2008 September/October by SCCMA

SEPTEMBER / OCTOBER 2008 | Volume 14: Number 5

★ ELECTION 2008 ★

Presidential Nominees on Health Care Reform

New Coverage Lower Rates

GRAM – LONG TERM DISABILITY RATES DROP 15% ON THE SCCMA SPONSORED

on SCCMA’s sponsored Long Term Disability Insurance Program The Santa Clara County Medical Association is pleased to announce that due to favorable program experience, rates have been reduced on the sponsored Long Term Disability Insurance Program. At the same time, members now have access to two new coverage options: Ability Plus Coverage Option: Provides an additional $1,000, $2,500 or $5,000 monthly benefit while on disability and unable to perform two or more Activities of Daily Living (ADLs) or are cognitively impaired. Automatic Increase Coverage Option: Enables a member, once approved, to get increases in monthly disability benefits without additional underwriting equal to 10% of the total disability

Sponsored by:

monthly benefit initially in effect (maximum of 40% of the original monthly benefit.) As your income changes, reassess your disability income needs. Make sure you are adequately protecting one of your most important assets: your ability to earn an income. The Long Term Disability program provides important Medical Specialty Definition of Total Disability! You may apply for up to $10,000 per month if you are under age 50. Members ages 50 – 59 may apply for up to $6,000 per month. Call a Marsh Client Service Representative for more information at 800-842-3761, e-mail CMACounty.Insurance@marsh.com, or visit www.MarshAffinity.com.

Underwritten by:

Administered by:

Hartford Life and Accident Insurance Company, Simsbury, CT 06089. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. (AGP-5719) • #CMA1-824

© 2008 Seabury & Smith Insurance Program Management • CA License #0633005 • 9/08 777 S. Figueroa St., Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer, and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

SCCMA the

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Santa Clara County Medical Association Bulletin

Table of Contents

the Editor’s Desk 4 FromJoseph S. Andresen, MD

& More 5 Modifiers Sandie Becker, CMC

Printed in U.S.A.

From the CEO 6 News William C. Parrish, Jr.

7 Thank You CALPAC & SACPAC Supporters! 9 News Alert 10 Straight Talk on Health System Reform JohnMcCain.com

14 Barack Obama’s Plan for a Healthy America BarackObama.com

24 Presidential Nominees Respond to 10 Questions About Their Health Care Reform Proposals 30 Brominated Flame Retardants: What Your Kids, Cats, Couch, TV, and Food Chain Have in Common Cindy Lee Russell, MD

33 In Memoriam

34 MEDICO NEWS 36 Classified Ads

38 Alliance News Officers

President Howard Sutkin, MD VP-Community Health Cindy Russell, MD VP-External Affairs William Lewis, MD VP-Member Services James G. Hinsdale, MD VP-Professional Conduct Jim Crotty, MD Secretary Thomas M. Dailey, MD Treasurer Martin L. Fishman, MD

Chief Executive Officer William C. Parrish, Jr.

House Officer Representative

Jacob Ballon, MD

AMA Trustee - SCCMA John D. Longwell, MD

SCCMA/CMA Delegation Chair

Tanya W. Spirtos, MD

CMA Trustees - SCCMA

Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (District VII) John D. Longwell, MD (Hospital Based Physician)

Editor

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Councilors

Opinions expressed by authors are their own, and not necessarily those of The Bulletin or the Santa Clara County Medical Association. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by the Santa Clara County Medical Association of products or services advertised. Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org Copyright 2008 by the Santa Clara County Medical Association.

Community Hospital of Los Gatos:

Judith Dethlefs, MD El Camino Hospital:

Michael Curtis, MD Good Samaritan Hospital:

Eleanor Martinez, MD Kaiser Permanente Hospital:

Allison Schwanda, MD O’Connor Hospital:

Jay Raju, MD Regional Medical Center of San Jose:

Hossein Habibi, MD

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Saint Louise Regional Hospital:

John Saranto, MD Santa Teresa Community Hospital:

Efren Rosas, MD Stanford Univ. Medical Center:

Peter Cassini, MD Santa Clara Valley Med. Center:

Patrick Kearns, MD

SEPTEMBER / OCTOBER 2008

All of these challenges will take a concerted effort of our new president to provide a vision to the country that will bring out the best in our government, public, and private institutions to effectively solve.

From the

Editor’s

Desk…

August has quickly passed us by and the end of summer marks the beginning of fall. A return from family vacations and catching up with all those loose ends must be balanced, as we resume our many busy professional responsibilities and practice schedules. November 4 is the day our nation votes for a new president. While this occurs every four years, the election of the next president comes at a time that has arguably the most pressing national challenges in a generation. A battered economy where many families have lost their homes, wars in both Iraq and Afghanistan, the threat of global warming, and 47 million U.S. citizens who are currently without health insurance all appear ready to derail the American dream. All of these challenges will take a concerted

entirety. This is followed by a question-and-answer forum of both candidates in response to questions regarding their health care policy positions. It will quickly become evident that one candidate has significantly more information available regarding his health care policy platform. This is not to be construed as an endorsement of one candidate over another, but merely reflects what each campaign has made available at the present time. We urge each and every SCCMA member to read this information, and use it as a starting point to closely follow this important issue prior to the November 4 general election. Share your insights with your patients, colleagues, friends, and family. Your informed decision will decide the course of our nation’s health care future and it’s importance cannot be emphasized enough.

effort of our new president to provide a vision to the country that will bring out the best in our government, public, and private institutions to effectively solve. While each of these areas needs immediate attention, our patients, community, and business leaders tell us that health care reform is the second greatest concern among all Americans, with only the economy ranking higher. With rising health care premiums, health care costs predicted to reach 20% of the GNP, a reduction in reimbursement for physicians and teaching institutions, the solvency of Medicare in question, and a significant number of

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Americans uninsured, clearly a crisis is looming. With this in mind, we are devoting a significant

SEPTEMBER / OCTOBER 2008

portion of the September/October SCCMA Bulletin to the two major candidates positions on health care reform. All currently available material from Senator McCain’s and Senator Obama’s websites concerning their health care policy and reform is reprinted in its

Respectfully submitted, Joseph Andresen, MD | Editor

Modifiers

& More! By Sandie Becker, CMC SCCMA Reimbursement Specialist QUESTION: If I add modifier 51 (multiple surgical procedures on same day) to my claims, should I reduce the procedure by 50%? ANSWER: If a service is subject to the multiple surgery guidelines, Medicare and most payers are set up to automatically reduce the payment for the lesser fee schedule allowance procedure by 50%. You would not want to submit your claim with a reduced fee, as it will be reduced again and paid at a much lower rate than you are entitled. QUESTION: What is the difference between the 53 and 74 modifiers? ANSWER: The 53 modifier is used to identify a procedure that has begun, but must be terminated for some reason by the surgeon. The 74 modifier is used by the surgical center to identify a procedure terminated after anesthesia has begun. QUESTION: Would you use the modifier 78 (return to operating room for a related service, post-operative) when a patient had cataracts on the left eye and returns within 10 days to do the right? ANSWER: In this case, you would use the 79 modifier because it is an unrelated procedure by the same physician, post-operative. Note: the use of the RT and LT modifiers is useful and should be used following modifier 79. QUESTION: Could you go over the percentage of payment for a surgeon, assistant surgeon, and physician’s assistant assisting at surgery? ANSWER: The surgeon will be allowed at 100% of the physician’s fee schedule. Physicians assisting at surgery are allowed 16% of the fee schedule. Physician assistants assisting at surgery are allowed 85% of the 16% of the fee schedule. QUESTION: How would we bill unlisted procedures? Is there a specific modifier? ANSWER: You would use the unlisted procedure code from the correct section of the CPT book and list the description in item 19 of the CMS 1500 form or the electronic equivalent. There is no modifier for

unlisted procedures and you must submit a report in order for the insurance carrier to determine appropriate payment. (See more on billing unlisted procedures in the July/ August 2008 Bulletin.) QUESTION: A physician is seeing a patient in the office for a follow-up on a 90-day procedure and the patient has developed a seroma that he decides to treat in the office. This is not considered part of the surgical procedure recovery. What would we use for the modifier? ANSWER: If the service is not related to the original surgical procedure, then you would use a modifier 24 for the E&M code, if you perform a significant and separately identifiable service over and above what you would do for post-operative follow-up. The medical record must support the level of care provided to identify and determine treatment for the seroma. If the seroma is incised and drained, then the correct procedure code and modifier 79 must be used to reflect that it is unrelated to the original surgical procedure. QUESTION: When billing for three surgeons— one primary surgeon and two assistant surgeons—the second assistant surgeon is always denied as duplicate, even with separate dollar amounts and claims. Is this correct? ANSWER: If you are billing electronically, you may indicate in the comments field that this billing is for the second assistant surgeon. If billing on paper, you may submit a report indicating two assistant surgeons were used. If it is medically necessary to have two assistant surgeons for the procedure, and the second service is denied, you need to go through the redetermination process. Be sure to submit documentation to support the need for multiple assistant surgeons. QUESTION: Does the assistant surgeon maintain separate medical record documentation from the surgeon? ANSWER: The surgeon must describe the service provided by the assistant in the surgical operative report. You should obtain a copy from the surgeon for your records.

Would you like to receive updated coding & reimbursement news by email? If so, please call the SCCMA office to provide your email address at: 408/998-8850 ext. 3007 or email: sandie@ sccma.org. You may also visit our website at: www.sccma.org.

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NEWS FROM THE CEO

Physicians Speak With Unity…

and Win!

By William C. Parrish, Jr. SCCMA CEO

•

Extends the Physician Quality Reporting Initiative for two years with a 2% bonus.

When someone asks me, “What’s organized medicine done for me lately?,” my response is quick, clear, and decisive – we waged a huge political fight with the federal government, and won! Then, we continued to fight to kill the President’s veto! As you know, through the extensive efforts of organized medicine (AMA, CMA, and SCCMA), Congress agreed to pass HR 6331, the “Medicare Improvements for Patients and Providers Act of 2008,” which does the following:

•

Mental health service increase of 5% from July 1, 2008–2009.

•

Teaching anesthesiologists receive 100% payment for concurrent cases in 2010.

•

Extends the exceptions process for therapy caps through 2009.

•

Allows independent labs to bill for pathology services provided to hospital patients–2009.

•

Provides 2% bonus in 2009–2010 for physicians who electronically prescribe. Bonus is 1% in 2011–2012, 0.5% in 2013. Penalties for not e-prescribing: -1% in 2012, -1.5% in 2013, -2% in 2014 and beyond. Some exceptions apply.

•

Provides an 18-month Medicare physician payment fix to give Congress time to develop and enact a long-term payment system reform.

•

Requires physicians that furnish advanced diagnostic imaging services to meet Medicare accreditation standards by 2012.

•

Retroactively stops the 10.6% payment cut effective July 1, 2008. Continues the 0.5% payment update through 2008.

•

Stops the 5.4% payment cut effective January 1, 2009 and provides a 1.1% update.

Extends the accommodation for physicians ordered to active duty in the armed services, so they can engage in substitute billing arrangements for >60 days.

•

Because of the sustainable growth rate (SGR), physician cut in 2010 is 20%. Yet a Medicare Improvement Fund of $20 billion was established for use in 2014 for long-term payment reform.

Delays the Durable Medical Equipment (DMEPOS) competitive bidding program for 18 months and replaces it with reduced payments for DME. Exempts physician suppliers of DMEPOS from DME accreditation.

•

Many beneficiary improvements include coverage expansions for preventive services, cardiac and pulmonary rehabilitation, and benzodiazepines and barbiturates for Part D; an increase in the asset limit to qualify for the Part D (Prescription Drug) low-income subsidy and reductions in co-pays for mental health services to same level as other outpatient services (20%). Also allows the same Part B standard for offlabel drug coverage under Part D.

•

Primary care service increases of -1% (depending on the service, but including office and hospital visits) will begin in 2009 by applying the relative value unit (RVU) changes to the conversion factor, instead of the work relative values.

•

Provides funding and expansion of the Medicare Medical Home Demonstration Projects to help physicians better manage and

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coordinate patient care.

Organized Medicine— “This big dog will fight, when you rattle its cage”

NEWS FROM THE CEO HR 6331 is funded through reforms to the Medicare Advantage (MA) program: •

Phases out duplicative Indirect Medical Education (IME) payments to health plans that the hospitals already receive ($7.5 billion in savings over five years; $200 million in California).

•

Requires the Medicare Advantage Private Fee-for-Service (PFFS) plans to meet the same quality, marketing, and contracting requirements that all MA plans must meet.

•

Establishes tough marketing regulation to end abuse in California. Eliminates the ability of PFFS plans to “deem” physicians contracted without a physician’s consent ($4.5 billion in savings over five years).

A great victory? Yes. However, the biggest victory was experiencing

the power of unity. This sends a message to all players that organized physicians are a force to be reckoned with for all future battles. “This big dog will fight, when you rattle his cage.” Let this victory be a rallying cry. Let’s keep this power rolling. Clearly, this could not have happened without an organized effort. Just imagine what we could do if we were bigger, stronger, together. As every physician benefited from our efforts, I think its time for them to get off the bench and join the game. Don’t you? Share the word, take your credit, and ask your non-member colleagues to join the fight. The future is in our hands. How do we want to play it? Your “cage” has been rattled way too much! It’s time to fight for your patients and your profession. The health of the nation depends on it! Unite.

Thank You for Your Support

Thank you to the following 2008 CALPAC and SACPAC supporters! With your help, our voice will be heard in the Legislature and in the local political arena. CALPAC President’s Circle Martin L Fishman, MD James G Hinsdale, MD Edmundo Marroquin CALPAC 300 Club Arthur A Basham, MD Scott W Benninghoven, MD Rajan Bhandari, MD Kenneth S Blumenfeld, MD David H Campen, MD Jeffrey D Coe, MD Len Doberne, MD Kristina G Hobson, MD Michele E Raney, MD Lee Shahinian, Jr., MD Mark A Singleton, MD CALPAC Alliance & 300 Club Suzanne Jackson Debbi Ricks Siggie Stillman CALPAC Alliance Members Jean Cassetta Mary Hayashi Carolyn Miller CALPAC Sustaining Members Salwan S Abiezzi, MD Georgia K Abrams, MD A Richard Adrouny, MD Jeffrey J Anderson, MD Todd S Anhalt, MD Krikor Barsoumian, MD David A Berman, MD George Block, MD Edwin E Boldrey, MD Kristine A Borrison, MD Burt D Brent, MD Romualdas V Brizgys, MD William G Brose, MD Sara J Bunting, MD Hernan H Casanovas, MD

Michael T Charney, MD Richard S Cherlin, MD James R Cohen, MD Sara L Colby, MD Matthew W Cook, MD Eugene D Della Maggiore, Jr., MD Frederick C Delse, MD Michael S Denenberg, MD Morteza Dowlatshahi, MD Christine A Doyle, MD Richard S Eng, MD Stanley E Fischman, MD Christian Foglar, MD Brandt A Foreman, MD Frank C Galli, MD Patrick F Gartland, MD David P Ghilarducci, MD Shahram S Gholami, MD Robert M Gould, MD Robert S Gould, MD Stafford R Grady, Jr., MD Ronald S Greenwald, MD Philip A Grossi, MD B Thomas Hafkenschiel, MD Maury K Harwood, MD Roger M Hayashi, MD Paul F Hoar, MD Barbara M Hom, MD Duke T Khuu, MD Francis H Koch, MD Stuart E Krigel, MD Michael Lam, MD Peter S Levin, MD Zena A Levine, MD David M Lewis, MD William S Lewis, MD Sian R Lindsay, MD Edward C Littlejohn, MD Christine A Litwin-Sanguinetti, MD William A Martin, MD Daniel B Martinez, MD Eleanor M Martinez, MD

Robert J Marx, MD Joseph E Mason, Jr., MD Robert S Mastman, MD Jennifer Maw, MD Reginald V McCoy, MD Marjorie F McCracken, MD Andrew B Menkes, MD Prasanna Menon, MD Martin B Miller, MD Richard L Miller, MD Greg S Morganroth, MD Michael R Nagel, MD Suresh R Nayak, MD Lionel M Nelson, MD Vinh Q Nguyen, MD F Richard Noodleman, MD Narciso T Padua, MD Samuel N Pearl, MD Dennis I Penner, MD Kenneth T Phan, MD Rebecca A Powers, MD William B Ricks, MD Beth Robie, MD Marshal D Rosario, MD Howard L Rosenberg, MD Regina L Rosenthal, MD Ronald M Rossen, MD Jude T Roussere, MD Franklin A Rumore, MD Harmeet S Sachdev, MD Bassam G Saffouri, MD Hamed Sajjadi, MD Randall E Seago, MD Jack S Siegel, MD Mark A Snyder, MD Susan K Sorensen, MD Tanya W Spirtos, MD Philip C Stillman, MD Kevin D Stuart, MD R Lawrence Sullivan, Jr., MD Katherine K Sutherland, MD Connie T Tan, MD Jafar Tay, MD Ernest M Thomas, Jr., MD

Khanh C Tran, MD Huy N Trinh, MD Hugh G Walsh, MD William Waterfield, Jr., MD Gerald A Weiss, MD Patrick E Wherry, MD Susan M Wilturner, MD John M Wortley, MD David D Yeh, MD SACPAC Emil A Anaya, MD Arthur A Basham, MD David A Berman, MD Patrick H Bitter, Jr., MD Barry D Brummer, MD Emiro Burbano, MD Michael Charney, MD Richard Cherlin, MD Rodney D Clark, MD Kimberly P Cockerham, MD Anne Cole, MD James J Davilla, MD Len Doberne, MD Christine A Doyle, MD Stanley E Fischman, MD Martin L Fishman, MD Christian Foglar, MD Brandt A Foreman, MD Susan Gould, MD Stafford R Grady, Jr., MD Ronald S Greenwald, MD Maury K Harwood, MD Jerome E Hester, MD Barbara Hom, MD Seung K Kim, MD Francis H Koch, MD Andrew J Lan, MD Richard D Lee, MD Zena A Levine, MD William S Lewis, MD Edward C Littlejohn, MD William A Martin, MD

Eleanor Martinez, MD Robert J Marx, MD Jennifer Maw, MD Marjorie Mc Cracken, MD Andrew B Menkes, MD Prasanna Menon, MD Kenneth A Miller, MD Martin B Miller, MD Keshav Narain, MD Suresh R Nayak, MD Narciso T Padua, MD Samuel N Pearl, MD Dennis I Penner, MD Kenneth T Phan, MD Angela M Pollard, MD Nelson B Powell, MD Rebecca A Powers, MD Richard Powers, MD Bernard Recht, MD William B Ricks, MD Marshal D Rosario, MD Deborah S Rose, MD Regina L Rosenthal, MD Ronald M Rossen, MD Jude T Roussere, MD Frank A Rumore, MD Bassam Saffouri, MD Randall E Seago, MD Jan Segnitz, MD Kathryn A Shade, MD Mark A Snyder, MD Tanya W Spirtos, MD Philip C Stillman, MD R Lawrence Sullivan, Jr., MD Joseph D Toscano, MD Khanh C Tran, MD Hugh G Walsh, MD William Waterfield, Jr., MD Gerald A Weiss, MD Susan M Wilturner, MD Elizabeth Wu, MD Takashi Yoshida, MD

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SEPTEMBER / OCTOBER 2008

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SEPTEMBER / OCTOBER 2008

NEWS ALERTS! Don’t Get Stuck With Your Sharps—Dispose of Them Properly As of September 1, 2008, Senate Bill 1305 will take effect,

The Countywide Household

prohibiting a person from placing home-generated sharps in their

Hazardous Waste (HHW) Program

trash or recycling container. Home-generated sharps are defined

also accepts home-generated sharps,

as disposable hypodermic needles, syringes, lancets, and other

pharmaceuticals (no controlled

medical devices used for self-injection or blood test. Sanitation

substances), and other household

workers, adults, children, and even pets are at risk of needle-stick

hazardous waste from Santa Clara

injuries, when sharps are disposed of improperly. To safely dispose

County residents (except Palo Alto

of your used home-generated sharps, place them in a commercial

residents). For more information,

biohazard sharps container and contact your pharmacist, clinic

please visit the Household Hazardous

administrator, or personal physician, and ask if they have a “take

Waste Program’s website at

back” program. If you purchase sharps on-line, please remember

www.hhw.org or call

to request a pre-addressed, prepaid mail-back box for your used

408/299-7300.

sharps.

Free Treatment Studies at Stanford • Treatment for Adults Aged 16 and Over for Anorexia • Treatment for Adolescents With Bulimia For further information, visit the website: www.edrcsv.org or contact Judy Beenhakker at 650/723-7885; email: judybeen@stanford.edu.

When you have questions about eating disorders...

Eating Disorders Resource Center Medical education (CMEs) for you and your staff to help you address the needs of patients with eating disorders Advocacy for insurance issues Professionally-facilitated support groups for your patients and their family members (no fee; twice a month)

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Awareness, Recovery, Advocacy www.edrcsv.org 408-559-5593

An online and printed directory of local professionals who specialize in treating anorexia, bulimia, and other eating disorders. Our website provides useful links and information for patients

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SEPTEMBER / OCTOBER 2008

ELECTION 2008 SPECIAL

JohnMcCain.com John McCain

Straight Talk on Health System Reform   A “Call to Action”

Those obtaining innovative insurance that costs less than the credit

John McCain believes we can and must provide access to health care for every American. He has proposed a comprehensive vision for achieving that. For too long, our nation’s leaders have talked about reforming health care. Now is the time to act.

can deposit the remainder in expanded Health Savings Accounts.

Americans are worried about health care costs. The problems with health care are well known: it is too expensive and 47 million people living in the United States lack health insurance.

John McCain’s Vision for Health Care Reform    John McCain believes the key to health care reform is to restore control to the patients themselves. We want a system of health care in which everyone can afford and acquire the treatment and preventative care they need. Health care should be available to all and not limited by where you work or how much you make. Families should be in charge of their health care dollars and have more control over care.

Making Health Insurance Innovative, Portable, and Affordable   John McCain will reform health care making it easier for individuals and families to obtain insurance. An important part of his plan is to use competition to improve the quality of health insurance with greater variety to match people’s needs, lower prices, and portability. Families should be able to purchase health insurance nationwide, across state lines.   John McCain will reform the tax code to offer more choices beyond employer-based health insurance coverage. While still having the option of employer-based coverage, every family will receive a direct refundable tax credit —effectively cash—of $2,500 for individuals and $5,000 for families to offset the cost of insurance. Families will be able to choose the insurance provider that suits them best and the money would be sent directly to the insurance provider.

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SEPTEMBER / OCTOBER 2008

John McCain proposes making insurance more portable. Americans need insurance that follows them from job to job. They want insurance that is still there if they retire early and does not change if they take a few years off to raise the kids.  John McCain will encourage and expand the benefits of Health Savings Accounts (HSAs) for families. When families are informed about medical choices, they are more capable of making their own decisions and often decide against unnecessary options. Health Savings Accounts take an important step in the direction of putting families in charge of what they pay for.

A Specific Plan of Action: Ensuring Care for Higher Risk Patients    John McCain’s plan cares for the traditionally uninsurable. John McCain understands that those without prior group coverage and those with pre-existing conditions have the most difficulty on the individual market, and we need to make sure they get the highquality coverage they need.   John McCain will work with states to establish a Guaranteed Access Plan. As President, John McCain will work with governors to develop a best practice model that states can follow—a Guaranteed Access Plan or GAP—that would reflect the best experience of the states to ensure these patients have access to health coverage. One approach would establish a nonprofit corporation that would contract with insurers to cover patients who have been denied insurance and could join with other state plans to enlarge pools and lower overhead costs. There would be reasonable limits on premiums, and assistance would be available for Americans below a certain income level.  John McCain will promote proper incentives. John McCain will work with Congress, the governors, and industry to make sure this approach is funded adequately and has the right incentives to reduce

ELECTION 2008 SPECIAL costs such as disease management, individual case management, and

availability, we can improve lives and reduce chronic disease through

health and wellness programs.

smoking cessation programs.

A Specific Plan of Action: Lowering Health Care Costs

STATE FLEXIBILITY: Encouraging states to lower costs. States

John McCain proposes a number of initiatives that can lower

should have the flexibility to experiment with alternative forms of

health care costs. If we act today, we can lower health care costs

access, coordinated payments per episode covered under Medicaid,

for families through common-sense initiatives. Within a decade,

use of private insurance in Medicaid, alternative insurance policies,

health spending will comprise 20% of our economy. This is taking

and different licensing schemes for providers.

an increasing toll on America’s families and small businesses. Even Senators Clinton and Obama recognize the pressure skyrocketing

TORT REFORM: Passing medical liability reform. We must pass

health costs place on small business when they exempt small

medical liability reform that eliminates lawsuits directed at doctors

businesses from their employer mandate plans.

who follow clinical guidelines and adhere to safety protocols. Every patient should have access to legal remedies in cases of bad medical

CHEAPER DRUGS: Lowering drug prices. John McCain will look

practice, but that should not be an invitation to endless, frivolous

to bring greater competition to our drug markets through safe re-

lawsuits.

importation of drugs and faster introduction of generic drugs.   TRANSPARENCY: Bringing transparency to health care CHRONIC DISEASE: Providing quality, cheaper care for

costs. We must make public more information on treatment options

chronic disease. Chronic conditions account for three-quarters of

and doctor records, and require transparency regarding medical

the nation’s annual health care bill. By emphasizing prevention, early

outcomes, quality of care, costs, and prices. We must also facilitate

intervention, healthy habits, new treatment models, new public health

the development of national standards for measuring and recording

infrastructure, and the use of information technology, we can reduce

treatments and outcomes.

health care costs. We should dedicate more federal research to caring and curing chronic disease.

Confronting the Long-Term Challenge    John McCain will develop a strategy for meeting the challenge

COORDINATED CARE: Promoting coordinated care.

of a population needing greater long-term care. There have

Coordinated care—with providers collaborating to produce the best

been a variety of state-based experiments such as Cash and

health care—offers better outcomes at lower cost. We should pay a

Counseling or The Program of All-Inclusive Care for the Elderly

single bill for high-quality disease care which will make every single

(PACE) that are pioneering approaches for delivering care to people

provider accountable and responsive to the patients’ needs.

in a home setting. Seniors are given a monthly stipend which they can use to hire workers and purchase care-related services

GREATER ACCESS AND CONVENIENCE: Expanding access to

and goods. They can get help managing their care by designating

health care. Families place a high value on quickly getting simple

representatives, such as relatives or friends, to help make decisions. It

care. Government should promote greater access through walk-in

also offers counseling and bookkeeping services to assist consumers

clinics in retail outlets.

in handling their programmatic responsibilities.

INFORMATION TECHNOLOGY: Greater use of information technology to reduce costs. We should promote the rapid

Setting the Record Straight: Covering Those With PreExisting Conditions

deployment of 21st century information systems and technology that

MYTH: Some claim that under John McCain’s plan, those with pre-

allows doctors to practice across state lines.

existing conditions would be denied insurance.

MEDICAID AND MEDICARE: Reforming the payment system

FACT: John McCain supported the Health Insurance Portability and

to cut costs. We must reform the payment systems in Medicaid and

Accountability Act in 1996 that took the important step of providing

Medicare to compensate providers for diagnosis, prevention, and care

some protection against exclusion of pre-existing conditions.

coordination. Medicaid and Medicare should not pay for preventable medical errors or mismanagement.

FACT: Nothing in John McCain’s plan changes the fact that if you are employed and insured, you will build protection against the cost of

SMOKING: Promoting the availability of smoking cessation

any pre-existing condition.

programs. Most smokers would love to quit, but find it hard to do so. Working with business and insurance companies to promote

FACT: As President, John McCain would work with governors

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SEPTEMBER / OCTOBER 2008

�

ELECTION 2008 SPECIAL

John McCain: Straight Talk on Health System Reform, from page 11 to find the solutions necessary to ensure those with pre-existing

based interventions, and create autism Centers of Excellence for

conditions are able to easily access care.

Autism Spectrum Disorder Research and Epidemiology. John McCain understands that despite the federal and scientific research efforts

Combating Autism in America

to date, the exact causes of autism are not yet known and greater

John McCain is very concerned about the rising incidence of autism

research is needed to understand this disorder. That is why in

among America’s children and has continually supported research

November 2007, he joined with Senator Lieberman in requesting

into its causes and treatment. He has heard countless stories about

the leadership of the Senate Health, Education, Labor and Pensions

families’ hardships obtaining a diagnosis for their children’s autism

Committee, which has jurisdiction over federal research into autism,

and accessing quality medical treatment. He believes that federal

to hold a hearing on federal research efforts regarding factors

research efforts should support broad approaches to understanding

affecting incidence and treatment, in order to help determine where

the factors that may play a role in the incidence of autism, including

research efforts can best be directed. As President, John McCain

factors in our environment, for both prevention and treatment

will work to advance federal research into autism, promote early

purposes.

screening, and identify better treatment options, while providing support for children with autism, so that they may reach their full

John McCain was proud to lend his support to the Combating

potential.

Autism Act of 2006, which he cosponsored, and worked to ensure its enactment. This law is helping to increase public awareness and

Source: http://www.johnmccain.com/Informing/Issues/19ba2f1c-c03f-

screening of autism spectrum disorder, promote the use of evidence-

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SEPTEMBER / OCTOBER 2008

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ELECTION 2008 SPECIAL

BarackObama.com Barack Obama

Barack Obama’s Plan for a Healthy America: Lowering Health Care Costs and Ensuring Affordable, High-Quality Health Care for All The U.S. spends over $2 trillion on medical care every year, and offers the best medical technology in the world.1 Americans have their choice of top doctors and hospitals, and our national investment in scientific research has paid off handsomely. Diseases that were once life-threatening are now curable; conditions that once devastated are now treatable. Yet, the benefits of the American health care system come at a price that an increasing number of individuals and families, employers and employees, and public and private providers cannot afford.

billion every year.9 One-quarter of all medical spending goes to administrative and overhead costs and reliance on antiquated paperbased record and information systems needlessly increases these costs.10 Underinvestment in prevention and public health. Too many Americans go without high-value preventive services, such as cancer screening and immunizations to protect against flu or pneumonia. Providers are not adequately reimbursed for helping patients manage chronic illnesses like diabetes or asthma.11 Similarly, communitybased prevention efforts, which have helped to drive down rates of smoking and lead poisoning, for example, are under-utilized despite

Millions of Americans are uninsured or underinsured because

their effectiveness. The nation faces epidemics of obesity and chronic

of rising medical costs. Nearly 47 million Americans2—including

diseases, as well as new threats of pandemic flu and bioterrorism.

9 million children3 —lack health insurance. Eighty percent of the

Yet despite all of this, less than 4 cents of every health care dollar

uninsured are in working families.4 Even those with health coverage

is spent on prevention and public health.12 Our health care system

are struggling to cope with soaring medical costs. Skyrocketing

has become a disease care system, and the time for change is well

health care costs are making it increasingly difficult for employers,

overdue.

particularly small businesses, to provide health insurance to their employees.

BARACK OBAMA’S PLAN FOR A HEALTHY AMERICA Barack Obama believes, when it comes to health care, America can

Health care costs are skyrocketing. Health insurance premiums

and must do better. In the absence of national leadership, states have

have risen four times faster than wages in the past six years, and

been leading the way with health care reforms that lower costs and

increasing co-pays and deductibles threaten access to care.5 Many

provide coverage for all. Obama has a three-part plan to build upon

insurance plans cover only a limited number of doctors’ visits or

the strengths of the U.S. health care system, including innovative

hospital days, exposing families to unlimited financial liability.

state efforts, and address its glaring weaknesses, such as affordability.

Nearly 11 million insured spent more than a quarter of their salary

Through partnerships among federal and state governments,

on health care last year.6 And over half of all personal bankruptcies

employers, providers and individuals, the Obama plan will save

today are caused by medical bills.7 Lack of affordable health care is

a typical American family up to $2,500 every year on medical

compounded by serious flaws in our health care delivery system.

expenditures by:

About 100,000 Americans die from medical errors in hospitals every

1. Providing affordable, comprehensive, and portable health

year.8 Prescription drug errors alone cost the nation more than $100

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SEPTEMBER / OCTOBER 2008

coverage for every American;

ELECTION 2008 SPECIAL 2. Modernizing the U.S. health care system to contain spiraling

public insurance program, available to Americans who neither qualify

health care costs and improve the quality of patient care; and

for Medicaid or SCHIP nor have access to insurance through their

3. Promoting prevention and strengthening public health, to

employers, as well as to small businesses that want to offer insurance

prevent disease and protect against natural and man-made

to their employees; (2) create a National Health Insurance Exchange

disasters.

to help Americans and businesses that want to purchase private health insurance directly; (3) require all employers to contribute

Under the Obama plan, the typical family will save up to $2,500

towards health coverage for their employees or towards the cost of

every year through:

the public plan; (4) mandate all children have health care coverage; (5) expand eligibility for the Medicaid and SCHIP programs; and

Under the Obama plan, the typical family will save up to $2,500 every year through:

(6) allow flexibility for state health reform plans.

•

Health IT investment, which will reduce unnecessary

(1) OBAMA’S PLAN TO COVER THE UNINSURED. Obama will

spending in the system that results from preventable errors

make available a new national health plan which will give individuals

and inefficient paper billing systems;

the choice to buy affordable health coverage that is similar to the

Improving prevention and management of chronic

plan available to federal employees. The new public plan will be

conditions;

open to individuals without access to group coverage through their

Increasing insurance industry competition and reducing

workplace or current public programs. It will also be available to

underwriting costs and profits, which will reduce insurance

people who are self-employed and small businesses that want to offer

overhead;

insurance to their employees.

• •

Providing reinsurance for catastrophic coverage, which will reduce insurance premiums; and

The plan will have the following features:

Making health insurance universal, which will reduce

•

spending on uncompensated care.

Guaranteed eligibility. No American will be turned away FROM ANY INSURANCE PLAN because of illness or pre-existing conditions.

•

Comprehensive benefits. The benefit package will be similar

QUALITY, AFFORDABLE & PORTABLE HEALTH COVERAGE FOR ALL

to that offered through the Federal Employees Health Benefits

Barack Obama believes that every American has the right to

Congress get their own health care. The new public plan will

affordable, comprehensive, and portable health coverage. Currently,

include coverage of all essential medical services, including

Program (FEHBP), the program through which members of

there are nearly 47 million Americans lacking health insurance, and

preventive, maternity, and mental health care. Coverage will

millions more are at risk of losing their coverage due to rising costs.

include disease management programs, self management

Rising costs are also a burden on employers, particularly small

training, and care coordination for appropriate individuals.

businesses, which are increasingly unable to provide health insurance

•

coverage for their employees and remain competitive. Three million

Participants will be charged fair premiums and minimal co-pays

fewer Americans receive health insurance coverage through their employers now, compared to five years ago,14 and this trend shows no

Affordable premiums, co-pays, and deductibles. for deductibles for preventive services.

•

Subsidies. Individuals and families who do not qualify for

sign of slowing down. It is simply too expensive for individuals and

Medicaid or SCHIP, but still need assistance, will receive income-

families to buy insurance directly on the open market and impossible

related federal subsidies to keep health insurance premiums

for many with pre-existing conditions.

affordable. They can use the subsidy to buy into the new public plan or purchase a private health care plan.

The Obama plan will guarantee coverage for every American through

•

partnerships among employers, private health plans, the federal

plan will simplify paperwork for providers and will increase

government, and the states. The plan both builds on and improves our current insurance system, which most Americans continue to rely

savings to the system overall. •

upon, and leaves Medicare intact for older and disabled Americans. Under the Obama plan, Americans will be able to maintain their

Simplifying paperwork and reining in health costs. The

Easy enrollment. The new public plan will be simple to enroll in and provide ready access to coverage.

•

Portability and choice. Participants in the new public plan and

current coverage if they choose to, and will see the quality of their

the National Health Insurance Exchange (see below) will be able

health care improve and their costs go down. The Obama plan also

to move from job to job without changing or jeopardizing their

addresses the large gaps in coverage that leave 47 million Americans uninsured. Specifically, the Obama plan will: (1) establish a new

health care coverage. •

Quality and efficiency. Participating hospitals and

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ELECTION 2008 SPECIAL

Barack Obama’s Plan For A Healthy America, from page 15 providers that participate in the new public plan will be for health care quality, health information technology, and

MODERNIZING THE U.S. HEALTH CARE SYSTEM TO LOWER COSTS & IMPROVE QUALITY

administration are being met.

Health care spending is expected to double within the next decade.15

required to collect and report data to ensure that standards

Though Americans spend almost twice as much per person as (2) NATIONAL HEALTH INSURANCE EXCHANGE. To provide

citizens of other industrialized countries,16 their health status is no

Americans with additional options, the Obama plan will make

better and by many measures actually worse. Americans die younger,

available a National Health Insurance Exchange to help individuals

and their newborns die more frequently than in other developed

who wish to purchase a private insurance plan. The Exchange will

nations.17

act as a watchdog and help reform the private insurance market by creating rules and standards for participating insurance plans to

Inefficient and poor quality care costs the nation at least $50 to

ensure fairness and to make individual coverage more affordable

$100 billion every year.18 Billions more are wasted on administration

and accessible. Through the Exchange, any American will have

and overhead because of inefficiencies in the health care system.19

the opportunity to enroll in the new public plan or purchase an

America has the best health care technology in the world, but it is

approved private plan, and income-based sliding scale subsidies will

often not used well, and due to varying practices, it is often wasted.

be provided for people and families who need it. Insurers would

A growing body of research points to substantial opportunities to

have to issue every applicant a policy, and charge fair and stable

improve quality while reducing the costs of care. Some researchers

premiums that will not depend upon health status. The Exchange

estimate that as much as 30% of health care is not contributing

will require that all the plans offered are at least as generous as

materially to patient outcomes.20 Health care systems in many

the new public plan and meet the same standards for quality and

parts of the country deliver high quality care to the populations

efficiency. Insurers would be required to justify an above-average

they serve at half of the costs of other equally renowned academic

premium increase to the Exchange. The Exchange would evaluate

medical centers in other parts of the country.21 The key is to provide

plans and make the differences among the plans, including cost of

information, incentives, and support to help physicians and others

services, transparent.

work together to improve quality while reducing costs. Barack Obama believes we must dramatically redesign our health

(3) EMPLOYER CONTRIBUTION. Employers that do not offer

system to reduce inefficiency and waste and improve health care

meaningful coverage or make a meaningful contribution to the cost

quality, which will drive down costs for families and individuals. The

of quality health coverage for their employees will be required to

Obama plan will improve efficiency and lower costs in the health

contribute a percentage of payroll toward the costs of the national

care system by: (1) offering federal reinsurance to employers to help

plan.

ensure that unexpected or catastrophic illnesses do not make health insurance unaffordable or out of reach for businesses and their

(4) MANDATORY COVERAGE OF CHILDREN. Obama will

employees; (2) ensuring that patients receive and providers deliver

require that all children have health care coverage. Obama will

the best possible care; (3) adopting state-of-the-art health information

expand the number of options for young adults to get coverage by

technology systems; and (4) reforming our market structure to

allowing young people up to age 25 to continue coverage through

increase competition.

their parents’ plans. (1) REDUCING COSTS OF CATASTROPHIC ILLNESSES FOR (5) EXPANSION OF MEDICAID AND SCHIP. Obama will

EMPLOYERS AND THEIR EMPLOYEES. Catastrophic health

expand eligibility for the Medicaid and SCHIP programs and ensure

expenditures account for a high percentage of medical expenses for

that these programs continue to serve their critical safety net

private insurers.22 In fact, the most recent data available reveals that

function.

the top 5% of people with the greatest health care expenses in the U.S. spent 49% of the overall health care dollar.23 For small businesses,

(6) FLEXIBILITY FOR STATE PLANS. Due to federal inaction,

having a single employee with catastrophic expenditures can make

some states have taken the lead in health care reform. These efforts

insurance unaffordable to all of the workers in the firm. The Obama

are laudable and are helping to lead the way toward meaningful

plan would reimburse employer health plans for a portion of the

health care reform. The Obama plan is a national one that builds on

catastrophic costs they incur above a threshold, if they guarantee such

these efforts, and it will not replace what states are doing. Indeed,

savings are used to reduce the cost of workers’ premiums. Offsetting

states can continue to experiment, provided they meet the minimum

some of the catastrophic costs would make health care more

standards of the national plan.

affordable for employers, workers, and their families.

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SEPTEMBER / OCTOBER 2008

ELECTION 2008 SPECIAL Obama will accelerate efforts to develop and disseminate best (2) LOWERING COSTS BY ENSURING PATIENTS RECEIVE

practices, and align reimbursement with provision of high

AND PROVIDERS DELIVER QUALITY CARE. Experts agree

quality health care. Providers who see patients enrolled in

that several steps should be taken immediately to help patients get

the new public plan, the National Health Insurance Exchange,

the care they need and to help providers improve medical practice.

Medicare, and FEHB will be rewarded for achieving performance

Obama will expand and support these and other efforts to lower

thresholds on physician-validated outcome measures. •

costs and improve health outcomes.

Comparative effectiveness reviews and research. The U.S. provides some of the best health care and most sophisticated

HELPING PATIENTS

medical technologies in the world, but at a cost that is making

•

Support disease management programs. Over 75% of total

the effort to expand access to care ever more difficult. In order

health care dollars are spent on patients with one or more

to be able to provide health care coverage for all, we need to

chronic conditions, such as diabetes, heart disease, and high

deliver the same quality of care at much lower cost. This is

blood pressure.24 Many patients with chronic diseases benefit

possible because there is considerable waste in our health care

greatly from disease management programs, which help patients

system and, at the same time, we are failing to provide highly

manage their condition and get the care they need.25 Obama

effective services to patients who should have them. One of

will require that plans that participate in the new public plan,

the keys to eliminating waste and missed opportunities is to

Medicare, or the Federal Employee Health Benefits Program

increase our investment in comparative effectiveness reviews

(FEHBP) utilize proven disease management programs. This will

and research. Comparative effectiveness studies provide crucial

improve quality of care and lower costs, as well.

information about which drugs, devices, and procedures are the

Coordinate and integrate care. Rates of chronic diseases

best diagnostic and treatment options for individual patients.

have skyrocketed in the last two decades.26 Over 133 million

This information is developed by reviewing existing literature,

Americans have at least one chronic disease. With proper care,

analyzing electronic health care data, and conducting simple,

the onset and progression of these diseases can be contained

real world studies of new technologies. Obama will establish

for many years. In addition to the needless suffering and early

an independent institute to guide reviews and research on

death they cause, these chronic conditions cost a staggering $1.7

comparative effectiveness, so that Americans and their doctors

trillion yearly. More than half of Americans with serious chronic

will have accurate and objective information to make the best

conditions have three or more different physicians,29 leading to

decisions for their health and well-being.

•

duplicate testing, conflicting treatment advice, and prescription

•

Tackling disparities in health care. Although all Americans

drugs that are contraindicated. Obama will support providers to

are affected by problems with our health care delivery system,

put in place care management programs and encourage team

an overwhelming body of evidence demonstrates that certain

care through implementation of medical home type models, that

populations are significantly more likely to receive lower quality

will improve coordination and integration of care of those with

health care than others. Minority Americans are less likely to

chronic conditions.

receive early and timely health care for many conditions, such

Require full transparency about quality and costs. Health

as cancer, when such conditions could be treatable.32 Further,

care quality and costs can vary tremendously among hospitals

minority patients are less likely to receive recommended care

and providers; however, patients have limited access to this

that meets accepted standards of medical practice, which

information.30 Obama will require hospitals and providers to

similarly has a negative impact on health outcomes.33 Other

collect and publicly report measures of health care costs and

patient populations, including female34 and rural35 populations,

quality, including data on preventable medical errors, nurse

experience disparities in health care, as well. Obama will tackle

staffing ratios, hospital-acquired infections, and disparities in

the root causes of health disparities by addressing differences

care, and costs. Health plans will be required to disclose the

in access to health coverage and promoting prevention and

percentage of premiums that actually goes to paying for patient

public health (see below), both of which play a major role in

care as opposed to administrative costs.

addressing disparities. He will also challenge the medical system to eliminate inequities in health care by requiring hospitals and

ENSURING PROVIDERS DELIVER QUALITY CARE

health plans to collect, analyze, and report health care quality

•

Promoting patient safety. Obama will require providers to

for disparity populations and holding them accountable for

report preventable medical errors, and support hospital and

any differences found; diversifying the workforce to ensure

physician practice improvement to prevent future occurrences.

culturally effective care; implementing and funding evidence-

Aligning incentives for excellence. Both public and private

based interventions, such as patient navigator programs; and

insurers tend to pay providers based on the volume of services

supporting and expanding the capacity of safety-net

provided, rather than the quality or effectiveness of care.31

institutions, which provide a disproportionate amount of

•

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SEPTEMBER / OCTOBER 2008

�

ELECTION 2008 SPECIAL

Barack Obama’s Plan For A Healthy America, from page 17 •

care for underserved populations with inadequate funding and

reports that 95% of insurance markets in the United States are

technical resources.

highly concentrated41 and the number of insurers has fallen by

Reforming medical malpractice while preserving

just under 20% since 2000.42

patient rights. Increasing medical malpractice insurance

•

These changes were supposed to make the industry more

rates are making it harder for doctors to practice medicine36

efficient, but instead premiums have skyrocketed, increasing

and raising the costs of health care for everyone . Barack

over 87% over the past six years.43 Over the same time period,

Obama will strengthen antitrust laws to prevent insurers from

insurance administrative overhead has been the fastest-growing

overcharging physicians for their malpractice insurance. Obama

component of health spending. The 2007 Commonwealth Fund

will also promote new models for addressing physician errors

Commission on a High Performance Health System reported that

that improve patient safety, strengthen the doctor-patient

between 2000 and 2005, administrative overhead – including

relationship, and reduce the need for malpractice suits.

both administrative expenses and insurance industry profits –

increased 12.0% per year, 3.4 percentage points faster than the average health expenditure growth of 8.6%.44 (3) LOWERING COSTS THROUGH INVESTMENT IN

•

And while health care costs continue to rise for families, CEOs

ELECTRONIC HEALTH INFORMATION TECHNOLOGY

of these insurance companies have received multi-million dollar

SYSTEMS. Most medical records are still stored on paper, which

bonuses.45 Barack Obama will prevent companies from abusing

makes them difficult to use to coordinate care, measure quality, or

their monopoly power through unjustified price increases. In

reduce medical errors. Processing paper claims also costs twice as

markets where the insurance business is not competitive, his

much as processing electronic claims.38 Obama will invest $10 billion

plan will force insurers to pay out a reasonable share of their

a year over the next five years to move the U.S. health care system

premiums for patient care instead of keeping exorbitant amounts

to broad adoption of standards-based electronic health information

for profits and administration. Obama’s new National Health

systems, including electronic health records. He will also phase in requirements for full implementation of health IT and commit the

Insurance Exchange will help increase competition by insurers. •

Drug reimportation. The second-fastest growing type

necessary federal resources to make it happen. Obama will ensure

of health expenses is prescription drugs.46 Pharmaceutical

that these systems are developed in coordination with providers

companies should profit when their research and development

and frontline workers, including those in rural and underserved

results in a groundbreaking new drug. But some companies

areas. Obama will ensure that patients’ privacy is protected. A study

are exploiting Americans by dramatically overcharging U.S.

by the Rand Corporation found that if most hospitals and doctors

consumers. These companies are selling the exact same drugs in

offices adopted electronic health records, up to $77 billion of savings

Europe and Canada, but charging Americans a 67% premium.47

would be realized each year through improvements, such as reduced

Obama will allow Americans to buy their medicines from other

hospital stays, avoidance of duplicative and unnecessary testing,

developed countries, if the drugs are safe and prices are lower outside the U.S.

more appropriate drug utilization, and other efficiencies.

•

Increasing use of generics. Some drug manufacturers are

(4) LOWERING COSTS BY INCREASING COMPETITION

explicitly paying generic drug makers not to enter the market,

IN THE INSURANCE AND DRUG MARKETS. It is not right

so they can preserve their monopolies and keep charging

that American families are paying skyrocketing premiums, while

Americans exorbitant prices for brand name products.48 The

drug and insurance industries are enjoying record profits. These

Obama plan will work to ensure that market power does not

companies benefit most from the status quo, and in many cases,

lead to higher prices for consumers. His plan will work to

are the greatest obstacles to reform. The Obama plan will tackle

increase use of generic drugs in the new public plan, Medicare,

needless waste and spiraling costs by increasing competition in the

Medicaid, FEHBP and prohibit large drug companies from

insurance and drug markets.

keeping generics out of markets.

•

Increasing competition. The insurance business today is

•

Lowering Medicare prescription drug benefit costs.

dominated by a small group of large companies that has been

The 2003 Medicare Prescription Drug Improvement and

gobbling up their rivals. In recent years, for-profit companies

Modernization Act bans the government from negotiating down

have bought up not-for-profit insurers around the country. Other

the prices of prescription drugs, even though the Department

not-for-profits found business so lucrative, they converted to for-

of Veterans Affairs’ negotiation of prescription drug prices with

profit companies. There have been over 400 health care mergers

pharmaceutical companies has garnered significant savings for

in the last 10 years, and just two companies dominate a full

taxpayers.49 Obama will repeal the ban on direct negotiation

third of the national market.40 The American Medical Association

with drug companies and use the resulting savings, which could

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SEPTEMBER / OCTOBER 2008

ELECTION 2008 SPECIAL be as high as $30 billion,50 to further invest in improving health •

care coverage and quality.

(1) EMPLOYERS. Reduced workforce productivity from illness and

Preventing waste and abuse in Medicare. Medicare’s private

disability represents an additional drain on business. To address

plan alternative, called Medicare Advantage, was established

employee health, an increasing number of employers are offering

to increase competition and reduce costs. But independent

worksite health promotion programs, onsite clinical preventive

reports show that on average the government pays 12% more

services, such as flu vaccinations, nutritious foods in their cafeterias

than it costs to treat comparable beneficiaries through traditional

and vending machines, and exercise facilities. Equally important,

Medicare. These excessive subsidies cost the government

many employers choose insurance plans that cover preventive

billions of dollars every year and create an incentive structure

services for their employees. Barack Obama believes that worksite

that has led to fraudulent abuses of seniors. Obama believes we

interventions hold tremendous potential to influence health and will

need to eliminate the excessive subsidies to Medicare Advantage

expand and reward these efforts.

plans and pay them the same amount it would cost to treat the same patients under regular Medicare.

(2) SCHOOL SYSTEMS. A generation ago, nearly half of all schoolaged children walked or biked to school.56 Today, nearly nine out

PROMOTING PREVENTION & STRENGTHENING PUBLIC HEALTH

of ten children are driven to school.57 And once there, children are

Covering the uninsured and modernizing America’s health care

not very physically active—only 8% of elementary schools require

system are urgent priorities, but they are not enough. Simply put, in

daily physical education.58 Childhood obesity is nearly epidemic,59

the absence of a radical shift towards prevention and public health,

particularly among minority populations,60 and school systems can

we will not be successful in containing medical costs or improving

play an important role in tackling this issue. For example, only

the health of the American people.

about a quarter of schools adhere to nutritional standards for fat content in school lunches.61 Obama will work with schools to create

This nation is facing a true epidemic of chronic disease. An

more healthful environments for children, including assistance

increasing number of Americans are suffering and dying needlessly

with contract policy development for local vendors, grant support

from diseases, such as obesity, diabetes, heart disease, asthma and,

for school-based health screening programs and clinical services,

HIV/AIDS, all of which can be delayed in onset, if not prevented

increased financial support for physical education, and educational

entirely. One in three Americans—133 million—have a chronic

programs for students.

condition, and children are increasingly being affected.52 The Centers for Disease Control and Prevention has reported that one in three

(3) WORKFORCE. Primary care providers and public health

children born in 2000 will develop diabetes in their lifetime.53 Five

practitioners have and will continue to lead efforts to protect

chronic diseases—heart disease, cancer, stroke, chronic obstructive

and promote the nation’s health. Yet, the numbers of both are

pulmonary disease, and diabetes—cause over two-thirds of all deaths

dwindling,62 and the existing workforce is further challenged by

each year.

inadequate training about new health threats, such as bioterrorism

and avian flu, antiquated funding and reimbursement mechanisms, In addition to the tremendous human cost, chronic diseases exact

and limited access to real-time information and technical support.

a tremendous financial toll on our health care resources. Care for

Barack Obama will expand funding—including loan repayment,

patients with diabetes costs $130 billion each year alone, and this

adequate reimbursement, grants for training curricula, and

amount is growing.55 Tackling chronic diseases is also straining our

infrastructure support to improve working conditions—to ensure a

public health departments and finances, which are already stretched

strong workforce that will champion prevention and public health

too thin carrying out traditional public health functions, which

activities.

include ensuring our water is safe to drink, the air is safe to breathe, and our food is safe to eat. And these traditional public health

(4) INDIVIDUALS AND FAMILIES. The way Americans live, eat,

functions have evolved to include disaster preparedness and response

work, and play have real implications for their health and wellness.

for both natural and man-made disasters.

Reports show that over half of U.S. adults do not engage in physical activity at levels consistent with public health recommendations.63

Barack Obama believes that protecting and promoting health and

And the Surgeon General’s report has shown that smoking kills

wellness in this nation is a shared responsibility among individuals

an estimated 440,000 Americans each year and costs $75 billion in

and families, school systems, employers, the medical and public

direct medical costs.64 Preventive care only works if Americans take

health workforce, and federal and state and local governments. Each

personal responsibility for their health and make the right decisions

must do their part, as well as collaborate with one another, to create

in their own lives – if they eat the right foods, stay active, and stop

the conditions and opportunities that will allow and encourage

smoking.

Americans to adopt healthy lifestyles.

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ELECTION 2008 SPECIAL

Barack Obama’s Plan For A Healthy America, from page 19 Individuals and families must have access to essential clinical preventive services, such as cancer screenings and smoking cessation

insurance/7527/index.cfm 6. FamiliesUSA (2004). Health Care: Are You Better off Today than

programs, and the Obama health plan will require coverage of

You Were Fours Years Ago? http://www.familiesusa.org/assets/

such services in all federally supported health plans, including Medicare, Medicaid, SCHIP, and the new public plan. Americans

pdfs/Are_You_Better_Off_rev20053139.pdf 7.

David U. Himmelstein, Elizabeth Warren, Deborah Thorne,

also benefit from healthy environments that allow them to pursue

and Steffie Wooldhandler (February 2005). “Illness and Injury

healthy choices and behaviors that can help ward off chronic and

as Contributors to Bankruptcy,” Health Affairs, http://content.

preventable diseases. Healthy environments include sidewalks, biking paths, and walking trails; local grocery stores with fruits

healthaffairs.org/cgi/content/abstract/hlthaff.w5.63v1 8. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson,

and vegetables, restricted advertising for tobacco and alcohol to

Editors; Committee on Quality of Health Care in America,

children; and wellness and educational campaigns. In addition,

Institute of Medicine (2000). To Err is Human. Washington, DC:

Obama will increase funding to expand community-based preventive interventions to help Americans make better choices to improve their health.

National Academy Press. 9. Wayne Ray (2001), “Value of Appropriate Use.” Presentation at a workshop for state and local policymakers sponsored by the for Agency for Healthcare Research and Quality. Denver, CO. http://

(5) FEDERAL, STATE, AND LOCAL GOVERNMENTS. The federal government and state and local governments play critical roles

www.ahrq.gov/news/ulp/pharm/pharm2.htm 10. Steffie Woolhandler, Terry Campbell, and David U. Himmelstein

across the full range of disease prevention and health promotion

(2003) “Costs of Health Care Administration in the United States

activities. First, working together, governments at all levels should

and Canada.” New England Journal of Medicine.

lead the effort to develop a national and regional strategy for public health, and align funding mechanisms to support its implementation. Second, the field of public health would benefit from greater research to optimize organization of the 3,000 health departments in this

11. Jeanne M. Lambrew, (April 2007). A Wellness Trust to Prioritize Disease Prevention. The Hamilton Project, Brookings Institution. http://www3.brookings.edu/views/papers/200704lambrew.pdf 12. Jeanne M. Lambrew, (April 2007). A Wellness Trust to Prioritize

nation,65 collaborative arrangements between levels of government

Disease Prevention. The Hamilton Project, Brookings Institution.

and its private partners, performance and accountability indicators,

http://www3.brookings.edu/views/papers/200704lambrew.pdf

integrated and interoperable communication networks, and disaster

13. Census Bureau, “Census Bureau Revises 2004 and 2005 Health

preparedness and response. Third, the government must invest in

Insurance Coverage Estimates,” March 23, 2007. http://www.

workforce recruitment, as well as modernizing our physical structures,

census.gov/Press-Release/www/releases/archives/health_care_

particularly our public health laboratories. And finally, the government

insurance/009789.html

must examine its own policies, including agricultural, educational, environmental, and health policies, to assess and improve their effect on public health in this nation. As President, Barack Obama will prioritize all of these activities, to ensure a 21st century public health system and healthy America.

14. Census Bureau (2006), Income, Poverty, and Health Insurance Coverage in the United States: 2005. Table C-1. 15. Office of the Actuary. (February 2007). National Health Expenditures http://www.cms.hhs.gov/ NationalHealthExpendData/downloads/proj2006.pdf 16. Uwe E. Reinhardt, Peter S. Hussey, and Gerard F. Anderson

1. CMS. (February 2007). National Health Expenditures, http:// www.cms.hhs.gov/NationalHealthExpendData/downloads/ proj2006.pdf 2. Census Bureau, “Census Bureau Revises 2004 and 2005 Health Insurance Coverage Estimates,” March 23, 2007. http://www.

(June 2004), “U.S. Health Care Spending in an International Context,” Health Affairs, http://content.healthaffairs.org/cgi/ content/abstract/23/3/10 17. OECD, Health at a Glance: OECD Indicators 2005. 18. Commonwealth Fund, Why Not the Best? Results from a National

census.gov/Press-Release/www/releases/archives/health_care_

Scorecard on U.S. Health Systems Performance, September 2006,

insurance/009789.html

http://www.cmwf.org/publications/publications_show.htm?doc_

3. Kaiser Family Foundation, Enrolling Uninsured Low-Income Children in Medicaid and SCHIP. January 2007, http://www.kff. org/medicaid/upload/2177-05.pdf 4. Kaiser Family Foundation, The Uninsured: A Primer (2006), http://kff.org/uninsured/upload/7451021.pdf

id=401577 19. Steffie Woolhandler, Terry Campbell, and David U. Himmelstein (2003) “Costs of Health Care Administration in the United States and Canada.” New England Journal of Medicine. 20. Elliott S. Fisher, David E. Wennberg, Therese A. Stukel, et al.

5. Kaiser Family Foundation and Health Research and Educational

“The Implications of Regional Variations in Medicare Spending.

Trust. (2006). Employer Health Benefits 2006, http://kff.org/

Part 1: The Content, Quality, and Accessibility of Care.” Annals

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ELECTION 2008 SPECIAL of Internal Medicine, 138(4): 273–288, 2003. http://www.annals. org/cgi/reprint/138/4/273.pdf 21. Dartmouth Atlas Project (2006), The Care of Patients with Severe Chronic Illness, http://www.dartmouthatlas.org/atlases/2006_ Chronic_Care_Atlas.pdf 22. Mark W. Stanton and Margaret Rutherford (June 2006), The High Concentration of U.S. Health Care Expenditures. Agency for Healthcare Research and Quality. Research in Action Issue 19. 23. Mark W. Stanton and Margaret Rutherford (June 2006), The High

35. Stephen D. Wilhide (March 20, 2002), Testimony: Rural Health Disparities and Access to Care, http://www.iom.edu/Object.File/ Master/11/955/Disp-wilhide.pdf 36. Kenneth Thorpe (January 21, 2004), The Medical Malpractice ‘Crisis’: Recent Trends and the Impact of State Tort Claims, Health Affairs, http://content.healthaffairs.org/cgi/content/full/hlthaff. w4.20v1/DC1#39 37. Department of Health and Human Services (March 3, 2003), Addressing the New Health Care Crisis: Reforming the Medical

Concentration of U.S. Health Care Expenditures. Agency for

Litigation System to Improve the Quality of Care, http://aspe.hhs.

Healthcare Research and Quality. Research in Action Issue 19.

gov/daltcp/reports/medliab.htm

24. Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson Chronic Conditions: Making the Case for Ongoing Care (2004). Partnership for Solutions (Johns Hopkins and Robert Wood Johnson Foundation). 25. Center on an Aging Society at Georgetown Univeristy, Disease Management Programs: Improving Health and while Reducing Costs?, p4, (January 2004). http://hpi.georgetown.edu/ agingsociety/pdfs/management.pdf 26. Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson Chronic Conditions: Making the Case for Ongoing Care

38. Federico Girosi, Robin Meili, and Richard Scoville (2005), Extrapolating Evidence of Health Information Technology Savings and Costs. RAND, page 79. 39. Federico Girosi, Robin Meili, and Richard Scoville (2005), Extrapolating Evidence of Health Information Technology Savings and Costs. RAND, page 36. 40. Edward Langston, “Statement of the American Medical Association to the Senate Committee on the Judiciary, United States Senate” (September 6, 2006). Testimony. 41. Edward Langston, “Statement of the American Medical

(2004). Partnership for Solutions (Johns Hopkins and Robert

Association to the Senate Committee on the Judiciary, United

Wood Johnson Foundation).

States Senate” (September 6, 2006). Testimony.

27. Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia

42. Russ Britt, MarketWatch (April 17, 2006), Health Insurers Build

Johnson Chronic Conditions: Making the Case for Ongoing Care

Up Market Clout http://www.marketwatch.com/News/Story/Story.

(2004). Partnership for Solutions (Johns Hopkins and Robert

aspx?guid={D2334AAB-0321-432E-B5AE695FDBCF258B}&siteId=a

Wood Johnson Foundation).

olpf&dist=special

28. CMS. (February 2007). National Health Expenditures; Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson Chronic Conditions: Making the Case for Ongoing Care (2004). Partnership for Solutions (Johns Hopkins and Robert Wood Johnson Foundation). 29. Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson Chronic Conditions: Making the Case for Ongoing Care

43. Kaiser Family Foundation and Health Research and Educational Trust. (2006). Employer Health Benefits 2006, http://kff.org/ insurance/7527/index.cfm 44. Karen Davis, Cathy Schoen, Stuart Guterman et al. (January 2007), Slowing the Growth of U.S. Health Care Expenditures: What are the Options? Commonwealth Fund 45. Forbes.com, 2007 CEO Executive Compensation – Health Care

(2004). Partnership for Solutions (Johns Hopkins and Robert

Equipment & Services, http://www.forbes.com/lists/2007/12/

Wood Johnson Foundation).

lead_07ceos_CEO-Compensation-Health-care-equipment

30. National Committee for Quality Assurance (2006), The State of Health Care 2006, http://www.ncqa.org/communications/ sohc2006/sohc_2006.pdf 31. Jeanne M. Lambrew, (April 2007). A Wellness Trust to Prioritize Disease Prevention. The Hamilton Project, Brookings Institution. http://www3.brookings.edu/views/papers/200704lambrew.pdf 32. FamiliesUSA (January 2006), Minority Health Initiatives, http://

services_9Rank.html 46. Karen Davis, Cathy Schoen, Stuart Guterman et al. (January 2007), Slowing the Growth of U.S. Health Care Expenditures: What are the Options? Commonwealth Fund. 47. Patented Medicine Prices Review Board, Annual Report (Ottawa, Ontario: PMPRB, 2002), p. 23. 48. Marc Kaufman (April 25, 2006), “Drug Firms’ Deals with

www.familiesusa.org/assets/pdfs/minority-health-tool-kit/Quick-

Allowing Exclusivity,” Washington Post, http://www.

Facts-Care.pdf

washingtonpost.com/wp-dyn/content/article/2006/04/24/

33. Agency for Healthcare Research and Quality (July 2003), National Healthcare Disparities Report, http://www.ahrq.gov/ qual/nhdr03/nhdr2003.pdf 34. Agency for Healthcare Research and Quality (2004), Fact Sheet: Women’s Healthcare in the United States, http://www.ahrq.gov/ qual/nhqrwomen/nhqrwomen.htm

AR2006042401508.html 49. Families USA (December 2005), Falling Short: Medicare Prescription Drug Plans Offer Meager Savings, http://www. familiesusa.org/assets/pdfs/PDP-vs-VA-prices-special-report.pdf 50. Roger Hickey & Jeff Cruz (April 2007), Waste and Inefficiency in the Bush Medicare Prescription Drug

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Barack Obama’s Plan For A Healthy America, from page 21 Plan: Allowing Medicare to Negotiate Lower Prices Could Save $30 Billion a Year, Institute for America’s Future, http://cdncon. vo.llnwd.net/o2/fotf/medicare/National_Savings.pdf 51. Glenn Hackbarth, Medicare Payment Advisory Commission (April 11, 2007), Testimony: The Medicare Advantage Program

59. NIH, Childhood Obesity, June 2002 Word on Health http://www. nih.gov/news/WordonHealth/jun2002/childhoodobesity.htm 60. CDC National Center for Health Statistics, http://www.cdc.gov/ nchs/pressroom/06facts/obesity03_04.htm 61. GAO (2003), School Lunch Program: Efforts Needed to Improve

and MedPAC Recommendations, U.S. Senate Committee on

Nutrition and Encourage Healthy Eating, http://www.gao.gov/

Finance, http://www.medpac.gov/publications/congressional_

new.items/d03506.pdf

testimony/041107_Finance_testimony_MA.pdf?CFID =6602154&CFTOKEN=81609996 52. Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson Chronic Conditions: Making the Case for Ongoing Care (2004). Partnership for Solutions (Johns Hopkins and Robert Wood Johnson Foundation). 53. CDC, http://www.cdc.gov/nccdphp/publications/factsheets/ Prevention/pdf/diabetes.pdf 54. CDC, http://www.cdc.gov/nccdphp/overview.htm 55. CDC, http://www.cdc.gov/nccdphp/press/index.htm 56. CDC, http://www.cdc.gov/nccdphp/dnpa/kidswalk/then_and_ now.htm 57. CDC, http://www.cdc.gov/nccdphp/dnpa/kidswalk/pdf/ factsheet.pdf 58. CDC, http://www.cdc.gov/HealthyYouth/shpps/factsheets/pdf/ pe.pdf

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62. The Robert Graham Center (October 2003), http://www.grahamcenter.org/x468.xml; Institute of Medicine (2002), The Future of the Public’s Health in the 21st Century, p.364. 63. CDC, http://www.cdc.gov/nccdphp/dnpa/physical/health_ professionals/index.htm 64. U.S. Surgeon General (May 27, 2004), The Health Consequences of Smoking: A Report of the Surgeon General, http://www. cdc.gov/tobacco/data_statistics/sgr/sgr_2004/00_pdfs/ executivesummary.pdf 65. Bob Prentice and George Flores (December 15, 2006), Local Health Departments and the Challenge of Chronic Disease: Lessons From California, NIH, http://www.pubmedcentral.nih. gov/articlerender.fcgi?artid=1832141

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ELECTION 2008 SPECIAL

Presidential Nominees Respond to Ten Questions About Their Health Care Reform Proposals This Q&A appeared in the June 2008 issue of the ACCMA Bulletin. A key objective of the American Medical Association’s (AMA) “Voice for the Uninsured” campaign has been to bring national attention to the issue of the uninsured. The AMA is pleased that each of the leading 2008 presidential candidates have made health care a top priority in their respective campaigns. In response to a set of ten questions posed to the candidates about their health care reform proposals, listed below are the verbatim responses received from the campaigns of Senator John McCain (R-AZ) and Senator Barack Obama (D-IL). Disclaimer: The American Medical Association and Santa Clara County Medical Association do not endorse presidential candidates. Inclusion of the responses by the candidates to these questions is not intended to imply endorsement of nor opposition to any candidate, nor support for a specific candidate’s health care reform proposal. We have alternated the order of responses to avoid giving any special prominence to one candidate’s responses.

How would your Administration address rising health care costs? Senator McCain’s response: I believe that the root cause of our nation’s health care problem is rising costs, and bringing them under control must be the first step in any meaningful health care reform. I will do so by transforming the practice of medicine in America, making sure that consumers are offered more choice, that there is pricing transparency, that payment is focused on quality outcomes, and that they are empowered by giving them a more direct role in the decision-making process regarding their own health. Senator Obama’s response: My plan will allow the typical family to save up to $2,500 every year on medical expenditures. The savings in costs will be achieved through: •

Investing in health care information technology, which will reduce unnecessary spending in the health care system that results from preventable errors and inefficient paper billing

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systems; •

Improving prevention and management of chronic conditions;

•

Increasing insurance industry competition and reducing underwriting costs and profits, which will reduce insurance overhead;

•

Providing reinsurance for catastrophic coverage, which will reduce insurance premiums; and

•

Making health insurance universal, which will reduce spending on uncompensated care.

How many Americans would have health care coverage under your proposal, and what are the total costs and sources of financing for your proposal? Senator Obama’s response: My plan will provide affordable, high-quality, and portable health insurance to all Americans, and ensure that all children, American citizens, and legal immigrants have coverage. My plan will cost approximately $50 – 65 billion per year, when fully phased in. I will ensure that this plan is revenue neutral by rolling back the Bush tax cuts for those earning above $250,000 per year and retaining the estate tax at its 2009 level, which has a $7 million exemption for couples. Senator McCain’s response: With the reforms that I am proposing, tens of millions of Americans who are currently uninsured would have access to coverage – which is a significant step toward making sure that all Americans ultimately have access to meaningful and affordable coverage. My plan is an approach to address the rising cost of care through competition, tort reform, a focus on preventative care, and reforms to Medicare payments. Accordingly, my plan will reduce costs to the federal government and the American taxpayer.

What are the roles and responsibilities of individuals, employers, or other relevant stakeholders under your proposal? Senator McCain’s response: I believe that every participant in the health care system – doctors, hospitals, insurance companies, patients, drug companies, medical

ELECTION 2008 SPECIAL device makers, state governments, and the federal government – must

adequate reimbursement, grants for training curricula, and

be prepared to change to make the system more responsive to the

infrastructure support to improve working conditions – to ensure

needs of American families. The most important players in health

a strong workforce that will champion prevention and public

care, however, are the patient and their health care provider – as

health activities.

everyone else merely plays a support role. Patients and their families

4. Individuals and families. I will require all parents to provide

will have the opportunity to manage their health care dollars and

health insurance coverage to their children. I will also require

will benefit from taking an active role in their own health care –

insurance plans to include coverage of essential clinical

understanding the state of their health and their risks, engaging

preventive services such as cancer screenings and smoking

in prevention, and being an active participant in the management

cessation programs in all federally supported health plans,

of their health. Health care providers must be accountable to their

including Medicare, Medicaid, SCHIP, and the new public plan.

patients by educating their patients regarding their health status and

In addition, I will increase funding to expand community-based

steps they can take to maintain their health, practice evidenced-based

preventive interventions to help Americans make better choices

medicine, and provide transparency regarding their costs and the

that can help ward off chronic and preventable diseases and

options for treating illnesses. The health care systems and practices in

improve their health.

which providers serve patients must remain vigilant in their focus on quality, efficiency, and transparency.

5. Federal, state, and local governments. The federal government and state and local governments play critical roles in disease prevention and health promotion activities. First, working

Senator Obama’s response:

together, governments at all levels should develop a national

I believe that protecting and promoting health and wellness in this

and regional strategy for public health that includes funding

nation is a shared responsibility among individuals and families,

mechanisms for implementation. Second, the field of public

school systems, employers, the medical and public health workforce,

health would benefit from greater research to optimize

and federal and state and local governments. I also believe that

organization of the 3,000 health departments in this nation,

insurance companies have a critical role to play by reducing

collaborative arrangements between levels of government and

administrative costs, focusing more on preventative care, issuing

its private partners, performance and accountability indicators,

all Americans fair insurance policies no matter any “pre-existing”

integrated and interoperable communication networks, and

conditions, and charging all Americans fair and reasonable premiums.

disaster preparedness and response. Third, the government must

All of these parties must do their part, as well as collaborate with one

invest in workforce recruitment, as well as modernizing our

another, to create the conditions and opportunities that will allow

physical structures. And finally, the government must examine its

and encourage Americans to adopt healthy lifestyles.

own policies, including agricultural, educational, environmental,

1. Employers. I believe that employers, except for small businesses,

and health policies, to assess and improve their effect on public

have a responsibility to contribute to their employee’s health

health in this nation. As president, I will prioritize all of these

insurance coverage. Employers that do not offer or make a

activities to strengthen prevention and public health.

meaningful contribution to the cost of quality health coverage

health promotion programs and many employers choose

What is the role of public programs under your proposal, and how would you assure adequate payment levels within these programs to maintain sufficient patient access to care?

insurance plans that cover preventive services for their

Senator Obama’s response:

employees. I believe that worksite interventions hold tremendous

I will make available a new national health plan that will allow

potential to influence health and will expand and reward these

individuals without access to affordable insurance coverage, including

efforts.

the self-employed and small businesses, to buy affordable health

for their employees will be required to contribute a percentage of payroll toward the costs of the national plan. Small employers that meet certain revenue thresholds will be exempt. An increasing number of employers are also offering worksite

2. School systems. I will work with schools to create more healthful

coverage that is similar to the plan available to members of Congress.

environments for children. I will work to get junk food out of

I will also expand the Medicaid and SCHIP programs to ensure

vending machines in schools and improve nutritional content of

that more low-income Americans have access to affordable health

lunches through financial incentives, increase grant support for

insurance coverage. My plan will also seek to align reimbursement

physical education, expand federal reimbursement for school-

with provision of high quality health care. Providers who see patients

based health services, and provide grants for health educational

enrolled in the new public plan, the National Health Insurance

programs for students.

Exchange, Medicare, and FEHB will be rewarded for achieving

3. Workforce. I will expand funding – including loan repayment,

performance thresholds on physician-validated outcome

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ELECTION 2008 SPECIAL

Presidential Nominees Respond, from page 25 measures.

move residences.

Senator McCain’s response:

Public programs have been and remain an important vehicle for

By providing the tax subsidy, regardless of the source of coverage,

ensuring access to care and coverage for a number of populations,

my reform permits the option of applying it to individual coverage.

including the elderly, those who are or who have served our country

Permitting families to purchase health insurance across state lines

in the military or the public sector, Native Americans, and the poor.

makes health insurance even more portable. This would allow an

It is certainly important that there is fair payment for the delivery of

individual to maintain the same coverage, regardless of factors such

services; however, just like the rest of the health care system, there

as employment status or geographic location. It may be that a family

is work to be done to provide adequate transparency and a focus

who moved from Omaha, Nebraska to New York City will need to

on pay for high quality and superior outcomes. My proposal would

pay a higher premium because the market price for medical care

accelerate the use of information technology to achieve real time

in NYC is higher, the same way car insurance and home owners

measurement of adherence to best practices, then link payment to a

insurance would be higher, but the coverage would still be the same.

higher bar of medical care quality.

By restructuring the tax treatment of health care, my proposal would empower individuals and families with the ability to select the policy

If your proposal incorporates the use of public subsidies, how are they designed or administered? Are they based on income, health status, employment status, or some other measure?

that is right for them, allowing them to choose policies that would follow them from job-to-job. Moreover, I would allow non-traditional groups, including churches and professional organizations, to sponsor health insurance plans in which Americans could participate, irrespective of their employment status.

Senator McCain’s response:

and regardless of the source of their private insurance coverage. To

What choice of benefit coverage options, including covered services, cost-sharing requirements, and premium levels, would be available under your proposal, and how would these decisions be made?

qualify for the tax credit, an individual consumer must purchase a

Senator McCain’s response:

health care plan or take an employer-sponsored health plan.

The array of private insurance contracts today is quite varied, and

A tax subsidy has long-supported private health insurance. I will provide universal and fairer provision of the tax subsidy in the form of a $5,000 refundable tax credit ($2,500 for an individual) that will be available to every American, in the same amount for rich and poor,

will expand when the market is operating at a greater degree of Senator Obama’s response:

innovation and choice. I look forward to products that are tailored to

Individuals and families who do not qualify for Medicaid or SCHIP,

the needs of families. It makes sense to ensure that the tax subsidy

but still need assistance, will receive income-related federal subsidies

is reserved for policies that meet standards for creditable coverage,

to keep health insurance premiums affordable. They can use the

including policies offered with no-cost sharing for preventive care

subsidy to buy into the new public plan or purchase a private health

for clearly best practices and demonstrated effective treatments like

care plan. Co-pays and deductibles for preventive care will be

childhood immunizations or a periodic physical exam for adults.

minimal in both the public and private plans. In addition, all plans will be required to use state-of-the-art disease management programs

Senator Obama’s response:

that help people manage their chronic diseases.

Under my plan, the benefit package will be similar to that offered by the Federal Employees Health Benefit Program (FEHBP), the program

How would your proposal impact health insurance coverage portability, so that individuals would be able to maintain the same coverage regardless of factors such as employment status and geographic location?

through which members of Congress get their own health care.

Senator Obama’s response:

reported and minimized so that government, business, and patient

Both the new public plan and the National Health Insurance

money goes directly to improving health care outcomes, not

Exchange will have fully portable plans, so that individuals do not

bureaucratic processes.

need to worry about losing their insurance when they switch a job or

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The new public plan will include coverage of all essential medical services, including preventative, maternity, and mental health care. Moreover, coverage will include disease management programs, self-management training, and care coordination for appropriate individuals. I will also ensure that administrative costs are accurately

ELECTION 2008 SPECIAL Individuals will also be able to purchase separate private insurance

New Jersey than they would for an identical policy one mile across

as an alternative to, or as a supplement to, my plan’s public

the Delaware River, in Pennsylvania. Letting residents buy insurance

component. There is no limit on what services these private plans

across state lines would reduce the uninsured. In addition, policies

will provide for, but the National Health Insurance Exchange will

that are fair for those with chronic illnesses are a must, as well. I

assure that every participating insurer provides a common baseline

will encourage the development of multi-year insurance contracts to

level of benefits that equals those provided by my new public plan.

encourage insurers to design benefits that maintain or enhance the quality of life of those with chronic illnesses, as well as manage their

What, if any, provisions are included in your proposal for changing the health insurance market, and how would they improve the market, especially for people with predictably high medical costs?

costs in a competitive environment.

Senator Obama’s response:

What is the role of health information technology (HIT) under your proposal, and how would the purchase and maintenance of HIT tools be financed?

My plan would ensure that all insurance companies issue fair policies

Senator McCain’s response:

with reasonable premiums to all individuals who apply, regardless

HIT is essential to the success of my proposal. It amazes me a health

of any “pre-existing conditions.” Additionally, my plan will reduce

economy of over two trillion dollars, that epitomizes advanced

administrative costs across the health industry by investing $10 billion

technology, has an underdeveloped HIT infrastructure. Any national

a year over the next five years to adopt standards-based electronic

or global retail chain has invested in and reaped enormous rewards

health information systems, including electronic health records and

from IT investment. What needs to be done to take health care to

billing systems. This transition should save our economy up to $77

the next level? We need to transform the practice of medicine to

billion dollars, which can and should be used to help guarantee that

reward coordination that supports the use of available health IT

health insurance is available to all Americans who seek it.

wherever possible, and that gives patients and providers the data they need to get the best possible value of care delivered. Today,

Additionally, competition between insurance companies within my

much of medical records data is being recorded digitally. My proposal

new National Health Insurance Exchange will lower administration

provides payment reforms for federal health programs and others to

costs. I will also require full transparency about costs to insurance

integrate medical, pharmacy, and service data on as near a real time

companies. Under my plan, health insurers will be required to

basis for a given patient at any location. Physicians and patients need

disclose the percentage of premiums that actually goes to paying for

access to previous drug histories, medical test results, and surgical

patient care, as opposed to administrative costs. Finally, the exchange

notes to know how to proceed on treatment pathway, to ensure

will look to the loss ratio as a guide for deciding if premiums are

the best possible outcome. There will be a role for government in

appropriate.

developing standards and supportive regulation, but the bulk of ongoing investment will remain a private sector activity, as it is in the

My plan will also offer federal reinsurance to employer health plans

remainder of the economy.

to help ensure that unexpected or catastrophic illnesses do not price health insurance out of reach for businesses and their employees.

Senator Obama’s response:

For many small businesses, in particular, having a single employee

I will invest $10 billion per year for five years to transition our health

with catastrophic expenditures can make insurance unaffordable

care system into the electronic age. These funds will be used to move

for all of the workers in the firm. My plan will reimburse employer

the U.S. health care system to broad adoption of standards-based

health plans for a portion of the catastrophic costs they incur above

electronic health information systems, including electronic health

a certain threshold – if they guarantee that such savings will be used

records and will phase in requirements for full implementation of

to reduce the cost of workers’ premiums. Providing reinsurance for

health IT. I will also phase in requirements for full implementation

catastrophic coverage will also reduce premiums.

of health information technology and commit the necessary federal resources to make this change happen. My plan will provide for

Senator McCain’s response:

maximum integration by ensuring that these systems are developed

We live in a highly mobile society. We need health insurance that is

in coordination with providers and frontline workers, including those

portable from job-to-job and job-to-home. Allowing someone to buy

in rural and underserved areas.

insurance across state lines and keep it as they move would not only be more convenient, it could lead to lower premium prices that could reduce the number of uninsured. A family with a husband, wife, and two kids would pay twice as much for a health insurance policy in

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ELECTION 2008 SPECIAL

Presidential Nominees Respond, from page 27 How would your Administration address quality reporting in the delivery of health care? Senator Obama’s response: Health care quality and costs can vary tremendously among

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providers; however, patients have limited access to this information. My plan will require hospitals to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, disparities in care, and costs. This effort builds on my successful effort in the Illinois State Senate to make hospital “report cards”

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mandatory. My plan will also implement initiatives to improve quality of care by accelerating efforts to develop and disseminate best practices, and aligning reimbursement with physician-validated outcome measures. Senator McCain’s response: Better HIT will enable quality reporting. By using the federal health programs as a catalyst, we will provide incentives to showcase effective and substantial quality reporting at the provider and regional levels. We will work with provider communities to establish a list of critical quality benchmarks and rapidly place incentives for their use.

Email New Photos for the 2009 Directory to Pam Jensen at pjensen@sccma.org or call for an appointment to have your picture taken at no cost: 408/998-8850.

COMING SOON! Now’s the time! Advertise in the 2009 Physician Membership Directory and Reach YOUR Target Audience! For details, contact Pam Jensen at 408/998-8850 or pjensen@sccma.org.

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Medical Condos for Sale or Lease-to-Own

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Units from 1,104 sq. ft. Starting at $299,000

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Don’t wait! Arrange for a tour of the property, ask for Larry Bengiveno.

Borelli Investment Company is Silicon Valley’s business condominium specialist.

www.junctioncondos.com

408.453.4700

Ask for a copy of our informative paper: “Commercial Real Estate a Winner in the 2008 Economic Stimlus Act”

Flame retardants migrate out of our textiles, foam, and electronics. PBDEs are often an additive to the product and do not stay in the product, but slowly give off gas for years. They are found in high concentrations in indoor environments including house dust, vacuum cleaner bags, and washing machine effluent.

Brominated Flame Retardants:

What Your Kids, Cats, Couch, TV, and Food Chain Have in Common By Cindy Lee Russell, MD | Chair, Environmental Health Committee; Vice President, Community Health Several decades of research have shown that the flame retardants commonly used in furniture, mattresses, infant car seats, and electronics are increasingly found in humans and wildlife. Many of the commonly used brominated flame retardants – PBDEs (Polybrominated Diphenyl Ethers) are persistent, toxic chemicals that are now widespread in the environment. Far from benign, they have been shown to be endocrine disruptors and mutagens. PBDEs have demonstrated adverse effects on the immune system, thyroid function, reproductive effects, and cause developmental neurobehavioral toxicity. They are suspected of contributing to learning disorders and attention deficit disorders. Although many of the flame retardants have been shown to have adverse health effects, most lack critical toxicity data. Dust and breast milk studies show much higher levels of toxic flame retardants from our furniture in California, and Californians, than other states. This is likely to have huge health and environmental costs for our state. Flame Retardants in Kid’s Pajamas

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“In the 1970s, the flame retardants brominated Tris [tris(1,3-dichloro-2,3-dibromopropyl) phosphate] and chlorinated Tris were removed from children’s sleepwear after being shown to be mutagenic and absorbed through the skin into children’s bodies. Today, chlorinated Tris is the second most commonly used fire retardant in furniture,” says Arlene Blum, a biophysical chemist who was instrumental in getting the ban on Tris in kids nightwear, and who has been working on the flame retardant issues for decades. Tris is still widely used, especially in furniture, but no longer in pajamas. There are regulatory proposals to increase fire

standards and Tris is one of many similar chemicals that could be used to meet standards for children’s toys and pillows.

Brominated Flame Retardants Many flame retardants are brominated. Some of these brominated flame retardants (BFRs) are similar in structure to PCBs (polychlorinated biphenyls) and PBBs. All are persistent, bioaccumulate in living organisms, are highly mobile in the food chain, and are toxic. The most widely produced brominated flame retardants are decaBDE(decabromodiphenyl ether), TBBPA (tetrabromobisphenol A), and HBCD (hexabromocyclododecane). While decaBDE is used in electronics and TVs, pentaBDE (pentabromodiphenyl ether) has been the major product in furniture and cushions. Banned in Europe and the U.S. since 2004, pentaBDEs will continue to emanate from furniture and textiles for many years. Furthermore, decaBDE also appears to break down into lower more toxic forms, including pentaBDE.

Brominated Flame Retardants Now Listed as Persistent Pollutants Substances found to accumulate in the environment pose special hazards to living organisms, and, thus, government agencies have regulated these types of chemicals known as Persistent Bioaccumulative Toxins (PBTs) or Persistent Organic Pollutants (POPs). These chemicals are usually fat soluble, hydrophobic, and poorly metabolized. They travel long distances and move readily from land, air, water, and within migratory species. These chemicals have been found in high levels in whales, polar bears, and seals, as well as other mammals around the world. As these persistent chemicals migrate up food webs, they have unintended consequences on wildlife and humans. The Stockholm Convention on Persistent Organic Pollutants was ratified by 131 countries in 2004 to eliminate the worst offenders. The original dirty

dozen toxic substances included DDT and PCBs. Brominated flame retardants were just added to this infamous list.1

probable toxins. Reproductive and developmental neurotoxicity studies are to be completed by 2009. Firemaster 600 will replace Firemaster 550 in December 2008.

Highest Levels of BFRs in Californians and Children Flame retardants migrate out of our textiles, foam, and electronics. PBDEs are often an additive to the product and do not stay in the product, but slowly give off gas for years. They are found in high concentrations in indoor environments including house dust, vacuum cleaner bags, and washing machine effluent. A 2003 study on BFRs in the blood of San Francisco Bay Area women from the 1960’s confirmed earlier studies showing a dramatic rise in BFR concentrations. Levels measured from samples from the 1990s reveal levels in California women to be 3 to 10 times higher than in Europe, in the same period. Stored samples from the 1960s showed no polybrominated diphenyl ether (PBDE) contamination present.2 Levels are steadily increasing. Scientists at the Cal EPA Department of Toxic Substances Control announced, in 2004, that they had found that California seabird eggs have by far the highest levels of PBDEs measured in wildlife in the world.3 Concentrations measured in children are the highest because they crawl on the floor and furniture and then ingest the dust from their hands or toys. Nursing babies are at the top of the food chain. A well publicized study of an Oakland family showed the highest levels measured of PBDEs.4 The toddler and infant studied had respectively 7 and 10 times higher levels of PBDEs than the parents. House dust contains PBDEs in significant amounts. The U.S. EPA estimates that children ingest on average 100 milligrams of house dust per day. The infant had a much higher level than the toddler or parents. This could be accounted for by breast feeding adding more PBDEs to the mix.

Toxicity of Brominated Flame Retardants Studies have shown that brominated flame retardants can cause developmental neurotoxicity affecting learning, memory, and alter habituation behavior in mice.5 Fetal and neonatal exposure to neurotoxicants can adversely affect brain development, especially in critical brief windows of rapid brain growth. This may be due to interference with thyroid hormone balance. Studies have shown PBDEs to act as hormone disruptors. Zhou showed a reduction in L-thyroxine with exposure to PBDEs in mice.6 Ilonka, et. al. found that PBDEs, which resemble the hormone L-thyroxine (T4 ), bind competitively with transthryetin, a protein found in serum and cerebral spinal fluid, which transports L-thyroxine. A striking finding was that many of the flame retardants studied were more powerful than T4 in their binding capacity.7 Some brominated flame retardants have been shown to activate breast cancer cells and stimulate or inhibit aromatase. Unfortunately, much more research needs to be done on these compounds that are increasing and that are being substituted with other compounds of questionable safety. Firemaster 550 replaced pentaBDE, in 2004, and is now found in dust and sewage sludge. Chemical analysis showed it to contain Bis(2-ethylhexyl) tetrabromophthalate and three other

Fire Retardants Appear Especially Toxic to Cats Scientists at the Environmental Protection Agency have noted a possible connection between thyroid disease and flame retardants. Hyperthyroidism has become increasingly common in older cats. Prior to 1980s, it was virtually unheard of. This rise in thyroid disease has paralleled the rise in brominated flame retardants in the environment and also the tissues of cats. Cats participating in the study had 23 to 100 times the levels of PBDEs than people in North America, who already have the highest levels measured. Dry cat food had significantly more PBDEs and those cats which consumed dry food had high levels of PBDEs.8 Cats also lick their fur and, thus, ingest more PBDEs through dust.

Recycling and Brominated Flame Retardants Greening of ourselves and our planet considers that, ideally, everything we buy or consume can have another life, be recycled, or biodegrade into harmless substances. As flame retardants can be found in everything from computer casings, circuit boards, plastics, paints, paper, polystyrene, carpet backing, a variety of textiles, and foam cushions, an area of concern arises with production and disposal. No labeling is required to determine the identification of flame retardants used. How do we recycle products that have a toxic waste component? In this age of recycling, computer manufacturers are now concerned this will be a major problem as the flame retardants, when added to the plastic, render the casing not only unrecyclable, but also convert it to hazardous waste.

Fire Risk Assessment California passed a stringent fire standards code, TB117, in 1980. Since then, levels of brominated flame retardants in California dust and breast milk have risen dramatically, compared to other states. Just because a retardant has been added to the product doesn’t mean it is not combustible. It is just less combustion able. With burning, the flame retardants release toxic dioxins and furans, as well. “There is no fire data to show that 28 years of TB117 has impacted fire deaths in Californians,” according to scientist Arlene Blum, a visiting scholar at U.C. Berkeley. In addition, cigarettes are considered the number-one cause of fire deaths in the U.S., about 600–800 per year. Fire-safe cigarettes have been implemented in 22 states, including California in 2007. Companies state they add speed bumps of extra layers of less porous paper. If unattended, the cigarette will self extinguish, instead of smoldering and possibly starting a fire. Deaths from cigarette related fires reduced by 33%, when New York’s law went into effect in 2004. The question then is where do we really need flame retardants and are there less toxic alternatives? Wool, for instance, is much less likely to burn than polyester. Mark Leno’s California Assembly Bill 706, if passed, will address some of these issues and begin using hazard assessment for moving to safer alternative chemicals.

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Brominated Flame Retardants, from page 31 Limiting Exposure Aside from avoiding products with flame retardants (i.e., polyurethane foam, TVs) in the home, these tips may help to reduce exposure: • Keep house as dust-free as possible. • Use a vacuum cleaner with hepa or other high efficiency filter. • Keep house well ventilated. • Cover mattresses with dust covers. • Wash bedding regularly to control dust. • Turn off electronics that are not in use. Standby mode maintains temperatures that can result in continuous offgassing. Ultimately, government regulation, both locally and on an international level, will be necessary to replace these poorly studied dangerous chemicals with safer alternatives that are properly studied prior to their use. Otherwise, we are just trading one danger for another that may have more catastrophic and global consequences. Green chemistry alternatives will be safer for our children, ourselves, and the environment.

References: 1. Kelly, Barry C., et al. Food Web-Specific Biomagnification of Persistent Organic Pollutants. Science 13 July 2007: Vol. 317. no. 5835, pp.236-239. 2. Petreas, M., J et al. High body burdens of 2,2’,4,4’ - tetrabromo diphenyl ether (BDE-47) in California Women. Environmental

Health Perspectives, Vol. 111:1175-1179 (2003). 3. Press Release. California Scientists Find Highest PBDE Levels In Wildlife In San Francisco Bay Area Seabird Eggs. DTSC. Sept 9, 2004. 4. Fischer, D., et al. Children Show Highest Levels of Polybrominated Diphenyl Ethers in a California Family of Four: A Case Study. Environmental Health Perspectives 114:1581-1584 (2006). 5. Eriksson, P. et al. Brominated Flame Retardants: A Novel Class of Developmental Neurotoxicants in Our Environment? Environmental Health Perspectives 109:903-908 (2001). 6. Zhou,T., et al. Developmental Exposure to Brominated Diphenyl Ethers Results in Thyroid Hormone Disruption. Toxicological Sciences 66:105-116. 7. Ilonka, A., et al. Potent Competitive Interactions of Some Brominated Flame Retardants and Related Compounds With Human Transthyretin in Vitro. Toxicological Sciences 56: 95-104 (2000). 8. Dye, J. A., et al. EPA Study: Comparison of PBDE’s in Cat Serum to Levels in Cat Food: Evidence of Deca Debromination? Sept, 2007. 9. Birnbaum, L., Brominated Flame Retardants: Cause for Concern? Environmental Health Perspectives 112: 9-17 (2004). 10. Schecter, A., Polybrominated Diphenyl Ethers (PBDEs) in U.S. Mothers’ Milk. Environmental Health Perspectives. Vol. 111:17231729 (2003).

Thinking about electronic medical records? What about your paper records? If you are planning going to do with all those records into records to a CD alternative:

to move to an electronic medical record system, what are you your paper patient charts and billing files? Consider scanning a digital database with deliverExchange™. Let us scan your or DVD, and realize the benefits of this cost-effective

Safe secure storage that you control • Records are accessible 24/7 Files can be printed out or electronically transmitted • Save time spent filing and retrieving records • Eliminate lost or misfiled records • Save space and storage costs • Keep a copy for backup, security •

•

We pick up your records, scan them at our imaging unit in San Jose, produce quality images on CDs or DVDs, and handle the destruction of the paper records. 2054 Zanker Road San Jose, CA 95131 Contact: Liz Allan phone 408.436.1701 ext.131 fax 408.436.1625

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You may not know our name, but if you practice in Santa Clara county you know our service. For over 30 years, SOURCECORP Deliverex has been the vendor of choice for record management in the Bay Area.

In Memoriam… Norman S. Buys, MD *Ophthalmology 5/21/25 – 7/18/08 SCCMA member since 1957

Richard L. Keefe, MD *Dermatology 11/14/35 – 7/6/08 SCCMA member since 1968

Benjamin H. Moore, MD *Family Practice 1/8/26 – 4/19/08 SCCMA member since 1957

Maurice Fox, MD *Internal Medicine Endocrinology, Diabetes & Metabolism 12/24/32 – 7/31/08 SCCMA member since 1965

Steven A. Leibel, MD *Radiation Oncology 6/7/46 – 2/7/08 SCCMA member since 2006

John T. O’Brien, MD General Practice 3/3/13 – 4/22/08 SCCMA member since 1947

Thomas Y. Locke, MD *Anesthesiology 2/12/24 – 5/24/08 SCCMA member since 1964

Harold Y. Randle, MD Occupational Medicine Industrial Medicine 1917 – 7/08 SCCMA member since 1947

Allen H. Johnson, MD *General Surgery 1/23/22 – 5/2/08 SCCMA member since 1956

IN ASSOCIATION WITH THE DIABETES COALITION OF SANTA CLARA COUNTY

Presents:

14TH ANNUAL DIABETES SYMPOSIUM FOR HEALTH PROFESSIONALS Biltmore Hotel & Suites • Santa Clara, CA

Saturday, November 8, 2008 • 8:00 AM to 4:00 PM Symposium Description

This one day symposium is designed for physicians, podiatrists, nurses, dietitians,pharmacists, and other health professionals to enhance the knowledge of the practitioner in the management of diabetes. Experts in the field will cover the challenges of managing diabetes providing both practical and theoretical information related to diabetes. Although the final agenda is pending, the presentation will cover cultural competency in diabetic care; diabetes and kidney disease; continuous glucose monitoring and artificial pancreas; obesity and diabetes; gestational diabetes/TIDM/pregnancy & celiac disease ; and more. Tuition just $50.

For more information and to register please visit: http://www.diabetessociety.org/Events/sympSC.html Los Angeles Symposium: November 1, 2008 Past Sponsors providing unrestricted educational grants to the Diabetes Society:

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MEDICO NEWS

MEDICONEWS

Budget Gridlock in Sacramento – Fate of Health Care Cuts Uncertain

Facing a $15.2 billion shortfall, Governor Schwarzenegger and legislative leaders have not yet reached agreement on the budget for the 2009 fiscal year, which began July 1. The fate of the 10% cuts to Medi-Cal reimbursement rates remains uncertain as legislators and the governor grapple with how to close the shortfall.

This past month, the Assembly voted on the Assembly Democrats’ budget plan, which restored Medi-Cal rates to their levels prior to the cut, and reduced the budget shortfall with a mix of tax increases on corporations and wealthy individuals. The plan fell 9 votes short of the 54 votes needed under the 2/3 majority rule for legislative budget votes. It received no Republican votes.

At the end of August, the Senate is expected to vote on a slightly different proposal. That plan could keep some portion of the 10% cuts to Medi-Cal reimbursement rates, but likely not all. The Senate plan is also expected to contain a mix of new revenues.

It is not clear how or when the impasse will end. While both parties generally want to avoid cuts, they disagree on how or whether to raise new revenues to deal with the shortfall. Some Republicans may eventually agree to targeted tax increases, but will likely insist on a mandatory budget cap in return, which is generally opposed by Democrats. Until these issues are largely resolved, we will remain without a budget.

What is clear is that cutting health care remains an option for a legislature under increasing pressure to resolve a huge budget shortfall. CMA urges you to contact your legislator and ask them to commit to passing a budget which doesn’t cut health care. You can find your legislator by typing in your address at the legislature’s website: http://192.234.213.69/ lmapsearch/ framepage.asp.

Contact: Ned Wigglesworth, 916/444-5532 or nwigglesworth@cmanet.org.

(CMA Alert, August 18, 2008 issue)

CMA Publishes New Silent PPO Guide CMA’s Center for Legal Affairs has published a newly updated “Silent PPO Action Guide” to help physicians understand the complexities of health plan contracting and protect themselves from unlawful or unauthorized leasing of their health plan contracts. The revised guide incorporates new case law that gives physicians more power to extricate themselves from “silent PPOs.”

union trusts, or even other health plans. These “silent PPOs” allow the third-party payors to take advantage of discounted rates that health plans have negotiated with their contracted physicians. Health plans make a great deal of money, sometimes as much as $4 per subscriber per month, leasing physician networks. Health plans often conceal silent PPO clauses in lengthy contracts and use language that applies in perpetuity.

What Is a Silent PPO? Health plans often lease their networks of contracted physicians to other third-party payors, such as self-insured employers,

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CMA’s action guide contains an overview of physician discount contracts and discusses the laws that regulate silent PPO network

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leasing. The guide will help physician practices to detect and prevent silent PPO activity.

The silent PPO action guide is available through CMA ON-CALL (document #1907). ON-CALL documents are available free to members at CMA’s members-only website: www.cmanet.org/member.

Contact: Samantha Pellon, 916/551-2872 or spellon@cmanet.org.

(CMA Alert, August 18, 2008 issue)

MEDICO NEWS

DMHC Finalizes Balance Billing; CMA Calls Regulation a Giveaway to HMOs at Expense of Physicians and Patients After several months of receiving and reviewing comments on its proposal, the Department of Managed Health Care (DMHC) last month finalized its balance billing regulation. The regulation defines “unfair billing patterns” to include the practice of balance billing patients for the unpaid balance of bills only partially paid by HMOs for noncontracted emergency services. While the DMHC describes the regulation as an attempt to “restrict the practice of balance billing,” DMHC has no statutory authority to enforce or promulgate such a regulation. This regulation must now go to the Office of Administrative Law (OAL), to review the regulation for necessity, authority, clarity, consistency, reference, and nonduplication. If OAL finds that the regulation does not meet these standards, it will be sent back

to DMHC to try to correct the deficiencies. If OAL approves the regulation, CMA will take legal action to stop it from being implemented. CMA has already assembled an outside legal team and is in the process of raising funds for the legal fight. After DMHC proposed this regulation in March, CMA organized physicians to appear at hearings around the state to voice our opposition to these physician-unfriendly and unlawful regulations. Additionally, CMA filed extensive comments explaining our opposition to the regulation and why we believe DMHC to be overstepping its authority. The issues raised in these comments will serve as the basis for much of the OAL review and for our legal opposition. Essentially, DMHC has used a law intended to protect physicians to promulgate

Blue Shield Clarifies Contract Amendment CMA has received a number of calls from physicians concerned about a new Blue Shield contract amendment that was issued in response to the California Department of Insurance’s new health care access regulations. CMA has been working with Blue Shield to clarify what this amendment means to physicians. Blue Shield has assured us that the amendment is not intended to create any new onerous obligations for physicians or interfere with the scope and level of services a physician provides in his or her practice. Blue Shield has also indicated the amendment’s nondiscrimination language, while not taken directly from the regulations, will be interpreted within the framework of applicable state and federal law. (Log on to www.calphys. org/html/cc744.asp for a formal clarification statement jointly developed by CMA and Blue Shield on this issue.) If you have any questions about the amendment or the clarification statement, contact Blue Shield Provider Services at 800/258-3091. CMA continues to have concerns about the regulations themselves and has taken several steps to address both the underlying regulations and implementation efforts by insurers. CMA is working with the DOI to obtain clarification with respect to the newly mandated language. Contact: CMA’s reimbursement help line, 888/401-5911 or awetzel@cmanet.org. (CMA Alert, August 18, 2008 issue)

a regulation that attempts to prevent physicians from getting fully paid for the services they provide. Unlike previous proposals on balance billing, this version does nothing to regulate or obligate HMOs in any manner – failing to address both fair payment of physicians and inadequate physician networks. This regulation is an attempt by the Schwarzenegger Administration to appear to be defending the interests of patients, when, in fact, it is simply a giveaway to HMOs at the expense of physicians and patients. CMA will continue to provide updates as OAL completes its review. Contact: Armand Feliciano, 916/444-5532 or afeliciano@cmanet.org. (CMA Alert, August 4, 2008 issue)

CMA Legislative Victory – Physicians Removed From Costly and Burdensome Reporting Legislation In response to months of persistent lobbying by CMA and doctors in the author’s district, AB 2967 (Lieber), a bill which could impose unlimited data reporting requirements on health care providers, has been amended to exclude physicians and physician groups. CMA has long supported efforts to improve medical outcomes, the stated intent of AB 2967. However, prior to being amended, the bill would have required physicians and physician groups to give to a newly created state agency as much patient data as the agency demanded. This new bureaucracy would be created despite the fact that the state already has a successful outcomes reporting program under the Office of Statewide Health Planning and Development. By being excluded from AB 2967, physicians’ and physicians groups are also saved from paying the tens of millions of dollars in costs related to the legislation. Not only would they have been forced to pay for any additional staff necessary to collect and provide the data, physicians and physician groups would have been required to pay unlimited fees to fund the state agency. Intent language reflecting these concerns was also amended into the bill, so that any reporting requirements reflect an understanding of the financial burdens such requirements impose on physicians and physician groups. Contact: Lisa Folberg, 916/551-2880 or lfolberg@cmanet.org. (CMA Alert, August 18, 2008 issue)

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Classified

ADS office space for rent/lease MEDICAL OFFICE SPACE FOR LEASE • East San Jose 1,380 sq. ft. excellent medical suite across from Regional Medical Center. Available October 2008. First floor, with lab and xray suites in the building to make it convenient for your patients. Lots of parking available. Great visibility at corner of N. Jackson and Montpelier Dr., located at 244 N. Jackson Ave. Call Tania at 408/923-0257.

MEDICAL SUITES • WEST SAN JOSE/ CAMPBELL/LOS GATOS Medical Art Suites. 1,595 sq. ft. and 2,705 sq. ft. designed for 5+ treatment rooms, bathroom, and elegant reception area. Tenant improvement allowances. Minutes from hospitals and Hwys. 85 & 17/880. Excellent visibility. Located at 2242 Camden Ave. (Bascom Ave.), San Jose. Call 408/3777383.

MEDICAL SUITES • LOS GATOS – SARATOGA Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking. Located next door to Los Gatos Community Hospital. Both units currently available. Call 408/355-1519.

MEDICAL OFFICE FOR LEASE/ SUBLEASE Office in close proximity to O’Connor Hospital for lease/sublease. Please call 408/923-8098 for more information.

MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.

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MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA

PRIME MEDICAL SPACE • PRIME SAN JOSE LOCATION

Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/2280454.

2,048 sq. ft. ready to occupy medical office, previously occupied by RAMBLC Pediatric Group. Located at 6140 Camino Verde Dr, San Jose, in the Santa Teresa Medical/ Professional Center across from Kaiser Hospital. Call Virginia at 408/528-0571.

OFFICE SPACE FOR LEASE • SAN JOSE 600–1,900 sq. ft. in West Valley Medical Building, second floor, elevator, separate entrance. Call Helen at 408/243-6911.

OFFICE SPACE FOR RENT • MTN VIEW Consult room and exam room available in shared office suite, near El Camino Hospital. Shared receptionist and billing services available if desired. Contact Len Doberne, MD at 650/967-8841.

OFFICE SPACE FOR SUBLEASE • MTN VIEW Two exam rooms and one doctor’s office, five days a week, shared waiting room, in Mountain View, on South Drive. Call 650/967-7471.

OFFICE TO SHARE • LOS ALTOS Options include two exam rooms plus office. Newly remodeled office space perfect for cosmetic dermatologist, facial plastic, or plastic surgeon. Near El Camino Hospital. Call 650/804-9270.

OFFICE EXAM ROOMS TO LEASE Two nice and large exam rooms (dedicated), shared waiting room. Available five days a week, 2585 Samaritan Drive, San Jose. Please call 408/356-7788 for more information.

MEDICAL OFFICE SUITE FOR RENT • SAN JOSE Medical office suite for rent at 93 N. 14th St. San Jose 95112. Contact Dr. Sajjadi at 408/294-1825 or 408/867-1111.

SEPTEMBER / OCTOBER 2008

PROPERTY MANAGEMENT & LEASING BAYSIDE REALTY PARTNERS specializes in the property management and leasing of medical office buildings in the Bay Area, resulting in superior results for our clients. Should you wish to receive a free assessment of your property and a proposal, please contact Trask Leonard, CEO, at 650/282-4620, or tleonard@baysiderp.com.

PRIVATE PRACTICE for sale PRIVATE PRACTICE FOR SALE IM/FP/GP. Primary care practice for sale, including inventory and equipment. Close to O’Connor Hospital. If interested, please call Stacy at 408/297-2910.

PRIVATE PRACTICE FOR SALE Established/Active Internal Medicine/ Primary care practice for sale. Work/live in Coastal California. Enjoy best of everything. If interested, please call 831/345-9696.

EMPLOYMENT OPPORTUNITY MEDICAL PRACTITIONER WANTED Physicians, Physician Assistants, or Registered Nurses needed for contract

BRAND NEW HIGH END MEDICAL CONDOS–DOWNTOWN LOS GATOS Design/build-to-suit opportunities for sale/lease. On-site parking. In the heart of prestigious downtown Los Gatos. Unit sizes 1,400 sq. ft. and up. Contact Matt–408/282-3835. www. colliersparrish.com/losgatos. positions at the San Jose Military Entrance Processing Station, 546 Vernon Ave. Mountain View. Medical Practitioners will conduct medical qualifications examinations of applicants for all branches of Armed Forces. Must hold a current unrestricted license. Practitioners will be subject to credentials approval by the Headquarters U.S. Military Entrance Processing Command prior to employment. Excellent opportunity for someone looking for a flexible, part-time work schedule from 1-2 days per week to as little as a few hours per month. If you are searching for this unique opportunity, contact Ms. Veronica Knight at 650/603-8236 to become part of our team.

OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Dan R. Azar MD, MPH at 408/7902907 or e-mail dazar@ allianceoccmed. com for additional information. Owners Bill & Debbi Ricks 408-354-5613

FAMILY PHYSICIAN NEEDED MD or DO wanted. F/P in Santa Clara. Phone: 408/515-2222; Fax: 408/556-6773.

FAMILY MEDICINE PHYSICIAN NEEDED Part- or full-time physician sought to join existing practice. Currently, we have two full-time MDs and one part-time MD. Busy PPO-only practice. Very light call schedule, approx. one weekend in 17. Hospital work by choice only, close to Good Samaritan Hospital. Employee or expense sharing are options. If interested or for further details, please fax your information to 408/3589028. Upon reviewing your resume, we will call you.

condo/COTTAGE rentals CHRISTMAS/NEW YEAR • NORTH SHORE LAKE TAHOE Front lake, three bedroom, two & half bath townhouse. Sleeps eight. Linen, internet, year-round pool. $400 per night. Call Christiane at 408/356-7453.

COTTAGE FOR RENT • SARATOGA Cottage in Saratoga. Retreat-like setting. Close to great hiking and biking trails. Close to Hwy 85. One large bedroom, living room, kitchen, and bath. Private driveway and fenced yard. Rent $1,290 per month. Available mid-August. Contact Carolyn Silberman 408/867-1815, or cell 408/2217821, or email wwswolfe@aol.com.

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the bulletin

SEPTEMBER / OCTOBER 2008

alliance news

Alliance

News

Kathleen Miller, Membership; Siggie Stillman, Treasurer; Mary Hayashi, President-elect; Carolyn Miller, President; Meg Giberson, Legislation; Debbi Ricks, Installing Officer

On June 18, 2008, Carolyn Miller was installed as President of the Santa Clara County Medical Association Alliance, for a second term, at an installation luncheon held in Heather Goodmanâ&#x20AC;&#x2122;s lovely Saratoga home. Debbi Ricks, CMA Alliance President, installed Carolyn and her new board, Mary Hayashi, President-elect, Kathleen Miller, Membership Chair, Siggie Stillman, Treasurer, and Meg Giberson, Legislation. Special thanks go to Heather for hosting this delightful event.

Special thanks go to Dr. Stephen and Suzanne Jackson for hosting a funfilled afternoon in their lovely back yard. Everyone enjoyed the games, ice cream, and a chance just to get together on a warm summer afternoon. Thanks also go to Kathleen Miller and her husband, Dr. Craig Thomas, for organizing all of the details for the event, and to Wayne Miller, photographer.

the bulletin

SEPTEMBER / OCTOBER 2008

How Would You Treat A Patient After a Cryptogenic Stroke?

The California Pacific team also treats adult and pediatric patients with pulmonic stenosis, patent

ductus arteriosus, aortic coarctation, hypertrophic cardiomyopathy and atrial septal defect. After

Doctors at California Pacific Medical Center have

you make the diagnosis with appropriate imaging

device closure of patent foramen ovale in patients

be easily arranged with a single phone call. At

lism. The percutaneous closure procedure is per-

service and care for your patients, and seamless

been very successful in performing percutaneous

studies, patient referral and/or transfer can

with cryptogenic stroke from paradoxical embo-

CPMC, we pride ourselves on providing the best

formed under local anesthesia and is extremely

communication with you, the referring physician.

safe. Patients are typically discharged within 24 hours and are back to work the same week. California Pacificâ&#x20AC;&#x2122;s Heart and Vascular Center offers quality, comprehensive, patient-centered cardiovascular care by a team of pioneering physicians integrating leading-edge technology.

www.cpmc.org

For more information, to find a specialist or to schedule a patient transfer, please call

888-637-2762

Kalyani Trivedi, M.D. Pediatric Interventional Cardiologist

Peter Hui, M.D. FACC, FSCAI Adult Interventional Cardiologist

the bulletin

SEPTEMBER / OCTOBER 2008

It’s Good to Have Endorsements in an Election Year The Santa Clara County Medical Association and 27 other California medical societies endorse NORCAL as the professional liability insurer for their members. That’s because they know that 9 out of 10 claims NORCALprocessed last year were closed without indemnity payments. They also know NORCAL has returned $358 million in dividends to our policyholder owners since 1975. Visit www.norcalmutual.com today, or call 800.652.1051. NORCAL. Your commitment deserves nothing less.

You practice with passion. Our passion protects your practice. THE

BULLETIN

A PUBLICATION OF THE SANTA CLARA COUNTY MEDICAL ASSOCIATION

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