other national medical organizations will be working diligently over the coming days to make positive changes in the Senate proposal, including more favorable SGR provisions, medical liability reforms, amending the Independent Medicare Advisory Commission provisions, and eliminating the Medicare/Medicaid provider enrollment fee of $350 per physician.

MMA will continue to update members and their staffs on the work going on in Washington through the Weekly Update and other channels of communication.

Appropriations & HHS Committees Monitor State Fiscal Developments

During the month of September, both the legislature's Appropriations and Health & Human Services Committees have met to monitor the State's financial situation and to plan for a supplemental budget to cover a widening budget gap.  The Appropriations Committee has asked all state agencies to prepare a list of program priorities as it anticipates that cuts will be necessary when the legislature returns to the State House in January 2010.  The following excerpts from the legislature's Office of Fiscal & Program Review are noteworthy.

General Fund revenue continued its downward slide in August, although the descent was not as steep.  August's revenue variance was much less than the previous 3 months since the May revenue revisions.  This brief reprieve from substantial negative variances was just that - brief.  Preliminary data for September revenue shows a return to the pattern of the early months.  Sales tax performance will be under budget by more than $5 million despite the positive effect of the "Cash for Clunkers" program.  Estimated payments for individual and corporate income taxes due in September were also substantially below budget.  Individual income tax withholding returned to negative territory in September.


General Fund revenue was under budget by $3.4 million in August increasing the negative variance for the first 2 months of FY 2010 to $14.2 million or 4.9%.  General Fund revenue fell by 11.2% during the first 2 months of FY 2010 compared to the same period in FY 2009.


MaineCare caseload and weekly payment cycles continued to be a concern.  Last month, the Department of Health & Human Services (DHHS) requested a transfer of funds within FY 2010 from the 2nd, 3rd, and 4th quarters totaling $55.6 million to address 1st quarter MaineCare funding needs.  DHHS currently believes that this transfer does not represent an additional shortfall that requires a supplemental budget request, but remains concerned about continued increases in MaineCare caseload.

The Revenue Forecasting Committee and the Consensus Economic Forecasting Commission both are scheduled to meet next month to produce a fall financial forecast.

You can find Fiscal News, the monthly newsletter of the Office of Fiscal & Program Review on the web at:  http://www.maine.gov/legis/ofpr/other_publications/fiscal_news/FiscalNews_2009_09.pdf.


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Prepare Now for Compliance with Breach Notification Requirements of HITECH Act

The so-called HITECH Act (the "Health Information Technology for Economic & Clinical Health Act"), part of the American Recovery & Reinvestment Act ("ARRA"), includes provisions requiring "covered entities" under the HIPAA privacy and security rules to notify patients of a "breach," as defined in the HITECH Act, of their unsecured protected health information or PHI.  The provisions also make business associates directly subject to the requirements of these HIPAA rules.  The federal government issued guidance in rulemaking published in late August establishing a compliance date of September 23, 2009.  The U.S. Department of Health & Human Services has said, however, that it will use its discretion NOT to enforce the requirements until February 22, 2010.  

These provisions of the HITECH Act will require modest amendments to practices' Notice of Privacy Practices and business associate agreements. Also, the AMA has developed a useful guidance document entitled, What You Need to Know About the New HIPAA Breach Notification Rule.  You can find this document on the web at:  http://www.ama-assn.org/ama1/pub/upload/mm/399/hipaa-breach-notification-rule.pdf.  The MMA has amended its model Notice of Privacy Practices and required elements of a business associate agreement.  Practices may contact Andrew MacLean, Deputy EVP (amaclean@mainemed.com; 622-3374, ext. 214), or Gordon Smith, EVP (gsmith@mainemed.com; 622-3374, ext. 212), with any questions about compliance with the new requirements.   [return to top]

MMA Committee on Membership and Member Benefits to Meet on Tuesday, Oct. 6

MMA's Committee on Membership & Member Benefits will meet this coming Tuesday night, October 6th, at the MMA offices in the Frank O. Stred Building in Manchester.  The meeting will begin at 6:30 pm following dinner which will be available at 6:00 pm.  Brian Pierce, M.D., a family physician in private practice from Rockport, is the new chair of the Committee.  On the agenda for Tuesday is a discussion of the MMA group health plan for members, their families, and staff and a report on the current status of membership.  The group health plan is offered through Anthem Blue Cross Blue Shield of Maine which is requesting a 29% increase in rates.  The agenda will also include a review of possible committee work for the upcoming year.

All MMA committee meetings are open to all MMA members, whether they are committee members or not.  But, any non-committee members wishing to attend should communicate with Lisa Martin who staffs the committee so we can be sure to have enough food and materials.   Lisa can be reached by calling 622-3374, ext. 221 or via e-mail to lmartin@mainemed.com.  Any members wishing to serve on the committee should contact EVP Gordon Smith at 622-3374, ext. 212 or via e-mail to gsmith@mainemed.com. [return to top]

Aetna's H1N1 Flu Vaccine Coverage

Aetna's H1N1 Flu vaccine coverage

NEW 9/30-- Aetna will cover administration of the H1N1 flu vaccine for all fully insured medical plan members and self-funded plan members unless the plan sponsor decides otherwise. Aetna is offering this coverage even in instances where members’ plans do not include coverage for preventive care or have limits on such coverage. Co-pays, co-insurance and deductibles will not apply for the administration of the vaccine.

NEW 9/30 -- We will pay providers for the administration of the H1N1 vaccine using the appropriate CPT code 90470 or HCPCS code G9141.  

Based on CDC recommendations, we will pay for the administration of one or two doses of H1N1 flu vaccine. While we will pay the vaccine administration code whether or not a vaccine code is submitted, we will not pay for the H1N1 vaccine itself as it is being supplied by the federal government at no charge. The government is also providing needles, syringes, alcohol swabs, and sharps containers.

Aetna will pay for the seasonal flu shot and its administration on the same or different dates of service as the H1N1 vaccine, based on CDC recommendations.

NEW 9/30- Aetna’s Prescription antiviral medication coverage

Aetna plans that include a pharmacy benefit that covers brand-name drugs will cover Tamiflu and/or Relenza for treatment of a diagnosis, or as a preventive measure as prescribed by a health care provider. Member co-payments or co-insurance are applied as noted in the member's benefit plan.

For members who are in an Aetna pharmacy plan that covers only generic medications, Tamiflu and/or Relenza would be covered at the brand tier. This could result in a higher out-of-pocket cost for the member.

NEW 9/30 - Recommended guidelines for treating the H1N1 disease

CDC guidelines state that people who are not at higher risk for complications or do not have severe influenza requiring hospitalization generally do not require antiviral medications for treatment or prophylaxis. 

NEW 9/30 - Recommended guidelines for H1N1 flu testing

Recent studies of rapid influenza tests found these test miss many cases of H1N1 flu. A study looking at the effectiveness of a rapid flu test found it detected less than half of the cases later confirmed by more sophisticated PCR testing. The findings, which appeared in the U.S. Centers for Disease Control and Prevention's MMWR, confirm the CDC's current guidelines that the use of tests for individual patients should most often be reserved for people at high risk from serious influenza complications, where diagnostic or therapeutic decisions could be life-saving. 

CDC guidelines state that H1N1 PCR testing should be prioritized for persons with suspected or confirmed influenza requiring hospitalization. 

Become an H1N1 vaccinator

Physicians are reminded to register with your state's Department of Health to become a vaccinator. This is required in order to receive and administer the H1N1 vaccine to patients.

State and local public health departments will designate which public and private sites will be given the vaccine. Public sites could include public health clinics and clinics located in schools. Private sites could include provider offices, workplaces or retail settings. A number of retail sites, including Minute Clinics/CVS, Take Care Health, and RediClinics, also are expected to be vaccinators. We will encourage our members to seek vaccines at any of these available outlets (note that emergency rooms are not the appropriate place to seek vaccines).

NEW 9/30 - State health departments can be located through this web link provided by the CDC: http://www.cdc.gov/h1n1flu/states.htm.

Where to go for additional information

In preparation for the anticipated second wave of H1N1 influenza, please review your business continuity plans and office policies, including phone triage and after-hours availability. The following resources are available to assist in your response planning:

Additional Resources

CDC 2009 H1N1 flu website: http://www.cdc.gov/h1n1flu/

CDC website "10 Steps You Can Take: Actions for Novel H1N1 Influenza Planning and Response for Medical Offices and Outpatient Facilities" at http://www.cdc.gov/h1n1flu/10steps.htm

HHS H1N1 website: http://www.flu.gov/ [return to top]

MMA Co-Hosts September 29th Immunization Congress Drawing 55 Participants

The Maine Medical Association, the Maine Chapter of the American Academy of Pediatrics, and the Maine Immunization Coalition held a successful one-day Immunization Congress beginning the day with two national speakers discussing the renewed necessity of stressing the benefits, safety, and perceived risks of childhood immunizations and improving the comfort level of handling questions from parents.

Dr. Iyabode Besolow, MD, MPH, National Center for Immunization and Respiratory Diseases, CDC addressed the most recent recommendations for childhood immunizations and H1N1 flu virus, stating that it is a quadruple-reassortant virus.  This means that it contains genetic pieces from four different virus sources.  They are: 

-        Swine influenza virus that is North American in lineage

-        North American avian influenza virus

-        One segment of human influenza virus

-        Swine influenza virus normally found in Asia and Europe

She also noted that as of 9/29/09, there were 593 deaths reported in the U.S., with 65% of persons who have died were between the ages of 25 and 64 years of age.

Dr. Gary Marshall, MD, Professor of Pediatrics, Chief, Division of Pediatric Infectious Diseases, and Director, Pediatric Clinical Trials Unit, University of Louisville addressed parents' concerns about vaccines and discussed the 10 Immunization Truths.

  1. Vaccines are good
  2. Public concern about vaccines is pervasive
  3. Fear of vaccines can lead to public harm
  4. Vaccines are not 100% safe
  5. Parents are human
  6. The public doesn’t understand vaccinology
  7. It’s all about risk perception
  8. There are vaccine anti-champions
  9. Questions remain
  10. Parents have to make a choice

Dr. Marshall also analyzed Dr. Bob’s Alternative Vaccine Schedule through a Argument/The Truth schematic, as well as the Vaccine Court Hearings.

Both speaker PowerPoint presentations are available at www.mainemed.com under the Public Health tab under Childhood Immunization.  Please note that Dr. Gary Marshall’s PowerPoint changes periodically and this is the presentation he provided on September 29, 2009.

The CDC Vaccines and Immunization Contact Information is below for your reference:

Telephone                   800-CDC.INFO (for patients and parents)

Email                           nipinfo@cdc.gov  (for providers)

Website                       www.cdc.gov/vaccines/hcp

Free Continuing Education products:  www.cdc.gov/vaccines/ed

The Afternoon Session, sponsored by the Maine Chapter of the American Academy of Pediatrics focused on, “Immunizations for all Maine Children:  Making It Happen Together” Congress.  A diverse group of participants came together to benefit the children of Maine by generating ideas and action to:

-        Increase the number of children who are adequately immunized

-        Ensure Maine’s financial ability to adequately immunize all children

-        Ensure Maine has a good system to measure the number of children who are adequately immunized

-        Reaffirm the public health necessity of the Maine Immunization Program

The group participants identified a set of action steps to move the above three priorities forward and a full report will be available soon at www.maineaap.org [return to top]

Bureau of Insurance Progumlates Emergency Rule on Insurance Carriers' Response to Public Health Emergencies

Maine's Bureau of Insurance recently issued the following emergency rulemaking providing guidance for health insurance carriers in responding to public health emergencies.




Table of Contents

SECTION  1.                 Authority

SECTION  2.                 Purpose

SECTION  3.                 Applicability and Scope

SECTION  4.                 Definitions

SECTION  5.                 Standards of Emergency Preparedness

SECTION  6.                 Contingency Planning Requirements

SECTION  7.                 Reporting Requirements

SECTION  8.                 Effective Date


This Rule is adopted by the Superintendent pursuant to 24-A M.R.S.A. §§ 211, 212, 471, 472, 478, and 4309.


            The purpose of this Rule is to establish requirements and procedures for carriers offering health plans to prepare for public health emergencies.


            This Rule applies to any carrier offering a health plan in Maine, as defined at 24-A M.R.S.A. § 4301-A.  Medicare Advantage, Medicare Part D, Medicare supplement, TRICARE supplement plans, and dental plans are not subject to the requirements of this Rule.


For purposes of this Rule, “Public Health Emergency” means an existing or imminent likelihood of need for a significant increase in health care services or insurance benefit payments due to injuries or sickness.”


Carriers subject to this rule must be capable of implementing the following actions within 72 hours in the event that the Superintendent issues a direction, rule, or order to do so pursuant to 24‑A M.R.S.A. § 478.

1.                  Suspension of plan rules for prior medical authorization, pre-certification, and utilization review.

2.                  Suspension of plan requirements for accessing prescription drugs, including prior approval requirements, refill limitations, and co-payments.  This includes, but is not limited to, suspension of formulary requirements that are more stringent than treatment guidelines established by the United States Centers for Disease Control.

3.                  Suspension of incentives or requirements for enrollees to obtain health services from contracted network providers.

4.                  Suspension of rate increases, extensions of grace periods, suspension of termination of coverage for employees losing group coverage, and easing of enrollment requirements.

5.                  Suspension of cost barriers for accessing needed services, including co-payments, co-insurance, and deductibles.

6.                  Suspension of time limits for filing claims.


Within 30 days after the effective date of this Rule, carriers offering health insurance plans in this state shall provide the Superintendent with the following information.

1.                  The name and contact information for an officer of the company primarily responsible for public insurance emergency planning in Maine.  If this contact information changes the carrier shall notify the Superintendent within 72 hours.

2.                  A description of health insurance coverage in force in Maine, which must be updated at least annually.  Carriers shall provide updated descriptions within 72 hours after a request by the Superintendent.  At a minimum, the description must include the following:

i.  The number of group and blanket policy enrollees.

ii.                   The number of individual policy enrollees.

iii.                  The number of enrollees who have coverage for prescription medications.

iv.                 The number of enrollees who have coverage for influenza and pneumococcal vaccinations.

3.                  A description of the carrier’s plans for assuring adequate staffing and business continuity during a public health emergency.

4.                  A description of the carrier’s plans for working closely with state and federal regulatory and emergency agencies to respond to the needs of enrollees and the public during a public health emergency.

5.                  A description of the carrier’s plans for providing enrollees and providers with essential information during a public health emergency.

6.                  A description of the carrier’s assessment and planning to address increased need and decreased availability of medical supplies, prescription drugs and vaccinations during a public health emergency.

7.                  A description of the carrier’s contingency plans for minimizing barriers for enrollees to access health care services and health insurance benefits during a public health emergency, including the carrier’s own guidelines for deciding when to implement contingency plans.  The plans and guidelines must be flexible and must include specific actions to assist the public in maintaining access to health care services and health insurance benefits depending on the nature, scope, and extent of the emergency.  At a minimum contingency plans and guidelines must include the ability to implement the actions described in Section 5 of this Rule within 72 hours after a direction, rule, or order to do so issued pursuant to 24-A M.R.S.A. § 478.


1.                  Carriers with health insurance plans covering Maine residents shall promptly provide any information requested by the Superintendent regarding an existing or potential public health emergency, including claims information.

2.                  Carriers offering health insurance plans in Maine shall file reports meeting the requirements of Section 6 within 30 days after the effective date of this Rule.  Reports shall be verified by the oath of the officer designated in Section 6, subsection 1 of this Rule and by one other principal officer of the carrier.  Updated reports shall be provided to the Superintendent within 72 hours after a request made to address an existing or potential public health emergency.  Business continuity plans shall be held by the Superintendent as confidential information in the same manner as insurers’ business plans.  If the insurer considers any other information that it files pursuant to this Rule to be confidential pursuant to Maine law, the insurer shall file a request for protection from disclosure, identifying with particularity the information the insurer considers to be confidential and the reasons the insurer believes the information filed is not a public record within the meaning of the Maine Freedom of Access Law, 1 M.R.S.A. §§ 401 et seq.

3.                  The Superintendent may, but is not required to, exempt carriers with fewer than 500 insured lives in Maine from the reporting requirements of this Rule.

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H1N1 Vaccine Update for Pregnant Women

H1N1 Update From MeCDC:

The LAIV (nasal spray) form of the H1N1 vaccine arriving next week is NOT licensed for pregnant women.  Pregnant women should receive inactivated (injectable) forms of both seasonal and H1N1 vaccine as soon as both are available. 

 The MeCDC anticipatse being able to order injectable vaccine for H1N1 next week, which should then arrive the week of October 12th.  Therefore, the earliest pregnant women will have access to H1N1 vaccine is the week of October 12th.  Seasonal flu vaccine is likely already available to them in many areas of the state.
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CORRECTION to The Coding Center's Fall E/M Chart Auditing Courses

Recent communications from MMA (last week's Maine Medicine Weekly Update and the current issue of Maine Medicine) have included information and/or a flyer about The Coding Center's fall E/M Chart Auditing courses.  The time of the course scheduled for Fridays from 10/16/09 through 11/13/09 at the Lincoln County Health Care Education Center at 66 Chapman Street, Damariscotta, Maine included the wrong time.  The course in this location will take place from 8:00 a.m. to noon, NOT 3:00 - 7:00 p.m.  

For more information about these courses, please contact Maureen Elwell at 622-3374, ext. 219 or melwell@mainemed.com. [return to top]

HHS OIG Issues FY 2010 Work Plan

On October 1, 2009, the DHHS Office of the Inspector General released its annual work plan, a document that highlights its priorities in fighting health care fraud & abuse.  You can find the work plan on the web at:  http://www.oig.hhs.gov/publications/docs/workplan/2010/Work_PLan_FY_2010.pdf.

 Of particular interest to physicians will be:

  • Review of Medicare payments for DME, specifically physician self-referral for DME;
  • Review of CMS' oversight of recovery audit contractors during the RAC demonstration project; and
  • Review of Medicaid payment for prescription drugs.
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For more information or to contact us directly, please visit www.mainemed.com l ©2003, Maine Medical Association