August 16, 2010

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MMA to Support Maine DEP Proposal on Bisphenol-A Thursday

On this coming Thursday, August 19th, the Maine Medical Association will offer testimony supporting a proposal by the Maine Department of Environmental Protection to ban the chemical bisphenol-A in baby products and food and beverage containers.  The chemical has been linked to a range of health problems.  A public hearing will be held on the proposal at 1:00 p.m. on August 19th at the Holiday Inn and Ground Round in Augusta.  The hearing will be conducted by the Maine Board of Environmental Protection.

MMA's testimony has been prepared by Norma Dreyfus, M.D., a pediatrician who serves as Co-Chair of the association's Public Health Committee.  A copy of the testimony is available on the MMA website at  More information about the proposal is on the DEP website at The comment period on the proposal extends until August 30th.  If the ban is supported by the board, it will go back to the Legislature, then back to the board for final approval.

The proposed ban is the result of a 2008 Maine law, supported by MMA, that seeks to protect children from harmful chemicals.  The law directed the DEP to prioritize the most dangerous chemicals in products for children.  BPA is the first chemical to go through the process.  If adopted, Maine would join Connecticut, Vermont, Washington, Maryland, Wisconsin, and Minnesota in banning the chemical in certain products.

As noted in the MMA testimony, BPA has been shown in animal studies to disrupt the hormone systems and has been linked to cancer, obesity and other diseases.  Following is an excerpt from the testimony, prepared by Dr. Dreyfus but which will be delivered Thursday by Mariah Gleaton, a recent graduate of the University of Maine who is a summer intern at MMA and who has been staffing the Public Health Committee since the departure of Kellie Miller to serve as Director of CME at UNECOM.

    BPA has been implicated as an endocrine disrupting chemical (EDC) at low doses and to have impacts on neuropsychological development.  As an endocrine disruptor it interferes with hormonal balance especially in the growing organism, the developing fetus and infant, who are so vulnerable to the effects of both natural and synthetic hormones.  The effects are fairly pervasive and include receptors involved in metabolism, obesity and brain signaling.  Some studies have linked BPA to breast and prostate cancers, diabetes, obesity, learning disabilities, and reproductive health problems.

We know that BPA is fairly pervasive in body fluids at levels that are biologically active and endocrine disruptors have even been found in amniotic fluid and breast milk.  There is also an implication that they effect DNA, the genetic materials, which would result in transmitting effects to subsequent generations.

The Center for the Evaluation of Risks to Human Reproduction concluded in 2008 that there is "some concern for effects on the brain, behavior, and prostrate gland in fetuses, infants, and children at the current human exposure to bisphenol A."

BPA is used to make clear, shatter-resistant polycarbonate plastics and is common in baby bottles, sippy cups, and reusable food and beverage containers.  The proposal may be opposed by the chemical  industry or grocery interests which have opposed the bans in other states.





What You Will be Missing if You Don't Attend the MMA's 157th Annual Session

Register now at for the Association's 157th Annual Session being held this year at the Harborside Hotel in downtown Bar Harbor.  Friday's CME session and opening reception will be held at the prestigious Jackson Laboratory which is again this year collaborating with MMA on the CME program.  The dates are September 10-12, 2010.

Here are some of the highlights of the meeting:

  • Six and one half hours of CME on the subject of Life Transitions, for Patients, Families, and Communities.
  • The awarding of the Mary Cushman Humanitarian Award Saturday evening, along with the President's Award for Distinguished Service.
  • First District Congresswoman Chellie Pingree's appearance at the General Membership Meeting on Saturday morning.
  • The recognition of those MMA members celebrating the 50th anniversary of graduation from medical school, including former MMA Presidents Robert McAfee, M.D., Larry Mutty, M.D., M.P.H., and Francis Kittredge, M.D., J.D.
  • The 30th anniversary of the annual MMA Road Race, being held this year at 7:00 a.m. on Sunday morning.  Enjoy this scenic three-mile run along the shores of Penobscot Bay!
  • The appearance of most, and perhaps all, of the five gubernatorial candidates at a Gubernatorial Candidates' Forum on Public Health.  Three candidates have confirmed and we expect confirmation soon from the remaining two.

 We look forward to seeing you at the meeting!  Please register today.  A variety of housing options are available.  If you have registered and faxed a reservation form to the Harborside Hotel, please call to confirm its receipt unless you have received a confirmation.  Several members have told us of problems with the faxing option.  Any questions can be directed to Diane McMahon at 622-3374, ext. 212 or via e-mail to

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2010 Medicare Trustees Report Confirms Steep Physician Cuts Ahead

On August 5th, the Medicare Trustees released their annual report on the status of and outlook for the Medicare program.  The report had been delayed for several months in order to incorporate the effects of the Affordable Care Act (ACA).  The Trustees project that as a result of changes made by the ACA, the solvency of the Hospital Insurance Trust Fund, which funds Medicare Part A, will be extended by 12 years to 2029.  For Medicare Part B, the most striking aspect of the Trustees Report is its confirmation of the precipitous declines in Medicare physician payment rates that will start in less than four months.  Specifically, the Trustees forecast a 23% cut on December 1, 2010, another 6.5% cut one month later on January 1, 2011, and an additional 2.9% cut on January 1, 2012.  With these cuts, 2011 payment rates would be 28% below November 2010 rates, and 2012 payment rates would be 30% below their November 2010 level.

As in each Trustees report for the last several years, Medicare Actuary Rick Foster states that while the Part B projections are a reasonable forecast of what would happen under current law, "they are not reasonable as an indication of actual future costs" because legislative action is expected to override the projected cuts.  The report also states that if the physician payment cuts do in fact occur, "secondary effects could include (i) substantially reduced beneficiary access to physicians; (ii) a significant shift in enrollment to Medicare private health plans; (iii) an increase in emergency room services; (iv) an increase in mortality rates; and/or (v) an increase in hospital services."

The extension in the solvency of the Hospital Insurance Trust Fund is due primarily to three ACA provisions:  reductions in payment rates to Medicare Advantage plans, reductions in hospital and certain other provider market baskets to account for productivity increases, and increased Trust Fund income due to an increase in the Medicare payroll tax for people above a certain income threshold.  The Medicare Actuary is skeptical that the productivity reductions can be sustained over the long term, so the Office of the Actuary has developed an alternative forecast for the Part A Trust Fund in which the full market basket updates are gradually restored.  Under this alternative scenario, the Part A Trust Fund would remain solvent until 2028 instead of 2029.  Under either the main or the alternative forecast, however, the Trustees project that the Part A Trust Fund will remain solvent for many more years as a result of the ACA. [return to top]

New Aggregate-Level 2010 PQRI Reporting Date Posted
CMS recently posted a 2010 PQRI aggregated quality data code error report by measure for January 1st through March 31, 2010.  While not a substitute for timely, individual feedback for program participants, these aggregate reports allow medical specialty societies and individual physicians to identify reasons why quality measure submissions were deemed invalid (e.g., incorrect age, gender, or diagnosis code).  This report is available under the "analysis and payment" section of the CMS PQRI, located at: [return to top]

AMA Health Reform Insights: Program Integrity Provisions

The AMA is continuing its dialogue with the U.S. Department of Health and Human Services (HHS) as it implements many of the new program integrity provisions in the health system reform law. The AMA would like to ensure that HHS' long-term strategies focus on:

  • Improving physician education and outreach
  • Streamlining the burdensome enrollment process
  • Devising targeted strategies to prevent true fraud
  • Working to prevent physician and beneficiary identity theft

Below are details on several initiatives being undertaken by the administration to implement the health system reform law program integrity provisions.

Regional summits

The U.S. Department of Justice and HHS are co-hosting regional summits in order to engage and enlist the help of physicians, other providers and beneficiaries to enhance program integrity while also combating fraud. The first regional summit took place in Miami to highlight the work of the Health Care Fraud Prevention and Enforcement Action Teams.

Other activities at the Miami regional summit included a provider specific workshop which, among other things, built in time for provider input and comments on current agency strategies and policies. After the Miami summit, the AMA urged HHS to significantly expand the opportunity at future summits for physicians to provide direct input on administration program integrity initiatives and learn how physicians can play an essential role in helping the government combat fraud.

The next regional summit will take place Aug. 26 in Los Angeles. Future summits are being planned in Detroit, New York and Philadelphia.

Exception to prohibition on self-referral and mandatory notification and disclosure

As part of the health system reform law, physicians who rely on the in-office ancillary services exception to the prohibition on physician self-referral will be required to inform patients in writing at the time they order magnetic resonance imaging, computed tomography and positron emission tomography that the patient may obtain these services elsewhere.

They must also provide the patient with a written list of those who furnish such services. In the recently released proposed fee schedule rule, HHS issued proposed regulations that would require covered physicians to provide the disclosure for services furnished on or after the effective date of the final regulation which is anticipated to be Jan. 1, 2011.

Practice-based compliance programs

The health system reform law directs HHS to establish mandatory essential elements of a compliance program that physicians and other providers must have in place as a condition of enrollment in Medicare, Medicaid and other federal health care programs. HHS has not yet issued the essential elements nor the timeline or deadline for the establishment of the core elements by providers. Nonetheless, it is anticipated that elements could include, but not be limited to, employee training, confidential/anonymous hotline, internal audits and designation of a compliance officer.

The agency will look to existing industry standards and will be soliciting input on the essential elements once a proposed regulation is issued. Efforts are underway to harmonize compliance program elements across payers (both government and private) to ensure that physicians do not have multiple (and potentially conflicting) obligations.

NPI and referrals and orders

Physicians who refer or order (with the exception of those who have filed an opt-out affidavit with their Medicare contractor) are required to be enrolled in the Provider Enrollment, Chain, and Ownership System (PECOS) database. This includes physicians who have been enrolled for decades, but are not in the PECOS database.

All physicians will need to re-enroll if they are not in the PECOS database (or opted-out). Other physicians who never bill Medicare—TRICARE physicians for example—will also need to enroll if they want to continue referring and ordering services for patients who see Medicare doctors.

The original deadline to be enrolled in PECOS was July 6, but due to AMA advocacy, the agency has reverted to a contingency plan. So long as the legal name and national provider identifier (NPI) of physicians who refer or order are listed on claims submitted by those physicians to whom they refer patients, the claims will not be rejected at this time. CMS will announce a date in the future when the edits will become effective.

Up-to-date information on this can be found on the AMA website at under "Medicare enrollment."

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MMA Re-constitutes Ad Hoc Committee on Governance

Wanting to make certain that MMA is employing all possible means to properly represent and advocate for its members, the Executive Committee recently re-instituted an ad hoc Committee on Governance.  A similar committee was established a few years ago which led to recommendations to abolish the Association's House of Delegates in favor of having an annual meeting of all the members.

The Committee is chaired by in-coming President Jo Linder, M.D. and held its first meeting this past Wednesday evening.  Among the issues to be reviewed by the Committee members are the following:

  • Should Executive Committee members continue to be elected on the basis of geographical representation (counties)?  Alternative means of representation could come from specialty societies, medical staffs, or large group practices.

  • Should the 28-member Executive Committee be re-named the Board of Directors and have the current Operations Committee established as a more traditional Executive Committee?

  • Should all the current standing committees continue and should the chairs of such committees serve on the Executive Committee (currently some do, but not all).

  • Should the Annual Meeting continue in its current form?

  • Should the Association undertake a leadership development program, either alone or in collaboration with other organizations?

  • How shall the Association go about properly orienting new Executive Committee members to their role and responsibilities?

  • Should the Executive Committee continue to meet at its current usual time (Wednesday afternoons at 2:00 p.m., about 7 times per year)?

The Committee expects to provide an interim report at the up-coming annual session and then to meet monthly during the remainder of the year.  Final Committee recommendations will be provided to the Executive Committee at its annual planning retreat in January.  Many of the proposals to be considered would require bylaw changes which would be voted upon in September 2011 at the Annual Meeting.

The Committee is made up of some existing Executive Committee members and some members who are not currently on the Committee, including some medical students and residents.  Members interested in the work of the Committee should contact Dr. Linder ( or Gordon Smith (, the Association's Executive Vice President.

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Draft Maine CDC Flu Vaccine Shortage Contingency Plan Available for Comment

At this point in time, Maine CDC is being told there should be sufficient influenza vaccine for the 2010-2011 season.  In fact, initial small shipments are expected in the coming week.  However, since there have been significant and unpredicted influenza vaccine shortages during three of the last six seasons, we believe it is important for contingency plans to be developed in case there is an unpredicted shortage. 

If there is a shortage, we will use as guidance the 2010-2011 Influenza Vaccine Recommendations published by the U.S. CDC July 29, 2010, which can be found at:  These recommendations in the situation of a vaccine shortage are included below. 

BOX. Summary of influenza vaccination recommendations, 2010

∙ All persons aged ≥6 months should be vaccinated annually.

∙ Protection of persons at higher risk for influenza-related complications should continue to be a focus of vaccination efforts as providers and programs transition to routine vaccination of all persons aged ≥6 months.

∙ When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to persons who:

-- are aged 6 months--4 years (59 months);

-- are aged ≥50 years;

-- have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus);

-- are immunosuppressed (including immunosuppression caused by medications or by human immunodeficiency virus);

-- are or will be pregnant during the influenza season;

-- are aged 6 months--18 years and receiving long-term aspirin therapy and who therefore might be at risk for experiencing Reye syndrome after influenza virus infection;

-- are residents of nursing homes and other chronic-care facilities;

-- are American Indians/Alaska Natives;

-- are morbidly obese (body-mass index ≥40);

-- are health-care personnel;

-- are household contacts and caregivers of children aged <5 years and adults aged ≥50 years, with particular emphasis on vaccinating contacts of children aged <6 months; and

-- are household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza.

Most influenza vaccine in Maine is distributed through private sector channels, such as health care providers purchasing it from vaccine distributors.  Maine CDC uses a combination of federal and tobacco settlement (Fund for a Healthy Maine) to purchase some influenza vaccine.  In March of this year, Maine CDC announced our plans for influenza vaccine distribution of state-purchased vaccine.  The full document can be found at:  The summary is below. 

Maine CDC for the 2010/2011 influenza season plans on providing seasonal influenza vaccine for:

·        all Maine children ages 6 months to 18 years-old;

·        employees of schools that provide onsite vaccine clinics on school days;

·        pregnant women and their partners (through health care providers who routinely care for pregnant women);

·        nursing home employees and residents;

·        high risk adults in limited public health settings, the scope and number of such settings determined by our vaccine supply.   

If there is an influenza vaccine shortage in Maine, the two top priority groups for distribution will be:

  • Pregnant women and partners through obstetrical providers and primary care providers who have ordered for pregnant women
  • All persons ages 6 months – 59 months

If Influenza A H3N2 appears to predominate based on surveillance data in the U.S. as well as in the Southern Hemisphere, then nursing home patients and their employees as well as high-risk adults in public health settings such as city and tribal health departments will be the next priority after pregnant women and young children (6-59 mos).

If Influenza A H1N1 pandemic 2009 strain appears to predominate based on surveillance data in the U.S. as well as the Southern Hemisphere, then all aged children with high-risk conditions will be considered as a high priority after pregnant women and younger children (6-59 mos). 

Type of influenza vaccine available will also determine distribution.  For instance, if a shortage is primarily among injectable vaccine, and nasal spray is available (as was the case in the fall of 2009), then all aged children will be a focus. 

In the context of no circulating disease, then we plan on providing vaccine to health care providers for their high-risk pediatric patients, then for schools that are ready to conduct clinics, assuming nasal spray is available for non-high risk school children.

Other high-risk populations as published by the U.S. CDC above will be a priority as the supplies allow.

Please provide any feedback on these draft plans to by August 31. 

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State Posts New Website for Health Care Reform

The Governor's Office of Health Policy & Finance (GOHPF) has posted a new website with information concerning the federal health care reform bill (now commonly referred to as the Affordable Care Act or ACA).  The site,, provides information about the law and its impact on the state and its citizens.  It also includes links to federal and state agencies and the Legislature's Joint Select Committee on Health Reform.

In announcing the site, Trish Riley, Director of the GOHPF, noted that the website is intended to help Mainers understand the provisions of the law and the actions the state is taking in response.  You can see the Governor's press release on this site at:
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President Signs Bill Including 6-Month FMAP Extension

On August 10th, President Obama signed the $26.1 billion bill extending aid to the states, including $16.1 billion of increased Medicaid funding (the FMAP increase) and $10 billion in education funding.  Earlier in the day on the 10th, the House passed the amendment to an aviation bill (H.R. 1586) by a vote of 247-161.  It was primarily a party-line vote with 2 Republicans voting for it and 3 Democrats voting against it.  The Senate had passed the bill on August 5th. [return to top]

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