December 5, 2011

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Countdown to a Medicare SGR Delay or Permanent Fix Continues

Congress continues to look at various options for delaying the Medicare payment reduction which will occur on January 1, 2012 without congressional action.  A week ago, the final payment rule published in the Federal Register showed an additional reduction in Maine because of the insidious geographic factor amounting to a 1% reduction in Cumberland and York counties and a 4% reduction in the rest of the State.  So the January 1st cut would be an eye-popping 31.4% in most of the State and 28.4% in Cumberland and York counties.

Reductions of this magnitude would obviously be devastating to physicians, other health care professionals and hospitals in the State.  Given the large number of patients on Medicare and Tri-Care, well over $100 million annually is at stake.  Fortunately, the Congress does seem to be coming to grips with the fact that action must be taken before adjourning for the holidays.  Members of Congress are not likely to look forward to returning home to the districts and explaining to seniors that their doctors will be receiving a nearly one-third reduction in fees for treating them. Such reductions would result in serious disruptions in care and lead to difficulties with access.

MMA has heard from members who are considering opting out of  Medicare if the sustainable growth rate formula (SGR) is not fixed.  A permanent fix is estimated to cost almost $300 bilion dollars ($289.7 billion according to the most recent estimate by the Congressional Budget Office).  But as the gap continues between what it costs to provide care and the fees paid for that care, it would cost twice this amount, or over $600 billion in 2016.  And to paraphrase former Illinois Senator Everett Dirksen, even in Washington, that is real money.

Each physician in Maine should communicate with Maine's Congressional delegation as soon as possible and emphasize what this cut would mean to them and their patients.  Time is running out.  Find contact information and a sample letter at the AMA Advocacy website.

The AMA also has some helpful guidance on Medicare participation options for physicians here.  

L.D. 1501 Work Group Continues to Address Prescription Drug Abuse; Final Meeting Dec. 9

The work group established  by L.D. 1501 continued its work at a three-hour meeting Friday, December 2nd.  Recommendations for the draft report developed by the task forces were reviewed and a final meeting scheduled for this coming Friday, December 9th.  All of the meetings are open to the public and are held at 41 Anthony Avenue in Augusta at the Office of Substance Abuse (use the rear entrance).

There appears to be consensus around a number of important issues, as follows:

  1. Participating in the state's Prescription Monitoring Program (PMP) will be strongly encouraged, but not mandated.
  2. Appropriate continuing education courses will be developed but any mandated education will come on the federal level, not because of any state mandate.
  3. Prescribers will be encouraged to exercise universal precautions when starting a patient on opioid therapy for chronic pain.
  4. Prescribers will be provided with appropriate assessment, screening and risk reduction tools.
  5. The licensing boards for the various prescribers will be asked to review the current rule, Chapter 21, regarding guidelines for treatment of chronic pain and adopt any necessary changes.
  6.  A number of enhancements to the PMP are recommended, all aimed at making the program more valuable to physicians and other prescribers.  Additional access to the program by law enforcement is also being considered.
  7. In order to decrease the number of deaths due to accidental overdose, a pilot project to provide naloxone kits will be recommended along with appropriate state legislation providing for protection of individuals who prescribe, dispense or otherwise intervene.     

Please bear in mind that the above recommendations could change based upon discussion and votes at the final meeting, but we have offered here what we believe are the most likely outcomes.

Next week's Update will contain a more complete review of the recommendations that will appear in the final report which will be delivered to the legislature on December 16th.  The legislature's Health and Human Services Committee  will consider these recommendations during the Second Regular Session of the 125th Legislature that will convene on January 4, 2012. [return to top]

Primary Care Physicians Needed for 90 Minute Focus Group on Health IT, Tomorrow Night!

MMA is assisting NORC, a research group associated with the University of Chicago, in assembling a small group of primary care physicians and physician assistants to provide feedback on the general issue of health information exchange.  The 90 minute session will take place at the MMA office in Manchester at 5:00pm Tuesday, December 6th, ending just prior to the MMA Legislative Committee meeting.  Dinner will be served and each participant will receive a $75 honorarium.  

Any interested physician or PA should communicate asap with Gordon Smith via e-mail to


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Governor LePage Proposes Cutting 19,000 from MaineCare

In his weekly radio address on December 2nd, Governor Paul LePage announced that he will seek to cut MaineCare eligibility for the so-called "non-categorical" population.  This would amount to cutting medical coverage for approximately 19,000 adults, aged 21 - 64, who do not have minor children at home, who are not disabled and whose income is below the poverty level.  The Governor stated that structural problems that developed over the past decade in the MaineCare program, including expanded eligibility and high spending per member while relying on one-time stimulus funding and other fiscal "gimmicks," led to state budget problems and the current $120 million shortfall in the Department of Health and Human Services budget. 

The full text of the Governor's address is available here.  It is expected that the administration will release a proposed supplemental budget addressing DHHS funding and including the MaineCare cut within the next several days. The legislature's Appropriations and Financial Affairs Committee will then consider the proposal and has scheduled public hearings for December 14th and 15th.  Physicians and practices with feedback on the proposal to cut coverage for noncategorial adults should contact Andrew MacLean (622-3374 x214, or Jessa Barnard (622-3374 x211,

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Bureau of Insurance Releases Draft Rule Eliminating Geographic Access Requirements

Maine's Bureau of Insurance has proposed completely eliminating Maine's geographic accessibility rule, found in what is known as Chapter 850, that has required managed care plan carriers to provide access to primary care services within 30 minutes travel time from an enrollee's residence and specialty care and hospital services within 60 minutes travel time.  The change comes in a draft rule released November 21st interpreting Public Law Chapter 90, the health insurance reform law that passed last session.  Under the proposal, managed care plan carriers would have no geographic network requirements.  Other changes to Chapter 850 found in the proposed rule include:

  • Eliminating standards for the incentives that carriers can have in place to encourage patients to use “designated providers.”  Some of the current standards include only allowing additional benefits to see a designated provider rather than reducing benefits for not using designated providers, using peer reviewed literature as a basis for determining high quality provider standards, and using data that is reliable and consistent to compare providers.
  • Requiring carriers to report on the time it takes to receive services, but eliminating the requirements for access to medically necessary primary care services within 7 days, preventive primary care within 90 days, urgent care specialty services within 24 hours and routine specialty care within 30 days.
  • Eliminating the requirement that emergency services be provided at the nearest participating facility unless the condition requires being transported.
  • Eliminating the requirement that primary care, and to the extent possible, specialty care services be available 24 hours a day, 7 days a week within the plan's service area.
  • Eliminating the requirement that adequate numbers of primary and specialty care physicians have admitting privileges at general hospitals within the managed care plan's service area.   And,
  • Eliminating the requirement that carriers submit to the Bureau of Insurance:
    • the percentage of physicians in network with open practices; 
    • a physician and health professional recruitment plan;
    • a plan for providing services for rural and underserved populations and developing relationships with essential community providers;
    • how the carrier will identify and address language and literacy barriers to needed services. 

The Bureau is holding a public hearing on the proposed rule changes on December 20th.  Comments are due by January 6th.  The notice of rulemaking can be found here and the full rule can be found here.  Any practice concerned about the impact of these rule changes and wanting to testify or submit comments is encouraged to contact the MMA:  Andrew MacLean (622-3374 x214, or Jessa Barnard (622-3374 x211, 

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DHHS Seeks Comments on Value Based Purchasing Strategy

The Maine Department of Health & Human Services recently released a request for comments regarding certain aspects of the Department’s Value Based Purchasing (VBP) Strategy, focusing on:

  1. The planned Accountable Communities Initiative, under which MaineCare will enter into alternative, risk-based contracts with qualified provider organizations that will align financial incentives for those providers to work together with the community to improve value and decrease avoidable costs.

  2. The Department’s plans to take advantage of Section 2703 of the Affordable Care Act, establishing Health Homes to serve MaineCare and Medicare-Medicaid dual enrollees with chronic care needs. 

The RFI and more information on the Department’s Value Based Purchasing Strategy, can be found here:

Any individual or entity may respond to the RFI, including individual health care practices. The deadline for final submission of comments is 5:00 p.m. December 14, 2011.  [return to top]

State Awarded $6 Million to Implement Health Insurance Exchange

According to a press release from the U.S. Department of Health and Human Services, Maine will receive nearly $6 million as one of 13 states awarded federal funding to set up health insurance exchanges under the Affordable Care Act.

As reported in the Bangor Daily News last Tuesday, the state’s Dirigo Health Agency will use the $5,877,676 grant to design and build an infrastructure for the exchange, including the integration of existing Medicaid eligibility systems. The funds will also support gathering input from stakeholders such as insurance companies, consumer groups and others.

The funding is part of nearly $220 million awarded to develop the exchanges, mandated by 2014 under the federal health care reform law.  The exchanges are designed to provide individuals and small businesses with a “one-stop shop” to compare private health insurance options.

Maine officials are evaluating whether Dirigo Health will transition into the state’s new health insurance exchange or be dissolved. [return to top]

MeHAF Grants Maine Medical Education Trust $120,750 for Health Care Advocacy

Maine Health Access Foundation (MeHAF) has awarded a total of $495,600 in grants to four Maine organizations working to ensure that the interests of uninsured and medically underserved Maine people are represented as state executive branch policy makers develop rules to guide the implementation of new laws, including the state’s new health insurance reform law (Public Law, Chapter 90) and key portions of the federal Affordable Care Act (ACA). MeHAF funding will also support the government-to-government consultation processes between the Tribal Nations and the state.

Organizations receiving grants for their work over the next two years include:

  • Consumers for Affordable Health Care Foundation: $125,000
  • Indian Township Tribal Government: $125,000
  • Maine Equal Justice Partners: $124,882
  • Maine Medical Education Trust: $120,75.  The MMET is contracting with the Maine Medical Association staff to carry out all grant activities. 

Passed during the last legislative session, Maine’s Public Law, Chapter 90 reforms state health insurance regulations for private insurers, and is intended to expand consumer choice and reduce the cost of private coverage.   Nationally, the ACA sets a federal framework for state implementation of many provisions including the health insurance exchanges where individual consumers and small businesses may compare products and buy private coverage – another tool intended to expand consumer choice and reduce the cost of coverage.  The ACA also requires states to establish government-to-government consultation processes for the Tribal Nations.

“It is essential that policy decisions that affect health insurance and the provision of health care services reflect the needs of underserved and uninsured people of Maine,” said Dr. Wendy J. Wolf, President and CEO of MeHAF.

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Fund for Healthy Maine Study Commission Finalizes Recommendations

The legislatively-appointed Commission studying the allocations within the Fund for Healthy Maine held its third and final meeting last Tuesday.   The Fund receives the money from a legal settlement with tobacco companies, as well as some funding from state racinos, and is the largest source of public health funding in the state.   The Commission was directed to review the State's public health priorities and make recommendations regarding use of the Fund going forward. 

The Commission agreed on the following recommendations, which will be presented in a report to the Legislature later this month:

  1. That the original intent of the legislation creating the Fund should be preserved and allocations should be limited to prevention and health-related purposes;
  2. To add obesity prevention, treatment and education activities to the statutory list of acceptable uses of the Fund;
  3. To track spending already used for obesity initiatives separately, rather than within other line items (e.g. the Healthy Maine Partnership community coalitions);
  4. To create a separate fund to hold Fund for Health Maine money, rather than simply tracking it separately;
  5. To require more detailed reporting from contractors on their use of the funds and to specify how their activities fulfill Fund purposes;
  6. To review the Fund every four years, the next time in 2015, with same format as this Commission;
  7. To move from rules to statue a requirement that if a legislative proposal effects the Fund, it come before the legislature's Health and Human Services Committee for review; and
  8. To give the Attorney General's Office adequate resources to enforce the settlement with the tobacco companies.

Several other proposals were not supported by the Commission, including removing funding for family planning, endorsing an increase in the alcohol or tobacco tax, and creating a body to perform an ongoing review of the Fund.  The MMA thanks all of the Commission members for their thoughtful deliberations, and is especially appreciative of the perspective shared by the physicians on the Commission, Dr. Joel Kase and Dr. Sheila Pinette of the MeCDC. 

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CMS Responds to Questions on Billing by Nonenrolled Physicians

Recently, the AMA provided updated information on Medicare participation options for physicians. The AMA Medicare participation kit describes three ways of relating to the Medicare program: participation, nonparticipation and opting out/private contracting.

The AMA asked the Centers for Medicare & Medicaid Services (CMS) whether there is a fourth option: to not enroll as a Medicare provider and have patients submit claims on their own using form CMS 1490s.  If legal, this option would have allowed a physician to be free from the Medicare limiting charges and other payment policies and rules just as a physician who has opted out and privately contracted with their patients would be, but, in addition, their patients could still be reimbursed by Medicare for services they receive from the nonenrolled physician.  CMS indicated, however, that the option of having physicians not enroll in Medicare and have beneficiaries submit claims on their own using the form CMS 1490s is not consistent with Medicare law and unenrolled physicians who engage in this type of practice are subject to penalties.  [return to top]

MaineCare Physician Advisory Committee Discussing PMP, Suboxone, Dec. 8

The Physician Advisory Committee (PAC) is a core group of six MaineCare physicians facilitated by the MaineCare Medical Director.  Presently this group meets on a quarterly basis.  MaineCare would like to open its Physician Advisory Committee meeting to wider participation.  Any provider interested in MaineCare initiatives may attend the meeting in person or by phone. 

The next meeting will be held on Thursday, December 8, 2011 from 3-5 p.m. at the Augusta MaineCare Office located at 442 Civic Center Drive.  The topics for this meeting will be the Prescription Monitoring Program and upcoming changes to MaineCare coverage of Suboxone.

The conference call line is 1-800-394-6604, with passcode 959468#.  If planning to attend in person, please reply to Charyl Malik at 207-287-3320 or .   [return to top]

Maine CDC Recognizes Efforts to Ward off Infectious Disease

The Maine Center for Disease Control and Prevention recently recognized three individuals and one organization by presenting them with the Pump Handle Award for their contributions to help reduce the impact of infectious diseases in Maine.

Kirk Doing, PhD, Director of Clinical and Molecular Microbiology of Affiliated Laboratory Inc. in Bangor, was honored for his lab's tireless energy to perform additional testing for widespread community transmission of pertussis in Penobscot County.

Maine Medical Center Research Institute's Vector-borne Disease Laboratory was recognized for its dedication to the control of emerging tick-borne disease by understanding the environmental interactions of ticks, hosts and habitats. The team increases public awareness of the threat of Lyme disease through continued monitoring of the risk statewide. 

Gus LeBlanc, Principal of Lewiston High School and his staff earned the award for their leadership and collaboration with Maine CDC in conducting an investigation of tuberculosis during 2011.  Just as the school year ended, it was determined that a student at Lewiston High School had TB and it was important to track down anyone exposed to this individual so that any secondary cases could be stopped.

Donald Piper, Chief Medical Technologist, Microbiology of NorDx Laboratories was chosen for his leadership in implementing Electronic Laboratory Reporting (ELR) through HealthInfoNet.  Since 2006, Maine CDC has worked collaboratively with the State Health Information Exchange and HealthInfoNet to develop and implement ELR, which helps expedite the reporting of infectious diseases. 

The Pump-Handle Award has been given for more than a decade in Maine. The award's name is a tribute to Dr. John Snow, who is considered by many to be the father of epidemiological science. Snow identified that a public water pump was the source of a cholera outbreak in London in 1854. Snow convinced authorities to remove the handle of the pump, preventing any more of the infected water from being collected. The spring that fed the pump was later found to be contaminated with sewage. 

"Maine CDC has long-held relationships with people across the state whose work helps prevent the spread of infectious disease,'' said Dr. Stephen Sears, State Epidemiologist.  "This award is just one small way to recognize and thank them for a job well done."

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