December 17, 2012

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MaineCare Opioid Limits Work Group Completes Work; Limits Take Effect Jan. 1

The MaineCare Opioid Limits Work Group, chaired by MaineCare Medical Director Kevin Flanigan, M.D. completed its work last Monday and forwarded to MaineCare staff its recommendations for implementing the limits required by the Supplemental Budget on Jan. 1.  The limits impact both prescriptions for acute pain and chronic pain and will be effective retroactively.  Specifics are in the draft proposal posted on the MMA website at (in Spotlight section).

The Work Group, consisting of physicians, mid-level providers, and advocates for MaineCare patients (MMA staff participated as well) met seven times over the summer and fall and received input from a wide variety of sources.  While the final supplemental budget took effect on August 30th, DHHS Commissioner Mary Mayhew agreed to delay the implementation of the limits until January 1, 2013, in order to provide the Work Group with time to receive input and provide recommendations for the emergency rule being drafted.  While the draft proposal is by no means perfect, it does take into consideration all the relevant interests and balances them in as fair and responsible manner as possible.

 The draft proposal, which is expected to be drafted into an emergency rule before January 1, is divided into sections dealing with acute pain, (pain expected to be resolved within 60 days) and non-acute or chronic pain.   Exceptions to the limits are made for the following categories:

 1.  A MaineCare member who is receiving opioid medications for symptoms related to HIV, AIDS and cancer and other qualifying diseases and conditions, as set forth on the Department's Preferred Drug List.

 2.  A MaineCare member who is receiving opioid medications during inpatient treatment in a hospital, in a nursing facility or during hospice care.

3.  A MaineCare member who is receiving 30 milligrams or less of morphine sulfate equivalents on a daily basis.

 4.  A MaineCare member for whom MaineCare reimbursement for opioid medications for the treatment of addiction is restricted by limits applicable to methadone and buprenorphine and naloxone combination medications.

 While prescribers impacted by the limits are encouraged to review the details of the proposal on the MMA website (in Spotlight section) at, the essence of the proposal is a limit of 15 days of medication for acute pain, with the ability to receive up to two 14 day renewals through prior authorization so long as there is a face to face visit with the patient.  A renewal beyond 43 days would require a treatment plan consisting of incorporation of non pharmacologic treatments and functional assessment of the member by the physician or other prescriber.  In essence, treatment beyond 43 days will move the patient to the non-acute, or chronic pain limits.

 For treatment for chronic pain, opioids will be covered by MaineCare only after one or more non-pharmacologic treatment alternatives are attempted.  The proposed rule includes as such alternatives physical therapy, occupational therapy, chiropractic therapy, osteopathic manipulative treatment, cognitive behavioral therapy, and acceptance commitment therapy. Note that the Department may waive the requirement of a non pharmacologic intervention treatment through prior authorization when participation is not feasible and opioid treatment is medically necessary.

 Post-surgical pain is treated as acute pain, but a more liberal provision applies as after the first fifteen day script, the surgeon may renew the script for a total of 60 days, in one or multiple prescriptions through prior authorization.  But there is a requirement that the patient be seen by a provider (not necessarily the surgeon).

 Efforts are being made to notify patients and prescribers before the limits take effect.  Dr. Flanigan is doing a webinar this week (see article in this issue of the Update) to discuss the proposal.  MMA staff is also available to present CME programs on this topic to medical staffs and other interested groups.  If your practice or staff is interested in a presentation, contact Gordon Smith, Esq., at or by calling 622-3374, ext. 212.

 Finally, physicians are reminded that these limits imposed by the Legislature are limits on the ability of MaineCare to pay for the medication.  The physician is free to write for whatever medication he or she believes is appropriate for the patient and the patient may pay cash for the medication if it is not covered by MaineCare.  But in doing so, he prescriber may wish to consider whether these limits will eventually be considered the appropriate standard of care for treatment of pain.



MaineCare Pain Management Policy Webinar, Dec. 20

Effective January 1, 2013, MaineCare will be implementing a new Pain Management Policy (see lead article). 

On Thursday, December 20th from 9-11 a.m. MaineCare’s Medical Director, Kevin Flanigan, MD, will host a webinar for opioid prescribers to discuss the new Pain Management Program.

 To join the webinar:

  1. Go to:
  2. Select “Enter as a Guest”
  3. Enter your first and last name to sign in.
  4. When the “Join the Audio Conference” screen appears, enter your telephone number including the area code, in the “Dial-Out” box.
  5. Select “Join.”
  6. The Adobe computers will call your telephone number. When you answer the call, press 1 to connect to the conference.

If you choose to listen in without participating in the webinar, call 1-877-455-0244 and enter code 1127267168.

You can email with questions. Webinar materials and a recording will be available on the MaineCare Provider Updates webpage at:

These changes are part of the Department of Health and Human Services’ supplemental budgets and administrative savings Initiatives that were signed by Governor LePage.   See Public Law 2011, c. 477 and c. 657.

You can find emergency, proposed and adopted rules at: [return to top]

Specialty Society Comments Sought on Maine's Essential Health Benefits Package

The Maine Medical Association is seeking feedback from physicians and specialty societies regarding the package of benefits proposed to be offered by all private health insurance plans sold in the individual and small group insurance markets starting in 2014.  It is critical for physicians to review and provide feedback on the coverage as many of your patients will be receiving benefits based on this package.   It is especially important that we hear from Maine physicians as this is a Maine-specific proposal and national specialty societies will not be reviewing the state-specific plans. 

The Affordable Care Act (ACA) requires that beginning in 2014 health insurance plans sold to individuals and small businesses provide a minimum package of services in 10 categories called “essential health benefits.”  Under HHS's intended approach announced Dec. 16, states have the flexibility to set their essential health benefit's package by selecting a benchmark plan that reflects the scope of services offered by a “typical employer plan.” Because Maine did not select one of plan options, HHS has proposed that the default benchmark will be the small group plan with the largest enrollment in the state

This means that Maine is slated to default to the Anthem Health Plans of ME (Anthem BCBS) PPO Blue Choice 20 plan with Rx 10 30 50 50 

The benefits offered by this plan can be found here:

Please review the package of benefits and let MMA know if you have any concerns about what services are covered.  Please also take a moment to review the table beginning on page 13 titled PRESCRIPTION DRUG EHB-BENCHMARK PLAN BENEFITS BY CATEGORY AND CLASS .   This table lists the number of drugs per class that all plans will be required to offer (though it does not specify which drugs, plans will simply have to offer the same number but will be able to select the actual drugs).  

Please direct any comments or concerns to Gordon Smith, or 207-622-3364 x 212 by Friday, December 21st.  [return to top]

Forecast for Medicare Physician Pay Fix is Cloudy

(Credits to our friends at the American Academy of Ophthalmology for this catchy title.)

While serious negotiations are reportedly going on in Washington, particularly between President Obama and House Speaker John Boehner (R-Ohio), an agreement that would avoid the so-called fiscal cliff is not imminent.   While the prospect for fixing the SGR problem is largely tied to year-end federal budget negotiations that would prevent the across the board cuts brought on by sequestration, if no year-end deal is reached,  Congress could pass a stand-alone physician pay fix.

Republicans in the House have proposed a solution that would kick the can down the road for another year, but would pay for some of that delay by eliminating provider-based reimbursement in hospital outpatient departments and eliminate or postpone the primary care rate increase effective Jan. 1 because of provisions in the Affordable Care Act.   Both of these "pay-fors" are very unpopular with many Democrats and with hospitals and primary care physicians.  In previous issues of the Update we have noted the strong opposition of Maine's hospitals to elimination of provider-based reimbursement.  With respect to the primary care fee increase, MaineCare announced just last week that it would be bumping up MaineCare payments to primary care physicians to Medicare levels for 2013 and 2014, effective Jan. 1, 2013.  

MMA continues to be in touch with the members of our Congressional delegation urging them in the strongest possible terms to at least delay the nearly 30% reduction, due Jan. 1.  The following talking points from the AMA provide a sense of the impact of the impending SGR cut in Maine.

  • Maine seniors face significant challenges obtaining access to physicians.  These challenges will get much worse unless Congress acts very soon to permanently prevent steep cuts in Medicare payment rates.  At just 14 practicing physicians per 1000 Medicare beneficiaries, Maine is well below the national average.  Twenty-nine percent of Maine's Medicare beneficiaries are living below 150% of the federal poverty level.  Maine is also one of 29 states and the District of Columbia that have imposed cuts in services for low-income elderly, such as home care and rehabilitation.
  • Congress needs to avert the SGR cut and eliminate the formula that leads to this annual crisis.  SGR legislation would prevent a loss of $100 million annually for the care of elderly and disabled patients in Maine.  On average, a cut of this magnitude will reduce 2013 practice revenues by $21,000 per Maine physician, which will worsen access problems and make it extremely difficult to pay for office space and other expenses and avoid staff layoffs.  
  • 14,935 employees of medical practices, 262,290 Medicare patients and 42,524 Tricare patients in Maine will be helped by the legislation that averts these cuts.
  • Compared to the rest of the country, Maine, at 20%, has an above-average proportion of Medicare patients.
  • Almost 50% of Maine's practicing physicians are older than 50, an age at which surveys have shown many physicians consider reducing their patient care activities.
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MMA Legislative Committee Reviews Priorities for 126th Session

The MMA Legislative Committee held its organizational meeting for the 126th Maine Legislature last week, Dec 12.   The meeting was well attended by MMA members, representatives of specialty societies and other allied organizations such as Medical Mutual Insurance Company, MaineHealth, and the Downeast Association of Physician Assistants. 

The meeting began with an overview of the incoming legislature and brief overview of the federal political landscape.  The bulk of the meeting was spent reviewing legislative proposals the MMA expects to see from organizations other than the MMA (such as the state budget and Medicaid, health reform implementation, changes to the medical marijuana statute and health data issues) and discussing potential MMA or specialty society legislation for the session.   The last day to introduce bills for the upcoming session is January 18th.   MMA staff will be spending the next several weeks drafting bills to reflect the issues prioritized at the meeting. 

If you or your specialty society were unable to attend the meeting and have bills you are considering, please contact Andrew MacLean at or 207-622-3374 x 214.   You are also invited to participate in our weekly Legislative Committee phone calls which will be held at 8 pm on Tuesday evenings, beginning Tuesday, January 8th[return to top]

Former Insurance Superintendent Kofman to Direct District of Columbia Health Insurance Exchange

The Executive Board of the DC Health Insurance Exchange voted unanimously last Monday, Dec.10 to appoint Mila Kofman as the Executive Director of the District of Columbia Health Benefit Exchange.  Ms. Kofman, who served as Maine's Insurance Superintendent from 2008 into 2011, will begin her duties on Jan. 2, 2013.  She will manage the Exchange operations, advance health care reform in the District, and recommend strategic priorities.

 "We are very fortunate to have Mila Kofman to serve as our Executive Director," said Dr. Mohammad Akhter, chairman of the Health Benefit Exchange Authority.  "Her vast array of experiences in the insurance and health policy arenas will serve us well as she leads us in implementing health care reform and in creating the best health insurance exchange in the country."

 "I am honored to be selected by the Board of Directors and excited about the opportunity to work with government leaders, the regulated community, health care leaders and most of all, the businesses and residents of the District of Columbia to improve the quality of health care through affordable health care coverage," said Mila Kofman.  "Together, we can establish a robust and viable health insurance exchange marketplace second to none."

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Model Policy on Concussion Management Released

The Maine Department of Education’s model policy on concussion management is now available on the student health website. Every school district and private schools must adopt a concussion management policy that is consistent with Maine DOE’s model policy by Jan. 1, 2013.

The model policy was developed by the Maine DOE Concussion Work Group, which includes members from the fields of health care, athletics, school nursing, physical therapy and neuropsychology. Various associations, including the Maine Principal’s Association, Maine School Management Association, Maine Concussion Management Initiative and the Brain Injury Network of Maine, were also involved.

Maine statute directed the committee to develop this model policy based on the current research and best practice guidelines from the national Centers for Disease Control and Prevention and other states’ concussion management documents.

The implementation of the policy will take place between Jan. 1, 2013, and June 30, 2014. The Maine DOE will provide concussion resources for parents and students as well as materials for districts to conduct concussion awareness training for staff.

A web-based concussion toolkit will be available in the near future to help districts meet this policy, as well as provide resources for primary care and other health providers in the community. Please revisit the DOE website in the coming weeks: [return to top]

Maine Quality Forum Advisory Committee Reviews Options for Public Reporting of Patient Experience of Care Surveys

The Maine Quality Council Advisory Committee, chaired by Robert Keller, M.D., met on Friday, Dec. 14 to conduct its regular business but set aside the majority of the meeting to review options for the public reporting of Patient Experience Survey Data which is expected in 2013.  A total of 284 medical practices (175 primary care, 95 specialty and 15 mixed) have agreed to participate in the collection of the data with 90% of the cost being covered by the state. These practices represent over 1300 individual providers.  A condition of participating was agreement to have the survey results publicly reported on the MQF website.

To assure consistency in approach, the Dirigo Health Agency contracted with four vendors to administer the survey,  The surveys are being completed during this period of time.

The initiative is being conducted in collaboration with the Maine Health Management Coalition and Maine Quality Counts.  The ultimate purpose is to collect survey date using a standardized instrument (CAHPS) and approach so that valid publicly reported comparisons can be made about primary and specialty healthcare in Maine at the practice site level.  The survey results will not drill down to the level of the individual provider within a practice. Many large employers or the Maine Health Management Coalition may use the survey data to rank and tier provider networks.

No conclusions were reached on the choices presented by consultants to the project, Dale Shaller and Lise Rybowski, but the Advisory Council will continue to discuss the options while the data is being collected.

No practices in Maine have ever used the CAHPS version for the patient centered medical home which focuses on how well the practice provides patient-centered care, coordinates with other providers and supports patient engagement. [return to top]

MaineCare Announces ACA Primary Care Payment Bump in January

At the Maine Medical Association Board of Directors meeting Wednesday, Dec. 5, MaineCare Medical Director Dr. Kevin Flannigan announced that MaineCare will be prepared to pay primary care physicians at Medicare rates for primary care services delivered after January 1, 2013.  As reported in previous issues of the Weekly Update, this is a benefit provided because of the Affordable Care Act and is funded with federal dollars. Primary Care physicians practicing in the areas of family medicine (with or without OB), internal medicine and pediatrics are included.  Provider-based physicians will receive the increase, as well as physicians in private practice.  FQHC's will not be receiving the increase as they are already paid higher rates under the federal law.

Physicians will have to fill out a form attesting to their area of practice and to the fact that 60% of their charges are for office based services to be eligible for the extra payment.  MaineCare will be releasing the form shortly and the link will be provided in future editions of the Update.  While a majority of states will be making quarterly payments to their primary care physicians to reflect the increase, Dr. Flannigan stated that MaineCare is committed to incorporated the bump into its regular fee schedule and payments.   If physicians do not submit their attestation form before January 1, physicians will receive retroactive payments beginning after they submit the form.  

For more information about the payment increase, click here for an AMAnews article or here for a CMS fact sheet on the rule.   [return to top]

Free First Friday Education Program on Prescription Drug Abuse, Feb. 1

The MMA's First Fridays Educational Series for 2013 begins on Friday, Feb. 1 from 9:00am to noon and includes an unusual feature.  THERE IS NO COST to attend, either in person at the MMA offices in Manchester or via webex from a laptop or desktop.  Because of grant funding by the state Office of Substance Abuse and Adult Mental Health Services, we are able to present the program without charge.

Faculty for the program includes Tamas Peredy, M.D. of the Northern New England Poison Control Center, John Lipovsky, the new coordinator of the Prescription Monitoring Program, Noel Genova, PA-C of the Chronic Pain Consultation Program and Gordon Smith, Esq. of MMA.  MaineCare Medical Director Kevin Flanigan will also be available to describe the MaineCare limits on opiate medication, effective Jan. 1, 2013.

Registration is available on the MMA website at  Although the registration form notes that a fee is charged, just complete your registration form without including that portion.  A new form with a full agenda and goals and objectives will be available shortly and will be distributed electronically to all of the e-mail addresses we have available for members and their staffs.

Only twenty five remote sites are available so sign up as soon as possible if you know that your facility or practice would like to attend.

A complete list of all the 2013 First Friday programs is also on the website and was included with your Fall issue of Maine Medicine. [return to top]

Acadia Hospital Requests Your Opinion Regarding Establishing a Program for Eating Disorders

 Acadia Hospital, a mental health and substance abuse treatment facility in Bangor, has asked for MMA's assistance in disseminating an on-line survey tool assessing the viability of establishing a program to treat eating disorders.  Below is a link to the survey which they are requesting psychiatrists, primary care physicians, hospitalists and Ob-Gyns to complete.  Please complete the survey only if you have not done so previously.

This survey will close on December 28.  Your participation is much appreciated.


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Upcoming Events & Conferences

Save the Date: 2013 Quality Counts Conference 

April 3, 2012

Augusta Civic Center, Augusta 

QC 2013 will feature Dr. Donald Berwick, former CMS Administrator, as keynote speaker highlighting the theme of reaching the Triple Aim of improvement.  Registration materials and detailed agenda will be available January 2013.


Save the Date: First Annual Conference of the Medical Professional Health Program 

Health, Wellbeing and Awareness 

April 5, 2013

Holiday Inn By the Bay, Portland

This will be the first Medical Professionals Health Program Health Conference focusing on addiction, recovery and wellness. The conference is open to all licensed professionals.  [return to top]

Job Openings

PSYCHIATRIST – Tri-County Mental Health Services – Lewiston, Maine

Our Assertive Community Treatment (ACT) Team has an exceptional opportunity available for a full-time Psychiatrist. Under the direction of the Director of Psychiatry, the Psychiatrist is responsible for outpatient psychiatric management of individuals with severe and persistent mental illness with an emphasis on medication management.  Additional duties include assessments, development of the plan of treatment, recommendation of consultations and referrals, participation in discharge planning, and on-call coverage.

Position Requirements:  Must possess active State of Maine Medical Doctor license, Board Certification (ABPN or AOBNP) in Psychiatry, and DEA Certificate.  Computer proficiency and valid driver's license are also required.  Equal Opportunity/Affirmative Action Employer.

For consideration, forward resume with cover letter to:

As one of Maine’s largest and most comprehensive agencies providing services addressing mental health, substance abuse and intellectual disabilities, this year Tri-County Mental Health Services celebrates 60 years of giving home to Maine people.

Visit us at:


PRIMARY CARE POSITIONS Available at Mayo Regional Hospital

Mayo Practice Associates, a department of Mayo Regional Hospital in Dover-Foxcroft, Maine, has several openings for primary care physicians. Positions are available at our rural health centers in Dover-Foxcroft, Guilford and Milo for either internal medicine or family medicine-trained physicians. Mayo offers a competitive base salary and benefits plan, productivity incentives, medical educational loan reimbursement and a relocation allowance. Mayo Regional consistently ranks among Maine's top critical access hospitals for overall quality of care.

Applicants should send resume and cover letter to: Ben Dever, Mayo Practice Associates, 897 West Main St., Dover-Foxcroft, ME 04426, or


PHYSICIAN MEDICAL DIRECTOR for Hospice of Southern Maine

Hospice of Southern Maine seeks a full time Physician Medical Director responsible to assist the CEO in the administration of HSMs clinical services program, and for liaison activities with the local medical community. Provides oversight of the medical services of the program to ensure an adequate and qualified medical staff for clinical service and coverage needs. Reviews patient eligibility for hospice services; certifies patients meet medical criteria for admission and recertification based on available prognostic indicators. Performs home visits and visits for inpatient hospice services related to patient assessment and care as needed and appropriate.  

Job Requirements:
Completion of medical education and relevant residency training required. Fellowship in Palliative Medicine preferred. Work experience in internal medicine, geriatrics, palliative medicine or other relevant field of medicine required. Work experience in a certified hospice program and administrative experience preferred. Physician licensure by the State of Maine as a doctor of medicine or osteopathy required; board certification in hospice and palliative medicine preferred. Valid drivers license with an automobile that is insured in accordance with state and/or agency requirements and is in good working order required.

For additional information or to apply contact HR at

Hospice of Southern Maine is an equal opportunity employer, and does not discriminate against applicants or employees on the basis of race, color, sex, sexual orientation, religion, national origin, age, veteran status, disability or any other characteristic protected by applicable law. All employment decisions shall be consistent with the principles of equal employment opportunity. In order to ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act, the Vietnam Veterans Readjustment Act, the Maine Human Rights Act, and Title I of the Americans with Disabilities Act, applicants that require accommodation in the job application process may contact the Human Resources Office at 207-289-3640 or by e-mail at for assistance.


MEDICAL DIRECTOR/PHYSICIAN - Health Access Network - Lincoln, Maine

Health Access Network (HAN), a Federally Qualified Health Center (FQHC) in Lincoln, Maine, is seeking a dynamic physician leader to serve in the role of Medical Director to provide overall direction and oversight of our clinical team, as well as provide part-time direct patient care. The Medical Director will join the health center’s leadership team in meeting the goals and objectives of the health center’s mission. Responsibilities include, but are not limited to administrative and clinical leadership of medical staff, quality improvement, credentialing & privileging, peer review, strategic planning, budgeting, provider recruitment and assist with the development of clinical policies and procedures. Position is two days a week administrative and three days providing direct patient care.

Qualifications: Board Certified in family medicine, Maine License, and have at least five years primary care and leadership experience. A practicing physician wishing to transition to a part time medical-administrative/management role is encouraged to apply. Community health center experience a plus. Familiarity with disease registries and electronic medical records is required. Must have exceptional verbal and written communication skills, and possess compassion, innovation, integrity, and excellence which are the health center’s values.

For more information or to forward your curriculum vitae' contact:  Sonia Maxwell, HR Director/Compliance Officer, P.O. Box 99, Lincoln, ME  04455, 207-794-6700,


DFD Russell Medical Centers seeking NURSE PRACTITIONER

The DFD Russell Medical Centers (DFDRMC) operates three community health centers in central Maine.  We are looking for a full-time NP for immediate placement.  A current unencumbered Maine license and proficiency with electronic medical records are required.

Excellent benefits, including medical, dental and life insurance, 403(b) retirement plan, flexible spending accounts, a generous paid time off plan and incentive plan.  Salary is commensurate with experience.
We are an equal opportunity employer committed to diversity in the workplace. 

To submit your resume, please email or fax Laurie Kane-Lewis, CEO or fax 207-524-2549.     


HOSPITALIST - Belfast, Maine

Multi-specialty community hospital on the coast of Maine seeks full-time BC/BE Hospitalist to join an established group and provide full medical oversight of hospital inpatient and critical care activities. Belfast offers beautiful views of Penobscot Bay and is ideal for outdoor enthusiasts. Exceptional family environment with excellent schools.

Send CV to Dan Bennett, Director of Operations, Waldo County General Hospital, P.O. Box 287, Belfast, Maine 04915. Tel. (207) 930-6741, Fax (207) 338-6207, e-mail:

 2/11/13 [return to top]

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