February 15, 2010

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White House Plans Health Care Summit

President Obama on Friday (Feb. 12) issued invitations and challenges to three dozen Republican and Democratic lawmakers, asking them to attend a summit on health care later this month.  The summit is considered by some observers to be the last, best attempt to revive in Washington D.C. the effort to enact a comprehensive health reform bill.  Recent dramatic increases in health insurance rates by Anthem plans in California, Maine and other states was cited as a compelling reason that the stalled reform effort must be completed.

In a letter to congressional leaders, White House Chief of Staff Rham Emanuel and HHS Secretary Kathleen Sebelius cited the recent 39 percent requested rate hike in California by Anthem Blue Cross .  "As the President noted this week, if we don't act on comprehensive health insurance reform, this enormous rate hike will be just a preview of coming attractions," they wrote.

In response to similar criticism, Anthem Blue Cross in California announced at the end of the week that it would postpone its plan to raise rates for California residents in the individual market, after reaching an agreement with state regulators. Anthem's increases in that state would have affected about 700,000 customers and would have averaged 25 percent and reached as high as 39 percent for some.  The health plan agreed to postpone the increase from March 1 until May 1 so the state could have outside experts review the company's rate filing. California requires that insurers spend at least 70 cents of every premium dollar on medical care.  Maine has a similar provision for plans offered to individual subscribers, as well.

In Maine, Anthem Blue Cross and Blue Shield is asking for increases in the individual market of 23% for some policy holders. Increases in the small group market were also significant, with the Maine Medical Association members plan taking an increase of 29%.  Anthem is also appealing in court the Insurance Superintendent's decision in the rate case last year.  In that decision, Superintendent Mila Kofman denied a portion of the increase, citing substantial profits that the company had made in Maine on other products outside of the individual market.




Legislative Committee Conference Call Information/Forum Scheduled for February 25th

The weekly MMA Legislative Committee conference call will take place this Thursday, February 18th at 8:00 p.m. using the following toll-free call-in number and access code:  call 1-877-669-3239; access code 23045263.  As usual, any interested physician or physician staff member is welcome to participate.

There are no new bills for review this week, but the MMA staff will provide an update on legislative action of the week and will seek further input from physicians about bills scheduled for public hearing in the near future.

Also, remember that the Committee has scheduled a forum on the current state budget situation at the MMA office from 6 to 8 p.m. on Thursday, February 25th.  The MMA has invited a bipartisan group of legislators from the Appropriations and Health & Human Services Committees and a representative of the executive branch to participate in the forum.  All are welcome, but please RSVP to Maureen Elwell, Legislative Assistant, at melwell@mainemed.com or 622-3374, ext. 219 for our planning.  We plan to have hot and cold hors d'oeuvres, wine, and soft drinks available during the forum. [return to top]

Medicare Physician Payment Reform Comes Up in Jobs Bill

Last Thursday, February 11th, Senate Finance Committee chair Max Baucus (D-MT) and ranking member Charles Grassley (R-IA) released the draft of a bipartisan jobs bill, known as the Hiring Incentives to Restore Employment (HIRE) Act.  In addition to various recession relief provisions such as extensions of unemployment insurance benefits and COBRA premium assistance for terminated workers, the draft bill would extend a number of health care provisions that expired at the end of 2009, such as the 1.0 floor on geographic adjustments to physician work under the Medicare fee schedule.

The draft bill also calls for extending current Medicare physician payment rates for seven more months, through September 30, 2010, once again postponing the 21.2 percent cut that was scheduled to take effect on January 1.  Our understanding is that this 7-month reprieve represents a compromise between Senators who wanted to implement a routine one-year payment fix through the end of the year and others who were seeking another short bridge period to provide still more time for Congress to pass a permanent repeal of the Medicare sustainable growth rate (SGR) formula that calls for annual physician payment cuts.

The AMA continues to believe that it is time for Congress to address the SGR problem head-on and permanently repeal the formula once and for all.  The short-term, band-aid approaches  used in the past to stop imminent cuts only made future cuts steeper and increased the cost of permanent physician payment reform.  If Congress had fixed the problem in 2005, when physicians faced cuts of about 3.3 percent, the cost of permanent reform would have been about $49 billion.  Now, we are confronting a 21 percent cut and the cost of reform has skyrocketed to more than $200 billion.

Congress has passed legislation to reinstate statutory pay-as-you-go (PAYGO) rules, which require bills that would increase federal spending to include provisions that offset those costs through spending reductions or revenue increases.  That legislation would also exempt from PAYGO requirements $82 billion of the currently estimated $210 billion cost of a permanent SGR repeal.  The AMA is continuing its advocacy efforts to secure permanent Medicare physician payment reform, and will continue to oppose further short-term fixes.

By the end of the day, it appeared that provisions in the HIRE Act that are not directly related to job creation, including the health care extensions, would be stripped from the bill.  However, action on these extensions is still anticipated before March 1, and the draft circulated today offers insight into the policies the Senate intends to debate.  Of course, when a 7-month Medicare physician payment extension would expire in September, the legislative and fiscal challenges confronting physicians will still be formidable.  For that reason, the AMA is encouraging its Federation partners to remain actively engaged in advocacy efforts to support a permanent SGR repeal.  There is no requirement for Congress to wait until September to pass Medicare payment reform legislation, and the physician community must maintain the sense of urgency so that legislators do not ease up on their efforts to find a solution. 

Advocacy materials to support permanent SGR reform are posted on the AMA’s web site, at http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/payment-action-kit-medicare.shtml.

 A summary of the HIRE Act can be accessed at the Senate Finance Committees web site, at http://www.finance.senate.gov/press/Bpress/2010press/prb021110a.pdf.

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POLITICAL PULSE: HHS Committee is Closely Divided on Bill to Require Notice/Consent of Prescriber for Substitution of Anti-epileptic Medication


Last week, the HHS Committee held both a public hearing and work session on L.D. 1672, An Act to Require a Pharmacist to Provide Prior Notification to and Obtain Consent from the Prescribing Physician before Changing from One Formulation or Manufacturer of an Antiepileptic Drug to Another.  Senator Peter Bowman (D-York) sponsored the bill at the request of Patricia Locuratolo, M.D., a neurologist from York, Maine who witnessed a number of her patients having adverse effects from a switch in medications under the state's generic substitution statute, even from a generic drug produced by one manufacturer to that same generic drug produced by another manufacturer.

At the public hearing last Tuesday afternoon, Dr. Locuratolo and a representative of the Epilepsy Foundation in New England testified in favor of the bill.  Heidi Henninger, M.D., a neurologist specializing in epilepsy with Maine Neurology in Scarborough, submitted written comments in favor of the bill.  DHHS, pharmacy benefit manager Medco, and generic manufacturer Mylan Labs testified in opposition to the bill.  The MMA, Rite Aid, and the Maine Nurse Practitioners' Association testified "neither for nor against" the bill.  In its testimony, the MMA talked about the substantial internal debate about the need for the bill and that the neurologists had persuaded their colleagues that the epilepsy patients present unique challenges in medication management and unique potential consequences for themselves and the public at large from medication failure.  The MMA suggested that the Committee take some action to address this problem.  DHHS estimated that the original draft of the bill could have a fiscal note of as much as $7 million because of increased costs for the MaineCare drug management program.  

A key point of contention between the bill's proponents and opponents is whether prescribers have an adequate remedy for this problem under current law.  The current generic substitution statute, 32 M.R.S.A. section 13781, permits a prescriber to write "dispense as written" on any prescription, but there is substantial uncertainty whether this could prevent a switch from one generic manufacturer to another of the same medication.  

At the bill's work session last Thursday, the MMA offered a proposed amendment in an effort to mitigate the fiscal note and to address concern that the bill proposed a substantial departure from current law.  Based upon the MMA draft, the committee analyst drafted the following amendment to the generic substitution statute.

A pharmacist shall contact the prescriber and obtain the consent of the prescriber prior to any substitution of a drug or a drug formulation when the prescriber has written "epilepsy/seizure risk" on the prescription form.  This paragraph is repealed August 1, 2012.

The sunset provision was added because the FDA soon is expected to address issues of bioavailability that are at the root of this problem.

At the conclusion of the work session, the Committee split 6-5 with the majority voting "ought not to pass" (to kill the bill) and to send a letter to the MMA asking for some CME on this subject and the minority voting "ought to pass as amended" for the provision listed above.  Unfortunately, the clinicians on the Committee split on the bill.  House Chair Anne Perry (D-Calais), a nurse practitioner, voted with the majority while Linda Sanborn, M.D. (D-Gorham), a retired family practitioner spoke strongly in favor of the amendment and voted with the minority.  By the end of the week, it was unclear whether Senator Peter Mills (R-Somerset) and Senator Lisa Marrache, M.D. (D-Kennebec) had registered their votes.  Dr. Locuratolo had an opportunity to discuss the bill with Senator Marrache, but she seemed inclined to vote with the majority.  DHHS officials agreed to withdraw the fiscal note from the amended version of the bill.

The majority included the following members:

  • Senate Chair Joseph Brannigan (D-Cumberland)
  • House Chair Anne Perry (D-Calais)
  • Representative Mark Eves (D-North Berwick)
  • Representative Sarah Lewin (R-Eliot)
  • Representative Meredith Strang Burgess (R-Cumberland)
  • Representative Henry Joy (R-Crystal)

The minority included the following members:

  • Representative Linda Sanborn, M.D. (D-Gorham)
  • Representative Pat Jones (D-Mount Vernon)
  • Representative Matthew Peterson (D-Rumford)
  • Representative Peter Stuckey (D-Portland)
  • Representative James Campbell (U-Newfield)

Maine physicians will be interested to know that four lobbyists, two each for two out-of-state interests, Medco and the National Association of Chain Drug Stores (NACDS) spent most of the Thursday afternoon work session buttonholing members of the committee and appeared to have a substantial impact on those members who wound up in the majority.

Because of the close vote, L.D. 1672 should be the subject of a very interesting floor debate in both chambers.  It is likely to be at least a week, if not more, before the bill comes out of the committee and it could be longer before caucuses take place on it so that it is prepared for debate.  The only sure thing is that it will be debated before late March/early April.  Dr. Locuratolo and the MMA are working on a set of talking points in support of the bill.

Until alerted to floor action on the bill, physicians who are interested in influencing the outcome, may do some or all of the following:

  • Contact Senator Lisa Marrache, M.D. at 861-0154 or ltmmd77@aol.com
  • Contact Senator Peter Mills at 474-3821 (H) or 474-3324 (W) or pmills@mainelegal.net (with regard to Senators Marrache and Mills, make contact ASAP in case they have not yet registered their votes on the bill) 
  • Contact your own Senator and Representative to alert them that this divided report will be coming to the floor and to advise them of your thoughts on it
  • Contact any member of the HHS Committee, either to thank the member for a vote with the minority (and to help them prepare for the debate) or to continue education of the majority; you can find the HHS Committee members and their contact information on the web here:   http://www.maine.gov/legis/house/jt_com/hum.htm.

For additional background on this issue:


 On February 8th, the HHS Committee held a work session on L.D. 1544, An Act to Amend the Laws Governing the Maine Health Data Processing Center and the Maine Health Data Organization.  While much of the bill is not controversial, two sections of the bill have been the subject of some debate.  These provisions would permit health insurers to reject claims submitted without "all required fields filled with correct and complete information."  In particular, the MHDO is concerned that the rendering or service provider, the billing provider, and the location where the service was performed are data fields frequently not filled out or filled out properly.  Policymakers frequently ask the MHDO for this data to support various quality improvement initiatives.  The MMA would be interested in hearing feedback from physicians and their billing staffs about the practical implications of the following language from this bill:

Sec. 8. 24-A MRSA §2436, sub-§2-A, as amended by PL 2003, c. 469, Pt. D, §4 and affected by §9, is repealed and the following enacted in its place:


2-A.  For a claim submitted by a health care provider or health care facility with respect to a health plan as defined in section 4301A, subsection 7, for purposes of this section, "undisputed claim" means a timely claim for payment of covered health care expenses that is submitted to a carrier in conformity with the following requirements.


AThe claim must be submitted on one of the following claims forms:


(1) For a health care facility claim submitted on paper, the standard claim form, using standards approved by a national uniform billing committee;


(2) For a health care provider claim submitted on paper, the standard claim form, using standards approved by a national uniform claim committee; and


(3) For health care facility and health care provider claims submitted electronically, an electronic form using standards approved by an accredited standards committee of the American National Standards Institute.


BThe claim must use the most current published source codes with all required fields filled with correct and complete information. All fields identifying the rendering or service provider, the billing provider and the location where the service was performed are considered to be required fields and must be filled on all claims.


Sec. 9.  24-A MRSA §2436, sub-§2-B  is enacted to read:


2-B.  If a claim does not conform to the requirements specified in subsection 2A and payment is denied to a health care provider or health care facility by a carrier, the health care provider or health care facility may not request payment from the insured or beneficiary and shall attempt to rectify the deficiencies with the claim and resubmit the claim to the carrier.

The HHS Committee will discuss these two sections of the bill again.


The Appropriations Committee continues to deliberate L.D. 1671, the FY 2010-2011 supplemental budget, and continues to discuss problematic areas with the HHS Committee.  On Friday, February 12th, the HHS Committee members met with the Appropriations Committee to discuss various issues and the discussion produced the following list of questions or information requests:

Questions from the February 12th HHS-AFA meeting


1.  What is the detail on the fiscal note on LD 233, the bill that provides MaineCare reimbursement for independent practice dental hygienists?  (Chris Nolan, OFPR)


2.  Please provide a copy of the report from the Governor’s Office of Health Policy and Finance to the Legislature on reducing the use of emergency departments and reducing preventable admissions.  (Jane Orbeton, OPLA)


3.  Please provide information on the contract with Consumers for Affordable Health Care, on the list of DHHS OMS fiscal agent related contracts at $100,001 in federal funds in FY11.  (DHHS)


4.  Please provide information on the (Goold) GHS contract, on the list of DHHS OMS fiscal agent related contracts at $3,839,1162.75 in GF (with federal match) funds in FY11.  (DHHS)


5.  Please provide the list of smaller contracts with DHHS that were listed by Beth Ashcroft in a discussion with the AFA Committee recently.  (Jane Orbeton, OPLA)


6.  Please provide information on whether there are possible savings to DHHS/benefits to the ICF/MR’s from utilization of the LIHEAP program. (Maine Association of Community Service Providers and DHHS)


7.  Please provide information on the Change Package initiative with regard to day habilitation services.  (DHHS)


8.  Please provide information on voluntary State or Legislature memberships in organizations and from which accounts those memberships are paid.  (DAFS, DHHS, Executive Director of Legislative Council)


9.  Please provide information on whether with regard to long-term care in the MaineCare program federal eligibility and estate recovery requirements could/should be written into Maine law.  (DHHS, Attorney General’s Office)


10.  Please provide information on whether the initiatives with regard to sheltering assets and estate recovery place the State at risk of violating ARRA prohibitions on limiting eligibility for Medicaid benefits.  (DHHS, Attorney General’s Office)


11.  Please provide information on the services and accounts (MH and MH/DD) that are included in the tax and match information.  (DHHS)


12.  Please provide information on the effect of the outpatient hospital MH and SA rate cuts, including a comparison of the services and rates provided by hospital-based providers and those provided by community providers.  (DHHS, Maine Hospital Association, MAMHS, MASAP)

The HHS Committee has scheduled another budget work session for this Friday, February 19th at 9 a.m.  The HHS Committee is scheduled for another meeting with the Appropriations Committee on February 24th at 2 p.m.


At a work session last Thursday afternoon, the Business, Research & Economic Development Committee unanimously recommended the following language to replace L.D. 1608, An Act to Establish an Office of Administrative Law Judges for Licensing Boards.

Resolve, Directing the Department of Professional and Financial Regulation to Study the Complaint Resolution Process


Sec. 1.  Commissioner directed to study the need for procedural changes in the processes used by professional and occupational licensing boards within and affiliated with the Department to resolve complaints against licensees.  Resolved:  That the Commissioner of the Department of Professional and Financial Regulation, in consultation with interested parties including the Maine Regulatory Fairness Board, shall conduct a study of the need to establish protocols for occupational and professional licensing boards within and affiliated with the Department with respect to the resolution of complaints; and be it further


Sec. 2. Reporting date established. Resolved:  That the Commissioner of the Department of Professional and Financial Regulation shall submit recommendations under section 1 to the joint standing committee of the Legislature having jurisdiction over business, research and economic development matters by February 15, 2011.


Sec. 3. Legislation.  The joint standing committee of the Legislature having jurisdiction over business, research and economic development matters may submit legislation regarding the establishment of protocols to resolve complaints to the First Regular Session of the 125th Legislature.   


The MMA, MHA, & the Thomas Agency all raised concerns about the original draft of L.D. 1676, An Act to Protect Maine Citizens' Credit, sponsored by Senator Phil Bartlett (D-Cumberland).  Will Lund, the Superintendent of the Bureau of Consumer Credit Protection, and IFS Committee Analyst Colleen McCarthy-Reid collaborated to produce the following compromise language adopted by the Committee at a work session last week.

PROPOSED COMMITTEE AMENDMENT "." TO L.D. 1676, An Act to Protect Maine Citizens’ Credit

Amend the bill by striking out everything after the enacting clause and before the summary and inserting in its place the following:

Sec. 1. 9-A MRSA section 5-116-A is enacted to read:

Section 5-116-A. Debts owed to Health Care providers

1. Definition of health care provider. For purposes of this section, “health care provider” means a physician, health care practitioner, hospital, clinic, clinical laboratory, health care facility or other person or facility that provides health care services and is licensed or registered by the State.

2. Exclusion from definition of “consumer credit transaction.” An agreement by a health care provider, or by a debt collector on behalf of a health care provider, to accept partial payments over time without assessment of interest from a consumer on a debt for health care services is not considered a “consumer credit transaction” as defined by section 1-310, subsection (12).

3. Disclosure of available payment arrangements. A health care provider shall notify a consumer of the availability of any payment arrangements offered by the health care provider to satisfy a debt for health care services.

4. Rehabilitation of defaulted medical debt. Any payment arrangements offered pursuant to subsection 3 must provide the consumer the opportunity to reasonably rehabilitate, cure or remedy a defaulted status of a debt for health care services under terms and conditions established by the health care provider, such as by making payment in full or by making six consecutive monthly payments in a timely manner.


This amendment replaces the bill. It exempts from the definition of “consumer credit transaction” an agreement to accept payments on debts for health care services without interest over time, and requires that health care providers disclose to consumers any available payment arrangements, which, if offered, must enable consumers to rehabilitate defaulted loans by meeting certain payment requirements.  








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State and MMA Encourage Use of Prescription Monitoring Program

One of the most effective tools for preventing prescription drug diversion is the state's Prescription Monitoring Program (PMP).  The PMP maintains an electronic database of all transactions for controlled substances dispensed in the State.  This database is available online to prescribers and dispensers and is a free service of the Office of Substance Abuse (OSA) in the Maine Department of Health and Human Services.  The database is searchable online, so it is available anywhere a prescriber has internet access.  Physicians can use the program to check the history of a new patient and to monitor on-going treatment.  

An article in some Maine newspapers last week noted that only a minority of prescribers have signed up to use the program.  The program is only effective if health professionals take advantage of it.   MMA is concerned that under-utilization of the PMP will lead to legislative and regulatory calls for mandated use.  The mandated use would likely cause administrative hassles and be overly broad, picking up many physicians who do not prescribe narcotics regularly.

If you do prescribe narcotics, we encourage you to register with the state to use the program.  Upcoming training sessions are scheduled for Feb. 24 at noon and March 25 at 7:30am.  For more information, go to www.mainepmp.org.



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Save the Date: Annual MMA Breakfast for Corporate Affiliates, April 14, 2010

The Annual Breakfast for MMA Corporate Affiliates will be held on Wednesday, April 14, 2010 from 7:30am to 9:30am at the Portland Country Club in Falmouth.  There is no charge for this event which presents an opportunity annually for MMA to thank its many corporate affiliates and sponsors for their generous support throughout the year. Elected officers of MMA and staff will be present as well.

A formal invitation will be sent out shortly, announcing the speaker for the breakfast.  Traditionally, nearly 100 persons have attended the event.

 For more information, contact Lisa Martin, Membership Coordinator at MMA at 622-3374 ext. 221 or via e-mail to lmartin@mainemed.com.


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