December 20, 2010

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Congress and the President Act to Protect Medicare Payments Through 2011

Last week,  President Obama signed the legislation passed earlier by the U.S. House and Senate to continue the 2.2% increase in Medicare payments established in 2010 and to delay the 25% reduction in payments scheduled for January 1, 2011.  The legislation prevents cuts that would have totaled $90 million in Maine for 2011, representing $20,000 per physician. The delay is for twelve months, giving the Congress approximately one year to develop an alternative to the deeply flawed sustainable growth rate (SGR) formula developed in the 1990's as part of the Balanced Budget Act.  The legislation cost $19 billion which was paid for by making adjustments to the Affordable Care Act that provides for subsidies to persons who can not afford the offered health plan options.  

MMA had joined with the Maine Chapter of AARP to advocate for a delay in the cuts and for a long term solution to the SGR formula.  Both organizations met with the editorial board of the Portland Press Herald  on December 7th  to describe the serious consequences to the state if a 12 month delay was not achieved during the lame-duck session of Congress.  Among the points made:

  • There are more than 260,000 Medicare patients in Maine and more than 42,000 Tricare patients whose providers receive payments under the Medicare fee schedule.

  • In Maine, three out of ten (29%) Medicare beneficiaries are living below 150% of the federal poverty level.

  • Maine is one of 29 states that have imposed cuts in services for low-income elderly, such as home care and rehabilitation.

  • If the cut were to take place on January 1, 2011, over $90 million in reimbursement would have been lost to the physicians and other health providers in the state.

  • Twenty percent of Maine residents rely on Medicare for health insurance.  This is a higher percentage than the national average of 15 percent.

  • Nearly half (46%) of Maine's Medicare patients live in rural areas, with less access to physician services.

  • There are only 14 practicing physicians for every 1,000 Medicare beneficiaries in Maine.  This is well below the national average of 17 physicians per 1,000 beneficiaries.

  • About half (49%) of Maine's practicing physicians are over the age of 50.  Recent surveys have shown that it is typically around this age when physicians consider reducing the number of patients they treat.

A recent survey of Medicare beneficiaries in Maine showed that eighty-six percent of respondents said they'd be either "very concerned" or "somewhat concerned" that physicians might stop treating Medicare patients because of the anticipated cut.  In addition, 85 percent said they'd have trouble finding a new doctor that would take Medicare should the looming cut take effect.

The MMA, the AMA, and other state and national medical organizations, along with our partners such as the AARP, will be working with the new Congress early in 2011 to identify potential solutions to the SGR formula which, without further action, will again result in a deep cut on January 1, 2012.


Medicare Enhanced Benefits for Preventive Services, Effective Jan. 1, 2011

One of the more concrete benefits of the federal health reform law (Affordable Care Act or ACA) is the enhanced Medicare coverage of preventive benefits.  Under the existing law, Medicare has covered a number of preventive health screenings such as mammograms and colonoscopies but with varying levels of cost-sharing (including, as applicable, deductibles, coinsurance or copayments.)  Typically, this meant that the Medicare benficiary would pay 20% of the cost of the service, after they had met the $155 Part B deductible.  But beginning on Jan. 1, 2011, your Medicare patients will no longer have to pay any out-of-pocket costs for most preventive health services, including annual welness visits that are being added to the program.

In addition to the wellness visits (which are different than the one-time "welcome to Medicare physical"  which is only available to beneficiaries in the first year of their enrollment in Part B), CMS has announced the following list of preventive services subject to this provision:

  •  Breast cancer screening:  Yearly mammograms will be offered to women age 40 and older with Medicare. 
  • Colorectal cancer screening:  This includes a flexible sigmoidoscopy or colonoscopy for all beneficiaries age 50 or older.
  • Cervical cancer screening:  Pap smear and pelvic exams are available every two years or annually for those at high risk.
  • Cardiovascular screenings:  Free blood test to check cholesterol, lipid and triglyceride levels offered every five years to all Medicare recipients.
  • Diabetes:  Twice-a-year screening for those at risk.
  • Medical Nutrition therapy:  Available to help people manage diabetes or kidney disease.
  • Prostate cancer screening:  An annual digital rectal exam and PSA test for all male beneficiaries age 50 or older. 
  • Bone mass measurements:  This osteoporosis test is available every two years to those at risk, or more often if medically necessary.
  • Abdominal aortic aneurysm screening:  Available to men ages 65 to 75 who have ever smoked.
  • HIV screening:  Available to those Medicare beneficiaries who are at increased risk or who ask for the test.
  • Vaccinations:  An annual flu shot, a vaccination against pneumococcal pneumonia and the hepatitis B vaccine.
For more information, look on-line at

Beneficiaries covered through a Medicare Advantage plan may not have all these benefits or may have them all and more, depending upon the plan.  Most Medicare Advantage plans do presently offer Medicare-covered preventive services without cost-sharing.

MMA and nine other organizations in the state have one-year funding from the Maine Health Access Foundation (MeHAF) to educate patients about the enhanced coverage opportunities available through the ACA.  If you would like to have some of the materials developed as part of this grant for use in your office, please contact Gordon Smith or Jessa Barnard at MMA ( or


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Medical Marijuana Law Effective January 1, 2011; Applications Increasing

The State Department of Health & Human Services is receiving many applications because of the looming January 1st deadline under the state's medical marijuana law.  At that time, the possession of marijuana under the previous (1999) law will be invalid.  As of Decembe3r 17th, DHHS had issued patient ID cards to 215 Maine residents and an additional 173 applications were pending.  28 individuals had received cards authorizing them to be "caregivers" which allows them to grow marijuana for up to five registered patients.  About 53 physicians have prepared a medical certificate for use by one or more patients.

MMA's one hour CME course designed to inform physicians about the new law is still available for presentation to your medical staff, specialty society, or group practice.  The materials for the course can also be found on the MMA website at  Normally a fee of $200 is charged to cover travel and the cost of materials.  The course is delivered by one of MMA's attorneys, Gordon Smith, Andrew MacLean, or Jessa Barnard.  To schedule a presentation, contact Gail Begin, CME Coordinator, at or by phone at 622-3374, ext. 210.

The Maine Medical Association and the Maine Osteopathic Association also are still seeking volunteers for the Advisory Committee established under the law.  Members are still needed in the specialties of gastroenterology, medical oncology, infectious disease, hospice medicine, and gynecology.  To be considered for appointment to the committee, a physician must be board certified in the specialty and be "knowledgeable about medical marijuana."  To volunteer, contact Gordon Smith at

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DEAPA Seeks Nominations for Annual Awards

Downeast Association of Physician Assistants

Seeking 2011 Award Nominations

The Downeast Association of Physician Assistants (DEAPA) presents awards each year in recognition of outstanding service to the PA Profession and to DEAPA.  The award categories are:

Robert J. Lapham Award for Outstanding Service - This award is presented each year to a Maine physician assistant in recognition of outstanding service to the PA profession and to the Downeast Association of Physician Assistants.

Rural Physician Assistant of the Year - This award is presented to a Maine physician assistant in recognition of dedicated service to a rural community, both as a health care provider and as a citizen.

Physician of the Year - This award is presented to a Maine physician who has demonstrated outstanding support of physician assistants and the PA Profession by precepting, educating, and legislating, or by exemplifying the PA/Physician team approach to medicine.

Outstanding Health Care Professional - This award is presented to a health care professional who has demonstrated exceptional clinical knowledge and teaching skills, promoting the PA profession, and contributing to the health of Maine.

To make a nomination, click here to download the nomination form. Please complete the form and return no later than March 4, 2011.  You can mail or fax to:  DEAPA, 30 Association Drive, Manchester, Maine 04351; Fax:  207-622-3332. If you prefer to send your nomination by email, please send it or

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Home Health Face-to-Face Encounter; A New Home Health Certification Requirement

A new Medicare home health law goes into effect on January 1st that affirms the role of the physician as the person who orders home health care based on personal examination of the patient.   Effective in January, a physician who certifies a patient as eligible for Medicare home health services must see the patient. The law also allows the requirement to be satisfied if a non-physician practitioner (NPP) sees the patient, when the NPP is working for or in collaboration with the physician. 

As part of the certification form itself, or as an addendum to it, the physician must document that the physician or NPP saw the patient, and document how the patient’s clinical condition supports a homebound status and need for skilled services. The face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of care.   While the long-standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition.

A more detailed announcement on this subject will be available within the next few days, on the home health agency website at:, under the Spotlight section.  Additional guidance will be available next week via a Special Edition article on our Medicare Learning Network website at:  Questions and answers regarding this requirement will be available the week of December 13th via Medicare’s home health agency website,  Finally, we expect a video training module describing this new requirement to be released within the next few weeks.

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2010 Physician's Guide to Maine Law Now on MMA Website

Published until 2002 in a printed form, it has been our goal for several years to get an updated copy of the Guide on-line so that appropriate links could be provided and the document could be updated frequently.  It has been updated through the Second Regular Session of the 123rd Legislature and in the next six months will be updated through the actions of the 124th Legislature.  Several of the more significant health items approved by the 124th legislature have already been added to the Guide, such as the laws on the medical use of marijuana.

If you or your staff have not accessed the member's only section of the website, simply go to the site at and click on the member's only section.  You will then be asked for a user name which will be your e-mail address.  Our staff then will receive notification that you wish access and you will be sent an e-mail authorizing your use of the section.  You will continue to use your e-mail address as your user name but will be able to choose your own password.

At the December 3rd First Friday CME program entitled, "Current Topics in the Medical-Legal World," MMA attorney Jessa Barnard, Esq. presented an overview of the Guide.  Other topics during the three hour program included informed consent, the FTC Red Flag rule relating to identity theft (taking effect on January 1, 2011) and the Maine Health Security Act

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Public Health Updates from Maine CDC

The Maine CDC released its final public health update of the year today, including the following news items: 

  • Maine CDC has recently investigated five reports of gastroenteritis outbreaks from Cumberland, Oxford, Kennebec, and Hancock counties.  Four outbreaks occurred in long-term care facilities and one occurred in a school setting.  Public health partners are encouraged to consider norovirus when assessing clusters of gastroenteritis and to act promptly to prevent the spread of illness.  All of the above facilities have implemented preventive measures to control further spread of illness.  For more information, see this Health Alert: =alert 

  • The Food Safety Modernization Act of 2010 has passed the U.S. senate.  The bill focuses on preventing illnesses, by ensuring safety through the entire food production process.  Under this legislation, food processors are required to identify potential hazards in their production processes and put in place programs to eliminate those hazards.  The bill also requires the FDA to inspect all food facilities more frequently and allows them to recall contaminated food.  For more information, see this press release from the Trust for America's Health:


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Free In-Office Hypertension Education Available Through MMA's Academic Detailing Program

The Maine Medical Association and the Maine Independent Clinical Information Service Present: 

Academic Detailing Visits at No Cost

NEW Hypertension Module Available Now!  

Schedule your visit today: 207-622-3374 or 

The "Silent Killer" - Still at Large 

Most Americans over age 60 have hypertension.  Even among those whose blood pressure are normal at age 55, the lifetime risk of hypertension is 90%.  Despite the availability of dozens of effective treatments and decades of data, less than two-thirds of patients in the U.S. with hypertension are receiving treatment, and less than half are adequately controlled.

Effective hypertension control is one of the best ways a physician can make a real difference in patients' health by preventing myocardial infarction, stroke, renal damage, and premature death.  

Meet with our academic detailers to learn more about key steps that can improve current management, such as: 

  • Low-dose thiazides should play a central role as initial therapy for many patients, and as part of combination treatment for others; 
  • Choose other medications based on compelling indications; 
  • Combination therapy will often be needed;
  • When choosing agents, consider cost and compliance. 

For more information, visit  Three academic detailers have been trained in the new hypertension model and they are ready to go!  Put them to use in your practice. [return to top]

2011 Corporate Affiliate Breakfast to be held Thursday, April 14th

Corporate Affiliate members should note on their 2011 calenders the annual corporate affiliate breakfast which will be held at the Portland Country Club on Thursday morning, April 14, 2011.  A speaker has not yet been selected but we wanted the date to be available to the corporate affiliates as soon as possible.

There is no cost for corporate affiliates to attend the breakfast.  It is an opportunity once a year for the leadership and staff at MMA to thank the many corporate affiliates for their support of MMA.  In the past the breakfast has attracted about 100 guests.

 Questions about the event may be addressed to Lisa Martin or Buell Miller, M.D. at MMA ( or


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Current AMA Therapeutic Insights Topic: Management of Migraine in Adults

The latest AMA Therapeutic Insights newsletter has been released and is now available online.  This quarter, the AMA is reprising and updating the very first AMA Therapeutic Insights topic, "Management of Migraine in Adults."  Maine physicians can now access their personal prescribing profiles for this and the other diseases featured in recent newsletters:  "Community-Acquired Pneumonia, Hypertension, HIV, and Alzheimer's Disease."

You can find the AMA's Therapeutic Insights newsletters and related information on the web at:

AMA Therapeutic Insights

  • is free and online

  • highlights one disease condition per issue

  • features individual, state, national prescribing data and evidence-based treatment guidelines

  • is written by top disease experts in collaboration with the AMA

  • offers AMA PRA Category I Credit

While most treatment-oriented CME programs focus solely on disease management, AMA Therapeutic Insights takes it one step further.  This program delivers the actual prescribing patterns for the disease.

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DHHS OCR to Release Four HIPAA Final Rules Together in 2011

Last week, a US DHHS Office of Civil Rights (OCR) official announced that the agency plans to release the following four final HIPAA rules at the same time in 2011:

  • the final breach notification rule;

  • the final HIPAA enforcement rule;

  • the final rule implementing HIPAA privacy and security changes that were mandated in the Health Information Technology for Economic and Clinical Health (HITECH) Act; and

  • a final rule implementing HIPAA changes mandated in the Genetic Information Nondiscrimination Act (GINA).

Senior Health IT and Privacy Specialist Adam Greene made the remarks at a public meeting of the Office of the National Coordinator for HIT last week.

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2011 Medicare Fee Schedule Conversion Factor Still Unknown

Passage of two bills and publication of a final Medicare fee schedule rule, all within a two-week period, complicates the calculation of the 2011 Medicare physician payment update and fee schedule conversion factor. The starting point for calculating the update goes back to the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, signed into law June 25th.  It provided a 2.2% update to the 2010 payment schedule, effective for dates of service June 1 through November 30th, resulting in a conversion factor of $36.8729.  The Physician Payment and Therapy Relief Act of 2010 that was signed into law on November 30th continued this rate through December 31st.  

The bill signed into law on December 15th, the Medicare and Medicaid Extenders Act of 2010, established a payment update for 2011 of 0%.  However, the cost of this provision was covered by modifying a physical therapy provision in the final 2011 fee schedule rule.  As a result, the savings will no longer be redistributed to other fee schedule services.  In addition, the final rule made other changes to the conversion factor, including a re-weighting of the work, practice expense, and liability expense components of the relative value scale that resulted in a reduction in the numerical value of the conversion factor, even though the net impact of these changes is budget neutral.

Since the published final rule assumed a 25% pay cut for 2011, and since the physical therapy modifications in the new law require CMS to recalculate both the payment rates and the conversion factor, we do not yet know what the actual conversion factor will be for 2011.  Payment rates for particular services in each locality will also reflect various changes from the final rule in relative values, GPCIs, and payment policies, so physicians should not expect that their 2011 rates will be unchanged from 2010.  Nonetheless, the net effect of all the changes is to hold average payment rates at the same level as 2010, thus implementing an update of zero, not -25%.

Once CMS completes its calculations, carriers will make the new rates available.  While the AMA has urged CMS to share the information as soon as possible, it is unlikely that the new rates and conversion factor will be determined, tested, and delivered to carriers until some time in January 2011.  The Extenders Act also included $200 million for CMS to process the retroactive payment increases that were included in the ACA, and the AMA has been talking to CMS about how and when the contractors will make payment adjustments for these claims.  The AMA has urged CMS to disseminate information about this issue and begin processing as soon as possible and in the least burdensome manner for physicians.

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MaineCare Managed Care Initiative Timeline Extended

In early December, DHHS officials announced a decision to extend the timeline for the MaineCare Managed Care Initiative to accommodate the transition in gubernatorial administrations.  The Department will delay the release of the RFP to May 2011 and the implementation date to April 2012.  Department staff held a potential vendor conference on December 10th attended by more than 60 people, more than 10 of whom were thought to be potential bidders.  The Managed MaineCare Stakeholder Advisory Committee & Specialized Services Committee met jointly on Friday, December 17, 2010.  This meeting focused on the work of a Quality Work Group.

You can find all the materials of the advisory committees and project documents on the web at:

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