October 19, 2009

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Health System Reform Advances with Help from Senator Snowe

Maine Senator Olympia Snowe cast the sole Republican vote in favor of the health care reform bill drafted by the Senate Finance Committee last Tuesday.  The committee vote in favor of the bill was 14 to 9.  Stating that, "When history calls, history calls," Senator Snowe noted that the consequences of inaction dictated the urgency of Congress taking every opportunity to demonstrate its capacity to solve the monumental issues of our time.

The proposal would expand insurance coverage to 29 million people who wouldn't otherwise have it by requiring nearly everyone to buy a policy and offering subsidies to assist low and moderate income families.  While the cost of the bill over 10 years is $829 billion, it nonetheless is estimated to decrease the federal deficit by $81 billion over the same period according to the non-partisan Congressional Budget Office. 

Senator Snowe had already made her mark on the proposal during the committee deliberations, opposing a public option and working to reduce the penalties on individuals who do not buy a policy.  She also supported larger subsidies to make the policies more affordable.

The proposal advanced by the Committee now must be melded with the bill previously passed by the Senate HELP (Health, Education, Labor & Pensions) Committee prior to the full Senate voting on the bill.  Of course, the House has to pass a bill as well in order for the results of the two branches to be reconciled and a final bill sent to the President for his signature.  And Senator Snowe made clear that her vote for the committee bill was not a sure sign that she will vote for a final bill.  That will depend upon what changes are made to the bill in the processes described above.

The bill also has the following features:

  • Medicaid is expanded to most individuals with incomes up to 133% of the federal poverty level (approximately $14,404 for an individual);

  • While there is no employer mandate to offer health insurance coverage, companies with more than 50 full-time employees would have to pay a fee of up to $400 per employee if they do not offer coverage;

  • While there is no "public option," the bill would provide $6 billion toward creation  of non-profit, member-run health insurance cooperatives and insurance exchanges in each state;

  • Insurance companies are prohibited from denying coverage, or charging higher premiums because of a person's medical history or medical condition;

  • Raises revenue by imposing $13 billion in new annual fees on insurance companies, medical device manufacturers, and pharmaceutical companies and imposes an excise tax on high-cost health plans - generally 40 percent of the value exceeding $8,000 for individuals and $21,000 for families.  The tax would be paid by insurers;

  • Provides for a 0.5% update to physician fees from Medicare in 2010, instead of the planned 21% decrease.  But, there is no permanent repeal of the SGR (sustainable growth rate) formula which is causing negative updates in most years for physician fees.  

While there are several more potential barriers to final enactment of a bill, the progress this past week advances the cause of reform to the point where most observers now believe it is more likely than not that a bill will pass and be signed into law by the President before the end of the year.

Senate to Consider Bill on Permanent Fix to Medicare SGR This Week; Contact Maine Senators ASAP

In the midst of the ongoing national health care reform debate, the AMA and other physician organizations have succeeded in persuading a member to sponsor a bill solely on the SGR issue and in convincing the Senate leadership to allow the bill to come to the floor for debate without a cloture requirement.  Senator Debbie Stabenow (D-MI) has submitted the Medicare Physician Fairness Act of 2009 (S. 1776), a bill that would repeal the SGR formula and freeze Medicare physician pay for 10 years.  The bill is controversial on both sides of the aisle because it would cost $247 billion over ten years and the bill includes no payment offset.  The bill also includes no increase for physicians, but it is expected that this will be included in the final version of health care reform.

The MMA understands that S. 1776 could come up for debate any time this week after 2 p.m. tomorrow.  Members are involved in luncheon caucuses on health care reform and the SGR issue in particular, so the next 24 hours are crucial for our grassroots advocacy.  The MMA urges members to use the AMA's grassroots action center and toll free line (800-833-6354) to communicate with the offices of Senator Snowe and Senator Collins between now and noon tomorrow.  You can find more information on this bill on the AMA web site at: http://www.ama-assn.org/ama/pub/health-system-reform/bulletin/16oct2009.shtml.

On Friday, October 16th, the AMA and AARP sent a joint letter to Senate Majority Leader Harry Reid urging support for S. 1776.  The text of that letter follows:

On behalf of the American Medical Association and AARP, we strongly urge you to vote for consideration and passage of S. 1776 - legislation to permanently repeal the flawed Sustainable Growth Rate (SGR) formula, avoid looming Medicare physician payment cuts, and to provide Medicare patients with the security and stability they deserve.

Joint polling we recently conducted found that two-thirds of people over 50 years old are either very or somewhat concerned that the current health care system limits their ability to see the doctor of their choice.  These fears have been compounded by the annual legislative struggle to avert Medicare physician payment cuts - temporary "band-aids" which have only served to increase the size of future cuts.  The continuing threat of steep Medicare payment cuts jeopardizes seniors' access to care and physicians' confidence in the government's commitment to funding a strong and reliable Medicare program.

Physicians face an unprecedented 21.5 percent cut in Medicare payment rates in January 2010, with additional cuts in future years.  S. 1776 would repeal the SGR forumula and establish a zero update for ten years.  Erasing the SGR debt wipes the slate clean and sets the stage for additional Medicare physician payment reforms.  We believe repealing the flawed SGR formula is essential to achieving true delivery system reform in the future.

Seven times in the last seven years, Congress has passed legislation to over-ride the SGR formula.  In essence, Congress has been operating with an artificial budget baseline for Medicare physician spending which it has repeatedly decided is inappropriate from both policy and service delivery perspectives.  It's time for Congress to adopt a real baseline.  Those who are concerned about waiving budget requirements should recognize that the past practice of "temporary band-aids" on the SGR problem has only served to increase both the size of future cuts and the cost of subsequent interventions.  That is neither responsible budget policy nor in keeping with our obligations to provide access, choice and quality care to Medicare patients and military families enrolled in the TRICARE program.

As the nation's largest organizations representing physicians and older Americans, we urge you to vote for cloture, to waive the budget point of order and support final passage of S. 1776.

This letter provides useful talking points for your contacts with the offices of Senators Snowe and Collins.  The references to cloture in this letter and on the AMA site mentioned above are dated, as Senator Reid now has allowed to bill to go forward without a cloture vote. [return to top]

MMA and Maine Medical Assessment Foundation Featured on National Public Radio

The Maine Medical Association and the Maine Medical Assessment Foundation were recently featured in a major story on National Public Radio.  Prepared and produced by NPR's Alix Spiegel, the hour long story on This American Life focused on geographic variations in medical care and the work of Jack Wennberg, M.D.   Click here to listen to the full one-hour program.

A portion of the program was also featured Oct. 8 on All Things Considered, the popular nightly newprogram on NPR.

The program traced the history of Maine physicians examining variations in surgical treatment and medical treatment, beginning with Dr. Wennberg's work in Vermont and Maine in the mid to late 1970's.  In addition to Dr. Wennberg, portions of interviews with Elliott Fisher, M.D., Robert Keller, M.D., Frank Read, M.D. and Gordon Smith were included in the program.  Two patients from Lewiston who had undergone surgical procedures in the 1970's were also interviewed.

The Maine Medical Assessment Foundation, established through the leadership of Dr. Daniel Hanley,  operated as a non-profit medical research organization for nearly twenty years, ending in 1999.  Much of the Foundation's work is now carried on by the publicly funded Maine Quality Forum.


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Recognizing John P. Dow, M.D., of Pittsfield 1934-2009

The MMA family lost another member and friend this past week with the death of John P. Dow, M.D. of Pittsfield.  Dr. Dow, or J.P., or Jay as he was known to his friends, was born in the Dover-Foxcroft area and graduated from Foxcroft Academy, Bowdoin College, and Harvard Medical School.  He completed his internship and residency in family medicine at Hartford Hospital in Hartford, Connecticut.  While Dr. Dow could have pursued an academic medical career or practiced anywhere in the country, he chose to return to his native state and establish a private practice in Pittsfield in l963.  He practiced true family medicine in that community until his retirement in 1999.

Dr. Dow was an active MMA member and chaired the MMA Legislative Committee for several years in the early 1980's.  In 1982, he received at the MMA Annual Meeting the annual President's Award for Distinguished Service.  He was also active in the Maine Academy of Family Physicians.

As stated in his obituary, "For Jay, the practice of medicine and the care of his patients were not work but a calling.  He lived and breathed medicine and his patients' needs day and night, sitting most evenings calling patients to see how they were feeling."

MMA Past President Kevin Flanigan, M.D., who worked closely with Dr. Dow after arriving in Pittsfield, provided a eulogy at the service on Saturday and noted, with respect and humor, the many qualities that made Jay an icon.  Whether in his the role of husband, father, grandfather, physician, musician, raconteur, or commuity leader, Dr. Dow will be long-remembered by all of us at MMA and by hundreds of friends, patients, and colleagues in Somerset County and beyond.

Dr. Dow is survived by his wife Louise and their four sons, John, Michael, William, and David. [return to top]

Looking for Opportunities to Introduce Physicians to Pediatric Environmental Toolkit

Looking for opportunities to Introduce Physicians to the Pediatric Environmental Toolkit -

The Pediatric Environmental Health Toolkit (a PDA download of the toolkit is available via the PSR website at http://www.psr.org/resources/pediatric-toolkit.html), is a visually appealing, practical and easy to use in the busy physician practice.  Dr. Jim Melloh is available or another Maine PSR member welcome the opportunity to do clinical presentations on this subject.  This presentation would include a discussion of toxins children are exposed to, and why children are more vulnerable to these toxins.  The Toolkit is a combination of easy-to-use reference guides for health providers and user-friendly health education materials on preventing exposures to toxic chemicals and other substances that affect infant and child health.  The Toolkit is also endorsed by the American Academy of Pediatrics and there is also an excellent online course with fascinating cases, which walks providers through the toolkit.  It offers 1.5 hours CME credit at http://www.atsdr.cdc.gov/emes/health_professionals/pediatrics.html

Our nation is experiencing an epidemic of chronic health problems, some of which clearly have links to chemicals in our environment.  Reducing chemical exposures is an important primary prevention measure to help improve the health of our nation and the expense of providing health care.

Physicians for Social Responsibility (PSR), American Nurses Association, and Health Care Without Harm (HCWH) have joined the Safer Chemicals, Healthy Families Campaign, a diverse and growing coalition of organizations, businesses, and individuals united by concern about the toxic chemicals in our homes, places of work, and in products used every day.  The coalition is working to reform the federal law governing toxic chemicals, the Toxic Substance Control Act (TSCA) calling for eliminating the most dangerous chemicals from commerce, holding chemical companies responsible for information about health and environmental impacts of chemicals, and using the best science to protect all people and vulnerable groups, including children.  For additional information go to:   www.saferchemicals.org.

In 33 years, the Environmental Protection Agency (EPA) has tested for safety only 200 and banned only five of the more than 80,000 chemicals in commerce.   The Centers for Disease Control National Biomonitoring Project has found synthetic chemicals linked to health problems are present in every American. 

The Maine Medical Association’s 2008 resolution on “Reduction of Toxic Chemicals to Improve the Health and Well-being of Maine Citizens," supports increasing our knowledge base to improve our public health policies surrounding this issue as stated below:

THEREFORE, LET IT BE RESOLVED that The Maine Medical Association’s Public Health Committee and the Maine Chapter of the American Academy of Pediatrics work with environmental health organizations to link the bridge of knowledge of known and suspected medical consequences with an adequate chemical policy in Maine that is essential to safeguarding human health and the environment, that will additionally build a modern, vibrant economy with the collaboration the Governor’s Office of Health Policy and Finance through the State Health Plan, MeCDC, DEP, Alliance for a Clean and Healthy Maine, and other stakeholders.

For a full copy of the MMA's 2008 Reduction of Toxic Chemicals Resolution, contact Kellie Miller, Director of Public Health Policy at kmiller@mainemed.com or 207-622-3374, ext. 229. [return to top]

Toxic Chemicals Found in Doctors and Nurses

New Biomonitoring Study Detects Four Chemicals on EPA’s Recently Announced Top Priority List

Physicians for Social Responsibility (PSR) in partnership with American Nurses Association (ANA) and Health Care Without Harm (HCWH) released the “Hazardous Chemical In Health Care” report, detailing the first investigation ever of chemicals found in the bodies of health care professionals.  The inquiry found that all of the 20 participants (MMA Past President Stephanie Lash, MD participated from Maine) had toxic chemicals associated with health care in their bodies.  Each participant had at least 24 individual chemicals present, four of which are on the recently released Environmental Protection Agency list of priority of chemicals for regulation.  These chemicals are all associated with chronic illness and physical disorders.

The medical profession is asking whether we can reduce prevalence of disease by changing the way we manage chemicals.  Nurses and doctors volunteered for this study because they believe it is their responsibility to better understand how chemicals impact human health, explained Kristen Welker-Hood, ScD, MSN, RN, Director of Environment and Health Programs, Physicians for Social Responsibility, co-principal investigator and a co-author of the report.

Other findings include:

  • Eighteen of the same chemicals were detected in every single participant;

  • All Twenty participants had at least five of the six major types of chemicals tested;

  • Thirteen participants tested positive for all six of these major chemical types;

  • All participants had bisphenol A, phthalates, PBDEs and PFCs, priority chemicals for regulation by the EPA and associated with chronic illness such as cancer and endocrine malfunction.

The Hazardous Chemicals in Health Care Report offers preliminary indicators of what the broader health care community may be experiencing.  The project tested for 62 distinct chemicals in six categories:  bisphenol A, mercury, perflourinated compounds, phthalates, polybrominated diphenyl ethers, and triclosan.  The chemicals tested in the investigation are used in products common to the health care setting, from baby bottles, hand sanitizer, and medical gauges, to industrial paints, IV bags, and tubes and stain-resistant clothing.

In addition to data on testing, the report includes recommendations on how health care professionals can protect their patients and themselves by avoiding the use of toxic chemicals.  For more information and if interested in a copy of the report, contact Kellie Miller, Director of Public Health Policy at 207-622-3374, ext. 229 or via email at kmiller@mainemed.com. [return to top]

MMA Public Health Committee to Meet on Wednesday, October 21st

MMA's Public Health Committee will meet this coming Wednesday afternoon, 4:00 – 6:00 pm, October 21st, at the MMA offices in the Frank O. Stred Building in Manchester.   Norma Dreyfus, M.D., a retired pediatrician from Westport, is the new chair of the Committee.  On the agenda for Wednesday is a presentation by Hugh Tilson, MD, MPH from the Sagadahoc County Board of Directors regarding their infrastructure and work surrounding H1N1 planning and preparations.  The agenda will also include a review of the committee’s priorities and future directions for 2010.

All MMA committee meetings are open to all MMA members, whether they are committee members or not.  Please RSVP your attendance plans by contacting Kellie Miller, MMA staff by calling 622-3374, ext. 229 or via e-mail to kmiller@mainemed.com.    [return to top]

New Guidance from US CDC on Infection Control Measures Related to H1N1

The US CDC has issued new guidance for infection control measures in health care settings related to H1N1.  Below is a summary of the guidance, some options related to declaring a shortage if and when one exists, and the Q&A on the guidance.  Dr. Dora Mills and her New England Colleagues are meeting again today by phone to discuss these issues further, especially under which circumstances we as states should declare a shortage and what evidence we should use.  

Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel


Q&A on New Guidance


The new guidance: 

·  Applies uniquely to the special circumstances of the current 2009 H1N1 pandemic

·  Recommends the use of a "hierarchy of controls" including: 1) elimination of potential exposures, 2) Engineering Controls, 3) Administrative Controls, and 4) Personal Protective Equipment

·  Places strong emphasis on vaccination as an effective Administrative Control.

·  Defines healthcare personnel covered by this guidance as "all persons whose occupational activities involve with patients or contaminated material in a healthcare, home healthcare, or clinical laboratory setting...engaged in a range of occupations... and in the following settings: acute care hospitals, nursing homes, skilled nursing facilities, physician's offices, urgent care centers, outpatient clinics, and home healthcare agencies".  It also includes..."school nurses or personnel staffing clinics in correctional facilities."

·  Defines close contact as "working within 6 feet of the patient or entering a small enclosed airspace shared with the patient (e.g. average patient room.)"

·  CDC continues to recommend the use of respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for healthcare personnel who are in close contact with patients with suspected or confirmed 2009 H1N1 influenza.

·  The guidance acknowledges that some facilities are currently experiencing shortages of respiratory protection equipment and that further shortages are anticipated. In the face of shortages, appropriate selection and use of respiratory protection is critical and a key strategy is to use source control, engineering, and administrative measures to reduce the numbers of workers who come in contact with patients who have influenza-like illness to reduce the consumption of respiratory protection equipment.

·  Under circumstances were a shortage of respirators exists "despite reasonable efforts to obtain and maintain a sufficient supply for anticipated needs" ...a facility should consider shifting to a prioritized respirator use mode." In this mode, respirator use is prioritized to ensure availability for healthcare personnel at most risk from 2009 H1N1 influenza exposure, such as aerosol generating procedures. Prioritization should be adapted to local conditions, and should consider intensity and duration of exposure, personal health risk factors for complications of infection, and vaccination status. The objective is to reduce exposure while conserving supplies realizing that the flu season will last until May 2010 and we must also maintain a reliable supply for other highly communicable disease concerns such as TB.

·  In a prioritized respirator use mode, respirators may be carefully reused or their use may be extended, their use may be temporarily discontinued for employees at low risk of exposure or lower risk of complicated infection, and suitable facemasks could be used. It must be emphasized that even under this operating mode, N95 or better respiratory protection must be provided during high risk (e.g. aerosol generating) procedures. 

US Department of Labor's (OSHA) Position on Compliance and Enforcement:

  • OSHA fully intends to enforce this guidance through its Respiratory Protection Standard (including training and fit testing) and through its General Duty Clause.  Inspections will be done on a complaint basis and OSHA plans to release its detailed compliance directive in the next couple of weeks.

  • OSHA will require facilities to demonstrate a good faith effort to acquire sufficient supplies of N95s in accordance with the CDC guidance and document such efforts and outcomes.  Facilities unable to acquire sufficient quantities, substantiated by adequate documentation of effort, can shift to the prioritized use mode and would not be considered out of compliance as long as they also implemented the specified hierarchy of controls.

Declaring a Shortage - Some Options:

States may consider declaring a shortage when one or more facilities request supplies from the state cache as this may indicate that commercial supply has outstripped demand.

  • Professional judgment should be used in determining how many facilities must begin requesting supplies from the state in order to declare a shortage situation - e.g., if several small providers request supplies and the state cache is sufficient to meet these requests, a shortage may not exist; however, if one large hospital serving a wide area requests a large amount of respirators and state resources cannot meet this request, a shortage may indeed exist.

Facilities may consider declaring a shortage when their supply chain is not adequate to meet their estimated need through May 2010. Additional considerations and supporting statements:

  • Estimates of need should not include supplies from regional, state or federal stockpiles, as these are strategic resources which are intended to be immediately available and back-filled upon use for emergencies in addition to H1N1; in this instance, backfilling will likely not be possible due to anticipated shortages in the national supply chain.

    • States are making determinations for N95 respirator use in the context of all-hazards preparedness, which includes not only mass casualty events and natural disasters, but outbreaks of other infectious diseases such as tuberculosis.

  • Additionally, estimates of need should not be based solely on total supply; a shortage may exist if a particular type or size of respirators is needed but no longer available.  For example, if no small respirators are available, healthcare workers requiring this size will need to seek alternate protective measures and cannot be bound to the regulations of wearing an N95 respirator as outlined in the CDC guidance.

  • N95s require proper fit-testing of each individual who wears the respirator. Not only does a potential shortage of N95 masks exist, the shortage of staff trained to perform the fit-tests also exists, particularly if individuals need to switch between N95 products manufactured by different companies. Additionally, the new recommendations are so broad that they include individuals who have never before been fit-tested (e.g., healthcare workers in many private physician offices); this is an even more resource intensive proposition during an outbreak.

  • A shortage of N95s may also result in attrition in the workforce, as healthcare workers may opt not to show up for work without the appropriate and recommended PPE.

[1] An additional consideration when using these estimates to assess the adequacy of the current supply is that these numbers do not take into account the actual distribution of respirators and the relative ability (or lack thereof) to match supply with demand.

Q&A on New Guidance:

What steps can healthcare facilities take to minimize risk of exposure to 2009 H1N1 influenza and conserve supplies of disposable N95 respirators?

Healthcare facilities should take a multi-layered approach when designing a strategy to reduce exposure of healthcare personnel and patients to influenza and prevent influenza transmission within healthcare settings. The approach to conserving supplies of N95 respirators can be organized into these broad categories:

  • Minimize the number of individuals who need to use respiratory protection through the use of engineering and administrative controls;

  • Use alternatives to disposable N95 respirators where feasible;

  • Extend the use, and consider reuse of disposable N95 respirators; and

  • Prioritize the use of N95 respirators for those personnel at highest risk of exposure.

What can healthcare facilities do to minimize the need for disposable N95 respirators?

In order to reduce the need for respiratory protection, healthcare facilities should consider implementation of measures to eliminate or reduce exposure to 2009 H1N1 influenza. Such measures can be organized according to infection control principles and a “hierarchy of controls”, which prioritizes protective measures based on their likelihood of reducing the risk of exposure. Top priorities in this hierarchy are those measures which can effectively eliminate the source of potential exposure such as measures that prevent visits by ill individuals to healthcare facilities where those can be postponed. Where exposures cannot be eliminated, engineering controls should be considered as the primary means for reducing exposure. Engineering controls physically separate, shield or protect healthcare personnel from the sources of exposure. Examples include the use of partitions and barriers to separate potentially ill patients from well providers or use of closed suctioning systems for airways suction that prevent generation of aerosols. Engineering controls are particularly effective because they can be implemented without placing responsibility on individual employees for implementation. Administrative controls are work practices and policies which are designed to reduce or eliminate hazards, though their effectiveness is dependent on management implementation and personnel adherence. Examples of this include the placing of facemasks on ill individuals for source-control, vaccination of healthcare personnel, and the use of appropriate triage and isolation procedures. Although administrative controls are given lower priority in the classic hierarchy of controls, vaccination of healthcare personnel is particularly effective in that it protects against infections resulting from work, household, and community exposures. The use of personal protective equipment (PPE) is for protection from exposures that cannot otherwise be eliminated or controlled. PPE must be used and maintained properly to be effective. The prioritization of protective measures for healthcare personnel according to the hierarchy of controls is a concept that needs to be tailored to the needs, capabilities, and circumstances of each healthcare facility.

Further detailed recommendations for minimizing risk of 2009 H1N1influenza in healthcare facilities can be found in Table 1 of the Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel.

What options are available to facilities if disposable N95 respirator supplies are insufficient for routine use according to current interim guidance?

Facilities should eliminate potential exposures, and use engineering and administrative controls to minimize risk of exposure to the 2009 H1N1 virus. This will also reduce the number of personnel using respiratory protection.

Healthcare facilities can consider steps to extend the existing supply of disposable N95 respirators by either training personnel to wear them during serial patient encounters (“extended use,” i.e. without removing or re-donning between encounters) or to re-use them (“re-use,” i.e. removing and re-donning between patient encounters). Although these practices have the potential benefit of providing respiratory protection with limited supplies of respirators, there is the risk of respirator contamination and contact transmission. Either extended use or reuse of disposable N95 respirators could entail a risk of contact transmission by touching a contaminated surface of the respirator and subsequently touching the mucous membranes of the face or a hypothetical risk of re-aerosolization of virus from a used respirator. The precise balance between risk of contact transmission and benefit of extended use or re-use associated with this strategy is unknown, although the risk will be minimized if HCWs perform hand hygiene every time before and after touching the respirator. In general, if either of those options is chosen, wearing an N95 respirator over multiple encounters (while minimizing touching, removing, or re-donning between encounters) would be favored over re-use, as this strategy is expected to involve less touching of the respirator and therefore less risk of contact transmission. (See questions on extended use and re-use). Disposable N95 respirators worn during aerosol-generating procedures should be discarded after the procedure.

Another option to consider is use of respirators other than disposable N95 respirators.

When a shortage of respirators exists despite reasonable efforts to obtain or extend a supply for anticipated needs, facilities should consider shifting to prioritized respirator use mode. In this mode, respirator use is prioritized to protect healthcare personnel at greatest risk of 2009 H1N1 influenza exposure or who care for patients with other diseases such as tuberculosis that require respiratory protection.  Prioritization should be adapted to local conditions.  In making decisions about prioritization, facilities should consider needs for performing aerosol-generating procedures and for managing patients with diseases other than influenza that require respiratory protection.  To assure that respirators are likely to be available for the most important uses, facilities should maintain a reserve sufficient to meet the estimated needs for performing aerosol-generating procedures and for managing patients with diseases other than influenza that require respiratory protection until supplies are expected to be replenished.

At a minimum, any individuals attending aerosol-generating procedures should use respiratory protection at least as protective as fit-tested N95 respirators. When a shortage of respirators exists, respirator use can be temporarily discontinued for employees providing routine patient care who are not at high risk of complicated infection. Prioritization should consider intensity and duration of exposure, individual worker health risk factors for complications of infection, and vaccination status. An example of prioritization for personnel not attending aerosol-generating procedures is shown in Table 2 in “Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel”.

When respirator use for personnel who are not at high risk of complicated infection is temporarily discontinued during prioritized respirator use mode, those personnel should be provided with facemasks. Although facemasks do not filter particles from the air and allow air leakage around the edges, they are an effective barrier to splashes, droplet sprays, and autoinoculation of influenza virus from the hands to the nose and mouth. Thus, they should be chosen over no protection. Detailed information on prioritized respirator use can be found in Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel.

Routine chemoprophylaxis is not indicated for personnel wearing facemasks during the care of patients with suspected or confirmed 2009 H1N1 influenza.

What other respirators can be used to reduce dependence on disposable N95 respirators?

Other classes of disposable respirators (e.g., N99s, N100s), which are similar in design and shape to N95s, can be considered. Alternatives to disposable respirators, such as powered air purifying respirators (PAPRs), or elastomeric half-mask and full facepiece respirators, can also be considered, especially in settings such as procedure rooms (e.g. bronchoscopy suites) where higher-risk activities such as aerosol-generating procedures are intermittently performed, and in facilities that have prior experience with these respirators (see questions below on PAPRs and elastomerics, provide link). More information on respirators is available at: http://www.cdc.gov/niosh/npptl/topics/respirators/.

Is extended use over multiple patient encounters an appropriate strategy for extending supplies of respiratory protection?

Extended use refers to wearing disposable N95 respirators for serial patient encounters, where the respirator has not been removed and re-donned between encounters. This practice may result in a risk of contact transmission by touching a contaminated surface of the respirator and subsequently touching the mucous membranes of the face.   The precise balance between risk of contact transmission and benefit of extended use associated with this strategy is unknown, although the risk will be minimized if HCWs perform hand hygiene every time before and after touching the respirator. Extended use would be favored over re-use, because it is expected to involve less touching of the respirator and face. (See questions on extended use and re-use) Consultation with the facility's infection control experts should be sought in making decisions regarding the most appropriate and feasible personal protective equipment to protect workers from influenza if required by respirator shortages. If extended use practices are implemented as a means to extend respirator supplies, measures should be taken to reduce contact transmission, including:

  • Discarding disposable N95 respirators following use during aerosol generating procedures.

  • Discarding disposable N95 respirators if contaminated with blood, respiratory secretions, or other bodily fluids from patients.

  • Considering use of a face shield over the disposable N95 respirator to prevent surface contamination.

  • Performing hand hygiene before and after touching the respirator. 

Extended use may be most practical in selected practice settings where serial contact with multiple suspected or confirmed 2009 H1N1 patients might fit naturally into the workflow (e.g. such as triaging multiple patients in admissions and on dedicated wards for 2009 H1N1 patients). Additional training of personnel will be needed if this alternative is considered for implementation.

Can respirators be re-used to help extend the existing supply?

Re-use of disposable N95 respirators, where the respirator is removed and re-donned between patient encounters, can result in a risk of contact transmission by touching a contaminated surface of the respirator and subsequently touching the mucous membranes of the face. The precise balance between risk of contact transmission and benefit of re-use associated with this strategy is unknown, although the risk will be minimized if HCWs perform hand hygiene every time before and after touching the respirator. However, in general, extended use (i.e. wearing over multiple encounters while minimizing touching, removing, or re-donning between encounters) would be favored over re-use because it is expected to involve less touching of the respirator and face. (See questions on extended use). Consultation with the facility's infection control experts should be sought in making decisions regarding the most appropriate and feasible personal protective equipment to protect workers from influenza if required by respirator shortages. If re-use is chosen as a strategy to increase availability of respiratory protection, the following should be considered to minimize risk of transmission:

  • Discard disposable N95 respirators following aerosol-generating procedures.

  • Discard disposable N95 respirators contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients.

  • Disposable respirators must only be used and re-used by a single wearer. 

  • Do not re-use a disposable respirator that is obviously contaminated, damaged or hard to breathe through.

  • Consider use of a face shield over a disposable N95 respirator to prevent surface contamination.

  • Store the respirator in a clean, breathable container such as a paper bag between uses.

  • Avoid touching the inside of the respirator.

  • Wearer should perform hand hygiene with soap and water or an alcohol-based hand sanitizer before and after touching a used respirator.

Consultation with the facility’s infection control experts and training of healthcare personnel will be needed if this alternative is being considered for implementation.

What should be recommended for facilities that can only obtain models of disposable N95 respirators for which their personnel have not been fit-tested?

In settings where sufficient supplies of disposable N95 respirators are available, they must be used in accordance with a comprehensive respiratory protection program, which includes fit testing, training, and medical clearance (see OSHA standard 29 CFR 1910.134 or http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=12716&p_table=standards ). Healthcare personnel conducting the highest exposure risk activities (i.e., aerosol-generating procedures) should only wear fit-tested N-95 respirators. Using disposable N95 respirators that have not been fit tested does not provide the same assurance of respiratory protection as ones that are fit-tested because some individuals may have poor fit. Normally, a requirement for use of any NIOSH approved respirator, including disposable N95 respirators, is that the respirator be selected, fitted, used, and maintained in accordance with OSHA and other applicable regulations. However, in the context of supply limitations during the current pandemic, non-fit-tested disposable N95 respirators can be considered for personnel at lower risk of exposure or lower risk of complications from influenza until fit testing can be completed. This use will provide protection from droplets and splatter, as would facemasks, but also will provide some additional protection against small particle aerosols. Personnel using the replacement, non-fit-tested disposable N95 respirators should receive training on use of the model being used. Facilities should fit-test workers with the new model of disposable N95 respirator as soon as possible, beginning with those staff who are assigned to duties that involve higher-risk exposure. (refer to Table 2 in main guidance for relative risks of different activities)

In what settings could powered air-purifying respirators (PAPRs) be considered as an alternative to disposable N95 respirators?

One alternative for respiratory protection of healthcare personnel in settings when disposable N95 respirators are unavailable or in short supply is the powered air-purifying respirator (PAPR).  Some healthcare facilities and personnel have accumulated experience with these devices, most commonly in settings such as procedure rooms (e.g. bronchoscopy suites) and in certain laboratory settings. PAPRs have the advantages of being more protective than N-95 respirators and the hooded designs can be worn with facial hair and do not require fit testing.  PAPRs can also be cleaned and disinfected for reuse as indicated by manufacturers’ instructions. Cleaning and disinfection procedures must be compatible with clinical use.

PAPRs can interfere with important patient care activities such as using a stethoscope to listen to patients’ heart or lungs.  Thus, PAPRs are not a practical option for use in many patient care settings.  However, their use in even limited situations, such as aerosol-generating procedures, would increase the supply of disposable N95 respirators for other uses.

In what settings could elastomeric respirators be considered an alternative to disposable N95 respirators?

Elastomeric half-mask and full facepiece respirators with N95 or higher particulate filters can be considered as options for respiratory protection of healthcare personnel in certain settings where N95 respirators are not available. While there is little accumulated experience with their use in patient care settings, they do offer some advantages over disposable N95 respirators, including greater durability and their ability to be cleaned and re-used by the same user or by multiple users. In addition, full facepiece respirators offer a greater level of respiratory protection, as well as eye protection. Disadvantages in healthcare settings include the lack of healthcare personnel experienced in their use; the need for devices to be routinely inspected, cleaned, and disinfected; interference with communication with patients and coworkers and the presence of exhalation valves precluding their use in sterile fields. Effective communication with patients and other personnel is also generally limited when wearing these devices. Although elastomeric respirators may not be a practical option for use in many patient care settings, their use even in limited situations, such as aerosol-generating procedures and in clinical laboratory settings would increase the supply of disposable N95 respirators for other uses.

Where can I find more information on the various types of respirators?

Information on all types of respirators is available at: http://www.cdc.gov/niosh/npptl/topics/respirators/. A listing of all NIOSH-approved disposable respirators is available at www.cdc.gov/niosh/npptl/topics/respirators/disp_part/. [return to top]

MMA Operations Committee and Executive Committee Actions of October 14th

Both the MMA Operations Committee and the Executive Committee met this past Wednesday, October 14th, and took the following actions:

Operations Committee

  • Voted to not "clarify" any MMA Resolutions passed at the Annual Session in September;

  • Accepted the resignation of Gina Hobert, CPC, MBA as Director of the Coding Center; and

  • Received an update on the activities of the Medical Professionals Health Program, including the opportunity offer services to registered nurses in the state.

Executive Committee

  • Accepted the financial performance of the Association through September 30, 2009;

  • Voted to nominate Governor Baldacci for one of the AMA Nathan Davis Awards in 2010;

  • Agreed to renew the MMA Member's Group Health Plan with Anthem Blue Cross Blue Shield, effective February 1, 2010;

  • Voted to apply for one of the federal grants from HHS to pilot an alternative to the current medical liability system; and

  • Agreed to examine the possibility of the need for a physician leadership program in the state, in conjunction with the Hanley Center for Health Leadership.

Both Committees are chaired by Nancy Cummings, M.D., an orthopaedic surgeon from Farmington. [return to top]

House Will Consider Bill to Narrow Applicability of FTC "Red Flags" Rule

H.R. 3763, sponsored by Representative John H. Adler (D-NJ), would exclude health care, accounting, and legal practices with 20 or fewer employees from the definition of "creditor" in the FTC's so-called "Red Flags" rule requiring creditors to implement identity theft prevention programs.  By agreement of both sides of the aisle, the bill will go directly to the floor without mark-up in the House Financial Services Committee.  The bill could be considered this week.

As previously reported in the Maine Medicine Weekly Update, the current compliance deadline for the rule is November 1, 2009. [return to top]

AMA Practice Tip: Preparing for Physician Profiling

The American Medical Association's (AMA) Private Sector Advocacy unit created the educational resource "Physician profiling: How to prepare your practice" for physicians to reference when preparing for health insurers' profiling programs. This resource offers physician practices information on the five steps that encompass the basic elements of the physician profiling process: contract language, program metrics, data, coding and patient education.

Visit the American Medical Association's (AMA) Private Sector Advocacy Web site at www.ama-assn.org/go/pfp to access "Physician profiling: How to prepare your practice" and other educational resources. As a physician, you know there is strength in numbers. The AMA helps all physicians, regardless of specialty or practice setting, speak with a unified voice on the most important issues facing medicine. Please encourage the physicians in your practice to join or renew their AMA membership by visiting www.ama-assn.org/go/membership or calling (800) 262-8335.

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Blue Cross and Blue Shield Association Data Breach Alert

A Message from AMA President J. James Rohack, MD

You may have heard reports about a data breach at the Blue Cross and Blue Shield Association (BCBSA) involving provider identifiers.  We are working with BCBSA to recommend steps that it can take to help mitigate the risk of identify theft resulting from this data breach.

The breach involved a data set containing  names, addresses, taxpayer ID numbers, and NPI numbers of physicians and other health care professionals.  The data is used in performing internal matching analyses to compare BCBS provider networks to the networks of other health plans for employer groups.  Since some practitioners use their Social Security number as their taxpayer ID number, BCBSA is taking steps to protect these physicians. 

It is important to understand that the identifying information was not the intended target of the theft.  The data set was stored on a laptop that was stolen from a car, which was one of several cars in the immediate vicinity that were vandalized.  There is no reason to believe that the thief intends to use the data to commit identity theft.  However, as a precaution, BCBSA is offering credit monitoring services to those providers whose Social Security number was exposed.

Local BCBS Plans in each area are in the process of sending out notifications to affected physicians .  If you receive a letter from your local BCBS Plan offering credit monitoring services, we encourage you to take advantage of those services that BCBSA is providing through Experian.  Utilizing these services will help BCBSA monitor trends to see if identity theft may be occurring as a result of the breach and could help locate the source of any such identity theft.  If you have not been notified directly or if the letter you receive does not include the offer of such services, then it was determined that your Social Security number was not exposed. 

We also encourage all physicians to be vigilant in protecting themselves from those who may try to use their identity as a physician to submit fraudulent prescriptions or fraudulent claims. If you receive any suspicious calls or reports erroneously suggesting that you have ordered or prescribed certain goods or services, you should follow up promptly, and notify your local BCBS plan immediately if you confirm that your identity has indeed been stolen.

If you have questions about the data breach, please contact your local BCBS Plan at their regular customer service number.   AMA staff will continue to be in contact with BCBSA and will provide further information as it becomes available.

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MMA First Fridays November 6: Supervising and Delegating

Can my unlicensed MA give flu shots? Can she complete a patient history? What legal responsibility do I hold for my physician assistant?

These are some of the many questions MMA staff regularly receive from members across the state. On November 6, MMA will present a three-hour program focusing on the laws and regulations in Maine impacting on physician supervision and delegation, which have become confusing to many practices.

      • 8:30am   Continental breakfast and networking
      • 9:00         Introductions and overview Gordon Smith, Esq.
      • 9:45          View from the Board of Licensure in Medicine Sheri Oldham, MD, Chair
      • 10:15       Break
      • 10:30       Managing the Risks of Supervision and Delegation Cheryl L. Peaslee, RN, MBA, CPHQ
      • 11:15       Frequently Asked Questions Andrew MacLean, Esq.
      • 11:35       Panel Discussion, Q & A

Register today at www.mainemed.com. [return to top]

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