2010 November/December by SCCMA

NOVEMBER / DECEMBER 2010 | Volume 16 | Number 6

INSIDE THIS ISSUE: HEALTH REFORM TIMELINE FOR 2011-2018 ACCOUNTABLE CARE ORGANIZATIONS

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BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org

MEMBER BENEFITS Legal Services/On-Call Library Reimbursement Advocacy/ Coding Services Billing/Collections Discounted Insurance Referral Services With Membership Directory/ Website

From the Editor’s Desk.................................................................................6 Joseph Andresen, MD

From the MCMS President...........................................................................7 John T. Jameson, MD

Prevention: A Chance to Practice What We Preach..................................8 Tom Dailey, MD and Roger P. Kennedy, MD

James Hinsdale, MD, Is Elected CMA President.......................................10 Phil Lippe, MD, Receives the Gary F. Krieger Speaker’s Recognition Award....................................................................................................... 11

Legislative Advocacy/MICRA

House of Delegates’ Highlights................................................................14

House of Delegates Representation

Are Accountable Care Organizations In Your Future?............................16

Practice Management Resources and Education Financial Services Professional Development Health Information Technology Resources Publications

Health Reform Timeline for 2011-2018.....................................................18 Coding Corner.............................................................................................26 Sandie Becker, CMC

SCCMA/MCMS Alliance News....................................................................28 Getting Ready for the Cold and Flu Season.............................................32 Carol A. Lee, Esq.

CME Tracking

MEDICO News.............................................................................................34

Physicians’ Confidential Line

Classified Ads..............................................................................................36

Verizon Discount Human Resources Services PAGE 3 | THE BULLETIN | NOVEMBER/DECEMBER 2010

The Santa Clara County Medical Association Officers

AMA Trustee - SCCMA

Councilors

President Thomas Dailey, MD President-Elect William Lewis, MD Past President Howard Sutkin, MD VP-Community Health Cindy Russell, MD VP-External Affairs Rives Chalmers, MD VP-Member Services Scott Benninghoven, MD VP-Professional Conduct Eleanor Martinez, MD Secretary Sameer Awsare, MD Treasurer James Crotty, MD

James G. Hinsdale, MD

El Camino Hospital of Los Gatos: Art Basham, MD El Camino Hospital: Lynn Gretkowski, MD Good Samaritan Hospital: Jeff Kaplan, MD Kaiser Foundation Hospital - San Jose: Efren Rosas, MD Kaiser Permanente Hospital: Allison Schwanda, MD O’Connor Hospital: Jay Raju, MD Regional Med. Center of San Jose: Emiro Burbano, MD Saint Louise Regional Hospital: John Huang, MD Stanford Hospital & Clinics: Peter Cassini, MD Santa Clara Valley Medical Center: John Siegel, MD

Tanya W. Spirtos, MD (Alternate)

SCCMA/CMA Delegation Chair James Crotty, MD (District VII)

CMA Trustees - SCCMA Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (President) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)

Chief Executive Officer

Debbi Ricks (Alliance)

William C. Parrish, Jr.

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Editor

OFFICERS

THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Printed in U.S.A.

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin or the Santa Clara County Medical Association and the Monterey County Medical Society. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by the Santa Clara County Medical Association or the Monterey County Medical Society 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

President John Jameson, MD President-Elect James Ramseur, MD Past President William Khieu, MD, MBA Secretary Eliot Light, MD Treasurer John Clark, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD

Patricia Ruckle, MD

Valerie Barnes, MD

Scott Schneiderman, DO

Ronald Fuerstner, MD

Kurt Sliger, MD

David Holley, MD

Steven Vetter, MD

R. Kurt Lofgren, MD

For Physicians Only

In every medical community, there are those rare physicians, who after many years of practice, have been singled out to exist in a class of their own. These physicians often take care of the most distinguished and high profile people in their communities. These are the doctors whom MD2 will pursue as we open new offices in select cities.

Chicago

—

San Francisco

—

Seattle

—

Portland

—

Bellevue

If you are such a physician, with a primary care practice in the community surrounding Stanford, we would like to hear from you.

Palo Alto

FROM THE EDITOR’S DESK

MEDICINE – A PROFESSION WITH REWARDS AND CHALLENGES THAT WE ALL SHARE AND UNDERSTAND By Joseph Andresen, MD This past August, I had the unique opportunity to spend time with physicians on two different continents. With health care reform and the enactment of the Patient Protection and Affordable Care Act on all of our minds, it was fascinating to sit and talk with doctors working in very different health care systems and hear their accomplishments and frustrations first hand. In the end, I realized that despite our many differences in working environments and cultures, we all speak a common language. Patient care is a vocabulary that we all understand that transcends any distance or differences between us. Dr. Mats Bauer is an orthopedist and president of the Swedish Society of Medicine. Visiting the Society’s handsome and historic office located in downtown Stockholm, I was fortunate to spend time with him one afternoon. I was very curious to hear how medicine was practiced in this country known for its cradle-to-grave socialized health care system. How long did patients wait for surgery? Was there rationing? Did advanced age restrict elderly patients from certain therapies? Were financial resources adequate to provide quality care? How happy were Swedish physicians with their practices and ability to take care of patients? Our hour together concluded much too quickly and I was still eager to hear and share much more. However, in this relatively short time, I came away with a new perspective on health care and the practice of medicine in Sweden. Dr. Jose Morais, a graduate of the University of Lisbon School of Medicine, has been in general practice on the island

of Brava, Cabo Verde for the past 27 years. Cabo Verde is an archipelago of 10 islands, 300 miles off the coast of Senegal in the Atlantic Ocean. This country is a former colony of Portugal that declared its independence in 1975, becoming one of the stable model democracies of the continent. You might ask how I ended up visiting this place so far away? My wife, Maria, was born on the island of Brava and immigrated to Massachusetts with her family at 12 years of age. There is a large Cape Verdean community in New Bedford and New England, established when the whaling and shipping trades flourished in the early 1800s. Our journey was her first return visit to her birthplace with our son and daughter. It was a cultural awakening for our entire family. Well, you can imagine that Dr. Morais has faced much different challenges in his practice than our Swedish colleague. Arriving with just a stethoscope after graduation, Dr. Morais had to do a great deal with relatively little. He and one other physician run the island’s only clinic, treating emergencies, infectious diseases, chronic medical conditions, and performing all uncomplicated deliveries in caring for the island’s 6,000 inhabitants. One of the most difficult challenges is properly triaging patients, since Brava is an isolated island, ten miles away from its closest neighbor and only accessible by fishing trawler. There are no operating rooms, anesthesiologists, surgeons, or specialists available, so anticipating a patient’s needs early on and transferring them to the nearest hospital on the neighboring island of Fogo can mean the difference between life and death. What did I take away from these visits with two doctors in very

Joseph Andresen, MD is the editor of The Bulletin. He is board certified in anesthesiology and is currently practicing in the Santa Clara valley area. different parts of the world? Medicine is a profession with rewards and challenges that we all share and understand. We are often forced to make the best use of the resources available through skills and judgment, strengthened by years of training. The organization and resources dedicated to a nation’s health care system profoundly determine how effective we are as physicians. I hope to share much more of my visit with Drs. Bauer and Morais in the future. This month’s Bulletin provides a detailed time line for the implementation of the Patient Protection and Affordable Care Act. As the political intrigue and controversy continue, it will be important to share this information so that patients and our colleagues have a factual resource that details the benefits and requirements as the new law is implemented. As one can see, there are already a number of changes that provide immediate benefits such as removal of preexisting exclusions for children under 19, extension of young adult’s health insurance coverage up to age 26 with parents’ policies, tax credits for small businesses, and rebates and 50% drug discounts for seniors with Medicare Part D drug coverage. Being informed will enable you to be the best advocate for your patients.

PAGE 6 | THE BULLETIN | NOVEMBER/DECEMBER 2010

MESSAGE FROM THE MCMS PRESIDENT

MUSCLE TAKES MEMBERSHIP – YOUR PROFESSION NEEDS YOU! By John T. Jameson, MD 2010-2011 MCMS President The California Medical Association recently finished its convention in Sacramento at the beginning of October. In many ways, it is becoming better organized, better focused, and more proactively constructive than at times in the past, and I’m particularly impressed with the leadership of the new CEO, Dustin Corcoran, who is looking for ways to improve the CMA’s communications to the general membership, to listen to our needs, and promote our interests in Sacramento and Washington. At this time, I believe it is important for all Monterey County doctors, members and non-members of the Monterey County Medical Society alike, to be aware of significant legislative activities occurring in the near future. The first is the issue of Sustainable Growth Rates (SGRs), which the U.S. Congress has been avoiding a definitive fix to for some time now. Come November’s lame duck session, there will be a five-day period in which our congressional representatives need to be encouraged to enact a delay of at least 13 months of the 23% cut in Medicare rates scheduled to take place before the end of this year, and an additional 6% cut in January. If they fail to do this, many of us face punishing decreases in revenue. Congress needs to know that inaction would put many doctors’ offices in financial jeopardy, and seniors need to be told that it may become harder for them to find a doctor who will accept Medicare patients. The easy promise of an ultimate fix,

that retroactively reimburses us, will not sustain us during however-long-a-period of meager payments it would take for them to act (sounds like California!). The CMA liaison in Washington reports that our congressional delegation understands the issue and supports our position; but they are obstructed by a handful of other legislators from the South and Midwest (I’m guessing the Senate, given its proclivity for filibusters). If you have any friends in these states with influence, you might want to give them a call and get them to talk to their legislators; talk to your senior acquaintances there about what might happen to doctor availability if nothing is done. Another issue of significance: there is talk about California trial lawyers trying to raise the MICRA cap on pain and suffering awards in the 2011 legislative session in Sacramento. While this has been attempted in years past and successfully, even easily, quashed, there is a sense that this year could be different. In my opinion, the best defense could be a good offense. My three months last year in New Zealand gave me insight into how bad patient outcomes can be handled better: through a workmans’ compensationsort-of-arrangement, where the patient’s legitimate needs can be met through no-fault insurance without having to place blame on physicians, hospitals, or others. “Bad” providers, when identified, are dealt with through the equivalent of the Medical Board of California. Under this arrangement, there would be no reason, other than enriching lawyers, to have anything go through the tort system; and if the trial lawyers cannot be shamed into

John Jameson, MD, is the 20102011 President of the Monterey County Medical Society. He is board certified in pathology and is currently practicing at Natividad Medical Center. living with this arrangement, legislators, who can unfortunately be a rather shameless lot, still strive to be reelected and don’t want bad publicity. If we have the muscle, we can persuade them to see things our way. But whatever route we take, muscle takes membership; and now may be the time when, if you’re not already a member, you should become one. I know some of us would like for MCMS to suffice as a party club for convivial colleagues to enjoy each other’s company. It’s one of my regrets that there is too little partying these days and too much struggle for survival, both for your offices and for MCMS. But, the primary purpose of MCMS is to be the local grassroots organization for the CMA, which is the primary lobbying organization for medicine in California. If you love your profession, as I do, and if you think it’s worth defending and helping to prosper, as I do, you owe it to yourself to get involved any way you can. If you can’t afford to join the CMA/MCMS, you can give money to CALPAC to help sympathetic legislators, or give to the CMA Foundation to promote its good deeds. Your profession needs you!

PAGE 7 | THE BULLETIN | NOVEMBER/DECEMBER 2010

PRACTICE MANAGEMENT

PREVENTION: A CHANCE TO PRATICE WHAT WE PREACH By Thomas Dailey, MD, 2010-2011 SCCMA President; Roger P. Kennedy, MD, 1992-1993 SCCMA Past President In 2009, Congress passed the American Recovery and Reconstruction Act. One component of this stimulus act provided funds for a program called CPPW – Communities Putting Prevention to Work, administered by CDC. The program focuses on tobacco, obesity, and physical inactivity, all shown to be the biggest contributors to chronic disease costs. Santa Clara County was one of 44 communities across the United States to receive a grant, in part as recognition of all the significant work we have done over the past 20 years. The Public Health Department’s Center for Chronic Disease & Injury Prevention received a grant of $6.9 million dollars for projects to reduce tobacco use, to reduce exposure to secondhand smoke, and to help smokers quit. Overall, the CPPW program is expected to demonstrate that prevention really does work and that communities can effectively use evidence-based best practices to actually affect the health of communities. These 44 projects are being closely watched, and the success or failure will have a major impact on future funding for preventive medicine as health care moves forward. The stakes really are high! Best practices for tobacco control include local policies to restrict smoking in all public spaces, to reduce youth access to tobacco, to increase price of tobacco, consistent and repeated antitobacco messages, and ready access to evidence-based cessation programs, including nicotine replacement therapies. Among the initiatives planned for the CPPW project in Santa Clara County are:

7. Provide a network of cessation programs, focusing on high-risk groups, with free NRT. 8. Mobilize a young people’s network to advocate for policy changes. 9. Develop an advertising program to further change social norms around tobacco use. Breathe California has been awarded a grant to develop the network of cessation programs, and to work with residential health care facilities to help them become smoke free. They can be reached at 408/998-5865 or janet@lungsrus.org, and they will be able to provide you with information on the network and resources such as: 1. Best practices for addressing tobacco use and cessation in your office;

1. Eliminate loopholes in workplace smoking restrictions.

2. Ways to refer to culturally appropriate cessation services; and

2. Promote 100% smoke-free college campuses.

3. Materials, pamphlets, posters, etc. for your office and waiting room.

3. Establish smoking restrictions in outdoor eating areas, service lines, common areas of housing units. 4. Implement tobacco retail licensing. 5. Restrict sales and advertising near schools.

Again, we wish to emphasize that this program goes beyond helping the 1.8 million residents of Santa Clara County. This has national implications, and Congress will be watching to see if we can rise to the occasion!

6. Establish an abatement fee on tobacco to offset the cost of litter. PAGE 8 | THE BULLETIN | NOVEMBER/DECEMBER 2010

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Continued on page 10 PAGE 9 | THE BULLETIN | NOVEMBER/DECEMBER 2010

2010 CMA Annual Session

James Hinsdale, md, is elected cma president James Hinsdale says CMA will continue to fight for patients and the doctors who serve them, as health care reform presents new challenges. James Hinsdale, MD, a San Jose trauma surgeon, took over as president of the California Medical Association in October, as physicians elected new officers and voted on a wide array of medicallyrelated policies to guide the organization in the coming year. “No one in this state can deny that CMA has, and always will, put the care and well being of the residents of California first,” Dr. Hinsdale said in his acceptance speech. “Who can forget CMA’s leadership in health reform? All of it was devoted to guaranteeing access to care for patients and stopping insurance abuses such as dropping coverage for patients who get sick.” Dr. Hinsdale praised efforts to protect the integrity of the medical profession, including preserving California’s landmark tort reform law, MICRA, passed 35 years ago and the longstanding ban on the corporate practice of medicine that prevents hospitals from directly hiring physicians to ensure doctors’ treatment decisions are not influenced by financial interests. “I can say the one thing that binds doctors together is this: We would just like

everyone to stay out of our way and let us practice medicine,” Hinsdale said. “It isn’t about money. It’s about being a professional and having the autonomy needed to care for our patients.” Dr. Hinsdale was one of nearly 1,000 physicians from around the state who gathered in Sacramento for CMA’s 139th annual House of Delegates meeting. Dr. Hinsdale accepted the presidency of the 35,000-member organization, and Dr. James Hay, of San Diego County, was elected president-elect. At the convention, physicians debated more than 100 resolutions relating to medical ethics, public health, science, insurance, and public policy. Dr. Hinsdale, 61, is the director of trauma at Marin General Hospital and executive director of trauma at Regional Medical Center in San Jose. He is a board-certified surgeon and the founder and president of the Northern California Trauma Medical Group, a collection of 18 practicing trauma surgeons. Dr. Hinsdale is currently assistant clinical professor of surgery at the Stanford University School of Medicine and has been the medical director of California Shock/ Trauma Air Rescue for the past 23 years. He also maintains an active clinical practice in trauma and cancer surgery. Dr. Hinsdale received a medical degree from the University of Illinois College of Medicine. He had his internship and residency at Stanford University Hospital from 1974 to 1980. He is a past President of the Santa Clara County Medical Association.

Also serving on CMA’s Executive Committee are the following physicians: •

Immediate Past President Dr. Brennan Cassidy, who presently works in cosmetic dermatology in Santa Ana.

•

President-Elect Dr. James Hay, who is a family physician in Encinitas. He founded North Coast Family Medical Group in 1978 and North County Physicians Medical Group (an IPA) in 1990.

•

Speaker of the House Dr. Luther Cobb, who is a surgeon in Humboldt County. He is a former department chair of surgery and currently vice chief of staff at Mad River Community Hospital.

•

Vice Speaker of the House Dr. Ted Mazer, who is an ear, nose and throat specialist in private practice in San Diego.

•

Chair of the Board of Trustees Dr. Paul Phinney, who is a general pediatrician at Kaiser Permanente Medical Group in Sacramento. He has worked for Kaiser for over 20 years, almost all in pediatric settings.

•

Vice-Chair of the Board of Trustees Dr. Steve Larson, who is a practicing internist and infectious diseases consultant at Riverside Medical Clinic in Riverside County. Dr. Larson is also the clinic’s CEO and chairman of the clinic’s board of directors.

PAGE 10 | THE BULLETIN | NOVEMBER/DECEMBER 2010

2010 CMA Annual session

PHIL LIPPE, MD, RECEIVES THE GARY F. KRIEGER SPEAKER’S RECOGNITION AWARD During the 139th annual session of the California Medical Association’s recent House of Delegates, CMA honored Phil Lippe, MD, SCCMA and CMA member since 1964 and SCCMA president in 1978-79, with its Gary F. Krieger Speaker’s Recognition Award. The Krieger Award was established in 2002 in honor of Gary Krieger, MD, a physician who was a passionate advocate for MediCal and for patient care. The award is given to one physician each year who provides outstanding leadership and contributions for his or her fellow physicians to CMA and was a former member of the House of Delegates. Dr. James T. Hay, as Speaker of the House, made the following presentation speech: “From Drs. Rebecca Patchin and Hugh Vincent to Drs. Art Lurvey and Richard Butcher, the Speaker’s Recognition Award has been given to 13 members of the House of Delegates who have made significant contributions to CMA and to this House and who have not been officers of the Association. The award was created in 1995 and renamed the Krieger Award in 2002 to honor our late speaker and president-elect, Gary F. Krieger. It is one of the great pleasures of being speaker to be able to select someone each year from among the nominations solicited from your delegation chairs. A review of the accomplishments of the nominees is truly humbling. It will take me longer to introduce this year’s awardee because of the length of the list of contributions this man has made. He has been a member of CMA for 46 years, a delegate to this House for 33, and served on the CMA Council (now called the

Board of Trustees) from 1979 through 1987, serving as its secretary the last two of those years. He has been the president of his medical society and of his state specialty society and has served as an AMA delegate or alternate for many years. This year’s Krieger Award winner has served on many, many CMA committees and chaired four of them, including the Committee on Physician Supply and the Committee on Health Professions and Licensure. More recently, he has been an active participant on the Workers’ Comp TAC. I’m told he was one of the first to provide “MiniInternships” years ago, inviting legislators and other non-physicians to see what the work life of a physician is really like, and that must have been something to follow around a neurosurgeon. How many of us can ever expect to have an award named after us? The Krieger Award name occurred posthumously, but this gentleman’s name is attached to an award for a physician for outstanding contributions to the social and political aspects of his current specialty, Pain Medicine. I guarantee you, I have merely touched the surface of what this man has done in his career and, to have done so much, I assume he must be 112 years old. Ladies and gentlemen, please welcome the recipient of the 2010 Gary F. Krieger Speaker’s Recognition Award, Dr. Phil Lippe.” The Santa Clara County Medical Association and Monterey County Medical Society congratulate Dr. Lippe on this very special and well-deserved honor!

PAGE 11 | THE BULLETIN | NOVEMBER/DECEMBER 2010

Photos From Dr. Jim Hinsdale’s P 2010 House of Delega

Photo Credit: Jeffrey Coe

Changing of the guard from CMA’s Past President, J. Brennan Cassidy, MD, to new President, Jim Hinsdale, MD.

L to R: Richard Adrouny, MD; SCCMA/CMA Delegates David Campen, MD, and Marshall Yacoe, MD; MCMS President-Elect and MCMS/CMA Delegate James Ramseur, MD; and Valerie Barnes, MD.

Dr. Hinsdale poses with his wife Bonnie and family.

Dr. Hinsdale poses with his beautiful granddaughters.

SCCMA/CMA Delegate Dr. James Silva and his wife enjoy the evening.

SCCMA VP-Community Health and SCCMA/ CMA Delegate Cindy Russell, MD, was very happy to have her resolution passed at HOD! Congratulations Dr. Russell!

L to R: Dr. Ken Blumenfeld, Dr. Bill Ricks, and Debbi Ricks (CMA/SCCMA Alliance Past President and CMA Trustee). PAGE 12 | THE BULLETIN | NOVEMBER/DECEMBER 2010

Presidential Reception and the ates Annual Session

e, MD, and David Flatter

Dr. Hinsdale celebrates the special evening with his family.

SCCMA/CMA Delegate Rebecca Powers, MD enjoys the camaraderie at the HOD.

SCCMA Past President Howard Sutkin, MD, and SCCMA/MCMS’s CEO Bill Parrish.

SCCMA Past President and CMA Trustee Tanya Spirtos, MD, and SCCMA/MCMS’s CEO Bill Parrish.

12 15

SCCMA Past President Bob Burnett, MD, and colleague.

SCCMA/CMA Delegate Rebecca Powers, MD speaks up at the House of Delegates.

14 11

SCCMA/CMA Delegate Eleanor Martinez, MD, and colleague.

SCCMA/CMA Delegate Jeff Coe, MD, and CMA’s CEO Dustin Corcoran.

16 12

SCCMA’s Treasurer and SCCMA/CMA’s District VII Delegation Chair Jim Crotty, MD, and SCCMA Past President and CMA Trustee Martin Fishman, MD.

SCCMA/CMA Delegates Robert Gould, MD, and Seham ElDiwany, MD.

PAGE 13 | THE BULLETIN | NOVEMBER/DECEMBER 2010

2010 CMA Annual Session

House of delegates’ highlights Submitted by CMA Hundreds of California doctors convened in Sacramento in October for the 2010 House of Delegates, the California Medical Association’s annual meeting. Each year, physicians from all 53 California counties, representing all modes of practice, meet to discuss issues related to health care policy, medicine, and patient care, and to elect CMA officers. The following are summaries of some of the resolutions that the House adopted as policy.

(no copayment or deductible) for certain preventive services.

policy recommendations on marijuana legalization, regulation, and education.

Insurance coverage for smoking cessation: Building on CMA’s long-standing policy against the use of tobacco, the delegates voted to support state legislation requiring health plans to include coverage for tobacco cessation services, including counseling and both prescription and nonprescription medications approved by the FDA for tobacco cessation, without copayment, coinsurance, or deductible.

Hospital visitation rights: The delegates voted to support the right of all patients in hospitals and other health care facilities to choose their visitors and to designate decision-making power to whomever they wish. The delegates also resolved that hospitals should not deny visitation privileges on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability.

Accountable Care Organizations (ACOs): To ensure that quality of care and patients’ interests are the highest priority, the delegates directed CMA to support legislation requiring that ACOs created as a result of federal health care reform legislation only be permitted to function in California if they are physicianled organizations (unless preempted by federal law). See sidebar for CMA/AMA’s adopted principles.

Childhood immunizations: The delegates asked CMA to work with the California Department of Public Health to raise awareness of the importance of routine childhood immunization against vaccine preventable diseases. The resolution would achieve this by supporting mandatory posting of clearly visible signs in California schools, where the personal belief exemption rate exceeds 5%, alerting parents and families that their children are at increased risk of vaccine preventable disease due to potential loss of herd immunity.

Alternative medications: The delegates urged Congress to give FDA the authority and funding to regulate alternative medications, including homeopathic medications. The delegates also voiced support for requiring manufacturers of alternative medications to do studies to prove the efficacy of their products.

California’s physician workforce: The delegates created policy requiring CMA to develop a comprehensive strategy for achieving a more equitable distribution of physicians practicing in primary care specialties. Medical student debt: The delegates asked CMA to explore new state, federal, and private funding sources to reduce medical education debt for medical students, residents, and fellows. Preventive services awareness: The delegates voted that CMA, working with the CMA Foundation, seek funding to conduct a physician and public awareness campaign on the new federal requirement that insurers provide first dollar coverage

High fructose corn syrup: The delegates passed a resolution requiring CMA to advise the public that extensive and increasing consumption of caloric sweeteners (and especially high fructose corn syrup) threatens the health of Californians. The resolution also called on CMA to take action to limit public consumption of caloric sweeteners.

Tax deductibility for health care expenses: Reaffirming existing CMA policy, the delegates voted to support legislation allowing full income tax deductibility of all health insurance premiums, as well as out-of-pocket expenses for physician fees and physicianprescribed treatments and diagnostic examinations. The full text of these and other resolutions passed by the House of Delegates is available on CMA’s membersonly website, http://www.cmanet.org/ member.

Legalization of marijuana: The delegates recognized the public movement toward the legalization of marijuana and asked CMA to convene a technical advisory committee to develop

PAGE 14 | THE BULLETIN | NOVEMBER/DECEMBER 2010

CMA and AMA House of Delegates adopt ACO principles At its annual House of Delegates conferences, the California Medical Association and American Medical Association adopted principles for physicians to follow in evaluating accountable care organizations (ACOs) and medical foundations. One key element of health care reform involves establishing ACOs as a new model of care. Under the new law, groups of physicians who see Medicare patients and agree to work together – meeting certain government requirements to qualify as an ACO – would be eligible for bonuses if they meet spending benchmarks for caring for their patient population and other criteria. Many in the health care industry see ACOs as an opportunity to capitalize on health reform, realign and boost overall cost effectiveness, but exactly how ACOs will work remains unclear, as the federal government still must spell out regulations. Physicians need to make prudent decisions in the near future about their interest in participating, if they are to take advantage of the opportunities created by new health care reform laws and regulations. CMA/AMA’s adopted principles include: 1. Guiding principle – The goal of an Accountable Care Organization (ACO) is to increase access to care, improve the quality of care, and ensure the efficient delivery of care. Within an ACO, a physician’s primary ethical and professional obligation is the well-being and safety of the patient. 2. ACO governance – ACOs must be physician-led and encourage an environment of collaboration among physicians. ACOs must also be physician-led in order to ensure that a physician’s medical decisions are not based on commercial interests, but rather on professional medical judgment that puts patients’ interests first. 3. Voluntary participation – Physician and patient participation in an ACO should be voluntary, rather than a mandatory assignment by Medicare. Any physician organization (including an organization that bills on behalf of physicians under a single tax identification number) or any other entity that creates an ACO must obtain the written affirmative consent of each physician to participate in the ACO. Physicians should not be required to join an

ACO as a condition of contracting with Medicare, MediCal, or a private payer or being admitted to a hospital medical staff. 4. Savings used for patient care – The savings and revenues of an ACO should be retained for patient care services and distributed to the ACO participants. An ACO’s savings and revenues should not go to insurers. 5. Flexibility in patient referral and antitrust laws – The federal and state anti-kickback and self-referral laws and the federal Civil Monetary Penalties (CMP) statute (which prohibits payments by hospitals to physicians to reduce or limit care) should be sufficiently flexible to allow physicians to collaborate with hospitals in forming ACOs without being employed by the hospitals or ACOs. This is particularly important for physicians in smalland medium-sized practices who may want to remain independent, but otherwise integrate and collaborate with other physicians (i.e., so-called virtual integration) for purposes of participating in the ACO. 6. Quality performance standards – The quality performance standards required to be established by the secretary must be consistent with CMA policy regarding quality. The ACO quality reporting program must meet the CMA and AMA principles for quality reporting, including the use of nationally-accepted, physician specialty-validated clinical measures developed by the AMA-specialty society quality consortium; the inclusion of a sufficient number of patients to produce statistically valid quality information; appropriate attribution methodology; risk adjustment; and the right for physicians to appeal inaccurate quality reports and have them corrected. There must also be timely notification and feedback provided to physicians regarding the quality measures and results. For more detailed information, please visit CMA’s website at www.cmanet.org/aco to read the full report from CMA’s Physician-Hospital Alignment Technical Advisory Committee. CMA will continue to keep members apprised of all significant developments concerning ACOs and federal health care reform, as they unfold.

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PRACTICE MANAGEMENT

Are Accountable Care Organizations (ACOs) in Your Future? Submitted by the California Medical Association As physicians in this era of health care reform, we are facing unparalleled challenges. We have also been presented with some unique opportunities to move further toward a patient-centered and physician-led health care system. We certainly must now act swiftly to educate ourselves, and each other, about newly authorized hospital-physician organizations. We will need to make prudent decisions in the near future about our interest in participating, if we are to take advantage of the potential opportunities the changes in law and regulation will present. Many physicians across the state are being approached by hospital systems to join new hospital-physician organizations. These new entities contemplate being organized either through state law, as 1206(1) Medical Foundations, or through Medicare, as Accountable Care Organizations (ACOs), which were recently authorized by Congress in the federal health care reform legislation. Some physicians are concerned that hospitals are forming these organizations to exert more control over physician practices and to better position themselves financially in an environment of scarce resources. Other physicians would like to join these organizations, but need to understand their rights. And some physicians are seeking to form their own ACOs. CMA is working to help you navigate these negotiations with your colleagues and possibly your local hospitals, and to help you plan a future where physicians have financial and clinical

autonomy in the Medicare program and the private marketplace. To help you understand your rights and options, CMA is developing educational programs and materials, including legal and financial models, to help you understand how to form these organizations; practical tips to assist physicians joining with hospitals; and policy to guide regulatory implementation advocacy. Congress authorized ACOs, which are intended to create incentives for physicians who work together to coordinate care, improve quality and reduce unnecessary costs at the local level for a specific population of Medicare patients. Bear in mind, that the final rules of how ACOs will operate depend on regulations that have yet to be written at both the federal and state levels. The ACO concept couples payment and delivery system reform. ACOs are paid through a shared savings payment approach. ACOs allow physicians to be jointly rewarded for the efficiencies they achieve in both the Medicare Physician Part B and the Hospital Part A programs. Physicians in ACOs will continue to bill Medicare under the traditional fee-for-service program. If an ACO reports on quality measures and achieves savings by meeting a cost benchmark, Medicare will share a portion of the cost savings with the ACO. ACOs must have a legal and administrative structure to distribute the savings to physicians. ACOs do not have to involve a hospital and may be physician-led and comprised of physicians only. CMA fought very hard to maintain such physician autonomy in the legislation. ACOs can be primary care or multi-specialty medical

groups, or they can be IPAs or other networks of individual physician practices, all with or without integration with hospitals. The ACO must, among other things, establish a mechanism for shared governance, and agree to be accountable for cost, quality, and the overall care of the Medicare patients assigned to it. ACOs must participate in the program for at least three years, and must have an adequate network of primary care and specialist physicians to serve at least 5,000 Medicare patients. While Congress only contemplated a fee-for-service model, some medical groups are asking Medicare to expand the program to allow capitation. The creation and operation of an ACO could require substantial clinical, technical, and financial resources. While creating an ACO or joining one may sound like a daunting task, the ACO concept is not new in California. Many California physicians have been at the forefront of designing physician-led, patient-centered medical group/ IPA delivery models, which effectively function as ACOs already. CMA will rely on this experience and expertise, to ensure that as members you have the necessary tools and information to make the right decisions about your practice. ACOs could also provide a path to antitrust relief for physicians in the private sector. Some physicians are forming ACOs to eventually negotiate and contract with private payers. The Federal Trade Commission has allowed medical groups that meet certain standards for clinical integration, to collectively negotiate with private payers. FTC Chairman Jon Leibowitz recently stated that he does not see much enforcement risk with respect to ACOs in the Medicare program, and

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he believes there is room for ACOs to use joint contracting with respect to private payers, as long as they comply with the FTC’s well-established financial or clinical integration guidelines. ACOs could be financially integrated by virtue of distributing a shared savings, and clinically integrated through systems such as electronic health records, collaborative referrals, and quality reporting. Of course, the FTC will be monitoring ACO market power in the private sector. In an effort to capture the potential cost savings of ACOs, provide capital to physician practices, and/or compete with physician groups, some hospital systems and their associations are seeking to create hospital-led 1206(1) Medical Foundations. Contrary to the current trend, foundations can be, and often are, physician-led and not necessarily affiliated with a hospital. Indeed, Health and Safety Code Section 1206(1), which codifies the foundation law, was adopted to benefit two nonprofit, multi-specialty physician-controlled medical clinics and the communities they serve. The 1206(1) law exempts a clinic from the clinic licensing law, if it is operated by a nonprofit corporation that “conducts medical research and health education and provides health care to its patients through a group of 40 or more physicians and surgeons, who are independent contractors representing not less than 10 boardcertified specialties, and not less than twothirds of whom practice on a full-time basis at the clinic.” While the exemption was enacted to provide benefits to the communities they serve, the Medical Foundation model is sometimes used as a hospital-physician alignment strategy in order to, among other things, address declining reimbursements and increased financial pressures, and improve quality of care. Unfortunately, today, some hospitals are seeking to inappropriately apply the foundation model to gain control over physician practices,

since they have failed to change state law to employ physicians and are facing increased financial pressures. CMA’s overarching goal is to provide the best possible information to help physicians make individual decisions about the best practice arrangement for their professional situation. Some physicians will decide to join foundations or ACOs – whether led by physicians or hospitals. CMA will provide information to help those physicians negotiate optimal arrangements. Other physicians will choose to form their own organizations. CMA will provide information, tools, and models to help physicians establish such organizations. Webinars. CMA has launched a series of webinars on ACOs, other payment models, and the health care reform law in general, to help familiarize physicians with the new law and educate physicians about its impact on their practices. Upcoming webinars will be posted at www.cmanet. org/calendar and announced in CMA Alert. Archived Webinars. If you missed any of our recent webinars, they are available for on-demand viewing at the CMA website. Go to www.cmanet.org/ calendar and click on “Webinar Archive – Members click here.” ACO/Payment Model Issue Briefs. A series of Issue Briefs on ACOs and medical homes can be found on the CMA Federal Health Reform page at www. cmanet.org/healthreform, under the title “Federal Health Reform Series.” CMA will also soon be providing links to other noteworthy articles and white papers on the ACO concept at www.cmanet.org. CMA “On-Call” Document. A new CMA document, #0218, Legal and Practical Considerations Concerning Medical Foundations, can also be found on our website through the CMA OnCall system at www.cmanet.org. The document explains the legal requirements for these foundations, and any practical

considerations involved when deciding whether to join one. CMA Physician-Hospital Alignment Committee. Finally, CMA has formed a Physician-Hospital Alignment Technical Advisory Committee to advise the Board of Trustees on the development of future physician empowerment strategies; to guide our policy goals; to oversee the documents, tools, and models provided to CMA physician members; and to guide CMA advocacy through the legislative and regulatory arenas. While CMA is working to help physicians build collaborative organizations or make decisions about other models, we will also be offering a program at our annual Leadership Academy in June 2011 to help physicians explore the possibility of establishing a non-contracted status or a concierge practice. Many physicians across the state have successfully cancelled their private health plan contracts, and participation in Medicare, to contract directly with their patients. It is not a model that can work in every specialty, or in every region of the state, but we will help physicians make those assessments and learn from others who have done it successfully. It is a model that has allowed some physicians to spend more time with their patients, and to provide high quality care, without the interference from health plans, without reducing and sometimes increasing their net revenues. As your organization, CMA’s goal is to help you take charge of your own destiny in these challenging and changing times, particularly related to the health reform legislation and the regulatory changes it will generate. We want to ensure that medical decisions remain in your hands so that you can serve your patients. We look forward to working with you.

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healthreform

Health Reform Timeline for

2011-2018 The following health reform legislation changes are scheduled to be implemented between 2011 and 2018.

2011

Reprinted with permission by San Diego County Medical Society

INSURANCE reforms: • Health insurance providers that do not dedicate 85 percent (largegroup market) or 80 percent (individual and small-group markets) of revenue to direct patient care must provide a rebate to enrollees.

LONG-TERM CARE INSURANCE: • National, voluntary, long-term care insurance program established.

Tort Reforms: • Five-year demonstration grants awarded to states to develop, implement, and evaluate alternatives to current tort litigations. (NOTE: NOT APPLICABLE FOR CALIFORNIA)

MEDICARE PRESCRIPTION DRUGS: • Pharmaceutical manufacturers required to provide a 50 percent discount on brand-name prescriptions filled in the Medicare Part D coverage gap beginning in 2011. • Federal subsidies for generic prescriptions filled in the Medicare Part D coverage gap begun to be phased in.

2011

REIMBURSEMENTS TO physicians: • Ten percent primary care bonus for internists, geriatricians, family physicians, and pediatricians for five years for whom primary care services account for at least 60 percent of Medicare-allowed charges over a designated period of time. • Ten percent general surgeon bonus for general surgeons practicing in health professional shortage areas for five years. (NOTE: NOT APPLICABLE FOR CALIFORNIA)

reimbursements to hospitals: • Medicare payments to qualifying hospitals in counties with the lowest quartile Medicare spending for 2011 and 2012 provided. (NOTE: NOT APPLICABLE FOR CALIFORNIA)

Medical Homes: • Demonstration program for primary care medical homes for patients with multiple chronic conditions established. • Physicians eligible for shared savings bonus payments for medical homes.

Insurance Reforms Tort Reforms

• Nurse practitioners and physician assistants may lead medical homes but only if state scope-of-practice laws allow it. (NOTE: NOT APPLICABLE FOR CALIFORNIA) • New Medicaid state plan option created to permit Medicaid enrollees with at least two chronic conditions, one condition and risk of developing another, or at least one serious and persistent mental health condition to designate a provider as a medical home. • States taking up the option provided with 90 percent FMAP for two years for health home related services, including care management, care coordination, and health promotion.

medicaid: • Coverage for preventive services, and preventive services cost-sharing eliminated. • Federal payments to states for Medicaid services related to healthcare-acquired conditions eliminated. • State Balancing Incentive Program in Medicaid created to provide enhanced federal matching payments to increase non-institutionally based long-term care services.

Reimbursements to Physicians Reimbursements to Hospitals

Medicaid

Medicare Prescription Drugs Long-Term Care Insurance

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Medical Homes

Community First Choice Option in Medicaid created to provide communitybased attendant support services to certain people with disabilities.

Federally Qualified Health Centers: • Access to care improved by increasing funding by $11 billion for community health centers and the National Health Service Corps over five years; new programs to support school-based health centers and nurse-managed health clinics established.

PHYSICIAN-OWNED HOSPITALS: • Physician-owned hospitals banned after Dec. 31, 2010, with exception for those in place by this date.

WELLNESS: • Preventive services covered and cost sharing for Medicare preventive services eliminated. Medicare payments for certain preventive services increased. FMAP increased by 1 percent for these services for states that provide Medicaid coverage for preventive services and remove cost sharing for preventive services. • Medicare beneficiaries provided access to comprehensive health risk assessments and personalized prevention plans. Incentives provided to Medicare and Medicaid beneficiaries to complete behavior modification programs. • Grants for up to five years provided to small employers that establish wellness programs. • National strategy established to improve the nation’s health. • Chain restaurants and food sold from vending machines required to disclose the nutritional content of each item.

PHYSICIAN WORKFORCE: • Graduate medical education changes phased in, including redistributing unused residency slots for primary care and general surgery, allowing training in outpatient settings, and allowing teaching health centers to expand primary care residency programs. • National Health Care Workforce Commission to examine barriers to primary care careers, to authorize state grants, to increase funding for NHSC scholarship and loan repayment program; access to loans for primary care providers eased, health professions and diversity programs funded.

QUALITY: • Medicare quality reporting program continued. Physician bonuses of 0.5 percent to 1 percent provided in 2011–13. Participation mandatory in 2014 with penalties for nonparticipation. • ICD-9 to ICD-10 crosswalk. Secretary required to hold stakeholder meetings. • National quality improvement strategy developed. • Community-based Collaborative Care Network Program established to support consortiums of healthcare providers to coordinate and integrate healthcare services for low-income uninsured and underinsured populations. • New trauma center program established to strengthen emergency department and trauma center capacity.

Quality

Physician Workforce Physician-owned Hospitals

• Phase-in of fiscal neutrality for Medicare Fee-for-Service and Medicare Advantage (MA) started. Quality bonus for care coordination, care management, and quality established. • Medicare payment cuts to health insurance providers, pharmaceutical companies, medical device manufacturers, hospitals, home health, and nursing homes begun. • Income threshold for income-related Medicare Part B premiums for 2011–19 frozen at 2010 levels; Medicare Part D premium subsidy for those with incomes above $85,000 per individual and $170,000 per couple reduced. • Phase-in of multiple initiatives to curb fraud and abuse started. • Five percent penalty for physician utilization outliers eliminated. Current program to provide confidential feedback to physicians comparing their utilization and resources use to their peers continued.

INCREASE REVENUES: • Some revenue provisions, including the fees on health insurance providers, pharmaceutical and device manufacturers, and the Medicare tax start to phase in. • Tax on nonmedical distributions from HSA or MSA increased. • New annual fees on the pharmaceutical manufacturing sector imposed.

REDUCED TAX BREAKS: • Costs for OTC drugs excluded from being reimbursed by HRA, health FSA, HSA, or MSA.

Federally Qualified Health Centers Wellness

REDUCE MEDICARE EXPENSES:

Increase Revenues

Reduce Medicare Expenses

PAGE 19 | THE BULLETIN | NOVEMBER/DECEMBER 2010

Reduced Tax Breaks

2012

TORT REFORM:

MEDICARE:

• GAO reports whether the new practice guidelines and payments policies would create causes of action against physicians.

• Bonus payments to high–quality Medicare Advantage plans provided. • Rebates for Medicare Advantage plans reduced.

QUALITY:

ACCOUNTABLE CARE ORGANIZATIONS (ACOs):

• Enhanced collection and reporting of data on race, ethnicity, sex, primary language, disability status, and for underserved rural and frontier populations required.

2012: CMS required to establish ACOs to allow groups of physicians who report on quality and coordinate care to share in the savings achieved in their region.

REIMBURSEMENTS TO HOSPITALS: • Medicare payments to hospitals reduced to account for (preventable) excess hospital readmissions. • Hospital value-based purchasing program in Medicare established. • Plans to implement value-based purchasing programs for skilled nursing facilities, home health agencies, and ambulatory surgical centers developed. • Medicaid demonstration projects for bundled payments for episodes of care that include hospitalizations: to make global capitated payments to safety net hospital systems (effective fiscal years 2010–12); to allow pediatric medical providers organized as accountable care organizations to share in cost-savings (effective Jan. 1, 2012, through Dec. 31, 2016); and to provide Medicaid payments to institutions of mental disease for adult enrollees who require stabilization of an emergency condition (effective Oct. 1, 2011, through Dec. 31, 2015).

• CMS required to establish ACOs to allow groups of physicians who report on quality and coordinate care to share in the savings — particularly from preventing unnecessary ER visits or hospitalizations — achieved in their region. ACOs can be small groups of loosely affiliated physicians or large organized groups. ACOs do not have to involve a hospital. Because ACOs will be groups of physicians who are clinically and financially integrated, a path to physician antitrust relief to be established.

Tort Reform

2012

Quality

Accountable Care Organizations

Medicare Reimbursements to Hospitals

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2013

healthreform INSURANCE REFORMS:

MEDICARE:

INCREASED REVENUE:

• Program to foster nonprofit, memberrun health insurance companies created. • Health insurance provider administration simplified by adopting a single set of operating rules for eligibility verification and claims status (rules adopted July 1, 2011; effective Jan. 1, 2013), electronic funds transfers and healthcare payment and remittance (rules adopted July 1, 2012; effective Jan. 1, 2014), and health claims or equivalent encounter information, enrollment, and disenrollment in a health plan, health plan premium payments, and referral certification and authorization (rules adopted July 1, 2014; effective Jan. 1, 2016). Health insurance providers required to document compliance with these standards or face a penalty of no more than $1 per covered life, effective April 1, 2014.

• Public reporting of Medicare physician and private payer performance information related to quality (PQRI) and other factors such as care coordination, resource use, and patient satisfaction required. Data would meet certain safeguards (valid, risk-adjusted), and physicians would have prior opportunity to review the data. Appropriate attribution methodology, timely feedback, and accurate systems that can provide reliable data required. AMA and CMA worked to include multiple amendments to protect physician information and ensure that it is accurate based on the CCHRI experience in California. Further protections need to be addressed in clean-up legislation. • Administrative simplification requires health insurance plans to certify that their information systems comply with standards. New operating rules for eligibility and health plan claim status transactions to take effect.

• Threshold increased for itemized deduction for unreimbursed medical expenses from 7.5 percent to 10 percent of AGI, but waived for individuals age 65 and older for tax years 2013–16. • Medicare Part A (hospital insurance) tax rate on wages increased by 0.9 percent (from 1.45 percent to 2.35 percent) on earnings over $200,000 for individual taxpayers and $250,000 for married couples filing jointly; 3.8 percent assessment on unearned income imposed for higher-income taxpayers. • Contributions to flexible spending accounts for medical expenses limited to $2,500 per year. • Excise tax of 2.3 percent on the sale of any taxable medical device imposed. • Tax deduction for employers who receive Medicare Part D retiree drug subsidy payments eliminated.

MEDICAID REIMBURSEMENTS: • Medicaid payments to primary care doctors increased for 2013 and 2014 with 100 percent federal funding.

QUALITY: • Disclosure of financial relationships between health entities required — includes physicians, hospitals, pharmacists, other providers, and manufacturers and distributors of covered drugs, devices, biologicals, and medical supplies.

2013

Medicaid Reimbursements

MEDICARE: • Federal subsidies for brand-name prescriptions filled in the Medicare Part D coverage gap (to 25 percent in 2020, in addition to the 50 percent manufacturer brand-name discount) begun to be phased in. • Medicare pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care established.

Medicare

Ouality Insurance Reforms

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Medicare

Increased Revenue

2014

healthreform INSURANCE COVERAGE: • Individual mandate for uninsured individuals to purchase health insurance begun. Penalties of up to 10 percent of income for those who do not purchase insurance. Tax credits and cost sharing subsidies for low-income individuals. • Substantial fees on large employers who do not provide coverage, but no employer mandate. • State-based health insurance exchanges where individuals and small businesses with up to 100 employees can purchase qualified coverage with a choice of private health insurance providers, benefits packages, and doctors. • At least two multistate plans in each exchange required. At least one plan must be offered by a nonprofit entity, and at least one plan must not provide coverage for abortions beyond those permitted by federal law. • Refundable and advanceable premium credits and cost-sharing subsidies to eligible individuals and families with incomes 133–400 percent FPL to purchase insurance through the exchanges. • Health insurance providers prohibited from denying coverage to adults with preexisting conditions. • Rating variation based only on age (limited to 3 to 1 ratio), premium rating area, family composition, and tobacco use (limited to 1.5. to 1 ratio) allowed. • Health insurance providers required to limit waiting periods for coverage to 90 days.

• Out-of-pocket limits for those with incomes up to 400 percent FPL reduced. • Deductibles for small-group market health plans limited to $2,000 for individuals and $4,000 for families. • Essential health insurance package that provides a comprehensive set of services, covers at least 60 percent of the actuarial value of the covered benefits, limits annual cost sharing to the current law HSA limits ($5,950 per individual and $11,900 per family in 2010), and is not more extensive than the typical employer plan created.

MEDICAID: • Medicaid expanded to all non-Medicare-eligible individuals under age 65 (children, pregnant women, parents, and adults without dependent children) with incomes up to 133 percent FPL. Enhanced federal matching for new eligibles provided. 1.7 million Californians covered in Medi-Cal.

PREVENTION AND WELLNESS: • Employers may offer rewards of up to 30 percent — increasing to 50 percent if appropriate — of the cost of health insurance coverage for participating in a wellness program and meeting certain health-related standards. Establish pilot programs to permit participating states to apply similar rewards for participating in wellness programs in the individual market.

Insurance Coverage

2014

Prevention and Wellness

Medicaid

MEDICAID REIMBURSEMENT: • Increase in Medicaid reimbursement rates for primary care physicians (internists, family physicians, and pediatricians) up to Medicare levels for E&M services and immunizations provided in 2013 and 2014.

MEDICARE REIMBURSEMENT: • Independent Payment Advisory Board established to submit legislative proposals containing recommendations to reduce the percapita rate of growth in Medicare spending if spending exceeds a target growth rate. • Out-of-pocket amount that qualifies an enrollee for catastrophic coverage in Medicare Part D reduced.

INSURANCE: • Medicare Advantage plans required to have medical loss ratios no lower than 85 percent. • Administrative simplification operating rules for electronic funds transfers (EFT) and healthcare payment and remittance advice to take effect. Physicians also required to comply with the EFT standards for Medicare payments.

HOSPITALS: • Medicare Disproportionate Share Hospital (DSH) payments reduced initially by 75 percent and payments subsequently increased based on the percent of the population uninsured and the amount of uncompensated care provided. States’ Medicaid Disproportionate Share Hospital (DSH) allotments reduced.

Medicare Reimbursement Insurance

Medicaid Reimbursement

2015

Hospitals

PAGE 22 | THE BULLETIN | NOVEMBER/DECEMBER 2010

Medicare

2016

• Value Index Modifier to modify physician payments based on level of spending and quality reporting. Physicians who spend less than national average will be paid a higher rate. Physicians who spend more than the national average will be paid a lower rate. Rate adjusted for geographic practice expense and socioeconomic status of the patients.

COST:

2018

2015

MEDICARE:

COST:

• Multistate compacts to allow insurers to sell policies across state lines implemented. Implementation regulations due by 2013. • Additional Administrative Simplification rules to take effect. Operating rules for claims, (dis)enrollment, and health claims attachment standards. • Medicare payments to certain hospitals for hospital-acquired conditions reduced by 1 percent.

• Cadillac tax on health insurance plans offering high-end benefits implemented. Excise tax on insurers of employer-sponsored health plans with aggregate values that exceed $10,200 for individual coverage and $27,500 for family coverage imposed.

How Health Reform Will Affect … Physicians »» 2010: Medicare will increase payment for psychotherapy services by 5%. »» 2010: Medical liability protections under the Federal Tort Claims Act will be extended to officers, governing board members, employees, and contractors of free clinics. »» The federal government may award five-year demonstration grants to states to develop, implement, and evaluate alternative medical liability reform initiatives, such as health courts and early offer programs, beginning in 2011. (NOTE: NOT APPLICABLE FOR CALIFORNIA) »» Physicians will receive incentive payments of 1% in 2011 and 0.5% from 2012 to 2014 for voluntary participation in Medicare’s Physician Quality Reporting Initiative (PQRI). An additional 0.5% incentive payment will be made to physicians who participate in a qualified Maintenance of Certification Program (quality practice-based learning programs through specialty boards). In 2015, physician payments will be reduced by 1.5% if they do not participate in the PQRI program. In 2016 and beyond, the PQRI nonparticipation penalty will be 2.0%. »» 2011–2016: Physicians in family medicine, internal medicine, geriatrics, and pediatrics whose Medicare charges for office, nursing facility, and home visits comprise at least 60% of their total Medicare charges will be eligible for a 10% bonus payment for these services. »» 2011–2016: General surgeons who perform major procedures (with a 10or 90-day global service period) in a health professional shortage area will be eligible for a 10% bonus payment for these services. »» National rules will be developed and implemented between 2013 and 2016 to standardize and streamline health insurance claims-processing requirements.

Patients With Respect to Private Health Insurance Changes

2016 2018 Cost Cost

»» 2010: Insurer can no longer drop patients if they get sick. »» 2010: Insurers can no longer impose lifetime financial limits on benefits. »» 2010: Children ages 18 and younger can no longer be denied private insurance coverage if they have a preexisting medical condition. »» 2010: Young adults up to age 26 can remain as a dependent on their parents’ private health insurance plan.

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healthreform »» 2010: For adults with preexisting medical conditions who cannot obtain private insurance coverage, a temporary national “high-risk pool” will be established to provide coverage, with financial subsidies to make premiums more affordable, until all insurers are required to cover people with preexisting conditions in 2014. »» 2010: Preventive services for women, such as mammograms, and immunizations for children must be covered by insurers, with no co-payments or deductibles required. »» 2011: States can require insurance companies to submit justification for premium increases and can impose penalties for excessive increases. »» 2014: U.S. citizens and legal residents cannot be denied private health insurance coverage for any reason. »» 2014: All U.S. citizens and legal residents must obtain health insurance coverage or pay a tax penalty (with some exemptions). »» 2014: State-based health insurance exchanges (where those without access to employer-based insurance can shop and compare the benefits/ costs of private health insurance plans) will begin. All insurance companies in the exchange must provide at least a minimum benefit package, as well as additional coverage options beyond a basic plan. »» 2014: Federal subsidies through tax credits or vouchers will be provided for those who cannot afford the full cost of coverage provided by statebased health insurance exchanges.

Patients With Respect to Medicare and Medicaid Changes

»» 2010: Medicaid will be required to cover tobacco cessation services for pregnant women. »» 2010: Medicare patients whose prescription expenses reach the socalled Medicare Part D coverage “donut hole” ($2,700 to $6,150) in 2010 will receive a $250 rebate. During the following 10 years, the beneficiary co-insurance rate for this coverage gap will be narrowed in phases from the current 100% to 25% in 2020. »» 2011: Cost-sharing for proven preventive services will be eliminated in Medicare and Medicaid. Medicare payments for certain preventive services will be increased to 100% of payment schedule rates (that is, co-payments will be eliminated), and incentives will be available to encourage Medicare and Medicaid beneficiaries to complete behavior modification programs. »» 2014: Medi-Cal coverage expanded to all eligible children, pregnant women, parents, and childless adults under age 65 who have incomes at or below 133% of the federal poverty level.

The Healthcare Sector

»» 2010: Excise tax of 10% imposed on the amount paid for indoor tanning services. »» 2011: Annual fee on certain manufacturers and importers of branded prescription drugs (including biological products, but excluding orphan drugs) based on annual sales and set to reach a certain revenue target each year. »» 2013: Annual excise tax of 2.3% imposed on the sale of Class I (vast majority of orthotics and prosthetics, as well as durable medical equipment medical devices by manufacturers) with exemptions for eyeglasses, contact lenses, hearing aids, and any device that is generally purchased at retail for individual use. »» 2014: Annual fee on health insurance providers applied on net premiums of all health insurers based on their market share. For nonprofit insurers, only 50% of net premiums will be taken into account in calculating the fee. Exemptions are granted for: nonprofit plans that receive more than 80% of their income from government programs targeting low-income or elderly populations, or people with disabilities; voluntary employees’ beneficiary associations (VEBAs) not established by an employer; certain nonprofit insurers with medical loss ratios within specific limits; and selfinsured plans and federal, state or other government entities. (The fee does apply to companies that underwrite government-funded insurance, such as Medicaid managed care plans and the Federal Employee Health Benefits Program.) »» 2018: Excise tax imposed on the coverage provider (i.e., insurer, plan administrator, or employer depending on the type of coverage) of highcost, employer-sponsored health plans with aggregate values exceeding $10,200 for individual coverage and $27,500 for family coverage. The tax is equal to 40% of the value of the plan that exceeds these threshold amounts. For insured plans, the coverage provider will be the health insurance issuer; for self-insured plans, the coverage provider will generally be the plan administrator. Employers that make contributions to a health savings account (HSA) or medical savings account (MSA) must pay the excise tax if those contributions exceed the thresholds. The tax is not imposed on the individual enrollee. The dollar thresholds are indexed to inflation.

Individuals

»» 2010: Payments made under any state loan repayment or loan forgiveness program that is intended to provide for the increased availability of healthcare services in underserved or health professional shortage areas will be excluded from gross income. »» 2011: Tax on distributions from a Health Savings Account (HAS) raised to 20%. »» 2011: Cost of over-the-counter/nonprescibed medicines not reimbursed by FSA or HSA.

PAGE 24 | THE BULLETIN | NOVEMBER/DECEMBER 2010

»» 2013: For high-income individuals earning more than $200,000 and joint filers earning more than $250,000, Medicare payroll tax will increase by 0.9%, and a 3.8% Medicare tax will be imposed on net investment income from interest, dividends, annuities, royalties, rents, and taxable net gain. »» 2013: The threshold for claiming the itemized tax deduction for unreimbursed medical expenses will increase from 7.5% to 10% for taxpayers under 65. The increased threshold applies to individuals 65 years and older in 2017. »» 2013: Contributions to Flexible Savings Accounts (FSAs) capped at $2,500. »» 2014: Tax penalties for failure to obtain health insurance coverage. Individuals must obtain minimum essential coverage for themselves and their dependents, with certain exemptions (i.e., hardship, religious reasons). Those without coverage will pay a tax penalty of the greater of $695 per year up to a maximum of three times that amount ($2,085) per family, or 2.5% of household income. The penalty will be phased in according to the following schedule: $95 in 2014, $325 in 2015, and $695 in 2016 for the flat fee; or 1.0% of taxable income in 2014, 2.0% in 2015, and 2.5% in 2016.

2014: Individual mandate for uninsured individuals to purchase health insurance begun. Penalties of up to 10 percent of income for those who do not purchase insurance.

CRAFT YOUR IMAGE TO MATCH YOUR PROFESSIONALISM Medical office build-outs take a specialized skill to get done right. With rents nearing $4.00/sq ft in spaces adjacent to the local hospitals many doctors are converting professional office space to medical use for almost half the cost. Married to a surgeon, I understand the business of medicine and can help you manage your facilities costs to help reduce your overall cost structure. Trust the experience of Kokinos Builders to build an office that reflects your commitment to professionalism.

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PAGE 25 | THE BULLETIN | NOVEMBER/DECEMBER 2010

Coding Corner With Sandie Becker, CMC

Observation Care Scenarios The following article is excerpted from CPT Assistant September 2010 issue There continues to be confusion regarding the appropriate reporting of services provided to patients designated or admitted as “observation status” in a hospital. The patients in this status are observed to determine whether they should be admitted to the hospital, transferred to another facility, or sent home. However, these services may be provided in any area of the hospital; it is not necessary for the hospital to have a designated physical area in which these observation services are performed. A source of coding confusion relates to prolonged stays at observation status, which appears to be more common based upon the level of care criteria that many acute care hospitals are using to determine patient status. The following CPT codes are used to report hospital initial and discharge observation services. Note that there are two families of codes relating to whether discharge occurs on the same day as the initial care or not.

Observation Care Discharge Services 99217

Observation care discharge day management; to report services to a patient designated as “observation status” and discharged on the same date, use codes 99234-99236 as appropriate.

Initial Observation Care 99218

99219

Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: •

A detailed or comprehensive history;

•

A detailed or comprehensive examination; and

•

Medical decision making that is straight forward or of low complexity.

Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: •

A comprehensive history;

•

A comprehensive examination; and

•

Medical decision making of moderate complexity.

99220

Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: •

A comprehensive history;

•

A comprehensive examination; and

•

Medical decision making of high complexity.

The following scenarios demonstrate the appropriate reporting of hospital observation services.

Scenario 1 An established patient presents to her physician’s office on Monday. During the evaluation of the patient, the physician decides to send the patient over to the hospital to be admitted to observation care for further treatment and monitoring. Since it is later in the day, the physician does not see the patient in the observation setting until the next morning (Tuesday), but calls in orders and keeps in touch with the nursing staff. On Tuesday, the physician performs an initial observation care service on the patient in the observation setting and then determines that the patient has improved significantly enough to be discharged. How should his services be coded? Monday - codes 99212-99215 (Office/outpatient E/M service) code level as appropriate. Tuesday - codes 99234-99236 (Same-day initial observation care/discharge) code level as appropriate. This is because from the reporting physician’s perspective, observation care was initiated and discharge services were performed on the same date. The instructions in the descriptor of 99217 relate to the professional services performed, not the date used by the facility.

Scenario 2 An established patient presents to her physician’s office on Monday. During the evaluation of the patient, the physician decides to send the patient over to the hospital to be admitted to observation care for further treatment and monitoring. Since it is later in the day, the physician does not see the patient in the observation setting Continued on page 31

PAGE 26 | THE BULLETIN | NOVEMBER/DECEMBER 2010

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SCCMA Alliance

Alliance News Through the summer months, Alliance members distributed posters and bookmarks for its campaign “Not Even for a Minute,” reminding drivers that it is unsafe to leave children unattended in a vehicle. Packets were sent to local hospitals, and posters and bookmarks were distributed to physicians and businesses. The project will resume next summer. Alliance members also continue to volunteer for the Food Basket Program in Santa Clara County. Alliance member Donna Spagna will be coordinating with the American Cancer Society and Stanford Hospital to bring the ACS Wig Bank to Stanford Cancer Center once a month, beginning in 2011. The ACS Wig Bank provides free wigs for cancer patients. Other Alliance members have volunteered to assist Donna with the project. In September and October, Alliance members attended various fall conference meetings including the AMAA Fall Leadership Conference in Chicago, the first Alliance Regional Conference in Fresno, and the CMAA Fall Board Meeting in Sacramento. At the CMA House of Delegates meeting in Sacramento, Debbi Ricks introduced a video presentation that represents the Alliance at work throughout the state.

Between health projects, members found time to socialize with coffee meetings and a September wine tasting that was held at Enoteca Restaurant in Los Gatos. Open to all members, the no-host event was attended by physicians, spouses, and Friends of Medicine. The 2010-2011 Alliance membership drive is ending this month. New and renewing Alliance members may pay in one of three ways: by paying online at www.sccmaa.org; by paying dues through the invoice from the Medical Association; or by mailing a check to Debbi Ricks, Membership Chair. For additional information on membership, Debbi can be reached by email at debbiricks@aol.com.

Upcoming Events: December: Registration continues for membership for 2010-2011. All current and perspective members may register online at www.sccmaa.org, by mail, or through the SCCMA office. December 13: Holiday Luncheon. January 10: Planning Meeting. 10:00 AM at the SCCMA office. All members are invited. February 3-5: CMAA Western Regional Conference, San Diego. May 6-7, 2011: CMAA Annual Session, Toll House Hotel, Los Gatos.

Pictured at a local wine tasting event are Alliance members Heather Goodman, Mary Hayashi, Dr. Bill Lewis, Jean Cassetta, Debbi Ricks, Dr. Roger Hayashi, Suzanne Jackson, Donna Spagna, and Kathleen Miller. PAGE 28 | THE BULLETIN | NOVEMBER/DECEMBER 2010

MONTEREY COUNTY MEDICAL SOCIETY ALLIANCE 2010-2011

MCMS Alliance... Join Us! Make a Difference in Monterey County.

Welcome to the Alliance The A!iance is the Voice and Vision of Today’s Family of Medicine.

Planning Luncheon July 27, 2010 Reactivating the Monterey County Medical Society Alliance

Who We Are Our members are physicians, spouses, partners, medical students, family, and friends of medicine.

What We Are

What We Do

The Medical Alliance is the largest volunteer arm of the Medical Society in our counties, state & nation. MCMSA is chartered by the California Medical Association, affiliated with the AMAA, and is in partnership with the California Medical Association Alliance and the Monterey County Medical Society.

We work to promote quality health through education, community service programs, and legislative advocacy. We fundraise, volunteer in the community, collaborate with other interested organizations, and pro vide networking opportunities for our members, all while having fun together.

Membership Application __________________________________________________________________________________________ Name Spouse/Partner’s Name Address___________________________________________________________________________________ Street City ST Zip Contact Phone_________________________________ FAX Number__________________________________ Contact Email Address___________________________________ Thank you for joining the MCMSA. During our Alliance’s organizational year, regular county dues will be waived. Reduced dues of $15.00 will be collected for CMAA during the organizational year. (This is a bylaws requirement.) Send application to: MCMS Alliance, 700 Empey Way, San Jose, CA 95128. For further Information: 408-998-8850 ______ My check for $15.00 written to MCMS (Monterey County Medical Society) is enclosed. ______ Please charge my credit card ____ Mastercard ____ Visa ____ Am Ex

Expiration Date______________

Name on Card______________________________________ Card #___________________________________ Signature____________________________________________________________

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company. Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. To learn more about our medical professional liability program, including the Tribute Plan, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293, or visit us at www.doctorsagency.com.

PAGE 30 | THE BULLETIN | NOVEMBER/DECEMBER 2010

Coding Corner, from page 26 until the next morning (Tuesday), but calls in orders and keeps in touch with the nursing staff. On Tuesday, the physician performs an E/M service on the patient in the observation setting and determines that the patient is not improving enough to be discharged. The physician returns on Wednesday morning and determines that the patient has improved enough to be discharged. How should his services be coded? Monday - codes 99212-99215 (Office/ outpatient E/M service) code level as appropriate. Tuesday - codes 99218-99220 (Initial observation care) code level as appropriate. Wednes. - code 99217 (Observation care discharge). In this case, observation initiation and discharge services were performed on different days.

Scenario 3 On Monday evening, a physician admits a patient by phone to observation care. The physician sees the patient on Tuesday morning in the observation setting. The physician performs an initial observation care service and determines that the patient has improved enough to be discharged. The physician also performs the discharge service. What can the physician report for his service? Monday - No separate CPT code can be reported. Tuesday - codes 99234-99236 (Sameday admit/discharge) as appropriate. As noted, the dates of professional services, not the date of actual initiation of observation services, are what is used to determine the code(s) to report.

PAGE 31窶ポ窶サHE BULLETIN窶ポ窶クOVEMBER/DECEMBER 2010

practice management

getting ready for the cold and flu season CMA Foundation’s AWARE Project Encourages Health Care Providers to Educate Patients About Antibiotic Resistance By Carol A. Lee, Esq., President and CEO, CMA Foundation What do sinusitis, most sore throat, bronchitis, runny nose, and the regular cold have in common? They are respiratory tract infections usually caused by viruses that can’t be cured with antibiotics. Yet, each year, health care providers in the U.S. prescribe tens of millions of antibiotics for viral infections. Respiratory infections (otitis media, sinusitis, pharyngitis, bronchitis, and the common cold) account for threequarters of all antibiotics prescribed by office-based physicians. If antibiotics were always prescribed appropriately, the resulting increase in resistance could be seen as inevitable and unavoidable. However, antibiotics are often used inappropriately. Even though prescribing rates have decreased, current data suggest that, for all ages combined, more than ten million courses of antibiotics are prescribed each year for viral conditions that do not benefit from antibiotics.

Because we cannot eliminate respiratory conditions, including seasonal flu, recognizing appropriate treatment and managing such illness are equally important. To aid in prevention efforts, the AWARE Project has developed its fourth annual AWARE Provider Toolkit for the 2010 - 2011 cold and flu season. In September 2010, AWARE (in partnership with twelve California health plans) distributed 14,000 toolkits to California primary care physicians. Additionally, the toolkit materials are posted on the AWARE website, www.aware.md, and include materials for both you and your patients.

Facts About Antibiotic Resistance •

Antibiotic resistance has been called one of the world’s most pressing public health problems.

increased in the last decade. Many bacterial infections are becoming resistant to the most commonly prescribed antibiotic treatments. •

Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug-resistant bacteria.

•

Misuse of antibiotics jeopardizes the usefulness of essential drugs. Decreasing inappropriate antibiotic use is the best way to control resistance.

•

Children are of particular concern because they have the highest rates of antibiotic use. They also have the highest rate of infections caused by antibiotic-resistance pathogens.

•

Parent pressure makes a difference. For pediatric care, a study showed that doctors prescribe antibiotics 65% of the time if they perceive parents expect them to, and 12% of the time if they feel parents do not expect them to.

• The number of bacteria resistant to antibiotics has

With eleven other federally funded state and local health department programs, the California Medical Association (CMA) Foundation, through its Alliance Working for Antibiotic Resistance Education (AWARE) Project, provides education about respiratory conditions. The AWARE Project encourages you to take the time to educate your patients about antibiotic resistance. Antibiotic resistance in outpatient settings can be reduced dramatically, without adversely affecting patient health, by not prescribing antibiotics for vital illnesses such as colds, most sore throats, coughs, bronchitis, and the flu.

• Antibiotic resistance can cause significant danger and suffering for people who have common infections that once were easily treatable with antibiotics. When antibiotics fail to work, the consequences are longerlasting illnesses, more doctor visits or extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death. For more information about AWARE and additional materials regarding influenza prevention, please contact Sandra Navarro, PhD, MPH, AWARE Project Director, at 916/779-6620, or by email at aware@thecmafoundation.org.

PAGE 32 | THE BULLETIN | NOVEMBER/DECEMBER 2010

When someone in your family gets sick, it feels like you are going walking by yourself. But when hospice comes, you feel like somebody is guiding you and you are not alone. Thank God there’s a program like this that picks you up and helps prepare you for the journey you and your loved ones are going to take. Hospice of the Valley helps everyone prepare for that. — Carmen V. Gary Bertuccelli, social worker Pam Nates, chaplain

When patients and families are coping with serious, life-limiting illness,

they require expert care, compassion and personal attention. Whether it is spending time with loved ones, fulfilling dreams, or simply remaining comfortable and independent for as long as possible, Hospice of the Valley guides patients and their families to meet their goals. • The hallmark of hospice care is that it serves patients wherever they live—be it in their home, nursing home, hospital or assisted-living facility • Hospice of the Valley team members consist of physicians, nurses, social workers, chaplains, hospice aides, volunteers, and grief counselors who are experts in palliative and hospice care and are available to assist in the management of your patient’s needs Margarita Vizcaya, hospice aide

Jeanne Fabricius, RN, case manager

• For those dealing with grief and loss, the Community Grief and Counseling Center at Hospice of the Valley provides families and individuals with one-on-one counseling and loss-specific support groups to adults, teens and children • Since 1979, Hospice of the Valley‘s legacy of compassionate palliative and hospice care, community education, advocacy and outreach has set the standard for quality hospice care state wide and nationally, and our organization is a locally-based, operated, and supported non-profit organization Monique Kuo, MD, medical director

4850 Union Avenue, San Jose, CA 95124 408.559.5600 l hospicevalley.org

MEDICO NEWS

MEDICONEWS Congress postpones Medicare cuts until January Congressional leaders reached a bipartisan agreement to postpone Medicare cuts mandated by SGR for one month, meaning physicians’ current payment rates will remain in effect through December 31, 2010. The Senate passed the measure by unanimous consent on November 18 and House leaders said they would follow suit when they return from Thanksgiving break. The agreement — announced by Senate Finance Committee Chairman, Max Baucus, D-Mont. and ranking Republican, Charles Grassley, R-Iowa — stops the 23% Sustainable Growth Rate (SGR) payment cut scheduled to take effect on December 1 and continues the 2.2% update in payments. Baucus and Grassley said the 30-day measure would give Congress more time to develop a longer-term extension during the month of December. When lawmakers return next month, they will consider a one-year SGR deal that prevents cuts through December 31, 2011, and provides an update. They are working to secure a way to pay for the yearlong cost of stopping the cuts. Democratic leaders in Congress have suggested rolling those costs into a larger bill that addresses the expiring Bush tax cuts. Leaders of both parties are scheduled to meet with President Obama to negotiate the tax package. The cost of the one-month extension is paid for with savings from a Centers for Medicare and Medicaid Services (CMS) proposal that reduces Medicare payments for multiple therapy services provided by therapists to patients in one day. The California Medical Association (CMA) is pleased that Congress is blocking the devastating 23% payment cut facing

physicians from taking effect on December 1. This stop-gap measure will allow physicians to continue to see Medicare patients and protect access to care for California’s seniors and military families. CMA will continue to aggressively advocate for a longer-term fix to the SGR. Because Medicare rates also affect private sector rates, they have an enormous impact on California physicians and patients in all sectors. CMA is also working to include the California Geographic Price Cost Index (GPCI) fix in the SGR bill. The GPCI provision would update the Medicare geographic payment localities in California to more accurately reflect the cost of doing business in many recently urbanized counties. CMA thanks all county medical societies and physicians for their advocacy to stop the SGR cuts. California physicians working together proved to be a powerful force that helped persuade Congress to step in. CMA urges physicians to continue to call, e-mail, and meet with their congressional representatives during the month of December until Congress passes a yearlong fix. After that package is adopted, it will be incumbent on organized medicine to help develop an ultimate long-term solution to the unsustainable SGR payment formula. Also, please continue to refer those interested in the issue to CMA’s SGR video, “Keep the ‘Care’ in Medicare” which can be viewed at http://www.youtube.com/watch?v=YrCiwCF19EQ. The six-minute video addresses the issue of low reimbursements head on, in a way any patient, legislator, or member of the media can understand. (CMA Alert, November 29, 2010 issue)

CMA publishes guide to obtaining federal  funding for electronic health records As part of its ongoing efforts to keep physicians informed about health care reform implementation and associated issues, the California Medical Association (CMA) has published a guidebook for doctors on how to obtain federal funding for electronic health records. In order to qualify for federal electronic health record (EHR) incentives, physicians must demonstrate “meaningful use” of a certified EHR system. The federal

government spelled out the regulations for meaningful use in July. In short, meaningful use is a set of criteria and clinical quality measures on which physicians will have to report. Physicians must report either to the federal Centers for Medicare and Medicaid Services (CMS) or the California Department of Health Care Services. To help physicians understand the criteria for meaningful use, CMA has

published the “Physician Guidebook for Meaningful Use.” This book explains each of the reporting measures required. The guidebook will help physicians set up their practices and EHR systems to begin reporting on meaningful use as early as January 2011. The guidebook is available at the CMA website at http://www.cmanet.org/HIT and is free to all CMA members.

PAGE 34 | THE BULLETIN | NOVEMBER/DECEMBER 2010

(CMA Alert, November 15, 2010 issue)

MEDICO NEWS

2010 state legislative wrap up Governor Arnold Schwarzenegger wrapped up the 2009-10 state legislative session by signing CMA-sponsored legislation to implement the federal ban on rescissions and vetoing a CMA bill requiring private insurers to pay an administrative fee designed to cover physicians’ full cost of providing immunizations. Schwarzenegger’s signing of AB 2470 capped a three-year drive by CMA to end rescissions. The measure allows patients to appeal insurers’ decisions to retroactively cancel their coverage after they get seriously ill, a practice known as rescission, to the Department of Managed Health Care or Department of Insurance. Until a state regulator rules on the appeal and determines whether the cancellation was legal, the patient would retain his or her health insurance. The legislation gives patients an important tool to hold insurers accountable to the ban on rescissions that was part of federal health care reform enacted earlier this year. Under the new law, insurers are now allowed to rescind coverage only if they can prove the patient lied or committed fraud. “This is a great day for California patients and the doctors who have fought for them,” said CMA Past President Brennan Cassidy, MD. “Thanks to CMA, which pressed this issue both in Sacramento and Washington, insurers must honor their commitment to cover patients and can no longer dump them willy-nilly just to boost their bottom line.” Another CMA-sponsored bill, AB 2093, was vetoed by the governor. The legislation sought to ensure a physician’s full cost of providing a vaccination is covered by private insurers. In his veto message, the governor called the bill “an inappropriate effort to carve various elements out of negotiated provider contracts and set those reimbursement rates in statute.” California law requires health plans and insurers to provide coverage for recommended immunizations, but many don’t pay physicians the entire cost of providing the vaccinations, forcing doctors to lose money,

charge copays or quit providing vaccinations entirely. CMA argued the legislation was crucial to ensuring high vaccination rates and protecting public health. Other CMA-sponsored bills the governor signed: AB 583: This “truth in advertising” legislation will require a health care professional to disclose information in various health care settings to help patients understand who will be helping them with their health care, such as information about license, education, and recognized board certification. Other CMA-sponsored bills the governor vetoed were: AB 1235: This bill sought to improve an already robust peer review system to make it even more effective in ensuring high-quality care in California hospitals. AB 2248: This bill sought to clarify the EMS/Maddy Fund reporting requirements in existing law. It would have expanded the level of detail that counties are required to report to the state in order to make it easier for members of the public, including physicians, to access thorough and helpful information on counties’ Maddy Funds. In addition, the governor signed measures creating a state health insurance exchange, as allowed under federal reform. The two bills, SB 900 and AB 1602, together create the framework for the California Health Benefit Exchange to begin operating in 2014. The exchange will provide individuals and small businesses an opportunity to compare plans online and buy them in five different categories of coverage. California is the first state in the nation to set up an exchange under the new federal law. For more information on this and other bills of interest to physicians, see CMA’s Legislative Hot List at http://www.cmanet.org/news/hotlist. asp. (CMA Alert, October 5, 2010 issue)

As pertussis spreads, new state law mandates  booster vaccination Pertussis (also known as whooping cough) has been seen in epidemic numbers in California this year, with 5,658 reported cases, including 137 infant hospitalizations and nine infant deaths from the disease so far. These are the highest numbers the state has seen since 1955. To combat this outbreak, Governor Schwarzenegger recently signed a law that makes a pertussis booster (Tdap) mandatory for all students in grades 7 to 12, starting with the 2011-2012 school year. State public health officials have also broadened recommendations for those who should be immunized against the disease to include seniors and women in their childbearing years. Because pertussis immunity from previous infection or vaccination wanes over

time, even fully immunized children become susceptible to pertussis by adolescence. Unfortunately, immunization rates are low for the recommended Tdap booster vaccine, which has been available since 2005. The most recent CDC survey data indicates that 44% of adolescents in California and only 6% of adults nationwide had received a Tdap booster shot by 2008. Public health officials are urging physicians to offer Tdap booster shots to all adolescents (10 years and older) and adults who haven’t yet received it. Give Tdap now to your unimmunized adolescent patients to protect them against the current threat and to meet the forthcoming school requirement. As a reminder, effective September 1, 2010, the California Occupational Safety and

Health Administration (Cal/OSHA) Aerosol Transmissible Disease (ATD) standard requires health care entities, including hospitals, nursing facilities, clinics, medical offices, long-term care facilities, emergency services and transport providers, and other defined high-risk workplaces to offer Tdap vaccines to their employees. For more information on the new ATD standard, see CMA On-Call document #1842, “Protecting Employees From ATDs in the Health Care Workplace.” On-Call documents are free to members at the CMA members-only website, http://www.cmanet.org/member. For more information on pertussis vaccination, see the California Department of Public Health website, http://cdph.ca.gov.

PAGE 35 | THE BULLETIN | NOVEMBER/DECEMBER 2010

(CMA Alert, October 18, 2010 issue)

CLASSIFIED ADS VOLUNTEER OPPORTUNITies

General, family, gyn, and internal medicine physicians or providers are needed for a Wednesday night from 6:15 PM – 9:00 PM. If you can help, please email Dr. Henry Lew at henry-lew@att.net.

MAKING A DIFFERENCE AT ROTACARE Rotacare in Mtn View is one of nine clinics in the Bay Area serving uninsured patients. We have urgent need for more physicians and mid-level providers to provide care for adults and children. The clinic is held in the basement of YMCA building adjacent to El Camino Hospital in Mtn View. It is fully staffed with nurses, educators, translators, pharmacists, and other support staff. Malpractice insurance is covered by Rotacare. Hours of operation are Mon, Wed, Thurs evenings. Providers usually work 2.5 hours monthly, or according to availability. Specialists can see patients at Rotacare or arrange to have patients referred to their office. Our volunteers have found this a rewarding experience and a way to make a difference in our own community. For further information, please call Lila Steiner at 650/988-7948 or email Lila_Steiner@ elcaminohospital.org.

MAKING A DIFFERENCE AT FREE CLINICS Two of the free clinics that serve uninsured adults are short of doctors this Fall/Winter – Gilroy and downtown San Jose. The latter is located at Washington Elementary School about a mile from the Fairmont.

METRO MEDICAL BILLING, INC. • Full Service Billing • 25 years in business • Bookkeeping • ClinixMIS web-based software • Training and Consulting • Client References Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website www. metromedicalbilling.com

office space for rent/lease MEDICAL/DENTAL/PODIATRIST OFFICE Two treatment rooms (third room available), receptionist area, waiting room, x-ray area, doctor’s office; Scott Blvd., Santa Clara. Especially suitable for podiatrist. Call 408/296-6245.

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/SALE

office with balcony. Street signage to 100,000 cars a day. Marble entry. Zoned medical/office. No variance required. Looking for established business/practice that values prime location in beautiful building. Please be qualified. No start ups. Contact Dr. Newman at 408/9968717. Brokers welcome if you have a client. Compare with space by Good Sam at $3.50 sq. ft. Located at 1196 South De Anza at Rainbow.

MEDICAL/DENTAL OFFICE SPACE FOR LEASE • MTN VIEW Medical/dental office space located at 2500 Hospital Dr, Bldg I, Mountain View. Call 831/375-6105.

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 TO SHARE • SUNNYVALE

Office in close proximity to O’Connor Hospital for lease/sublease/sale. Please call 408/923-8098 for more information.

One exam room plus one large office, shared waiting room and front office. Newly built, 1,280 sq. ft. Call 408/4381593.

MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA

ELEGANT AND SPACIOUS LOS GATOS MEDICAL OFFICE

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 408/228-0454.

OFFICE/LAB SPACE FOR LEASE • MTN VIEW One room space. Office/lab – upstairs. Located at 2500 Hospital Dr, Bldg I, Mtn View. Call 831/375-6105.

OFFICE SUITE AVAILABLE Location is highway 85 at De Anza. One suite available. Currently configured with six Tx rooms/offices, entry, large master

Available to share with prominent aesthetic dermatologist. This upscale office has seven exam rooms, a lab, two large administrative offices, and a marble and granite waiting room with comfortable seating for eight patients. Call Irene at 408/358-5757 to schedule your private showing. Price is negotiable.

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.

PAGE 36 | THE BULLETIN | NOVEMBER/DECEMBER 2010

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/644-9800.

Pajaro Dunes

MEDICAL/DENTAL CONDOMINIUMS FOR SALE OR LEASE

Beachfront Condo

Two-story, medical/dental condominiums for sale or lease located in Willow Glen. Beautiful building completely renovated and remodeled. Suites range from 1,376 sq. ft. to 6,000 sq. ft. or full building for 13,170 sq. ft. Elevator served. Plenty of on-site parking and great visibility. Call brokers to tour: Alice Teng 408/282-3808 or Steve Hunt at 408/282-3846.

MEDICAL OFFICE TO SHARE IN MEDICAL BUILDING OF O’CONNOR HOSPITAL One large exam room and one office, shared waiting room, and receptionist area. Email at minasehhat@yahoo.com.

MEDICAL/PROFESSIONAL OFFICE FOR LEASE Medical/Professional office 2,600 sq. ft., ground floor near Santana Row. $2.00 sq. ft. Available now. Email at sksiddiqui@ yahoo.com.

MEDICAL SUITE NEAR O’CONNOR 840 sq. ft. and 900 sq. ft. near O’Connor Hospital, Santana Row, and Valley Fair. Three operative rooms, private doctor office, reception area, waiting room, two bath, two entrances, modified gross lease, $2.00 sq. ft. Available immediately. Call 408/891-6453.

ATHERTON SQUARE MEDICAL/DENTAL BUILDING A newly upgraded Class A building offers a variety of spaces from 1,166 sq. ft. and up for medical/dental use at 3301-3351 El Camino Real, Atherton. Tenant improvement allowances available to design suite to meet your needs. Excellent onsite parking, close to Stanford and Sequoia. Trask Leonard, Bayside Realty Partners, 650/282-4620 or Alice Teng, Colliers, 408/282-3808.

Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families Owners Bill & Debbi Ricks 408-354-5613

Rental Agent Pajaro Dunes Company 1-800-564-1771

EMPLOYMENT OPPORTUNITY

AGRESSIVELY PRICED MEDICAL/ DENTAL OFFICES FOR LEASE • CAMPBELL, CA 3,000 sq. ft. and 1,600 sq. ft. office spaces conveniently located on Bascom Avenue between O’Connor and Good Sam Hospital. Larger suite has two separate entrances and break area. Space is ideally suited for separate office/procedure area configuration. Covered parking, monument signage, and elevator included. Vascular surgeon currently occupies second floor. 50 K TI package offered for 5+ year lease. Owner will build to suit. $2.25/sq. ft. NNN. Call 408/858-3586.

MEDICAL OFFICE SPACE TO SUBLET • MTN VIEW Adjacent to El Camino Hospital. Two treatment rooms, consult room. Available three days per week. Basement storage included. Contact cell 650/269-1030.

PRIME MEDICAL OFFICE FOR LEASE • SAN JOSE Excellent location. Westgate area. 1,584 sq. ft. West Valley Professional Center, 5150 Graves Ave, Suite 2/stand-alone unit. Private office, reception area, exam rooms with sinks. Available 2/1/11. Call owner at 408/867-1815 or 408/221-7821.

PRIVATE PRACTICE/ OFFICE 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.

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 408/790-2907 or e-mail dazar@allianceoccmed.com for additional information.

FOR SALE OB/GYN PRACTICE DOWNSIZING Exam tables, reception room furniture, computers, file cabinets, NovaSure, suction machine, ultrasound, fetal monitor, colposcope, LEEP machine, microscope, speculums, instruments, refrigerators for sale. Call 650/988-7533 for great deals!

Collector Publications These publications are for true collectors or first timers. The real history of the

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Continued on page 38

Classifieds, from page 37

Tracy Zweig Associates

American Indian and what really happened hundreds of years ago to 500 nations! Publications include art works by James Bama, Tom Lovell and Howard Terpning. Editorials include: The Native Americans; Americans Fascinating Indian Heritage (Reader’s Digest hardcover); First NationsFirst Hand; A Circle of Nations; and many more! Prices range from $70 - Seven Arrows Hyemyohsts Storm, to as low as $10 - Bury My Heart at Wounded Knee and many more selections. Only serious collectors call: 408-866-0558 and ask for Lee! Local area, Santa Clara County.

REGISTRY

PLACEMENT

FIRM

Physicians

Nurse Practitioners ~ Physician Assistants

WANTED

Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

PEDIATRIC PRACTICE Will buy Pediatric practice in South Bay. Call 408/455-2959.

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m

RECORD MANAGEMENT SOLUTIONS Electronic Document Management • Application Services • Business Process Automation Solutions • Scanning & Conversion Services Record Retention Management & Confidential Destruction

S.C.C.M.A. 8-12-08

Secure Offsite Storage 1.800.957.5051 x137 www.srcpdeliverex.com

Which One?

Can you identify which of these people has the ventricular assist device (VAD)? The HeartMate® II VAD is the size of an egg, implanted alongside a patient’s weakened heart to take over pumping. The lightweight computer and batteries attached to the VAD are easily worn underneath clothing, allowing people to live active, normal lives. More importantly, VAD implementation is no longer used only for those waiting for a transplant. It is as much a therapy for heart failure as transplant, medica-

tion, bypass, biventricular pacing – anything – especially for younger patients with good immune systems that may reject a donor heart. Surgeons at CPMC have unparalleled experience – they’ve performed 200 VAD implantations as well as nearly 400 transplants since our program began. We are the only Northern California hospital to perform HeartMate® II implantations for destination therapy since 2006 – and one of the first to be CMS-approved. The old thought process was ‘Let’s get the patient the heart transplant ASAP.’ But the HeartMate II is as good an intervention for heart failure as a transplant. This is not your Mother’s VAD.

Our program offers: n

24/7 DIRECT PHYSICIAN ACCESS: 866-207-4417

Urgent outpatient consultations and evaluations of your patients – within 48 hours. We can also accommodate same-day hospital transfers.

Expert evaluation and treatment of patients with NYHA functional class III/ IV heart failure and AHA/ ACC stages C and D heart failure.

** All four of these people have VADs

cpmc.org/services/heart PAGE 39 | THE BULLETIN | NOVEMBER/DECEMBER 2010

BULLETIN THE

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Call NORCAL Mutual today at 800.652.1051. Or, visit www.norcalmutual.com. NORCAL Mutual is proud to be endorsed by the Monterey County Medical Society and the Santa Clara County Medical Association as the preferred medical professional liability insurer for their members.