March 19, 2012

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POLITICAL PULSE: Insurance Committee Splits on Exchange issue & Other Legislative Highlights of the Week

While the Legislature is due to adjourn by mid-April, significant issues remain to be resolved including several of interest to physicians.  Last Thursday, Republicans took a step back from the idea of a state-run health insurance exchange by voting in the majority (7-6) in favor of the amended version of a bill, L.D. 1497, that even the bill's sponsor described as a "defensive move" against the ACA and the notion of a state-run exchange.


Thursday's vote concluded a year's work in the Insurance & Financial Services Committee regarding the exchange issue.  The state had received $6 million from the federal government last November to begin designing the exchange, following up on an earlier $1 million planning grant in 2010 that was received and has been spent.  The $6 million will remain in a federal account pending further developments.  It now appears that the LePage Administration and the Maine Heritage Policy Center (author of an op-ed piece in last week's Bangor Daily News) prefer not to have an exchange and are willing to wait until the decision of the U.S. Supreme Court on the constitutionality of the Affordable Care Act before working further on an exchange.

The six Democrats on the IFS Committee voted for their own version of the exchange and pointed out that subsidies offered through the exchanges would make health care insurance more affordable to Maine families.

The two bills will now go to the floor of the House and Senate for debate.

In the meantime, the federal Department of Health & Human Services released final rules last week creating a framework for states to set up health insurance exchanges under the ACA.  A fact sheet on the final rule can be found here


The Appropriations & Financial Services Committee began work last week on a supplemental budget bill to address funding for 2012-2013.  While it does not focus on Department of Health & Human Services or MaineCare funding (and there is a separate bill to deal with 2013 DHHS funding), the bill still does contain a number of changes to DHHS.   It also includes a considerable amount of restructuring of executive branch agencies and senior positions to suit the preferences of the LePage Administration.

Of particular note: 

  • Page A-25, Dirigo Health Agency, $5.9 M in FY 12,  from "a federal grant to support continued progress toward the planning and establishment of a Maine health insurance exchange”
  • Page A-41, Dorothea Dix Psychiatric Center, $2 M, from eliminating 91 positions effective 5/1/12, about half of which are filled
  • Page L-32, Part R, cuts to TANF/General Assistance 
  • Page L-46, Part CC, elimination of State Planning Office
  • Page L-48, Part DD, establishment of Governor’s Office of Policy and Management
  • Page L-141, Part OO, changes to Child Development Services System
  • Page L-156. Part VV,  a sweep of over $4M of unexpended Fund for Healthy Maine money to the General Fund
  • Page L-165, Part CCC, sales tax exemption for “positive airway pressure equipment and supplies,” defined as “continuous positive air pressure and bi-level positive air pressure equipment and supplies, repair parts and replacement parts for such equipment, used in respiratory ventilation”

    The Committee is holding a public hearing on the DHHS aspects of the bill this Thursday beginning at 2:30 pm.  You can sign up beginning at 1 pm.  

    The complete budget documents can be found on the web here:



    The Maine Department of Health & Human Services announced last Wednesday a proposal to consolidate program areas and reduce staff.  The restructuring plan has been in development over several months and is not related to the recent issues with the DHHS computer system.

    Under the proposal, the Offices of Substance Abuse and Adult Mental Health Services will merge to become the Office of Substance Abuse and Mental Health Services (SAMHS).  Additionally, the Offices of Elder Services and Cognitive and Physical Disabilities Services will become the Office of Aging and Disability Services (OADS).  Finally, the Office of Child & Family Services will reorganize, moving to a department-wide approach that focuses on policy, prevention, intervention and care management.  Previously, OCFS' structure featured four major service areas.

    Contracts will be consolidated across the programs, with the goal of reducing administrative costs and improving efficiency.   In all, 91 positions will be eliminated and 44 will be created for a net loss of 47 positions. Many of these positions are vacant and others will transition to the private sector. 


    The Bureau of Insurance has released final changes to Bureau Rule Chapter 850.  As covered in previous issues of the Weekly Update, one major purpose of the amendments was to reflect changes in underlying Maine law relating to health plan network adequacy standards enacted pursuant to Maine's new health insurance reform law (Chapter 90).   The Bureau released proposed rules this winter that would allow carriers to provide incentives for patients to travel to "designated" providers and would eliminate the current geographic network requirements including a maximum of 30 minutes travel time to primary care from an enrollee's residence and a maximum of 60 minute travel time to specialty care and hospital services.   While the Bureau still eliminates a travel maximum, they have improved the rule in response to comments, including: adding a definition of "designated provider," requiring that services be "reasonably" accessible, and stating that incentives must be an additional benefit under a plan, such as waiver of a copay.  Because they are major substantive rule changes the rules now go to the legislature for final approval. 


    The Judiciary Committee held a final work session last week on L.D. 1796, An Act Relating to False Claims under the Medicaid Program.  Among other things, this bill would have allowed private citizens to sue in the name of the State (qui tam actions) for Medicaid fraud.   After hearing from the Attorney General's office that this would require additional staff and resources on their part and not bring in much additional money to the state the Committee voted unanimously that the bill ought not to pass.  


    The Health & Human Services Committee held a public hearing last Wednesday on L.D. 1840, An Act To Limit MaineCare Reimbursement for Methadone Treatment, which would limit methadone treatment to 24 months without prior authorization.  The work session, initially scheduled for immediately after the public hearing, has been rescheduled for today.

    Only the bill’s sponsor spoke in favor of the bill, while more than a dozen speakers testified in opposition. Those speaking against the bill included Pat Kimball, Vice President of the Maine Association of Substance Abuse Programs (MASAP); Dr. Joe Pye, of Discovery House; Dr. Todd Mandell, Chief Medical Officer for Community Substance Abuse Centers/Merrimack River Medical Services; and MMA’s Andy MacLean.  Several Methadone patients, family members, and other providers also testified in opposition, as did representatives from the Maine County Commissioners Association and the Maine Community Action Association.  Bill opponents stated that the bill was inconsistent with current standards of care/prevailing practice, and would result in universal relapses, as well as a rise in blood-born diseases and increases in the many other health and societal costs associated with opioid addiction.  

    The Committee also held a hearing on L.D. 1848, which requires that notice be given in a newspaper published in the service area of a health care facility that may be negatively affected by a certificate of need application filed with the Department of Health & Human Services and to municipal officers of and Legislators representing the municipality where the facility is located.



    The Joint Standing Committee on Criminal Justice & Public Safety voted last Thursday to reopen discussion on L.D. 1825, which would extend 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.  The Committee had voted that the bill "ought not to pass," but is now resconsidering the bill with a proposed amendment that the increase in statute of limitations apply to all professionals licensed under Title 32 of the Maine Statutes (including all physicians) not just the limited number of mental health professionals originally proposed in the bill.  They will take the bill up again this Wednesday.  

    The Committee also held a work session on L.D. 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 initially raised a number of questions about the programs and has since worked with proponents on a compromise.  Only 12 pilots will initially be allowed and the MMA will work with a task force to craft the training, supervision and other requirements for the program.  The Committee voted to support the bill. 


    As reported in the Weekly Update, the Education Committee previously approved L.D. 98, dealing with head injuries in school athletics and sports.  For procedural reasons, the bill came back to the Committee and is now L.D. 1873.  The Committee unanimously approved the new bill last week, which directs the Commissioner of Education to invite interested parties to participate in a working group that will meet during the spring and summer of 2012 to develop a model policy that addresses the prevention, diagnosis, and treatment of concussive and other head injuries in students and student athletes.  It also establishes that schools are required to adopt a policy on management of head injuries and begin implementation of the policy by January 1, 2013.  The bill now goes to the floor. 



    Last week, the House voted on L.D. 882, An Act to Limit Health Care Mandates and the Committee amendment to the bill (stating that insurance companies cannot be required to offer plans that go beyond the minimum benefits required by the ACA) passed in a close 73-64 vote.  It remains tabled in the Senate awaiting debate in that chamber.  MMA endorses a "nay" vote on the bill.  

    MMA Legislative Committee Call, Tuesday Night at 8:00 pm; Several New Bills for Review!

    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 20th 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. 1857An Act To Enhance the Protection of Social Service Home Visitors (monitor)

    L.D. 1859An Act To Protect Firearm Ownership during Times of Emergency (monitor; Public Health Committee)

    L.D. 1860An Act To Allow Marriage Licenses for Same-sex Couples and Protect Religious Freedom (support)

    L.D. 1867An Act To Protect Victims of Domestic Violence (monitor or support; Public Health Committee)

    L.D. 1868An Act To Correct Errors and Inconsistencies in the Laws of Maine (monitor)

    L.D. 1870An Act To Make Supplemental Appropriations and Allocations for the Expenditures of State Government and To Change Certain Provisions of the Law Necessary to the Proper Operations of State Government To Address Revenue Shortfalls Projected for the Fiscal Year Ending June 30, 2012 (monitor)

    L.D. 1873An Act To Direct the Commissioner of Education To Adopt a Model Policy Regarding Management of Head Injuries in School Activities and Athletics (support; pediatricians, Public Health Committee)

    L.D. 1877An Act To Clarify Authorized Associations of Veterinary Practice (monitor)

    L.D. 1884An Act To Revise the Laws Regarding the Fund for a Healthy Maine (support, though there are drafting issues; Public Health Committee)

    L.D. 1886An Act Requiring Communication of Mammographic Breast Density Information to Patients (oppose; radiologists, OB/GYNs)

    L.D. 1887An Act To Restructure the Department of Health and Human Services (monitor)

    L.D. 1888An Act To Strengthen the State's Ability To Investigate and Prosecute Misuse of Public Benefits (oppose)

    L.D. 1891Resolve, To Amend the Pilot Project for Independent Practice Dental Hygienists To Process Radiographs in Underserved Areas of the State (monitor; Public Health Committee)

    L.D. 1893Resolve, Regarding Legislative Review of Portions of Chapter 850: Health Plan Accountability, a Major Substantive Rule of the Department of Professional and Financial Regulation (support Bureau amendments)

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

    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 considered 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.  An alternative proposal is under financial and policy review by several parts of state government.

    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. 

    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.  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:

    PART O

    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.

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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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    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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    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


    Save the Date: 

    Emergency Ultrasound Course

    October 25-26, 2012

    MaineGeneral Medical Center

    Waterville, ME 

    Primarily geared to emergency and intensivist physicians and mid-levels.  Expected 14 Category 1 CME Credits.  Course Director: John Joseph, MD, FACEP 

    To reserve your spot: 626-1303 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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    MMA and the Learning Center at Baker, Newman & Noyes Presents Annual Coding Seminar Friday, April 6

    The Maine Medical Association and the Learning Center of Baker, Newman & Noyes present the Annual Coding Seminar as part of MMA's First Friday CME series on April 6, 2012 from 9:00am to noon.  The seminar is available either live at the MMA office in Manchester or via webex.  There is a charge of $65 per person.

    Faculty for the seminar includes Laurie Desjardins, CPC, PCS, Jana Purrell, CPC-I, CEMC, and Gordon H. Smith, Esq.

     More information and an agenda are available on the MMA website at  You may also register for the program on the website.

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    House Republicans to Fund IPAB Repeal with Medical Liability Reform Proposal

    In early March, two House Committees (Energy & Commerce and Ways & Means) voted in favor of a bill (H.R. 452) to repeal the ACA's Independent Payment Advisory Board (IPAB).  H.R. 452 has 234 co-sponsors.  The full House is expected to vote on the bill shortly.  Though passage is likely in the House, controlled by Republicans, it is unlikely to pass the Democrat-controlled Senate.  The Congressional Budget Office (CBO) estimates the cost of the IPAB repeal to be $3.1 billion over 10 years.  House Republicans propose to cover this cost through passage of H.R. 5, the Help Efficient, Accessible, Low-cost, Timely Healthcare Act (HEALTH) which also passed two House Committees (Judiciary and Energy & Commerce) in 2011, but also is unlikely to pass the Senate. H.R. 5 includes the following provisions:

    • $250,000 cap on non-economic damages

    • 3-year statute of limitations for malpractice claims beginning when an injury is discovered

    • restrictive punitive damages

    • limits on attorney contingency fees

    • safe harbor from punitive damages for the manufacturers or distributors of medical products in certain instances, such as if the products were approved by the FDA

    You can read the AMA's statement in support of the IPAB repeal legislation on the web at:

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