September 13, 2010

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Highlights of MMA's 157th Annual Session in Bar Harbor

More than 100 physicians and 200 guests and exhibitors participated in some portion of the two day meeting that featured several recognition awards and remarks by AMA President Cecil Wilson, M.D., Congresswoman Chellie Pingree, and out-going President David McDermott, M.D., M.P.H.  The Mary Cushman Award for Humanitarian Service was presented to Paul Klainer, M.D. and the Knox County Health Clinic.  The President's Award for Distinquished Service was presented to Erik Steele, D.O. of Bangor by Dr. McDermott.   A second award was presented by Immediate Past President Stephanie Lash, M.D. to Edward David, M.D., J.D.  On Sunday morning, more than 200 people turned out to hear the five gubernatorial candidates respond to six questions prepared by the MMA Committee on Public Health concerning issues of tobacco control, obesity, physician recruitment and retention, mental illness, and the State's use of tobacco settlement money. 

Other highlights of the meeting included installation of in-coming President Jo Linder,  M.D., the presentation of 50 year pins to ten physicians, including three Past Presidents, and the appearance of all five Gubernatorial candidates at a Public Health Forum on Sunday morning.  Dr. Linder lives in Falmouth and practices emergency medicine in Portland.  She also serves as Director of the Department of Prevention and Community Service at the Maine Medical Center.  Nancy Cummings, M.D., an orthopedic surgeon practicing in Farmington, Maine was elected President-elect of the Association.  Kenneth Christian, M.D., an emergency physician in Ellsworth was elected Chairman of the 28-member  Executive Committee.

The Friday CME program once again featured talks by Jackson laboratory researchers paired with Maine clinicians working in the same clinical area..

Members voting during the Annual Meeting supported two resolutions brought before it by the MMA Public Health Committee, one involving toxic substances legislation pending before the Congress and the second urging the Congress to sign the START treaty deceasing the number of nuclear weapons in the world.

The President's remarks presented at the Annual Membership meeting on Saturday morning are on the MMA website, as are the remarks offered during the presentation of the Distinguished Service Award to Erik Steele, D.O. 

Make plans now to attend the Association's 158th Annual Session in Bar Harbor from September 9-11, 2011.

Insurance Superintendent Mila Kofman Reduces Anthem Premium Increase from 23% to 14%.

Maine Superintendent of Insurance Mila Kofman, J.D. last week issued a ruling on Anthem's requested 23% increase in premium in the individual health insurance market.  The decision, which can be appealed to the Superior Court, impacts approximately 11,000 individuals who purchase insurance in the individual or  non-group market.  In the ruling, the Superintendent reduced the increase to 14%.  The new rates will take effect on October 1, 2010. 

In her decision, Superintendent Kofman found that Anthem's original request was both "excessive" and "unfairly discriminatory."  She faulted Anthem's request on several counts, including its projections for increased costs and amount of health care services demanded by consumers.

The ruling grants Anthem an effective profit margin of 0.5%, as opposed to the 3% requested by the for-profit insurer.  In a similar decision last year, Kofman denied the company any profit in a decision that was later upheld in court and which led to widespread national attention.

You can find the decision on the Bureau's web site at:
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D. Joshua Cutler, M.D. Announces Resignation as Director of the Dirigo Heath Agency Maine Quality Forum

In an unexpected announcement made public last week, Josh Cutler, M.D., Director of the Maine Quality Forum, announced his resignation from the position.  The resignation is effective in October.  Dr. Cutler has served approximately three and one half years in the position and has worked diligently to improve the transparency of health data in the state.  Dr. Cutler became the Director following the resignation of the original Director, Dennis Shubert., M.D.

Dr. Cutler is a cardiologist and was President of Maine Cardiology Associates in Portland prior to leaving the practice.

Dr. Cutler's future plans are not finalized, but he is not retiring and may return to clinical  practice in the Portland area. [return to top]

AMA Health Reform Insights: What to Expect From Regulatory Implementation of Insurance Reforms

The Affordable Care Act (ACA) called for a broad range of significant health insurance market reforms. The AMA is actively involved in the implementation of these reforms through advocacy with both the National Association of Insurance Commissioners (NAIC) and the Obama administration.

Below are some of the key implementing regulations that have already been issued and a description of relevant AMA advocacy efforts.

Premium transparency/medical loss ratios

Insurance companies will be required to spend more premium dollars on actual medical care instead of profits, bonuses, advertising and overhead. Furthermore, they must submit data on the portion of premiums spent on health care and quality improvements compared to overhead costs (i.e., their medical loss ratios). The NAIC is charged with drafting uniform definitions, standard methodologies and information collection forms to determine medical-loss ratios and how data should be reported.

The AMA submitted comments on May 14 on premium transparency and medical-loss ratio standards in response to a request for information issued by the U.S. Department of Health and Human Services (HHS). The AMA also is actively engaged in discussions with the NAIC.

The AMA’s concerns since the beginning of the project have centered on ensuring that any definition of quality improvement included in the loss ratio have a clear nexus to direct patient care. The AMA drafted and sent five individual letters to the NAIC expressing concerns about multiple versions of the reporting requirements to which health insurers must comply when reporting medical-loss ratio data. The AMA also organized two sign-on letters: one with the Federation of American Hospitals (FAH) and the American Hospital Association (AHA) and the second with state medical associations.

The AMA organized a grassroots coalition of Pfizer, Pharmaceutical Research and Manufacturers of America, AHA, FAH and others to ensure that NAIC members heard the AMA’s message. The AMA continues to be engaged with the NAIC and HHS as the issue moves forward.

Grandfathered health plans

Health plans that existed on March 23 (the date the Affordable Care Act became law) may be grandfathered and are thus exempt from certain new market reform requirements. These requirements, include:

  • No cost-sharing for preventive benefits, internal appeals and external review procedures.
  • Treating emergency services as in-network benefits with no preauthorization.
  • Patient protections in choosing certain specialty physicians.
  • Minimum essential benefit requirements and prohibition on discrimination against individuals participating in clinical trials.

On June 17, the Departments of HHS, Labor and Treasury issued an interim final rule (IFR) to clarify when a group health plan will be deemed a grandfathered plan, the administrative steps necessary to keep its status as a grandfathered plan, and what changes will cause a plan to lose its grandfathered status.

The AMA submitted comments on August 12, focusing on concerns involving the Employee Retirement Income Security Act pre-emption and recommending additional actions that should trigger a loss of grandfathered status.

Pre-existing condition exclusions, lifetime and annual limits, rescissions and patient protections

On June 28, the Departments of HHS, Labor and Treasury issued an IFR regarding pre-existing condition exclusions, lifetime and annual limits, rescissions and other patient protections, such as choice of health professional, notice requirements, coverage of out-of-network emergency services and cost-sharing for such services.

The AMA’s comments were generally supportive of the rule but did raise concerns over determination of cost-sharing for out-of-network emergency services, defining fair payment, and limitations on balance billing. These key protections under the new law go into effect on September 23 (pre-existing condition protections take effect this year for children only; protections for adults go into effect in 2014).

Preventive services

The Departments of HHS, Labor and Treasury issued an IFR on July 19 to implement the preventive health services provisions. The rules require group and individual health insurance plans to cover certain preventive services without cost-sharing (when they are delivered by in-network providers), which include:

  • Mammograms.
  • Colonoscopies.
  • Cancer screenings.
  • Blood pressure and cholesterol tests.
  • Weight loss and smoking cessation counseling.
  • Healthy checkups and immunizations.

The AMA will be submitting comments by the September 17deadline that are generally supportive but will raise some practice issues related to billing and coding. The benefits go into effect on September 23.

Internal/external claims appeals

The Affordable Care Act provides consumers with the right to appeal decisions made by their health carrier to an outside, independent decisionmaker, no matter what state they live in or what type of health insurance they have.

An IFR was issued on July 23 on the ACA’s provision on internal and external claims appeals. Under the IFR, plans and issuers must comply with a state external review process or the federal external review process. State laws that meet or exceed the consumer protections in the NAIC Uniform External Review Model Act will apply to carriers that are subject to state law.

The AMA has expressed concern with the external review provisions of the NAIC’s model laws process because the external reviewer is not, in fact, as independent as it should be in light of the relationship with the insurer. The AMA will be submitting comments to the Obama administration by the deadline on September 21.

Health exchanges

HHS issued a request for information on August 3 regarding the planning and establishment of state-level exchanges to help HHS develop regulations regarding the exchange-related provisions of the Affordable Care Act. HHS is requesting comments on:

  • The factors states will consider in determining whether to create exchanges.
  • Governance and structure of such exchanges.
  • Qualifying health plan certification criteria.
  • Establishing standards for a plan rating system and quality measurements for plans.
  • Enrollment and eligibility issues.
  • Outreach.
  • Rating areas.
  • Employer participation.
  • Risk adjustment.
  • Reinsurance.
  • Risk corridors.

Comments are due to HHS on October 4, and the AMA will be submitting its views.

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Maine CDC Again Organizes Annual Infectious Disease Conference for November 9th

Please save the date for the upcoming Infectious Disease Annual Conference. 

When:  November 9, 2010 from 8:00 am – 4:00 pm.  Where:  Augusta Civic Center. 

Since 1983, the Division of Infectious Disease, Maine Center for Disease Control and Prevention has organized an annual infectious disease conference targeting public health issues of emerging concern. Health care practitioners, laboratorians, and public health partners are invited to receive current information on surveillance, clinical management and diagnosis, and disease control interventions. The conference will feature Cases of Interest – Epidemiology Presentations – and Clinical Updates.  

Who should attend:  Health Care Practitioners, Laboratorians, and Public Health Partners. Click on the following link for more information and to register online:

For more information please contact Dot Seigars, Medical Care Development, or 207-622-7566, ext. 232.

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Report Says Medical Liability Costs Are 2.4% of Total Health Expenditures

The report, appearing in the September edition of Health Affairs, examined medical liability costs in four categories:  indemnity payments ($5.72 billion), administrative expenses ($4.13 billion), defensive medicine costs ($45.59 billion), and other costs ($200 million).  The report breaks down the largest category, defensive medicine costs, into a hospital service component ($38.8 billion) and physician and clinical services ($6.8 billion).  The total cost in 2008 of the medical liability system was $55.6 billion or 2.4% of total health care costs.  The report concludes that while the cost of defensive medicine is not trivial, it is unlikely to be an area of significant savings in health care reform.

The report's authors acknowledge that they did not consider the social costs of the medical liability system, such as the emotional distress caused to providers or the injury to reputation.

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CMS & FTC Plan ACO Workshop in Baltimore on October 5th

On September 8th, CMS and the FTC announced that they plan a workshop for October 5th on issues concerning accountable care organizations (ACOs) at the CMS headquarters in Baltimore.  The agenda for the workshop will include the antitrust, physician self-referral, anti-kickback, and civil monetary penalty laws applying to ACOs.  The meeting is open to the public.

You can find more information about ACOs on the CMS web site at:


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US CDC Study Finds Increased Prescription Drug Use by Americans

The federal CDC released Prescription Drug Use Continues to Increase:  U.S. Prescription Drug Data for 2007-2008 on September 2nd.  The study finds that from 1999 to 2008, the percentage of Americans who took at least one prescription drug per month increased from 44% to 48%.  The study also found that the use of multiple prescription drugs increased by 20% (from 25% to 31%) and the use of five or more prescription drugs increased by 70% (from 6% to 11%) during the same timeframe.  Spending for prescription drugs was $234.1 billion in 2008, a figure that is more than double what was spent in 1999.

You can find the report on the CDC web site at:

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CMS Identifies Methodologies States Must Use to Control Improper Coding for Medicaid Claims After October 1st

On September 1st, CMS identified 5 National Correct Coding Initiative methodologies that Medicaid programs must use effective October 1st.  The 5 methodologies are:

  • procedure-to-procedure edits for practitioner and ambulatory surgical centers;

  • procedure-to-procedure edits for outpatient hospital services incorporated into the Medicare outpatient code editor (OCE) for hospitals reimbursed through the hospital outpatient prospective payment system (OPPS);

  • MUE units-of-service edits for practitioner and ambulatory surgical center services;

  • MUE units-of-service edits for outpatient hospital services for hospitals reimbursed through the OPPS and for critical access hospitals; and

  • MUE units-of-service edits for supplier claims for durable medical equipment.

This is a requirement of the ACA and CMS notified State Medicaid Directors of this requirement in a recent letter.  You can see a copy of the letter on the web at:

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Workers' Compensation Board Continues Work on Facility Fee Schedule

On Tuesday, September 8th, the Workers' Compensation Board held a workshop meeting on efforts to amend its Rule Chapter 5 concerning medical fee schedules to include a facility fee schedule for hospitals and ambulatory surgical facilities.  This is the latest in a continuing effort to reach agreement between labor and management members on a facility fee schedule methodology that has gone on for several years.  At this meeting, management members unveiled their latest proposal to adopt the federal Office of Workers' Compensation Programs (OWCP) fee schedule as a model.  The Board's consultant on the matter, Eric Anderson with Ingenix, discouraged the Board from moving in this direction for a variety of reasons.  The MMA and MHA pointed out that each organization had urged the Board to adopt Mr. Anderson's recommended facility fee schedule methodology more than 6 months ago, an approach that was estimated to save approximately $3 million per year in costs for inpatient and outpatient services in the system.  At this meeting, the labor members moved to adopt the Anderson recommendation with a 5% annual cost of living adjustment, but the management members balked, claiming that they needed more time to think about it.  The Board will return to the issue at its next meeting scheduled for September 28th.  Based upon one ASC's analysis, it appears that the OWCP methodology would result in substantial cuts in reimbursement to providers now participating in the workers' compensation system.

 At this meeting, the Board also swore in 2 new labor members.  
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