February 6, 2012

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POLITICAL PULSE: Legislative Highlights of the Week, Including MaineCare Limits on Prescribing for Pain

In another Saturday session (February 4th),  the Joint Standing Committee on Appropriations and Financial Affairs met to further discuss the Governor's Supplemental Budget and voted unanimously to limit MainceCare coverage  of opioid medication in order to generate savings in the MaineCare drug budget and to address the issue of prescription drug abuse, diversion and addiction in the State.  Once these recommendations are included in the Supplemental Budget, which is now a virtual certainly, there will be an immediate impact on many physicians and patients.  Please read this entire article to understand the full implications of these proposals.  MMA is particularly concerned that the proposals now impact prescriptions for both acute pain and chronic pain, with exceptions for cancer pain, aids patients, hospice patients and inpatients of a hospital.


The proposed two year limit on Suboxone, noted in last week's Update, has been vigorously resisted by MMA, the Northern New England Society for Addiction Medicine, the Maine Association of Psychiatric Physicians, the Maine Association of Substance Abuse Programs, and others.  By the end of the day Saturday, these efforts were partially rewarded when the Committee agree to delay any prior authorization for patients on Suboxone until January 1, 2013.  This extension was granted for the purpose of allowing MaineCare officials to work with members of the addiction treatment community in determining reasonable criteria for the review at the two-year point.  MaineCare officials are to report back to the Committee in September 2012 regarding the results of these efforts.  This work would be led by the MaineCare DUR Committee with consultation from the MaineCare Physician Advisory Committee and the Substance Abuse Services Commission.

Partially to find funds to offset the change in the Suboxone proposal, Committee members looked to limits on the prescribing of opioid medication for both acute pain and chronic pain.  Currently, MaineCare allows an initial script for 15 days but has no limits on renewal, resulting in patients receiving such medications for an average of seventy (70) days.  The Committee has proposed continuing the 15 day limit on the original script, but requiring any refill to be subject to a prior authorization process and to limit the refills to another 15 days with an absolute cap at 45 days.  Certain illnesses and conditions would be exempt including cancer and AIDS.  If a patient received a renewal beyond the 45 days, he or she could pay for the medication themselves if he or she chose to do so.  The major change from last week's report is that the proposal is now likely to expand beyond new prescriptions to even patients who have been on opioid medication for years.  The proposed effective date for this provision is April 1, 2012.  For a MaineCare member who, on April 1, 2012, was receiving opioids for the treatment of chronic pain for one year or longer continuously the application of the provision begins on September 1, 2012.

The Committee also made two further recommendations that do not generate any savings in the budget but are seen as important in the renewed effort to prevent diversion and addiction.  Recognizing that the state's Prescription Monitoring Program (PMP) is now six years old but that many prescribers of pain medication are not registered to access the information, the Committee voted to mandate registration in the PMP in 2014 among any class of prescribers which has not achieved ninety (90) percent participation by January 1st of that year.  The individual classes would be medical doctors, doctors of osteopathy, dentists, nurse practitioners, physician assistants, and podiatrists.  At this point, the proposal addresses only registration for the PMP, not actual usage.

Finally, a handful of legislators wanted to address the issues related to physician assistant and nurse practitioner prescribing of pain medications.  The only recommendation at this point involves PA's and provides that the supervising physician would have to review the PA's prescribing practices on a yearly basis as part of the written plan of supervision currently required by the Board of Licensure in Medicine.  Proposals impacting on APRN's have not yet been circulated.

The budget language on all of these proposals will be posted on the MMA web site, www.mainemed.com.

The above provisions have the unanimous support of the Committee members, it appears.  This coming week, the Committee is expected to present its proposals to the full legislature, but limited to those changes that will impact between now and July 1, 2012, the end of the exiisting state fiscal year.


Last Monday, the Insurance & Financial Services Committee voted that L.D. 1666, An Act to Guarantee Basic Preventive Dental Health for Children in Maine, ought not to pass.  The bill would have required insurance companies to cover fluoride treatments at least twice annually and was championed by Augusta pediatric dentist and past President of the Maine Dental Association, Jonathan Shenkin.  The MMA spoke in favor of its passage.  

The Committee requested that a group of stakeholders meet to discuss L.D. 1691, An Act Related to Specialty Tiers in Prescription Drug Pricing.  The bill would prohibit health insurers from including in plan designs so-called "specialty tiers" whereby the insurance carrier includes a fourth or even a fifth tier of drug coverage beyond the typical three tiers.  These specialty tiers have a co-insurance rather than a co-payment obligation by the patient and pose a significant cost barrier to patients with chronic conditions needing expensive drugs.  The MMA participated in the meeting, however it appears that there is little consensus between patient advocates and insurance carriers.  The Committee takes up the bill again tomorrow.  The MMA encourages you to contact Committee members to urge their support for this bill.  Committee members can be found here and you can look up your legislators here.  


The Health and Human Services Committee has been busy finalizing work on carry over bills and new legislative proposals.  The MMA has been closely following their efforts and testified on several bills last week. On Tuesday, the Committee heard public comments on LD 1629, which would allow the state to enter contingent fee agreements with MaineCare Recovery Audit Contractors.  In testimony in opposition to the bill, Gordon Smith, MMA EVP, reminded the Committee that the state had previously allowed contingent fee agreements with auditors but barred them in statute after very bad experiences.  While the federal government does allow for contingent fee agreements in both the MaineCare and Medicare RAC programs, the MMA believes the state is not obligated to implement this fee structure.  The Maine Osteopathic Association and Maine Hospital Association also testified in opposition.  The Committee work session on the bill is tomorrow. 

The MMA also testified on LD 1679, which repeals the statue that created Maine's prescription drug privacy laws and allowed physicians to opt-out of having their prescribing information shared with drug manufacturers.  Maine's law was found unconstitutional In light of a US Supreme Court's decision this summer on Vermont's similar law.  While the MMA does not oppose the repealing of the statute in light of the court decision, the MMA believes that there is still more the state can do to protect the privacy of prescribers' and patient's data and is proposing several options to the Committee.  The Committee will have a work session on the bill this Wednesday. 

Finally, Mr. Smith testified on behalf of the MMA and Maine Association of Psychiatric Physicians in favor of LD 1688.  This bill would clarify that getting "blue papered" or transferred to a psychiatric facility does not constitute being "committed" for purposes of reporting to employers, licensing boards or other entities. 

The Committee also held work sessions on several other bills, including: 

  • The Committee voted to pass an amended version of  LD 1624, which removes the requirement that an application for a medical laboratory license be notarized, clarifies that specimens may be collected or processed by licensed health care professionals as well as their designees, and removes the requirement that a licensed medical laboratory send a copy of an itemized statement of laboratory services to the patient.  The amendments addressed some of the MMA concerns with the bill, though the MMA still believes that patients should be provided a copy of their bill. 
  • The Committee tabled LD 1628, An Act to Limit Payment for Care and Treatment of Residents in State Institutions.  The bill  proposes to limit reimbursement for any medical services by community providers to the Medicaid rate for medical services provided in the community to residents of the Riverview Psychiatric Center and the Dorothea Dix Center.  Currently community providers receive charges.  The Committee appears to have been swayed by the Maine Hospital Association and agrees the State should reimburse more than MaineCare rates but wants to see something less than charges.  
  • The Committee voted to pass LD 1627, which expedites electronic filing of vital records.


Last week, the Criminal Justice and Public Safety Committee took up several bills of interest to the MMA. On Monday the Committee heard public testimony regarding LD 1603, which would allow state employees to keep a firearm in their vehicle on state property as long as the vehicle was locked and the firearm was not visible.  This bill expands on a bill passed last session that allowed private-sector employees to bring guns onto employer property. The Maine Chamber of Commerce, Maine Citizens Against Handgun Violence, and private business owners testified in opposition to the bill, stating that it prevented employers from being able to create their own gun policies and reduced workplace safety.  The Committee also heard testimony regarding LD 1728, which would prevent an out of state resident from getting a concealed handgun permit in Maine if they had applied for and been denied a concealed handgun permit by their state of residence.  The Department of Public Safety proposed this bill.  MMA is monitoring both pieces of legislation. 

The Committee is also considering LD 1744, which would expand the existing laws regarding carbon monoxide detectors to require that newly constructed inns, hotels, motels, dormitories, fraternities and sororities install carbon monoxide detectors.  On Friday, the Committee voted to table the bill to give them time to gather more information from colleges about their abilities to install the detectors. 


MMA Legislative Committee Call, Tomorrow 8 pm

The MMA's Legislative Committee has held three successful weekly conference calls so far this session.  They have been well attended and we appreciate the individuals and specialty societies that took the time to participate in the call and share their feedback on pending legislative proposals. 

The next call is tomorrow, Tuesday, Feb. 7 at 8:00 p.m.  Legislative Committee members and specialty society legislative liaisons are strongly encouraged to participate.  Any physician, practice manager, or other staff member who is interested in the MMA's legislative advocacy also is welcome to participate.  It is not necessary to RSVP for the calls.

Please use the following conference call number and passcode.  These will remain the same for every weekly call during the session:

Conference call number:  1-877-669-3239

Passcode:  23045263

The purpose of the weekly conference calls is to review and finalize the MMA's position on bills printed that week, to hear the views of specialty societies on the new bills or their concerns about any health policy issues, and to discuss the highlights of legislative action that week.  The calls rarely last longer than an hour and usually we can accomplish our business in much less time.  In addition to reviewing the two bills below, we will cover the ongoing supplemental budget negotiations, particularly new language on prescription drug diversion and suboxone treatment, and other pending issues at the State House.  For the full list of bills the MMA is currently tracking, click here

If you have any questions about the conference calls, please contact Andrew MacLean, Deputy EVP at amaclean@mainemed.com or 622-3374, ext. 214.

L.D. 1804An Act To Implement Recommendations of the Right To Know Advisory Committee Concerning Public Records Exceptions (monitor or support)

L.D. 1805, An Act To Implement Recommendations of the Right To Know Advisory Committee Concerning a Public Records Exception for Proposed Legislation, Reports and Working Papers of the Governor (monitor)

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Governor LePage Establishes The Maine Prescription Drug Abuse Task Force

On Wednesday, February 1st, Governor Paul LePage issued an Executive Order establishing a 17 member task force to continue to work on the issue of prescription drug abuse, focusing on the action items identified by the stakeholders present at the Drug Abuse Summit held by the Attorney General in October 2011.  The Task Force will be chaired by Joseph Bruno of Raymond, a pharmacist and former legislator.  Bruno also is CEO of Community Pharmacies, a chain of pharmacies located exclusively in Maine.  Other appointees include MMA CEO Gordon Smith, Esq. and Steven Gressitt, M.D., a psychiatrist with a special interest in proper drug disposal.

The action items identified at the Fall Summit include the following:

  1. Develop long-term controlled substance disposal solutions;
  2. Implement a statewide Diversion Alert Program that provides prescribers with drug crime information from local law enforcement to assist in determining whether patients are legitimately in need of controlled substance prescriptions;
  3. Develop and field an evidence-based public education campaign, with a unified message addressing prescription drug misuse, abuse and diversion for statement dissemination in both community education and prescriber training venues;  and
  4. Conduct an active review of the Maine Prescription Monitoring Program, including the scope of access, utilization of available data, thresholds for notification, and mean to achieve near-universal use by prescribers and pharmacists.                                                                                                   

The Task Force will submit a report to the Governor every six months detailing is progress in implementing the action items and other initiatives. The report shall also be sent to the Attorney General, the Commissioner of Public Safety, the Commissioner of Environmental Protection and the Joint Standing Committee on Health and Human Services.

The Task Force will hold its first meeting on Tuesday, February 21st at 3:00 pm at the Office of the Attorney General. [return to top]

House/Senate Conferees Consider Options for Medicare Physician Payment Problem

Members of the Congressional H.R. 3630 conference committee met for the third time on February 2nd and some members said there is a growing consensus that the group should recommend a "permanent fix" to the Medicare physician payment problem, the "sustainable growth rate" (SGR) methodology.  This conference committee has been directed to consider extending the current payroll tax and unemployment insurance law, in addition to the SGR issue.  The conference committee could meet several times this week.  

Both chambers are scheduled to be in recess during the week of February 20th and the current short-term fix expires at the end of this month.  According to a recent Congressional Budget Office (CBO) report, the cost to maintain the 2011 Medicare reimbursement rate for physicians would be $316 billion over 10 years.  Senator Jon Kyl (R-AZ), a member of the panel, has stated that the group has considered recommending use of unspent money for the wars in Iraq and Afghanistan to fund a permanent fix.  The time pressure may make a permanent fix before March 1st unlikely, but it is a positive sign that members of both parties in both chambers recognize the need to work hard to develop a new Medicare physician payment methodology.

In the meantime, the Centers for Medicare & Medicaid Services (CMS) has extended the annual Medicare participation enrollment period through February 14th. The previous deadline was December 31st.

 You can find more advocacy information about the issue on the AMA web site at:  http://www.ama-assn.org/ama/pub/advocacy/current-topics-advocacy/medicare-physician-payment-reform-regulatory-relief.page.

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Maine Medical Association Welcomes the Employed Physicians of Health Access Network

Health Access Network, a Federally Qualified Health Center located in Lincoln, Maine is the newest group member of MMA under the Association's group membership program.  We welcome the nine physicians employed at the health center and thank HAN interim CEO WIlliam Diggins and Medical Director Noah Nesin, M.D. for their support in getting this group membership accomplished.

If your medical group would like to discuss the benefits of a group membership at MMA, please contact EVP Gordon Smith at 622-3374, ext. 212 or via e-mail to gsmith@mainemed.com. [return to top]

Results of MMA Survey Monkey poll

Thank you to the 302 MMA members who took the time to complete MMA's survey monkey instrument in late January.  Here are the results:

1.  Currently MaineCare limits an initial opioid prescription for acute pain (non-cancer) to 15 days.  Would you support a proposal to not allow a renewal of this initial script without a prior authorization?

          147  yes         153   no      (two respondents skipped the question)

2.  Would you support a requirement that all controlled substances dispensed at the pharmacy be packaged in blister packs in order to facilitate pill counts?

          204   yes          95  no      (four respondents skipped the question)

The next survey questions will be sent in the spring.

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AMA Offers Grassroots Advocacy Training Webinar, Feb. 7

On February 7, 2012 at 8 p.m., the AMA will host a grassroots training webinar as part of the Very Influential Physician (VIP) program entitled, "Communicating with Congress:  How to be an Effective Citizen Advocate."

Led by Brad Fitch of the Congressional Management Foundation (CMF), this webinar will focus on the SGR cuts scheduled to take effect on March 1st, and how physicians can act as leaders in successfully influencing  lawmakers to permanently eliminate the SGR.  Brad and CMF have conducted exhaustive research on how Congressional offices process and respond to all the communications they receive, and what specifically impacts their thinking.

Take part in this webinar and learn:

  • What congressional staff believe are the most effective communications tactics for influencing members of Congress;
  • The differences between different forms of grassroots communications (email, mail, phone calls, in-person visits, etc.);
  • How to conduct effective in-person meetings, influence legislators at town hall meetings and other effective advocacy techniques that you can apply in your state/congressional district;
  • Where the AMA stands with current efforts to repeal the SGR once and for all, and how physicians can best leverage their relationships in Congress to amplify the repeal message.

Mark your calendars for this important webinar and stay tuned for registration and call-in details.  If you are not already a member of the VIP program, please visit the following page on the AMA web site to join:  https://www.surveymonkey.com/s.aspx?sm=NqXN8aqmcgUhAXC04fHeVg_3d_3d.

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MeCDC Division Medical Director Opening

Maine CDC Division of Population Health has an opening for a full time medical director based in Augusta.  The successful candidate will provide leadership for public health activities within the State that pertain to maternal and child health and chronic diseases and their prevention.  

Direct Hire applications must be completed and sent to Human Resources by Feb 17, 2012.  

To learn more, go to: http://www.maine.gov/tools/whatsnew/index.php?topic=dhhs_direct_hire_jobs&id=347967&v=dhhs

Position Description:

The Population Health Medical Director serves as the principal medical subject matter expert and resource in the Population Health Division of the Maine CDC. This position provides leadership and medical direction for public health activities within the State that pertain to maternal and child health and chronic diseases and their prevention. Assists program managers with program planning and implementation. Provides guidance and consultation to ensure programming is evidence-based or best practices. Provides technical assistance to epidemiologists in the Division and assists in developing reports on disease burden and epidemiology. Represents the Division as the medical subject matter expert on internal and external workgroups and committees.


Graduation from an accredited Medical or Osteopathic School in the United States (Graduates of foreign medical schools must present evidence of having passed FLEX or National Board Examinations or of current Maine licensure) AND a Masters Degree in Public Health or at least two (2) years of full-time experience in specialty area. Certificate of registration with the right to practice medicine and surgery in Maine as issued by the State Board of Registration of Medicine is required. Preference will be given to candidates with experience in public health, preventive medicine, or quality improvement. [return to top]

Gastroenterology Practice Seeking Part Time NP

Busy Gastroenterology practice seeks part-time temporary Gastroenterology Nurse Practitioner.  NP will work in conjunction with an experienced, board certified gastroenterologist to provide care to adult gastroenterology patients.  This includes assessment, diagnosis and treatment of GI illnesses, both acute and chronic. Candidates must have a MS in Nursing, current license to practice as NP by Maine State Board of Nursing and current CPR and DEA Licenses.  

For more information please contact Adam Shlager at 207-490-7861 or ashlager@goodallhospital.org 

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Emergency Preparedness Conference, April 24-25

Save the Date

4th Annual Maine Partners in Emergency Preparedness Conference 

Augusta Civic Center

April 24-25, 2012

 Free to attend, will include contact hours and CEUs

Tracks on Home & Family, Schools, Business, Communities, Emergency Management & Homeland Security and Hazmat

Visit www.maineprepares.com/conference for updates and registration information  [return to top]

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