December 14, 2009

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Health Care Reform: Focus on the Senate

Senate debate on H.R. 3590, the Patient Protection and Affordable Care Act, continued this past week.  While Senate Democrats hailed a proposal to expand coverage by allowing 55-to-64 year-olds to buy Medicare coverage, critics, including Maine Senators Olympia Snowe and Susan Collins opposed the measure on the grounds that Medicare payments in Maine fall significantly short of the cost of providing the service.  A Senate vote still is expected before Christmas.

While the past week brought several new story lines about the health reform debate, the proposed expansion of Medicare was atop the headlines.  With Medicare paying less than 80% of costs to Maine hospitals, the Maine Hospital Association expressed strong opposition to the proposal.  At the other end of the spectrum, supporters of a "public option" strongly supported the idea of a Medicare expansion.  And a Kaiser Family Foundation study released on Thursday stated that the Medicare expansion, "could provide coverage in a relatively short period of time, as early as 2011, and target help to those who are most likely to have difficulty purchasing coverage on their own in the individual market."  The non-partisan Congressional Budget Office (CBO) will be assessing the potential cost of the Medicare expansion and is expected to report back early this coming week.  But already, several Senate Democratic leaders, including Senaotr Max Baucus (D-MT), have indicated that they are working on amendments to the proposal that would address the concerns, which he said were legitimate.

Maine's junior Senator Susan Collins also became a prominent player in the health reform debate this past week.  She and Oregon Democratic Senator Ron Wyden introduced what they called three bipartisan amendments to the Senate bill aimed at offering consumers more choice and holding premium increases in check.

The Collins-Wyden amendments likely will be considered by Senate leadership over the next several days.  One amendment would let employers give their workers the option of choosing from among the health plans offered in the new insurance exchanges that the bill would create.  A second amendment would remove the age limit for allowing individuals who are not receiving government subsidies to purchase a catastrophic plan through the exchange (current draft allowed only individuals under age 30 to make such a choice).  The third amendment would amend the provision in the bill requiring health plans to pay enrollment fees based upon the number of persons joining the plan.

MMA representatives met on Thursday with Senators Snowe and Collins, along with their primary health staffers.  In addition to summarizing the provisions in the Senate bill supported by the Association, the MMA also discussed a list of problem areas.  Still, the MMA cited the unsustainability of the current system, with small groups in Maine receiving health plan renewals with 20 to 60% premium  increases.  MMA's own increase for the members' plan is 29%, effective February 1, 2010.  The MMA also stressed the need to immediately avert the January 1, 2010 decrease in Medicare reimbursement (21%).  The MMA will join this week in a joint letter to Congress with other state and national medical societies emphasizing the need to take immediate action on the SGR (sustainable growth rate) formula.  

During the meetings, the MMA also discussed the need for liability reform, and protecting the state reforms in place, and particular issues affecting cardiology ad neurology.

It remains questionable whether the Senate can enact a bill prior to Christmas, given the need to achieve 60  votes in order to overcome a threatened Republican filibuster.  One of the independents needed to get to 60 votes, Senator Joseph Lieberman (I-CT), has indicated that he will not vote for a bill with a public option or Medicare expansion.  And Senator Ben Nelson (D-NE) has indicated that he will not vote for the bill with the current provisions regarding funding for abortion.  Senator Nelson's amendment to limit more severely coverage for abortion has been previously defeated.  While one or more Republican votes are a possibility, they do not appear likely without some significant changes to the bill, as well as a more open process in the preparation of amendments.

In early December, the Center for American Progress Action Fund and the Commonwealth Fund released a report concluding that the health care reform bills would save more than estimated by the Congressional Budget Office (CBO) and CMS, primarily because the researchers gave more weight to the impact of delivery system and payment reform, and administrative streamlining.  This report estimated savings of $683 billion and $532 billion over 10 years from the Senate ahd House reform bills respectively.  According to the report, both bills could reduce the federal deficit by more than $400 billion.  You can find a copy of the report on the web at:

Watch the pages of this Maine Medicine Weekly Update each week to receive the latest information and commentary on the current situation in Washington D.C. 






MMA Testifies on Payment Reform Before Advisory Council on Health System Development

On Friday, December 11, 2009, MMA EVP Gordon Smith presented testimony on behalf of MMA to the Advisory Council on Health Systems Development on the subject of payment reform.  The testimony is available on the MMA website at (under spotlight section).  The MMA urged the Advisory Council to pilot any new payment models prior to widespread adoption and noted the danger of unintended consequences.  The Association also noted that payment reform needed to be considered in the context of the broader health system reform debate, and that adjustments in the report might be required depending upon the results of the health system reform debate in Washington.  Finally, MMA noted that some fee-for-service payment will still be necessary in any system likely to be designed.

The Advisory Council received public comment on its Proposed Report to the Legislature on Payment Reform in Maine which is due to the 124th Maine Legislature in February, 2010. 

In addition to MMA, additional parties commenting on the draft included the Maine Hospital Association, the Maine Association of Health Plans, Anthem Blue Cross Blue Shield, Consumers for Affordable Health Care, MaineHealth, the Maine Primary Care Association, and the Maine Bureau of Insurance. 

Three physicians are among the membership of the Council, including Lani Graham, M.D., M.P.H., Maroulla Gleaton, M.D., and Josh Cutler, M.D.  The Council is chaired by Brian Rines, Ph.D.    [return to top]

MMA Executive Committee to Meet on Wednesday, December 16th

The MMA Executive Committee will meet at the Frank O. Stred Building in Manchester this coming Wednesday, December 16th at 2:00 p.m.  In addition to a full agenda of business items, members will visit the recently opened John C. Dalco, M.D. House, home of the Medical Professionals Health Program.  The Dalco House was dedicated on December 4th in a ceremony attended by representatives of the Dalco family and more than 75 members and guests associated with the Program.  Robert McAfee, M.D. and David Simmons, M.D. made special remarks at a luncheon following the dedication.  MMA President David McDermott, M.D., M.P.H. presided at the luncheon.

At Wednesday's meeting, members will welcome a new member to the Committee, Richard Flowerdew, MBBS, representing Cumberland County.  Dr. Flowerdew is an anesthesiologist practicing with Spectrum Medical Group.

At Wednesday's meeting, committee members will preview a brief video from the Daniel Hanley Center for Health Leadership and will discuss two priority topics:  federal health system reform and MMA's participation in two federal grant opportunities.  The committee also will preview the agenda for the President's Retreat scheduled for January, 2010.   The MMA Budget & Investment Committee will meet following the Executive Committee meeting.  The Budget & Investment Committee will consider amendments to the proposed budget for 2010.

All Executive Committee agendas and minutes are posted in the members' only section of the MMA website (  Meetings also are open to any MMA member.

The Executive Committee consists of 28 members and is chaired by Nancy Cummings, M.D., an orthopedic surgeon practicing in Farmington.


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REMINDER: Meeting on Medical Marijuana Law, Tonight, at MMA

As noted in last week's Maine Medicine Weekly Update, physicians interested in providing input into the state's Medical Marijuana Work Group are invited to attend an informational meeting tonight, December 14th at the MMA offices in Manchester.  The meeting will be held from 6:30 to 8:30 p.m. with dinner being available at 6:00 p.m.  Please RSVP to Maureen Elwell at 622-3374, ext. 219 or via e-mail to if you plan to attend.

The third and last scheduled meeting of the implementation work group established by Governor Baldacci will be held on Tuesday, December 15th at the State House.  The first matter to be addressed during the meeting are issues relating to the physician's role under the new law.  So, it is important to hear from a broad spectrum of physicians Monday night in order for MMA to provide input Tuesday on behalf of physicians.

Regardless of how the deliberations go on Tuesday, MMA legal staff will assist those physicians interested in working with their patients who they believe may benefit from the medicinal use of marijuana, and those physicians who need assistance in explaining to their patients their rationale for not participating in medical marijuana treatment.

Those members wishing to provide input but not able to attend Monday night's meeting may send comments to Gordon Smith, Esq.,  MMA EVP via e-mail to  Mr. Smith represents the interests of physicians on the State's 14-member implementation work group.  [return to top]

Medical Marijuana Advocacy Group Offers Q&A Document on New Law

The following Q&A document has been prepared for practitioners and patients by the group Maine Citizens for Patient Rights, an advocacy group that worked in favor of Ballot Question 5 during the fall campaign.


1. What conditions can marijuana be used to treat?

Under the law physicians may recommend marijuana to patients diagnosed with any off the following conditions:

"A. Cancer, glaucoma, positive status for human immunodeficiency virus, acquired  immune deficiency syndrome, hepatitis C, amyotrophic lateral sclerosis, Crohn’s disease, agitation of Alzheimer’s disease, nail-patella syndrome or the treatment of these conditions;
B. A chronic or debilitating disease or medical condition or its treatment that produces intractable pain, which is pain that has not responded to ordinary medical or surgical
measures for more than 6 months;
C. A chronic or debilitating disease or medical condition or its treatment that produces one or more of the following: cachexia or wasting syndrome; severe nausea; seizures, including but not limited to those characteristic of epilepsy; or severe and persistent muscle spasms, including but not limited to those characteristic of multiple sclerosis;"

In the future, the Department of Health and Human Services may approve the use of marijuana to treat additional conditions.

2. Why recommend marijuana when comparable pharmaceuticals like Marinol are available?

Marinol is a synthetic version of delta-9-THC approved for use to treat nausea associated with chemotherapy and loss of appetite associated with AIDS.

Some patients who have responded well to marijuana have reported that Marinol has caused them to experience paranoia and has exacerbated their nausea.  There is speculation that other compounds in the marijuana plant may mitigate these side effects when whole plant extracts are used.

Delta-9-THC is just one of many medicinally useful compounds found in marijuana.  Other compounds play significant roles in decreasing muscle spasms and reducing pain.  Marinol is not likely to prove effective for patients with muscle spasms, seizure disorders, or pain disorders.  Whole plant marijuana extracts may help these patients.

3. I would like to recommend marijuana to a patient but I am concerned about the health effects of smoking any plant material.

Your patient could use a vaporizer which heats the plant matter to a high enough temperature to allow it to release vapors without releasing particulate smoke.

Alternately, a patient could ingest marijuana extracted into butter or other other fats, oil, alcohol, or glycerin.  

3. What do state and federal law say about physicians recommending marijuana to their patients?

In 2004, the U.S. Supreme Court ruled in Conant v. Walters that physicians have a First Amendment right to recommend marijuana to their patients.

Maine state law further states that physicians may not be prosecuted, sued, or subjected to professional discipline simply for recommending marijuana to patients in medically appropriate cases.

However, under state law physicians are not allowed to provide marijuana directly to patients unless they are designated as those patients' primary caregivers.

4. What is the formal process for recommending marijuana to a patient?

After discussing the risks and benefits of marijuana with your patient it is strongly suggested that you complete a "PHYSICIAN’S WRITTEN CERTIFICATION OF ELIGIBILITY FOR MEDICAL USE OF MARIJUANA."  This form is available online at

5. Where can I learn more about medical marijuana in Maine?

Maine Citizens for Patients Rights will be holding a conference, "Medical Marijuana in Maine: Beyond Question 5," on February 20 in Portland, Maine.  This will be a great opportunity to connect with patients, caregivers, patient advocates, and other physicians and learn more about how the new law medical marijuana law will work.  For more information e-mail

6. Is there a directory of physicians in Maine who work with medical marijuana patients?

Maine Citizens for Patients Rights is creating a directory of physicians who are open to working with medical marijuana patients.  If you would like to be listed in this directory please e-mail [return to top]

MMA Public Health Committee, "Our Public's Health" Rescheduled for January 6, 2010

Originally scheduled for December 9th, the MMA Public Health Committee is hosting a two-hour panel presentation on Our Public's Health - Climate Change, Energy Efficient Hospitals/MESHnet and Environmental Toxins on Wednesday, January 6th, from 4:00 p.m. to 6:00 p.m. at the MMA office in Manchester.  It also will be broadcast via video-conference link to the MMC Dana Health Education Center, Classroom 10.  Educational Credits are pending. 

Norma Dreyfus, MD, Chair of the MMA Public Health Committee, will serve as moderator and panelists include:

  • Lani Graham, MD, MPH providing an overview of health care and environmental toxins, which will include findings from the Hazardous Chemicals in HealthCare report, (detailing the first investigations ever of chemicals found in the bodies of health care professionals, including MMA Past President Stephanie Lash, MD).
  • Paul Santomenna, Executive Director of Physicians for Social Responsibility, will talk about hospitals' contribution to greenhouse gas emission and the work of the Hospital Network.
  • Matt Prindiville of the Natural Resources Council of Maine, will provide an update on federal and state legislation including TSCA reform.
  • Syd Sewall, MD, MPH will provide information on the use of the Pediatric Environmental Toolkit in clinicians' offices.

An application for two hours of educational credits is pending.  For more information and to pre-register for this free educational offering for all members and nonmembers, contact MMA at 207-622-3374, ext. 219 or via email to Maureen Elwell at .  Members and non-members are welcome to attend. 

In case of inclement weather, please contact the MMA office at the above number for information about the status of the program.

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MMC Grand Rounds to Address Physician Suicide, January 20th

In the wake of two physician suicides this year, the Medicine Grand Rounds at Maine Medical Center(MMC) will address the topic of physician suicide, 8 a.m. to 9 a.m., on January 20th in the Dana Auditorium at MMC.  Dr. Paula Clayton, former chair of psychiatry at the University of Minnesota and national medical director of the American Foundation for Suicide Prevention (AFSP), will speak and present a short film.  Dr. Clayton's organization has been quite involved in a variety of aspects of suicide prevention including a particular focus on physician suicide.  AFSP along with Wyeth and the American College of Psychiatrists funded a documentary film on this subject which aired on PBS stations.  They also were responsible for a companion film on suicide in medical students. [return to top]

MaineCare Re-enrollment Deadline of December 23rd Looming; Take Action Now!

The Health PAS portal for re-enrollment in the new Maine Integrated Health Management Solution (MIHMS), the MaineCare claims management system scheduled to go online in 2010, is now open for all health care practitioners and providers.  DHHS and MMA both are concerned that many current MaineCare practitioners and providers have not completed the necessary re-enrollment steps and that payment delays may be the result of a failure to re-enroll by the deadline.

The current claim system, MeCMS, will automatically deny any claims with dates of service beyond February 28, 2010.  YOU MUST RE-ENROLL IN MIHMS TO REMAIN A BILLABLE MAINECARE PROVIDER AT FULL MIHMS IMPLEMENTATION SCHEDULED FOR MARCH 1, 2010.  Practitioners and providers not re-enrolled by December 23, 2009 risk delays in claims processing and prior authorization approvals when MIHMS goes live.

Please follow this link, , to the Health PAS provider re-enrollment portal to complete your re-enrollment application today! 

If you need help with or have questions about your re-enrollment, please call 1-800-321-5557, option 6, or e-mail  Staff is available to assist you from 8:00 a.m. to 5:00 p.m.  One-on-one appointments also may be scheduled to help you with your online re-enrollment application.


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