March 12, 2012

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45-Day Limit on MaineCare Coverage for Certain Opioids Now Law But Alternatives Being Considered

There was action last week on several fronts relating to the strict limits placed on opioid-based medication for MaineCare two weeks ago via enactment of the FY 2012 supplemental budget, L.D. 1816.  Because as many as 62,000 current MaineCare patients will be impacted by the changes effective April 1st and September 1, 2012, MaineCare officials, MMA representatives, legislators, advocacy organizations, and other interested parties are working on alternatives to the proposal as well as other strategies to minimize the harm to patients.  Please read the more detailed summary below to stay abreast of these actions, particularly if you have MaineCare patients who are on these medications.  And don't hesitate to provide input to your own legislators, letting them know of your thoughts and opinions.

Although MMA has been reporting regularly on the measures the Appropriations Committee has taken aimed at addressing prescription drug diversion included as part of the supplemental budget debate, this week we are again highlighting the limit on MaineCare coverage of opioid treatment so that physician practices are prepared if this provision remains in effect.  While an alternative proposal is being prepared that would substitute for the harsher elements included in the supplemental budget, the alternative needs to first be accepted by HHS officials and then endorsed by the legislature, which could not take place soon enough to avoid the April 1st deadline.  It could, however, if passed, change the law prior to the September 1st deadline.

Many of you also may have heard about the prospect that advocacy groups for MaineCare patients may file a lawsuit to enjoin the application of these limits.  These groups claim that the medication restrictions violate the federal law governing Medicaid which requires that individuals receive an appropriate "amount, scope, and duration" of treatment.  Although a limit can be imposed if it addresses instances of fraud or abuse by individuals, the limits as drafted may not be subject to this exception as they apply across the board without regard to an individual's circumstances.  MMA advises that the best strategy for you and your MaineCare patients currently is to prepare for the possibility that the law will take effect as written but hope that an alternative proposal or the lawsuit may be successful.  The Attorney General's office is likely to express its opinion on the limits today or later this week.

Kevin Flanigan, M.D., MaineCare's Medical Director has held two sessions with interested prescribers to receive input into an alternate proposal.  Among other changes, the proposal would be likely to impose a yearly limit, as opposed to a lifetime limit.  There may also be exceptions for post surgical care.  However, the proposal is likely to be more restrictive with respect to coverage for opioid based drugs for conditions not supported by clinical evidence.  These include, at least for long term opioid therapy, unspecified back pain, neck pain, and headaches.  We should know by the end of this week whether an alternative proposal is likely to be presented.  Members with a real interest in this issue should talk to their legislators about it.  The weekly conference call the MMA Legislative Committee has on Tuesday nights also has proven to be an important resource for gaining physician reaction to the opiate limits.

As a reminder, below is what is in the law now as a result of the legislative action two weeks ago.

As of April 1, 2012 MaineCare coverage of opioids for members newly prescribed these drugs will be limited to a total of 45 days (an initial 15-day prescription, followed by 2 additional 15-day prescriptions with prior authorization).  This is intended to be a lifetime limit.  For patients who have been treated for chronic pain with opioids for one year or more, the 45-day limit becomes effective on September 1, 2012 to allow more transition time.  This means their 45 days would run out mid-October if they are taking the medication continuously.  The law exempts HIV/AIDS patients, those with cancer, in hospice care or receiving in-patient treatment from the limit.  

The opioid coverage limit is Part O of the first supplemental budget, L.D. 1816:


Sec. O-1.  22 MRSA §3174-TT  is enacted to read:

§ 3174-TT. Limitation on reimbursement for opioids

1 Limitation.    Except as provided in subsection 3, beginning April 1, 2012, the maximum time period for reimbursement under the MaineCare program for opioids is set forth in this subsection.

AFor a MaineCare member who is receiving treatment for HIV or AIDS or for cancer or who is in hospice care, reimbursement must be provided for the duration of the treatment or care.

BFor a MaineCare member who is receiving inpatient treatment in a hospital, reimbursement must be provided for the duration of the inpatient hospitalization.

CExcept as provided in subsection 2, for a MaineCare member who is receiving any treatment other than the treatments or care described in paragraph A or B, the maximum time period for reimbursement is 15 consecutive days.

2 Authorization for reimbursement for longer than 15 consecutive days.     For a MaineCare member who is receiving treatment under subsection 1, paragraph C, the department may authorize reimbursement for a period longer than 15 consecutive days in accordance with this subsection.

AThe department may authorize reimbursement after the first 15 consecutive days for an initial extension period of an additional 15 consecutive days.

BThe department may authorize reimbursement after the initial extension period authorized in paragraph A for a final extension period of 15 consecutive days.

The department may not authorize an extension beyond the final extension period authorized in paragraph B.

The department shall adopt rules to implement this subsection. Rules adopted under this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.

3 Exception; treatment of chronic pain for one year or longer.     For a MaineCare member who on April 1, 2012 has been receiving opioids for the treatment of chronic pain for one year or longer continuously, the limitation on the maximum time periods for reimbursement under the MaineCare program for opioids set forth in subsection 1 takes effect September 1, 2012.

Please keep in mind that this is a coverage decision by the legislature for the MaineCare program.  It is not a limit on physicians' prescribing rights.  Patients would still be able to fill prescriptions and pay cash.  While acknowledging the likely negative results of this decision, not just for the health of the individual patient but also the social costs, feedback on this policy decision received by the MMA has been mixed.  

Please share this information with your colleagues in your practice sites and your medical staffs, so that you can plan for management of these MaineCare patients should this policy remain in effect as of April 1, 2012.  And watch these pages of the Weekly Update for further information.

If you have further questions or comments about this matter, please contact MMA EVP Gordon Smith at or 622-3374, ext. 212.

MMA Legislative Committee Call, Tuesday Night at 8:00 pm

The MMA's Legislative Committee has held very 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 night, Tuesday, March 13th 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 one bill below, we will cover the ongoing supplemental budget negotiations, 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 or 622-3374, ext. 214.

L.D. 1840An Act To Limit MaineCare Reimbursement for Methadone Treatment (monitor; addiction specialists, psychiatrists)

L.D. 1848An Act To Require Notification of Health Care Facilities That May Be Negatively Affected by a Certificate of Need Application (support)

L.D. 1852An Act To Provide a More Comprehensive Ban on the Possession of Synthetic Hallucinogenic Drugs (support or monitor; emergency physicians)

L.D. 1855An Act Regarding the Fund for a Healthy Maine's Prevention, Education and Treatment Activities Concerning Unhealthy Weight and Obesity (support; Public Health Committee)

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POLITICAL PULSE: Legislative Highlights of the Week


The Appropriations and Financial Services Committee came to quick agreement last week over how to fill a $5 million shortfall in the 2012 state fiscal year budget, which ends June 30th.   The Committee agreed with recommendations made by Finance Commissioner Sawin Millett to plug the hole with various unencumbered funds, unaccounted for salary and pension savings and changes to debt service and the loan insurance reserve fund.  None of the changes impact the Department of Health and Human Services (DHHS).   

On Friday, the Committee heard from Commissioner of DHHS, Mary Meyhew, regarding the estimated 19,000 individuals who are no longer eligible from MaineCare but still have active MaineCare cards and may have been receiving services.   The Commissioner explained that the MaineCare claims processing system (MIHMS) was never designed to be able to talk with the eligibility system and so was not able to close all necessary cases.  The Department did put a fix into place in December 2011 but cases that should have been closed remained on the books at that time.   The Commissioner estimated that it would take 4-6 weeks to get more information regarding how many services at what cost had been used by the 19,000 people.  She took responsibility for not knowing of the issue or informing the Appropriations Committee earlier and is planning to restructure the Department to improve communications and efficiency.  The Appropriations Committee plans to temporarily pause its work on a 2013 DHHS budget to get more clarity on the timeline for for updated cost figures.  In the meantime, they will begin work this week on a supplemental budget that addresses non-DHHS needs.  


As reported last week, Maine Republicans are planning to delay major action on setting up a health insurance exchange until the Supreme Court rules on the constitutionality of the federal Affordable Care Act in June.  Instead, Republicans on the Insurance and Financial Services Committee have introduced proposed bill language that would allow the Governor to establish an exchange by Executive Order as an agency within the Department of Professional and Financial Regulation.  Presumably, this would allow the Governor to wait for a ruling on the ACA before having to establish the exchange. 


Last week, the HHS Committee held several work sessions on L.D. 1813, An Act to Amend the Laws Governing Confidentiality of Health Care Information.  The bill comes from the L.D. 1501 work group, but was also of interest to the Maine Chapter of ACEP and other groups (law enforcement, district attorneys, and emergency nurses) who supported a bill, L.D. 639, addressing violence in Maine hospitals.  The Committee unanimously recommended bringing Maine's confidentiality statute into conformity with the HIPAA Privacy Rule on the disclosure of information to law enforcement personnel.

The Committee also held a public hearing and work session on L.D. 1829, An Act to Require Photographic Identification for Prescriptions for Certain Controlled Substances, another bill based upon the recommendations of the L.D. 1501 work group on drug diversion.  The bill received support from the MMA, the Maine Osteopathic Association, and pharmacy interests.  The ACLU of Maine opposed the bill.  Based largely on the analysis of Committee Policy Analyst Jane Orbeton that current law already permits a pharmacist to request identification for any prescription drug, the Committee voted unanimously "ought not to pass" on the bill.  


The Joint Standing Committee on Criminal Justice and Public Safety held a work session last week on LD 1825, which would have extended the statute of limitations from 6 to 10 years for crimes involving  sexual contact or abuse if the alleged perpetrator was a psychiatrist, psychologist, licensed clinical social worker or other person in authority over the victim.  While recognizing the serious nature of crimes of this sort, the Committee did not feel comfortable picking out certain acts or actors for a longer statue of limitations without reviewing statutes of limitations as a broader issue, and a majority of the Committee voted that the bill ought not to pass.  

The Committee also held a public hearing on LD 1837 last week, a bill to create a pilot program for community paramedicine programs.  These programs would allow emergency medicine providers to work in the community on issues such as chronic illness management or reducing hospital readmissions.  It is not intended to be an expansion of scope of practice.  The MMA testified neither for nor against the proposal but raised a number of concerns such as fragmentation of care, training requirements for the providers and oversight of the programs.  The Committee tabled the bill until today to allow the MMA to work with proponents to address some of these questions.  

The Committee was also busy last Thursday addressing a number of bills dealing with domestic violence.   The Committee approved LD 1711, implementing risk assessments in domestic violence cases, but did not support several other bills, in part to await the Governor's bill on domestic violence issues.  


Last week, the House debated L.D. 882, An Act to Limit Health Care Mandates and the majority report passed in a close 74-70 vote.  MMA endorses a "nay" vote on the bill.  Following the initial vote, it was held in the House and debated again today.  Today's vote was 73-64.  You can see both roll call vote lists on the web here:  The bill now moves to the Senate.

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Inaugural OneMaine Roundtable Features Healthcare Discussion, March 14 in Bangor

OneMaine, a Maine-based nonprofit that provides a rallying point for citizens who believe that Maine politics will be more pragmatic and effective when voters support state legislators who are less partisan and who work across party lines to develop solutions that move Maine forward, has launched a series of roundtable discussions to provide Mainers with an unbiased, nonpartisan source of information on the critical policy issues facing the state.

The first roundtable will address healthcare policy and will be held at 5:30 p.m. on this coming Wednesday, March 14th at the Dyke Center at Husson University in Bangor.  The public is invited to attend.

Participants in the event include MMA EVP Gordon Smith, John Porter, President of the Bangor Region Chamber of Commerce, Jeff Austin, Vice President of the Maine Hospital Association, Shawn Yardley, Bangor Health and Community Service Director, Erik Steele, D.O., of Eastern Maine Healthcare Systems., and Jill Goldthwait, The Jackson Laboratory. The program will be recorded for future broadcast and will be moderated by Sarah Skillin Woodard.

More information can be found at




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Public Health Association Call for Abstracts

The Maine Public Health Association is pleased to announce its Call for Abstracts for breakout sessions at their 2012 Fall Conference.  The theme of the conference is Community Connections: Building Creative Partnerships for the Health of All Mainers and will be held October 17th at the Augusta Civic Center.  They encourage abstracts in all areas of public health. Students are also encouraged to apply. Abstracts should be no more than 500 words and must include learning objectives.

Authors must provide complete and accurate contact information in order to be notified of abstract status. You do not have to be a member of MPHA to submit an abstract, however, if your abstract is accepted, presenting authors must register for the Annual Meeting at a discounted rate.

All abstracts must be submitted via e-mail or fax by April 10th at 5 p.m. by email to or by fax to 207.622.3616. Call of Abstract form can be found at

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Evidence Based Guidelines for Discussing Environmental Toxins Released

A growing body of evidence suggests that preconception and prenatal exposure to certain environmental toxins can impact fetal development adversely and lead to potentially long-lasting health effects.  However, most reproductive health providers are not trained in environmental health and do not have the tools to counsel patients on this topic.  Now, a team of researchers, led by Sheela Sathyanarayana, MD, MPH of Seattle Children’s Research Institute, have created a guide outlining exposure risks and reduction tips for some of the most common environmental toxins.  The clinical opinion, “Environmental exposures: how to counsel preconception and prenatal patients in the clinical setting,” was published in advance online in the American Journal of Obstetrics & Gynecology. 

The guidelines include evidence-based recommendations on how to talk with patients about environmental toxins like lead, mercury, pesticides and other endocrine-disrupting chemicals such as bisphenol A (BPA), which is used in a variety of products including canned food linings and cash register receipts.  It also includes resources for each toxin area, outlining an easy and consistent way to deliver these important messages to women and their partners. The guidelines contain helpful information for patients, too.  The guidelines can be found here [return to top]

Request for HIPAA Version 5010 Feedback, E-Prescribing Additional Exemptions

The AMA has been monitoring the transition to HIPAA Version 5010 and communicating concerns to CMS as we hear of them. As you are aware, the compliance date for using Version 5010 was January 1, 2012 but CMS has elected not to enforce compliance until April 1. The AMA continues to encourage physicians to submit complaints using the Medicare complaint form at and for all other payers at

In other news, the AMA has secured an opportunity for more physicians to be exempted from the 2012 Medicare e-prescribing penalty.  Even if you have already contacted CMS, contact CMS again.  They are willing to hear your case (though there is no guarantee they will change their decision).  

Here are some examples of the hardships that physicians faced that CMS may now be willing to address: 

(1) You did e-prescribe in 2011 but due to errors or system/technical glitches (e.g., your 

billing vendor/clearinghouse removed the G8553 code from your Medicare Part B claims 

that you submitted), the G8553 code was removed from your Medicare Part B claims that 

you submitted to Medicare.  You also have documentation that shows that you  

e-prescribed for your Medicare patients in 2011. 


(2) You reported the wrong G-code (e.g., a 2009 e-prescribing G-code) on your Medicare 

Part B claims in 2011.  You also have documentation that shows that you e-prescribed for 

your Medicare patients in 2011. 


(3) You filed for an exemption request but you included your group NPI rather than your 

individual NPI number on the exemption request form and your exemption request was 



(4) You filed for an exemption request, but you have not yet heard from CMS regarding 

the status of your exemption request, or you believe that your exemption request was 

denied in error. 

If you faced any of the hardships described above or faced another type of hardship and believe you received the 2012 Medicare e-prescribing penalty in error please contact CMS to hear or reconsider your case.  You should contact CMS’ Quality Net Help Desk later this month (to give them time to educate their help desk) via telephone at 1-866-288-8912 or via email at

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Federal Judge Rules Graphic Cigarette Health Warnings Violate Free Speech

On March 5th, the U.S. Department of Justice appealed a federal judge's decision that found unconstitutional an FDA regulation requiring tobacco companies to place certain graphic health warnings on cigarette packages and in advertisements. 

On February 29th, U.S. District Judge Richard Leon ruled that requiring tobacco companies to use the warnings violated their First Amendment right to free speech.  In his decision, he said that the warning labels were too large and that the government has many other tools available to deter smoking, such as raising cigarette taxes or including more literal, and less compelling, images in the warnings. The judge finalized his earlier preliminary order blocking the rules from taking effect, a decision the government had already appealed.  The Department of Justice filed its latest appeal with the U.S. Court of Appeals for the District of Columbia Circuit. Under existing federal regulations, the warning labels were scheduled to take effect September 2012. 

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Doctor of the Day Openings in March

The MMA is currently seeking physicians who are interested in participating in the Doctor of the Day Program at the Maine State Legislature.  As the Doctor of the Day, you are provided with a  beeper to respond to any health care issues that may arise with legislators, staff, or the public. You need to arrive at the State House by 9 am (times may vary) with session ending around the noon hour. The MMA works diligently to secure a Doctor of the Day for each day the legislature is in session.

We currently have several dates in March that are still open.  If a date in March does not work for you, please let us know your availability for April and we'll try to schedule a date when the April legislative calendar becomes available.  

MARCH available dates:

Tuesday, the 13th

Thursday, the 15th

Monday, the 19th

Tuesday, the 20th

Wednesday, the 21st

For more information or to register, contact Maureen Elwell at or visit

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Upcoming Events & Conferences

Quality Counts 2012 Conference
 Partnering with Patients: Finding the Bright Spots to Transform Care
Wednesday, April 4, 2012 
Augusta Civic Center
A “best practice college”, offering participants specific models and tools for working collaboratively within communities to improve health and health care.
For more information or to register, click here


Cancer in the Family: Primary Care Matters

April 13, 2012 


The Jackson Laboratory 

 600 Main Street

Bar Harbor, ME

This half day free CME event will be held in conjunction with the annual meeting of the Maine Academy of Family Physicians with the goal of enhancing Maine health care providers' understanding of detecting and managing individuals with familial cancer syndromes.

For more information or to register, click here.


Immunization Annual Conference: Focus on Maine

Monday, April 23, 2012 
8:00 am - 3:45 pm 
Augusta Civic Center
Sponsored by the Maine Center for Disease Control and Prevention
 Dedicated to a review of emerging and existing issues relating to immunization practice, at the federal, state and local levels.
For more information or to register, go to:

Maine Association Medical Staff Services Biennial Education Conference: The Many Spokes of the Wheel

 May 9-11, 2012

 Residence Inn Hotel and Conference Center

Portland, ME

The conference welcomes physicians and other health professionals with an interest in medical staff activities, including credentialing and quality improvement.  Category I CME is offered for physicians.

An agenda and registration materials are available at


22nd Annual Maine GERIATRICS Conference - Save the Date

June 7-8, 2012 

Harborside Hotel & Marina

Bar Harbor, ME

Registration Open.  CME Available. 

 For more information or to register visit or

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Save the Date: MMA's 21st Practice Education Seminar Announced for Wednesday, July 25, in Augusta

The Association's 21st Annual Practice Education Seminar will be held on Wednesday, July 25, 2012 at the Augusta Civic Center.  Keynote presenters include Susan Turney, M.D., President of the Medical Group Management Association (MGMA) in Englewood, Colorado and Brian Atchinson, Esq., President of the Physician Insurance Association of America (PIAA).  Mr. Atchison is a former Insurance Superintendent in Maine and a former chair of the National Association of Insurance Commissioners (NAIC).  Dr. Turney is in her first year serving MGMA, having previously served as Executive Vice President of the Wisconsin Medical Society.

The program will be held from 8:30 a.m. to 4:00 p.m. at the Augusta Civic Center.  Watch for registration materials in your next issue of Maine Medicine.  Registration will also be available on the Association's website at

In addition to the keynote presentations, updates will be offered on MaineCare, Medicare, state legislation, Board of Licensure in Medicine activities, HIPAA, the federal Affordable Care Act, HealthInfoNet, the Regional Extension Center, and the recently updated Physician's Guide to Maine Law.

If your firm or company is interested in exhibiting at the program, contact Lisa Martin at or call her at 622-3374, ext. 221.  Sponsorship opportunities are also available through Ms. Martin.



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