May 24, 2010

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Short-term Medicare Physician Payment Fix Going Down to Wire Before Memorial Day Weekend

This past week saw the continuation of discussions in Washington regarding the impending May 31st reduction in Medicare payments to physicians, but no successful resolution of the issue.   The AMA and most medical specialty societies are calling for a permanent repeal of the flawed sustainable growth rate (SGR) formula, but the $210 billion price tag is making it difficult to secure any Republican support.  MMA continues to participate in regular conference calls with AMA staff and communicating regularly with Senators Snowe and Collins in hopes that the current impasse can be broken and a positive solution found prior to Congress recessing for the Memorial Day holiday. 

The U.S. House of Representatives plans to vote on an “extenders bill” that is expected to include a new proposal to avert the 21 percent cut in Medicare physician payments that is scheduled to take effect on June 1.  Elements of the proposal are:

  • 1.3 percent Medicare payment update for the remainder of 2010
  • 1.0 percent payment update in 2011
  • Updates for 2012-13 established under two expenditure targets
  • SGR formula resumes in 2014 to reflect current law

The two expenditure targets are patterned after those proposed in H.R. 3961, which passed the House last year.  An expenditure target for evaluation and management and preventive services will be set at GDP plus two percentage points; a separate expenditure target for all other physician services will be set at GDP plus one percentage point.  These targets are more generous than the current SGR, which is set at GDP with no additional growth allowance.  During the two-year period when the twin targets are in place, an update floor will be set at zero to prevent any conversion factor cuts in 2012-13.

In 2014, the current SGR formula will resume, with a conversion factor that is expected to be considerably lower than it is today.  The cost of repealing the SGR formula will also be higher.

The proposal is similar to one outlined early last week, scaled back to because of objections raised in the Senate over cost.  The MMA understands that a small reserve fund may be set aside for the remainder of 2010, in the event that Congress chooses to revisit the issue and make further adjustments to the payment formula.

The SGR proposal is being incorporated into H.R. 4213, The American Jobs and Closing Tax Loopholes Act of 2010, which is planned for consideration on the House floor early this week.  The Senate is expected to take up the bill shortly after it is passed by the House.

Even passage of this extension is not a sure thing, particularly in the Senate where Republicans are likely to object to the cost of the package.  MMA will be communicating the need to fix this problem with Senators Snowe and Collins, but all MMA members and their staffs should communicate as well, emphasizing the likely impact on access to care for seniors if the planned cut takes effect. 

You can help with this important effort as follows:

1.  Communicate with Maine's congressional delegation (Senators Snowe & Collins, in particular) through the AMA's grassroots action center:

2.  MMA is also participating in a petition drive initiated originally by the Texas Medical Association but now supported by all fifty state medical societies and several national specialty societies.  The goal is to deliver a petition with more than a million signatures to members of Congress stating support for a permanent solution to the SGR problem.  The petition is available for your signature on line at:

Also, the AMA is conducting a survey on the SGR problem and the MMA encourages you to follow this link for more information about the survey and how to access it:

You can read the AMA's statement on the latest proposal here:


June "First Fridays" Program Features Minors' Rights to Health Care Treatment

The MMA's next First Fridays seminar is scheduled for Friday, June 4th from 9:00 a.m. to noon at the MMA office in Manchester and is entitled, Treating Minors in a Primary Care Setting.  The subject of minors' rights to confidential health care treatment is one of the most common areas of question and concern for physicians and their office staff.  The faculty for the program are:

  • Kenneth Lehman, Esq., Chair of the Health Law Practice Group at Bernstein, Shur, Sawyer & Nelson
  • Carol Mansfield, M.D., a physician with Winthrop Pediatrics
  • Andrew MacLean, J.D., Deputy EVP, MMA

You can find more information about the program and you may register online on the MMA web site:  For more information, please contact Maureen Elwell at melwell@mainemed.comor 622-3374, ext. 219. [return to top]

MMA and OSA Team Up for Free CME in Wells on Friday, June 18

The Maine Medical Association and the State Office of Substance Abuse will present Comprehensive Management of Patients with Acute & Chronic Pain While Preventing Diversion, a three hour CME seminar in Wells on Friday, June 18th.  The program will be held from 9:00 a.m. to noon at the Village by the Sea on Rt. 1 (1373 Post Rd.) in Wells.  There is no cost for the program.

Faculty for the program include Mark Publicker, M.D., an addiction specialist and Director of the Recovery Center at Mercy Hospital, Daniel Eccher of the Office of Substance Abuse, and Gordon Smith, Esq., Executive Vice President of the Maine Medical Association.  Dr. Publicker will share best practices in the areas of pain control, addiction treatment, and prevention.  He will also discuss how to manage pain without causing addiction.

Registration materials are available from the MMA office (call 622-3374, ext. 219) or you may register on the MMA website at

The program is made possible through a grant by the Maine Office of Substance Abuse. [return to top]

MMA, MHA, & MOA Join Forces to Present Third Annual Quality Symposium on June 10

The Maine Osteopathic Association, the Maine Medical Association, and the Maine Hospital Association on June 10, 2010 will present the Third Annual Statewide Quality Symposium.  The theme this year is, Using Health Information Technology to Advance Quality:  Through Meaningful Use to Meaningful Improvement

The Symposium this year will precede the MOA's annual meeting at the Samoset Resort in Rockport.  Registration for the Symposium will begin at 8:00 a.m. on the 10th with the program beginning at 8:30 a.m. and concluding at 3:30 p.m.  The Keynote Speaker will be Joshua J. Seidman, Ph.D., Acting Director, Meaningful Use Division, Office of Provider Adoption Support, HHS/ONC.  Also presenting is Don Wright, M.D., M.P.H., Deputy Assistant Secretary for Healthcare Quality.  Dr. Wright will provide an overview of the newly created Office of Healthcare Quality within the federal Department of Health & Human Services.

This year's symposium would be an excellent opportunity for any medical practice that is anticipating moving toward an electronic medical record system in order to receive the financial benefits offered by the federal law.

For more information, contact Angela Westhoff, Executive Director of MOA at 623-1101.  There is a $75 registration fee which covers lunch breaks and all materials.  5.5 hours of CME have been sought for the program.

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Joint Select Committee on Health Reform Hears from National & Local Experts

The legislature's newly-appointed Joint Select Committee on Health Care Reform Opportunities & Implementation held its initial meeting last Thursday, May 20th.  The Committee and its staff spent a substantial amount of time on introductions and procedural matters, but then heard a comprehensive overview of the federal health care reform laws by Joy Johnson Wilson, a health policy expert with the National Conference of State Legislatures (NCSL).  In the afternoon session, the group heard presentations by the following 3 state agency heads who will be involved in the compliance effort:

  • Trish Riley, Director of the Governor's Office of Health Policy & Finance (GOHPF);
  • Brenda Harvey, Commissioner of the Department of Health & Human Services (DHHS); and
  • Mila Kofman, J.D., Superintendent of the Maine Bureau of Insurance.

The Joint Select Committee is composed of bipartisan representatives of the legislature's standing committees on Appropriations & Financial Affairs, Health & Human Services, and Insurance & Financial Services.  You can find the Committee membership on the web at:

You can find all of the Committee's materials on the web at:

The MMA will keep you informed of the work of this Committee through the Maine Medicine Weekly Update and other communications.  [return to top]

BOLIM Executive Director Randal C. Manning Named to FSMB Board of Directors

Randal C. Manning, Executive Director of the Maine Board of Licensure in Medicine, has been appointed to a two-year term on the Board of Directors of the Federation of State Medical Boards (FSMB).  There are two state or territorial board executives on the Board.  The FSMB represents the interests of the seventy licensing boards in the country which license Medical and osteopathic physicians.  [return to top]

Medical Societies Sue FTC to Block "Red Flags" Rule Enforcement

The most recent delay in the compliance deadline for the controversial FTC "red flags" rule expires May 31st, meaning that compliance by health care providers is expected June 1st.  The AMA has provided some excellent guidance on this subject on the web at:

This past week, the AMA, through the AMA Litigation Center, also filed suit in federal court asking the court to declare that the FTC rule not apply to physicians as they were not intended to be creditors under the law.  The American Osteopathic Association (AOA) and the Medical Society of the District of Columbia also joined in the suit.  A similar lawsuit excluding attorneys from the rule was successful in the lower courts but is under appeal.

You can find the AMA's statement on the lawsuit on the web here:

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Report on 19th Annual Practice Education Seminar Held last Wednesday

Nearly 100 physicians, practice managers, and faculty participated in the 19th Annual Practice Education Seminar last Wednesday at the Augusta Civic Center.  The theme of the day was,  What's Expected of Physicians in the New Paradigm.  David Howes, M.D., President of Martin's Point Health Care, keynoted the day and discussed the potential transition from a payment system driven by volume to a system characterized by caring for a population (population health).  Rob Otten of the AMA and Trish Riley presented attendees with information on the new federal health care reform law.  Panels of consumer interests, legislators/regulators, and employer interests completed the plenary sessions before the day concluded with eight breakout sessions.

Each year for the past nineteen years MMA has put together a similar program, the purpose of which is to provide Maine physicians and their staffs with information on the current and future trends that will influence medical practice in the state.

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Draft State Health Plan Released; Public Hearings Scheduled

The draft of the 2010-2012 State Health Plan targets efforts to improve health and health status through expanded primary care and prevention while producing savings by eliminating waste and inefficiency.

“It links evidence-based public health strategies with measurable outcomes to lower the trajectory of health care costs,” according to the plan’s introduction.  “Importantly, it lays out a path and identifies the policy choices now provided Maine through newly enacted national health reform law.”

The plan notes the progress that has been made, since the state started releasing the state health plan, including:

  • Maine improved from the 16th healthiest state in 2003 to the 9th healthiest in 2009.
  • Maine improved from 19th among states in covering the uninsured in 2003, to 6th in 2009.
  • Costs for health insurance premiums have grown more slowly in Maine than in the rest of the United States.
  • In 2003, Maine ranked 12th in the percent of surgical patients receiving the appropriate care to prevent complications; by 2007, Maine ranked 1st.

The plan suggests:

  • Reducing inefficient practices and waste, including:
  • Reducing preventable hospitalizations, emergency room admissions and unnecessary care;
  • Reducing duplicative and unnecessary laboratory tests and advanced imaging;
  • Increasing the number of Maine citizens with a stable relationship with primary care practice;
  • Reducing health care-associated infections; and
  • Improving access to specialist consultations through telemedicine.
  • Strengthening community-based public health and prevention;
  • Paying for what matters, in other words, payment reform;
  • Aligning policies and practices to support primary care and prevention;
  • Guiding the Certificate of Need program to support priority goals.

The plan also discusses workforce challenges, the importance of data and electronic medical records.   

The Advisory Council on Health Systems Development (ACHSD), the primary body advising the Governor's Office of Health Policy & Finance (GOHPF) on the state health plan, reviewed the draft at its meeting last Friday.  Public hearings are June 9th in the morning in Portland and in the afternoon in Augusta. [return to top]

Physicians in Unique Position as Educators on Effects of Climate Change

Environmentalists have spoken out on climate change for years, but another group is also trying to raise awareness about the issue: doctors.  Several dozen physicians met in Portland last week to discuss the impact of a warmer planet at an educational workshop organized by Harvard Medical School and the Maine Medical Association.

Doctors have spoken out on the link between air pollution and respiratory problems such as asthma and allergies.  But only more recently are they drawing global warming into their field of focus.  Dr. Norma Dreyfus, who co-chairs the Public Health Committee for the Maine Medical Association, stated that “we really need to pay attention to this and weigh in on it.”  We as physicians are in a unique position to act as educators, both in the office and in the community, on the mitigation of, and adaptation to the impending public health threats that come as a result of climate change.”

The Climate Change and Human Health Forum attended by 50 physicians, nurses, and physician assistants on Thursday last week exceeded attendees' expectations.  Renowned experts, Paul Epstein, M.D., M.P.H., Associate Director, Center for Health and Global Environment, Harvard Medical School, and Paul Mayewski, Ph.D., Explorer, Director & Professor at the Climate Change Institute, University of Maine held a lively discussion on the impact of climate change on human health.  Reactor panelists included Stephen Sears, M.D., M.P.H., State Epidemiologist, Maine Center for Disease Control and Prevention; Lisa Pohlmann, Deputy Director, Natural Resources Council of Maine, Norma Dreyfus, MD, Co-Chair of the Maine Medical Association Public Health Committee, and Paul Santomenna, Executive Director, Physicians for Social Responsibility/Maine. 

The Maine Medical Association’s Public Health Committee convenes again on June 9th, from 4-6 p.m. and will discuss next steps for climate change and involvement of physicians and health care providers.  For more information and to join the Public Health Committee, contact Kellie Slate Miller, Director of Public Health Policy at or 207.622.3374, ext. 229.

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ProSelect Insurance Company Announces 8.6% Base Rate Increase for Maine Policyholders

ProSelect Insurance Company, a member company of ProMutual Group, announces an 8.6 percent increase in base medical professional liability insurance rates for physician and surgeon policyholders in Maine.  It also announced a seven percent increase for the state's hospitals and healthcare facilities.  The decision is in response to an increase in the claim frequency in the state, inflation and healthcare costs associated with claim defense.

A careful analysis of all available data clearly supported the rate change.  The company cites data from the past three years that shows signs of continuously rising claim frequency.  This information contributed to the company's need to raise its rates to adequately cover the costs of defending future claims.  The rate increase impacts approximately 500 individual physicians and surgeons as well as a number of healthcare facilities, clinics and surgical centers as of May 1, 2010.

ProMutual Group is committed to controlling costs by continuing to help the healthcare community through aggressive defense and proactive risk management services.  The company employs one of the largest and most experienced risk management teams in the Northeast to assist healthcare providers identify and mitigate patient safety risks in their practice.  When claims do arise, ProMutual Group's defense panel of highly specialized medical liability attorneys will work with policyholders to aggressively defend the practice of good medicine.

"The environment for healthcare providers today is changing and challenging, but serving our policyholders now and in the future is our top priority," said Gregg L. Hanson, chief operating officer for ProMutual Group.  "In order to do this, we must set rates at a level that will enable us to provide defense and claim services for today and tomorrow.  We will continue to employ risk management services and strong claims defense to control costs."

ProMutual Group is a dedicated member of Maine's healthcare community.  Recently, the company made a significant donation to The Medical Professionals Health Program of Maine, a program of the Maine Medical Association, in support of its work to assist physicians with health concerns.

For more information about ProMutual Group contact Nina Akerley, public relations specialist for ProMutual Group, at or (617) 946-8665.

About ProMutual Group
ProMutual Group is one of the top 10 medical professional liability insurance providers in the country based on direct written premium. ProMutual Group member companies insure more than 22,000 physicians, surgeons, and dentists as well as nearly 500 hospitals, health centers and clinics in 20 states from coast to coast. ProMutual Group has net admitted assets in excess of $2.6 billion as of Dec. 31, 2009. ProMutual Group member companies Medical Professional Mutual Insurance Company, ProSelect Insurance Company and MHA Insurance Company have a Best's Rating of A- (Excellent) and Washington Casualty Company has a Best's Rating of B+ (Good).  ProMutual Group is acknowledged as a leader in providing risk management and claim services to the healthcare community, and it offers risk management consultations and educational activities at cost to healthcare providers across the country.  For more information, visit ProMutual Group's website at

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CMS Announces 2008 PQRI Payment Adjustments

CMS has initiated making payment adjustments for the 2008 PQRI program year as the result of the inquiry process established for the 2008 program year.  Through the inquiry process, physicians and other eligible professionals have been able to raise questions as to satisfactory reporting and the incentive payments for PQRI.

Eligible professionals who satisfactorily reported PQRI measures for the 2008 PQRI program year are entitled to an incentive payment of 1.5% of estimated total Physician Fee Schedule or PFS charges.  A number of inquiries identified apparent discrepancies between the estimated PFS allowed charges as reported in the CMS feedback reports and their own information.  

Following a careful review, CMS identified inaccuracies in the calculations of total estimated PFS allowed charges for physicians and other eligible professionals upon which the 2008 incentive payments were based. This applied to eligible professionals who submitted claims for reconsideration or for which Medicare was a secondary payer.  Although the amount of the inaccuracy was overall small, it affected a large portion of eligible professionals who satisfactorily reported for 2008 PQRI.  In the vast majority of cases the resultant incentive payment adjustment is very small.  In a few cases, the incentive payment adjustment is substantial, based on a large portion of an eligible professional’s claims being submitted for reconsideration or with Medicare as a secondary payer.

The Medicare contractors began making the incentive payment adjustments for the 2008 PQRI reporting period in late April, and will be finished no later than May 21, 2010.  If you receive paper checks, the message, “This is a PQRI incentive payment” on the check will signify it as the incentive payment adjustment.  If you receive electronic remittances, look for provider adjustment reason code “LE” in the PLB 03-1 segment, and PQ08 in the PLB 03-2 segment, on the 835P to alert you that the incentive adjustment payment is for the 2008 PQRI.  (The monetary amount will be in the PLB04 segment of the 835P.) 

CMS continues to review inquiries made regarding the 2008 PQRI payment and to make refinements to the PQRI program going forward. CMS also plans to publish a 2008 experience report which will detail the program results for 2008 including results of the inquiry process.

Should you have questions, please contact the QualityNet Help Desk at 1-866-288-8912 from 7:00 a.m.-7:00 p.m. CST Monday through Friday or via  

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Medicare Payment Adjustments Made for 2010

On May 10th, Medicare contractors received new files that will make significant payment changes for some services and geographic regions.  These include certain corrections in the fnal 2010 physician fee schedule rule, as well as implementation of several provisions in the Patient Protection & Affordable Health Care Act (PPACA) enacted earlier this year.  All the changes are retroactive to January 1, and all contractors must implement them by May 31.

The 6 PPACA provisions implemented in the new file would do the following:

  1. extend the 1.0 work geographic practice cost index (GPCI) floor that expired on December 31, 2009;
  2. raise practice expense GPCIs in low cost areas by reflecting only half the geographic wage and rent cost differences in their calculation;
  3. extend the current 5% add-on payment for specified psychiatry services;
  4. increase payments for bone density tests;
  5. extend the therapy cap exception that expired on April 1st; and
  6. extend a provision allowing independent labs to bill for the technical component of physician pathology services.

The corrections to the final 2010 rule involve a number of cardiology codes that were undervalued by CMS because of errors in the calculation of the practice expenses associated with myocardial perfusion imaging and professional liability insurance expenses for invasive cardiology procedures.  These changes will be implemented in a budget neutral manner and so lead to very minor payment rate changes for other services.

Once the contractors have the new files in place, all claims going forward will be processed at the revised rates.  However, CMS still is discussing the best way to handle the millions of 2010 claims that were paid at the rates in effect before these corrections and updates were made.  With many different changes occurring at the same time, the situation is complicated and the process for adjusting previously paid claims may vary by service, geographic area, or other factors.  Additional information will be made available once CMS has determined the best way to proceed.  Until then, physicians may want to hold off on resubmitting previously-processed claims affected by the payment changes, since these resubmissions will likely be denied as duplicate claims. [return to top]

CMS Announces New Time Period for Submission of Medicare Claims

In an effort to streamline the claims process, as required by section 6404 of the PPACA, CMS has changed the maximum period for the submission of Medicare claims to not more than 12 months after date of service, beginning with claims with dates of service on or after January 1, 2010.  For more details, please read the MLN Matters Article #MM6960 at:  This is a shorter time period than was previously allowed for filing claims.  Prior to the PPACA, the basic time limits for filing claims were on or before December 31st of the following year for services that were furnished in the first 9 months of the calendar year, and on or before December 31st of the second following year for services that were furnished in the last three months of the calendar year. [return to top]

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