November / december 2011 | Volume 17 | Number 6
CMA LEGISLATIVE WRAP-UP AND HOUSE OF DELEGATES HIGHLIGHTS
Open Wide...
With Confidence!
It’s Open Enrollment time for the Santa Clara County Medical Association and Monterey County Medical Societysponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). • During Open Enrollment only, members may join as an individual or as a group with your employees. Sponsored by:
• Low, calendar year deductible of $50 per person ($100 per calendar year maximum for families). • Pay no deductible on oral exams, x-rays and routine cleanings.
Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on January 1, 2012. Call a Client Service Representative at 800-842-3761 for more information, a brochure and application. Or visit www.MarshAffinity.com/cmadownload.html to download an enrollment kit.
Underwritten by:
Administered by:
Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage. 51764 ©Seabury & Smith, Inc. 2011 • AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 • Member.Insurance@marsh.com • www.MarshAffinity.com • CA Ins. Lic. #0633005
2 | THE BULLETIN | NOVEMBER / DECEMBER 2011
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 Membership Directory iAPP for the iPhone Legislative Advocacy/MICRA House of Delegates Representation Practice Management
5
From the Editor’s Desk
6
Message From the SCCMA President
8
2011 Legislative Wrap-Up: Batten Down the Hatches
Joseph Andresen, MD
William S. Lewis, MD
Jodi Hicks, CMA
16 Practice Management News Marsh
18 In Memoriam: Christopher C. Chow, MD; Robert J. Frascino, MD 20 CMA House of Delegates Annual Meeting Highlights and Photos 26 Hospital News: El Camino 30 MEDICO NEWS
Financial Services
34 Summary of CMS Final Regulations on Medicare Shared Savings/ACO Program
Professional Development
36 Award Nomination Form
Resources and Education
Health Information Technology
38 Hand-Offs: Which Mnemonic Is Right for You?
Resources
Publications
42 Medical Times From the Past: Origins of the Medical Societies
CME Tracking Physicians’ Confidential Line Verizon Discount Human Resources Services
Mary-Lynn Ryan, NORCAL Mutual Insurance Company
Gerald Trobough, MD
43 EHR in Medical Liability Litigation
Mary-Lynn Ryan, NORCAL Mutual Insurance Company
44 Classified Ads NOVEMBER / DECEMBER 2011 | THE BULLETIN | 3
The Santa Clara County Medical Association Officers President William Lewis, MD President-Elect Rives Chalmers, MD Past President Thomas Dailey, MD VP-Community Health Cindy Russell, MD VP-External Affairs Howard Sutkin, MD VP-Member Services Scott Benninghoven, MD VP-Professional Conduct Eleanor Martinez, MD Secretary Sameer Awsare, MD Treasurer James Crotty, MD
Chief Executive Officer
Councilors
William C. Parrish, Jr.
El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Lynn Gretkowski, MD Good Samaritan Hospital: Jeff Kaplan, MD Kaiser Foundation Hospital - San Jose: Seham El-Diwany, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Elaine Nelson, MD Saint Louise Regional Hospital: John Huang, MD Stanford Hospital & Clinics: Peter Cassini, MD Santa Clara Valley Medical Center: John Siegel, MD
AMA Trustee - SCCMA James G. Hinsdale, MD Tanya W. Spirtos, MD (Alternate)
CMA Trustees - SCCMA Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (Past-President) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)
BULLETIN THE
Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
Printed in U.S.A.
Editor
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 © Copyright 2011 by the Santa Clara County Medical Association.
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THE MONTEREY COUNTY MEDICAL SOCIETY OFFICERS President James Ramseur, Jr, MD President-Elect John Clark, MD Past President John Jameson, MD Secretary Eliot Light, MD Treasurer Steven Vetter, MD
CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.
DIRECTORS Paul Anderson, MD
R. Kurt Lofgren, MD
Valerie Barnes, MD
Jeff Keating, MD
Ronald Fuerstner, MD
Kelly O'Keefe, MD
David Holley, MD
Patricia Ruckle, MD
AMA Trustee - mcms David Holley, MD
FROM THE EDITOR’S DESK
Joseph Andresen, MD Editor, The Bulletin
Enlightened Action Will Determine... By Joseph Andresen, MD “Turn your pockets inside-out… Turn around so I can screen you with our metal detector… Okay, you now may enter.” I wasn’t going through airport security nor entering a secret government facility. I was at the Prometric Test Center in San Bruno and about to a take a four hour National Board of Echocardiography exam. For the past several months, I had watched a multitude of fuzzy video loops, interpreted shadows, and learned about the coumadin ridge, PISA, the “coanda effect,” flailed P2 mitral valve leaflets, diastolic dysfunction, the simplified Bernoulli’s equation, the continuity equation, and much more. My current practice has never been in a high-volume heart center, but I’ve always been fascinated by images of the heart and cardiovascular physiology that touches on all aspects of medical practice. So it was with this interest and curiosity that I embarked on a learning expedition to acquire more knowledge in an area that is now a routine part of residency training. I must admit that it was not easy. Reading text that was similar to many college math books of years past took a new fortitude and sense of accomplishment in each turned page. But several months, and now four hours later, I clicked the final screen and received a “Congratulations, your results will be sent out in 8 to 10 weeks” message. I left the test center with a sense of accomplishment and elation. Though it won’t change my day-to-day activities, I came to realize that the act of renewal and continued learning is one of the true gifts in the practice of medicine.
Regarding a love of learning, my son, now a college junior, recently sent me a link to an article in the New York Times, “Why Science Majors Change Their Minds (It’s Just So Darn Hard)”: http://www.nytimes.com/2011/11/06/education/edlife/why-science-majors-change-their-mind-its-just-so-darn-hard.html?hp This discussion has frequently been a topic of national concern, where fewer top students are pursing the sciences. Instead, they are opting to change career paths to avoid a precipitous drop in GPA, unimaginative and dry courses, or working in unsupportive and competitive environments. Should we not be encouraging and nurturing our next generation to explore their academic interests with passion and imagination? This may be hard to do, when our primary measure of academic excellence is narrowly measured by one’s grade-point average.
It seems to be much more than a coincidence that Bill Gates, Steve Jobs, and Mark Zuckerberg all left college prematurely to pursue their dreams and fully develop their talents. These are important questions that deserve thoughtful answers. Enlightened action will determine whether our best and brightest young minds pursue Wall Street or become physicians listening for the undetected diastolic murmur in their patient’s heart beats or finding cures for the many ailments of humankind. Finally, I want to mention a topic of some urgency. Unless Congress takes action promptly, Medicare conversion factors (CFs) will decrease by 27.4% percent in 2012. As announced in the “Final Rule,” for 2012, the general CF is $24.6712. Stuart Guterman, vice president for Payment and System and executive director of the Commonwealth Fund’s Commission on a High Performance Health System, (http://www.commonwealthfund.org/ Blog/2011/Nov/Medicare-Physician-Payment.aspx), puts it very succinctly: “We get what we pay for in our health system: an emphasis on the volume of services and complex and high-cost procedures, rather than patients’ needs. We need to start paying for what we want by rewarding providers for more coordinated, effective, and efficient care. But it’s hard to offer effective rewards for better care if the baseline is a 27% across-the-board cut in fees, which hits all physicians regard-
less of the appropriateness, effectiveness, or cost of the care they provide or its impact on the health of the patient.” This formula driven nosedive in physician payment rates would defeat the basic principles and goals of health care reform; namely, better access to quality care for all Americans. I urge our readers to join in the efforts of your medical society, CMA, AMA, MGMA, and other professional associations to bring about, once and for all, repeal of the SGR.
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. NOVEMBER / DECEMBER 2011 | THE BULLETIN | 5
MESSAGE FROM THE SCCMA PRESIDENT
william s. lewis, MD President, Santa Clara County Medical Association
The House of Delegates By William S. Lewis, MD President, Santa Clara County Medical Association Fed up with federal regulations? Sickened about public health? Fuming over formularies and pre-authorizations? Ready to do something about it, instead of just complaining? Then you need to partake in the CMA House of Delegates. Every October, the House of Delegates meets for a long weekend to debate the resolutions that then become the agenda for the CMA. If you are not at the House of Delegates, then you are represented by delegates from your county medical association, your specialty society, and your mode of practice. Any CMA member can submit a resolution and comment online about any resolution, before the
This year, several resolutions sponsored by our district were adopted. Drs. Cindy Russell and Robert Gould submitted resolutions regarding nanoparticles, triclosan, and nuclear power safety. As an aside, participating in the House of Delegates is not just an opportunity, but an education. Do you know what nanoparticles are and have you given any thought to how they interact with your body chemistry? Have you ever wondered what triclosan does to you and the environment, and did you just wash your hands with it? What lessons have we learned after the Japanese nuclear power disaster, and how do they apply to California? As a result of the leadership of Drs. Russell and Gould, the CMA now: 1) endorses responsible regulation of existing or new nanoparticles prior to their introduction in industrial or consumer products; 2) recognizes the toxicity and potential adverse health and environmental effects of triclosan-containing products and endorses efforts to eliminate this chemical from consumer and health care products; and 3) calls upon the Nuclear Regulatory Commission to expeditiously implement the recommendations of its Japan Task Force report, and encourages the Nuclear Regulatory Commission and other oversight agencies to apply new technologies that will assess seismic risk prior to any licensing renewal of nuclear plants. Numerous other important resolutions were adopted, from managing medical school debt to managing traumatic brain injuries. Some resolutions pass without opposition, and some pass contentiously. For example, the resolution to outlaw the deceptive marketing practices of pregnancy counseling centers that purport to provide family planning medical services but actually do not passed easily, but the proposal that all health plans cover FDA-approved contraceptive treatments without co-pays passed only after much passionate and principled debate. In the end, it’s a democratic process. No one always gets their way. Everyone can try again next year, and many do, again and again. Whether you agree with them or not, you have to admire their tenacity. I cannot list all of the resolutions of interest,
Democracy is the worst form of government, except for all those other forms that have been tried. Sir Winston Churchill House meets. The CMA is divided geographically into districts. The Santa Clara County Medical Association is part of District VII, which includes four other neighboring county medical societies. District VII is the largest district in the CMA (in terms of CMA members), and, therefore, we send more delegates to the House of Delegates than any other district in the state, and the Santa Clara County Medical Association is by far the largest county society in the district. Why does that matter? First, it means more of us can participate as delegates. Second, your resolution will carry more weight, if you gain the endorsement of the largest district in the state. William S. Lewis, MD, is the 2011-2012 President of the Santa Clara County Medical Association. He is a board certified ENT physician and is currently practicing in the Los Gatos area.
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but there are a few I want to mention. The CMA proposes to require health plans submit a list of alternative drugs anytime they deny a non-formulary prescription, adopt a uniform prior authorization form, and pay reasonable compensation for administrative services required to help patients access the medications they need. When it comes to malpractice issues, the CMA proposes the federal government extend federal liability protection to all EMTALA-related medical care, and the CMA vigorously opposes any effort by hospitals to shift liability to physicians by requiring doctors carry higher than usual malpractice insurance limits. The CMA wants to authorize the state of California to discipline physicians who offer deceptive or fraudulent expert witness testimony and to certify out-of-state expert witnesses and subject them to discipline, too. And my favorite, a “Lemon Law,” which would give physicians a refund within 90 days of any EHR purchase, if the EHR failed to meet the physician’s needs or if the vendor failed to live up to its promises. Unquestionably, the biggest news out of the weekend was a new CMA policy endorsing the legalization of marijuana for medicinal and recreational use. How did that happen? In 2010, the House of Delegates approved a resolution to develop a comprehensive white paper recommending policy on marijuana legalization. The recommendations of that white paper, available on the CMA website and entitled “Cannabis and the Regulatory Void,” were accepted at the 2011 meeting by the CMA Board of Trustees. It is a bold move, predicated on the same experience with prohibition almost a century ago. As you might expect, not everyone agrees. If you are one of them, don’t get mad, get involved. This is your House. New delegates are chosen to represent District VII every year. New, for next year, we will also be nominating delegates to represent the Solo and Small Group Forum. These nominees will be voted upon by an election organized by the CMA sometime in the spring. If you are interested, call the SCCMA and let us know. But be prepared, because if Sir Winston Churchill had witnessed democracy run by doctors, he might have changed his mind.
PRACTICE MANAGEMENT
Health Care Reform No Solution to Rising Medical Premiums
While the future of health care reform continues to be sorted out by Congress and the courts, members will have to make important decisions about health insurance for themselves and their employees, especially when it comes to managing premium costs. No matter which path health care reform follows, annual increases in health insurance premiums will likely be part of everyone’s immediate future.
So what can you do until then?
• If you are not enrolled in a qualified High Deductible Health Plan which enables you to open a Health Savings Account, consider the significant savings this option provides. In 2012, with individual-only coverage, you will be eligible to contribute up to $3,100 to your account, or $6,250 with family coverage, on a federally tax deductible* basis. Members between the ages of 55 and 64 will be eligible to add an additional $1,000 per year ($4,100 and $7,250 totals respectively) to their accounts. Many members utilize the savings from premiums to help fund their accounts. Funds may be accessed without penalty for health-related expenses. • Investigate RAF Sales – Health plans offer incentives through discounts off their risk adjustment factors (RAF’s) for you to
change health plans. Instead of your medical rates increasing this year, we might be able to help you offset some of that increase if you insure six or more physicians and employees. • Mercer Select HRKnowHow – If you play a role in your medical group’s health care and benefit plan decisions, staying current on these challenging issues is critical. Access to this resource is included at no charge for members who purchase group (2 – 50 members and employees) health insurance through Marsh. It includes: • News and analysis of important group benefit issues and the latest information on health care reform • Compliance Link – tool to assist with health care and group benefit plan administration and samples of notices and forms We serve members who want assistance in evaluating their medical insurance choices. Call Marsh at 800/842-3761 for more information or a quote. * Marsh and the Association/Society do not provide tax, investment, or legal advice. Please consult with your professional advisors for guidance on these issues.
NOVEMBER / DECEMBER 2011 | THE BULLETIN | 7
cma advocacy
2011 Legislative Wrap-Up: Batten Down the Hatches By Jodi Hicks Vice President, Government Relations California Medical Association We weathered a storm this year, plain and simple. In a year fraught with budget woes, redistricting chaos, and an unpredictable new administration, the California Medical Association (CMA) overcame enormous shifts in the legislative and political landscapes. In what is becoming more and more common with each election, this legislature was nearly one-third newly-elected members. We were faced with tackling the huge task of both getting to know new legislators and educating them on our complex issues. As for the year in politics, it was a new year, new governor. Well, not exactly new. Returning to the office he left 28 years ago, a reinvented Jerry Brown began his third term as governor. And while he is certainly not new to leading the state of California, this self-described “wiser and more experienced” governor was anything but predictable. Early indicators of Brown’s leadership style were highlighted in his no-frills inauguration. Even before he was sworn in, Brown’s handlers were unable to say with any certainty which postinaugural events he would be at and when. One of the larger union organizations hosted a popular event, dubbed “The People’s Inauguration Party,” on the Capitol lawn immediately after the swearing-in ceremony, complete with free hot dogs and sandwiches. People waited in line for food and a chance to hear the new governor speak, but in the first of many surprises to come, the Governor and his wife, Anne Gust Brown, stopped by for a few hot dogs and walked right past the tent and microphones. A short while later, he showed up impromptu to an unadvertised party and made a public speech to the small crowd. Brown seems to enjoy surprises, or he doesn’t like to be predictable, or both. And then came the budget. Because of recently passed ballot measures, the legislature can pass a majority budget, but still needs a two-thirds vote for revenue increases. Throughout the year, Brown made a deter-
mined effort to close the budget gap by proposing tax increases be put on the ballot. Time and again, negotiations with Republican leadership broke down, despite the dismal outlook for the state. In March, Brown signed a budget attempting to close a $26 billion dollar deficit by slashing services for the sick and elderly, including $1.7 billion in Medi-Cal services. This year, CMA was able to protect Maddy funds from being eliminated in this round of cuts, and continues to fight the Medi-Cal cuts, which require a federal waiver. In June, the legislature passed a rare, on-time budget that was described as “not perfect, but Plan B.” But it was not without political drama, including a historic budget-veto, legislative pay freezes, and a physical skirmish on the floor of the State Assembly. The brush-up began when a Republican legislator likened the Democratic budget to a “Tony Soprano” insurance scheme. A “proud Italian” Democratic legislator took offense, and after a few exchanges, another legislator rushed to the confrontation and the two had to be held back by their colleagues. Despite the heated debates, the legislature passed a budget the following night. But in a surprise to almost everyone in Sacramento, Brown treated the legislative deal to a swift veto the next morning, calling the budget “unbalanced.” Having passed the deadline, and now without pay, legislators scrambled. Two weeks later deals were made and Brown signed the spending plan without fanfare. This was the first budget passed by simple majority, but not without a bit of turmoil and unpredictable weather. The budget was not the only strife of the year, though. In California’s first ever attempt at politics-free drawing of districts, a “citizens commission” was charged with drawing maps without taking into account incumbents or partisanship. There were winners and losers in this process. Some legislators are now running for open seats in Congress, while others find themselves drawn into districts with other sitting legislators. The experiment has left many politicians flailing wildly in the wind as they attempt to move into another open seat or pre-
8 | THE BULLETIN | NOVEMBER / DECEMBER 2011
pare for an election to hold on to their political lives. While the district lines are final, the fallout is still being calculated. With lawmakers worrying about their paychecks and their jobs, there were still laws to be passed. Even with a large sector of the legislature being newcomers, many of the contentious issues of the year were reminiscent of years’ past. We fought and won corporate bar, again. This year’s bill had the same sponsor and same author as last year, but a slightly different outcome. After many of the same negotiations and same messaging around the dangers of corporate control over physicians, we reached
a breakthrough with the author. As chair of the Labor Committee, he began to understand the dangers in turning physicians into employees without any employee protections. The author split with his sponsors, and took all of CMA’s suggested amendments in Health Committee. In what would be the most confusing committee hearing to date, the sponsors quickly opposed and killed their own bill. And we battled the physical therapists, again. They wanted direct access to patients, again. And we opposed it, again. We tried to clear up an ambiguity in law that questions whether medical corporations can hire physical therapists as employees, they opposed. We killed their bill, they killed ours. What was most interesting about these events was the lack of debate about the issue of scope expan-
sion, or whether or not medical corporations should be allowed to employ physical therapists. The discussion seemed to be around compromise, specifically whether or not CMA should compromise. After all, they wanted something, we wanted something, and some politicians thought the logical solution was to give something to each, or more accurately, not allow CMA to get one without giving up the other, irrespective of the policy merits. SB 923 (Walters) would have allowed physical therapists to directly access patients without a diagnosis from a physician. The bill passed out of committee with one senator giving a courtesy vote with a promise to hold the bill in Appropriations if the bill was not worked out. The bill was then held in Appropriations. Then came AB 783 (Hayashi), which would clarify
the legal ambiguity, so that physical therapists, along with other physician extenders such as psychologists, nurses, physician assistants, and podiatrists, can continue to work within the legal boundaries of medical corporations as they have for decades. Committee members commented that they wanted to see the issue of direct access worked out before voting on this issue, or even combine the two issues. To be safe though, the chair and vice-chair of the committee stated they would write letters to the Physical Therapy Board of California asking it to not act on the issue of physical therapist employment until the legislature had more time to opine. And if the lawmakers were not frustrating enough, then came the physical therapy board. Ignoring the committee’s request, the board began the process of investigating and
Continued on page 10
NOVEMBER / DECEMBER 2011 | THE BULLETIN | 9
2011 Legislative Wrap-Up: Batten Down the Hatches, from page 9 potentially disciplining physical therapists on the basis of their employment. At this point, there wasn’t much time left in the legislative session for a solution, but it was clear that if the legislature failed to act, the board would continue pushing forward. In an end-of-session maneuver, President pro tempore Steinberg authored SB 543, which stated simply that the physical therapy board could not, for one year, discipline physical therapists solely on the basis of their employment. That was Senator Steinberg’s version of a compromise, which passed and is currently awaiting the governor’s signature. On a better note, MICRA was never introduced this year. There were rumors, even clear indicators, but in the end there was no bill that directly attacked MICRA. There were, however, three bills introduced by the consumer attorneys that bit around the edges. All three were opposed by CMA. One was amended to remove all offensive content and the other two died along the way. With a new legislature and administration in place, CMA made sure to introduce bills dealing with such important issues as physician workforce, protecting MICRA, and adequate physician reimbursement rates. We continue to be at the forefront of discussions surrounding health care reform implementation and public health. The year was filled with
tumultuous events and treacherous winding roads, but CMA captured decisive victories for physicians. The year ended without changes to the ban on the corporate practice of medicine, MICRA, or scope of practice. The storm has calmed, but it will be back. There will be new elections as politicians adjust to their new district lines and bills we defeated will surely be back next year. The state’s fiscal crisis remains – so much so that former Speaker Willie Brown recently wrote in the San Francisco Chronicle that “[Governor] Brown is on the brink—and legislators are becoming concerned because they don’t think he knows it.” There is no way to wrap up this legislative year without highlighting the efforts of our team. While there were many twists and turns, our great group of advocates shifted, adapted, and worked together to end the year successfully protecting physicians. The team has weathered this last storm, and is stronger for it. And most importantly we are ready for the next season, whatever it brings. Below are details on the major bills that CMA followed this year. Please feel free to contact any of us at CMA with questions. Stay tuned for information about Governor Brown’s actions on CMA-followed legislation.
CMA-Sponsored Legislation AB 589 (Perea): Medical School Scholarships Prior CMA-sponsored legislation provided $1,000,000 per year in funding for the Steve Thompson Loan Repayment Program, which gives physicians up to $105,000 in loan repayment if they agree to practice in an underserved area for at least three years. This bill mirrors the loan repayment program and would create the Steve Thompson Scholarship Program, which would provide scholarships to medical students who agree to practice in one of California’s medically underserved areas upon completion of residency. Status: Held on Senate Suspense File due to lack of specific non-state funding. Two-year bill. AB 655 (Hayashi): Peer Review In California, there is no general legal duty to share peer review information among hospitals, or between hospitals and peer review bodies. AB 655 would allow for a reasonable peer review sharing agreement between peer review bodies to maintain the confidentiality of peer review information and protect the public health. Status: Signed by the governor. AB 783 (Hayashi): Professional Corporations—Licensed Physical Therapists and Occupational Therapists Since 1990, the Physical Therapy Board of California has explicitly allowed physical therapy services to be provided by a medical corporation. On November 3, 2010, the board rescinded this policy, threatening to disrupt the lives of physical therapists who are happily and legally employed by medical corporations. It also threatens to disrupt the care of our members’ patients and their patients’ continuity of care. AB 783 would ensure that licensed physical and occupational therapists may continue to be employed by medical, podiatric, and chiropractic corporations, a practice which has been the norm for over two decades. (New temporary fix proposed in SB 543, see below.) Status: Held in Senate Business and Professions Committee. Twoyear bill.
10 | THE BULLETIN | NOVEMBER / DECEMBER 2011
SB 543 (Steinberg and Price): Business and Professions—Regulatory Boards Because AB 783 was held in committee, CMA, along with Senator Steinberg and others, worked to find an agreement from both sides while we find a more comprehensive solution. The Physical Therapy Practice Act authorizes the Physical Therapy Board of California to license and regulate physical therapists, including the suspending and revoking of licenses. This bill would, until January 1, 2013, prohibit the board from taking disciplinary action against a licensee for providing physical therapy services as a professional employee of a medical corporation, podiatric medical corporation, or chiropractic corporation. Status: Signed by the governor. SB 347 (Rubio): Postsecondary Education—Graduate Medical Education Payments (Medi-Cal) SB 347 would augment the amount in graduate medical education (GME) funding that California receives in order to increase the number of resident physicians in California. Currently, under fee-for-service Medi-Cal, hospitals are reimbursed for GME costs through separate direct payment. The average Medicaid GME payment per hospital is about $1.52 million. California does not make any GME payments under Medi-Cal managed care—either as a direct payment to teaching programs or through inclusion in capitation rates to managed care organizations. This bill would recalculate Medi-Cal managed care rates and carve out GME payments. Status: Held in Senate Health Committee. Two-year bill.
CMA-Opposed Legislation SB 173 (Simitian): Health Care Coverage—Mammograms This bill would require physicians to notify mammography patients with highly dense breasts about the density of their breast tissue and the possibility that they may require additional imaging services (including ultrasound or MRI). This bill would create both practical and legal problems for physicians. Because the scope of who must receive the notice is so broad, women will be “scared” into thinking they need these expensive additional screenings when it isn’t at all warranted, leading to increased costs and pressures on a physician’s practice. Moreover, because the grading of the condition that may/may not lead to their receipt of the prescribed notice is subjective in nature, the absence of the notice could lead to lawsuits against doctors if a patient is later diagnosed with breast cancer. Although density is an emerging issue in mammography and the fight against breast cancer, the science is still out on this matter and no definitive protocols have been developed by the industry, yet, in response to this condition. Finally, the only supportable portion of the bill, that guaranteeing that carriers pay for these screenings should they be necessary, was taken out of the bill. As a result, this bill drives up fear and demand for unnecessary and expensive screening procedures, at a time when our focus should be on obtaining regular mammography for age-appropriate women. Author moved language to SB 791. Language from this bill was moved from SB 173, which was held on the Assembly Suspense file. This bill would require, under specified circumstances, a health facility at which a mammography examination is performed to include in the summary of the written report, sent to the patient, a specified notice on breast density. Status: Vetoed by the governor.
AB 52 (Feuer): Rate Regulation AB 52 would require insurers to obtain prior approval from the Department of Managed Health Care or the Department of Insurance before increasing or decreasing in health care premiums, copayments, or deductibles. While CMA is very concerned about the effect of skyrocketing premiums on individuals and small businesses, a full rate regulation scheme could give insurance companies an excuse to further squeeze dollars out of health care delivery. Rate-setting in health care is a bad precedent and this type of rate oversight would be politically motivated. Arbitrary premium caps would not lead to sacrifice by the plans/ insurers and could merely be passed down to physicians, leading to lower provider reimbursement, less time with patients, and more barriers to care. Instead, CMA believes we should enforce rate review and new medical loss ratios standards and invest in meaningful ways to bring down health costs, such as medical homes, electronic medical records, chronic disease management, and increasing Medi-Cal and Medicare reimbursement rates. Status: Held in Senate Appropriations Committee at the author’s request. Two-year bill. AB 824 (Chesbro): Rural Hospitals—Physician Services This bill would erode the ban on the corporate practice of medicine by allowing rural hospitals to employ physicians. Specifically, through year 2022, a rural hospital would be allowed to hire up to 10 physicians, without the participation of the medical staff in the hiring process, and would allow them to exceed that number with permission from the Medical Board of California. Status: Failed to meet committee deadline. Two-year bill. AB 926 (Hayashi): Physicians and Surgeons: Direct Employment This bill would serve as the vehicle for any compromise between CMA and the California Hospital Association related to the corporate bar. This bill would reenact the pilot project to allow all qualified district hospitals to employ physicians by extending the sunset to 2022, allow for not more than 50 physicians to be hired, and require the Medical Board of California to report to the legislature on the effectiveness of the project. This bill goes far beyond the balance that was made in the original pilot project between the limited, direct employment of physicians by a hospital and patient health/physician autonomy to make decisions in the best interest of patient safety. Specifically, CMA should work with the author on amendments to have the bill apply to rural areas only and limit the amount of physicians that can be hired. Status: Corporate bar placeholder bill not used in 2011 legislative year. SB 920 (Hernandez): Optometry SB 920 was introduced by Senator Ed Hernandez to amend the Optometry Practice Act. Senator Hernandez previously authored legislation that has resulted in regulations to allow optometrists to treat glaucoma, a ruling that is being challenged in court. Status: Failed to meet committee deadline. Two-year bill. SB 924 (Walters): Physical Therapists: Direct Access to Services SB 924 would substantially expand the scope of practice for physical therapists in California by allowing them to evaluate and treat patients for up to 30 days without a previous diagnosis from a licensed physician. Current law does not specifically address physical therapy treatment
Continued on page 12 NOVEMBER / DECEMBER 2011 | THE BULLETIN | 11
2011 Legislative Wrap-Up: Batten Down the Hatches, from page 11 without referral, but the law does prohibit therapists from making medical diagnoses. A 1965 Attorney General Opinion on this proposed ambiguity found that prior diagnosis by a medical provider was necessary before physical therapy treatment may commence. This interpretation has since guided the scope of practice for physical therapists in California and it does so in the best interest of the patient. SB 924 would dismiss this long standing requirement of a diagnosis and allow physical therapists to perform treatment without knowledge of what they are treating. Status: Failed to meet committee deadline. Two-year bill.
SB 558 (Simitian): Elder and Dependent Adults Abuse or Neglect– Damages SB 558 would change the standards of proof for elder abuse to a preponderance of evidence. By filing a claim for relief under the act, plaintiff’s attorneys are able to circumvent the limits on non-economic damages and attorney’s fees provided to health care providers under the Medical Injury Compensation Reform Act (MICRA). This bill was opposed by CMA and CAPP. Status: Held in Assembly Appropriations Committee. Two-year bill. AB 1062 (Dickinson): Arbitration and Appeals AB 1062 would weaken the enforcement of arbitration agreements by prohibiting an appeal when a lower court refuses to enforce an agreement. Arbitration is an important MICRA component, and the bill was opposed by CMA and CAPP. Status: Died on the Senate Floor. Two-year bill.
CMA Bills of Interest
AB 1360 (Swanson): Physicians and Surgeons—Employment (Support) As amended, CMA is in support of this bill. In contrast to this author’s corporate bar bill last year, which CMA killed (AB 646), CMA successfully brokered a compromise in AB 1360. This bill would create an expanded pilot program to allow eligible district hospitals throughout the state to hire up to five physicians. Similar to the original pilot program, the medical staff at the hospital would have to concur with the hospital administration’s decision to hire prior to the employment of each physician. Status: Failed to meet committee deadline. Two-year bill.
SB 866 (Hernandez): Prior Authorization Standardized Form (Support) This bill would dramatically streamline and improve the prior authorization process for prescription drugs. The bill would require all plans, all insurers, and physicians to use a standardized form when requesting prior authorization for prescription drug benefits. If a health plan or insurer fails to accept the prior authorization form or fails to respond to a physician within 48 hours, the bill would deem the prior authorization request granted. The bill would require the Department of Managed Health Care and the Department of Insurance to jointly develop the form with stakeholder input. The form cannot exceed two pages and must be electronically available and electronically transmissible. Status: Signed by the governor. AB 369 (Huffman): Step Therapy Reform (Support) This bill would limit a health plan’s or health insurer’s ability to use to step therapy or “fail first” protocols for the treatment of pain. The bill would require that the duration of any step therapy or fail first protocol 12 | THE BULLETIN | NOVEMBER / DECEMBER 2011
be determined by the prescribing physician and would prohibit a health plan or health insurer from requiring that a patient try and fail on more than two pain medications before allowing the patient access to other pain medication prescribed by the physician. This bill would still allow step therapy to be used, but closes loopholes and puts the medical decisions back in the doctor’s hands, so the patient can get the right medication in a timely fashion. Status: Held in Assembly Appropriations Committee. Two-year bill.
AB 1059 (Huffman): Health Plan Penalties (Support) This bill seeks to ensure that enforcement actions by the Department of Managed Health Care (DMHC) make physicians and enrollees whole. Where the DMHC has found that an HMO has underpaid a physician, the bill would require the administrative penalty amount to, at a minimum, equal the amount of the underpayment plus interest. The enforcement action would also have to ensure that the physician and enrollee are compensated by the HMO for the full amount of the underpayment or financial value of the denied benefits. Status: Signed by the governor. SB 155 (Evans): Maternity Coverage (Support) This bill, cosponsored by the American Congress of Obstetricians and Gynecologists and Kaiser Permanente, would close a loophole exploited by health insurance companies in order to sell cheap, “subprime” non-comprehensive health insurance that lacks maternity coverage. This bill would bring two bodies of law into conformity by requiring all individual and group health insurance policies regulated under the Department of Insurance to cover maternity services, while HMOs regulated by the Department of Managed Health Care are already required to meet these standards. This bill would ensure fair, affordable access to maternity coverage in health care benefits, regardless of the type of plan offered. It was split into two separate bills, SB 222 and AB 210. Status: Bill was split into two different legislative vehicles. Updates on each bill below. SB 222 (Evans): Maternity Services (Support) This bill would require every individual health insurance policy to provide coverage for maternity services for all insured covered under the policy. This bill would become operative only if AB 210 is also enacted. Status: Signed by the governor. AB 210 (Hernandez): Maternity Services (Support) This bill would require every group health insurance policy to provide coverage for maternity services for all insured covered under the policy. This bill would become operative only if SB 222 is also enacted. Status: Signed by the governor. SB 100 (Price): Outpatient Surgery Settings (Support) This bill would improve the ability of accrediting agencies and the Medical Board of California to work together to ensure that the care provided in outpatient surgery settings is top notch and that any bad actors are immediately identified and remediated or disciplined. The bill would increase transparency about the accreditation status of these facilities to inform patients, improves the inspection and investigation processes in the event a complaint is received, requires emergency protocols to be in place if there are serious complications or side effects from surgery, and protects against “accreditation shopping.” This is a balanced and reasonable bill that closes gaps and adds important safeguards to provide even
more protection to patients. Status: Signed by the governor.
AB 499 (Atkins): Minor Consent for Prevention of STIs (Support) Current law allows minors to consent to treatment of sexually transmitted infections (STIs), but not to preventative care for STIs. This is a barrier to minors seeking the HPV vaccine and other methods of prevention of STIs who cannot or will not obtain parental consent. This bill would allow a minor who is 12 years of age or older to consent to medical care related to the prevention of a sexually transmitted disease. CMA policy supports legislation to allow patients 12 through 17 years of age to obtain vaccines to prevent sexually transmitted infections without parental consent, if it is not possible for the physician to discuss the matter with the parent. Status: Signed by the governor. AB 584 (Fong): Workers’ Compensation: Utilization Review (Support) This bill would require that physicians performing “utilization review” (UR) in California’s workers’ compensation cases be licensed by the Medical Board of California. Currently, many carriers hire out-ofstate physicians to perform UR. Because these physicians do not understand the nuances of California law and our workers’ compensation system, in many cases, they end up inappropriately modifying, delaying, or even denying treatment requests from the primary-treating California doctor seeing the injured worker. Moreover, this also leads to increased lien filings for payment by doctors due to these complications and delays, adding unnecessary costs and workload to the system. Finally, the medical board has stated that UR is the practice of medicine, but since
these physicians are not licensed in California, they cannot be held accountable for their actions to delay or deny treatment under California law. This bill is similar to AB 933 (Fong) of 2010, which CMA supported. Status: Vetoed by the governor.
SB 336 (Lieu): Emergency Room Crowding (Support) This measure would require every licensed general acute care hospital to assess the condition of its emergency department (ED), using a crowding score, every four or eight hours, and to develop and implement capacity protocols for overcrowding. California EDs are dangerously overcrowded and have reached a crisis level, ranking last in the nation in the number of emergency rooms available to its residents (six for every one million people). This bill—sponsored by the California College of the American Chapter of Emergency Physicians (CalACEP) —would help to address this overcrowding and is similar to AB 2153 (Lieu) of 2010, which CMA supported. Status: Held in Assembly Appropriations Committee. Two-year bill. SB 863 (Lieu): Workers’ Compensation—Liens (Support) This bill is an effort to address the increasing number of medical payment liens being filed in the California workers’ compensation system. In January of 2011, the Commission on Health and Safety and Workers’ Compensation published a report on this subject that outlined a number of policy recommendations. This bill is crafted based on some of those recommendations, the primary one being to reduce the amount of time allowed to file a lien. This would help to stem the increasing practice of third-party entities buying up physicians’ workers’ comp accounts receivables and filing new liens on them, even when the claims are 10 or more years old. CMA supports this bill as a means of securing efficienNOVEMBER / DECEMBER 2011 | THE BULLETIN | 13
2011 Legislative Wrap-Up: Batten Down the Hatches, from page 13 cies in the system without unduly hindering a physician’s ability to file a lien, a critical last resort for obtaining payment. Status: Held in Assembly Appropriations Committee. Two-year bill.
SB 923 (De Leon): Workers’ Compensation—Official Medical Fee Schedule (Oppose Unless Amended) This bill would require the Administrative Director (AD) of the Division of Workers’ Compensation to adopt a physician services fee schedule based on the Medicare system, the Resource-Based Relative Value Scale (RBRVS), by July 1, 2012. Under current law, the AD has the authority to do this based on the requirement to regularly update the physician fee schedule. However, past efforts to do so—as recently as mid-2010—resulted in significant payment cuts to various physician specialties, in some cases as much as a 40% reduction. Although this bill previously contained language that ensured such reductions didn’t occur, this language was removed during the bill’s hearing in Senate Labor Committee at the request of the California Labor Federation. CMA supported the prior version of SB 923 as an assurance of sufficient payment during this policy transition, but now may need to change position as there is new risk to sufficient payment. Moreover, the ground rules (or billing rules) are not dealt with in this bill in any way, but significantly impact payment to physicians. We are working on language to offer to the author, to address this concern. Status: Suspended in Assembly Appropriations Committee. Twoyear bill. AB 1000 (Perea): Health Care Coverage—Cancer Treatment (Support) This bill would help ensure that cancer patients are not denied the most appropriate and effective treatment by putting costs above care. According to the author, “there are significantly greater patient outof-pocket costs for oral cancer therapies covered under the pharmacy benefit than IV therapies covered under the medical benefit. These outof-pocket costs become a de facto denial of access, which, in a study by Prime Therapeutics, resulted in one in six patients not receiving treatment solely due to cost. Therefore, patient access to potentially the only life-saving cancer therapy available to them is restricted. Status: Held in Assembly Appropriations Committee. Two-year bill. AB 378 (Solorio): Workers’ Compensation—Pharmacy Products (Watch) This bill is meant to address a recent spike in prescriptions for and costs associated with compounded pharmaceutical products in the workers’ compensation system. In the past few years, the amount carriers have paid annually for these products have gone up over fourfold, with no legitimate clinical justification. It has been argued by the cosponsors of the bill—a coalition of labor, businesses, and insurance companies— that the same “bad actor” physicians who were profiteering from drug repackaging scams have now refocused on compounds. As a result, the author of this measure has in the past proposed utilization constraints to prevent unnecessary use of compounds, but CMA was able to kill that effort in the legislature. The new effort, as contained in AB 378, would curtail the amount payable for compounded drugs in workers’ comp cases in order to remove the incentive to overbill that currently exists in the system due to a lack of price controls for these products. The bill would also take a utilization approach to solving the problem, by adding “pharmacy goods” to the list of products and services in existing state law that a physician is barred from self-referring for. The final version of this 14 | THE BULLETIN | NOVEMBER / DECEMBER 2011
bill contains compromise language negotiated by CMA that would limit reimbursement for physician-dispensed products to a level that would cover a physician practice’s costs to dispense them, but won’t provide an unreasonable financial incentive to prescribe and dispense them. This was done by allowing a physician office to be reimbursed for compounds at 300% of the Documented Paid Cost to the office, capped at a margin of $20. When the author and supporters agreed to take this amendment, CMA took a Neutral position on the bill. Status: Signed by the governor.
SB 850 (Leno): Medical Records—Confidential Information (Watch) SB 850 purports to reduce medical errors. The information provided by the consumer attorneys stated “Many EHR software systems have design flaws that can cause serious errors if left uncorrected. In some situations, health care providers have taken advantage of these design flaws to cover-up errors by modifying or deleting earlier entries. SB 850 would ensure the accuracy, integrity, and efficiency of electronic health records in order to achieve the ultimate goal of reducing medical errors.” This was clearly introduced in order to highlight a particular case in which physicians were accused of fraudulently changing the patient’s electronic medical records. CMA opposes the bill, stating it is unnecessary and there are already laws in place to address fraud. After many discussions with the author, the bill was amended to merely reflect federal requirements related to EHR systems. In this form, CMA went neutral on the bill. Status: Signed by the governor.
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ROBERT J. FRASCINO, MD IN MEMORIAM
Robert James Frascino, MD, who fought HIV professionally for 30 years and personally for 20 years, died suddenly on September 17, 2011, in Mountain View, California. He was 59. The cause of death was bacterial sepsis. His husband, Steven Natterstad, MD, and his sister, Linda Godfrey of Glen Rock, New Jersey, were with Bob when he died. His dog, Presto, was also close by. Bob was a physician, an educator, a tireless advocate for the HIV/AIDS community, a trustee of Oberlin College and Conservatory of Music, and a concert pianist. His love of life, keen intellect, sense of humor and ever-present smile will be missed by all who knew him. His boundless generosity with his time, his energy, and his advocacy encompassed his family, his friends, and his community alike. Bob was born in Rochester, NY. He graduated with high honors from Oberlin College in 1974 with a degree in biology. He earned a medical degree at the University of Cincinnati College of Medicine, served his internship and residency in pediatrics at Children’s Hospital Oakland, and completed his postdoctoral clinical immunology/allergy fellowship at the University of California, San Francisco. Dr. Frascino was one of the first physicians to treat HIVinfected patients in the early ’80s. He subsequently founded two medical clinics devoted to the comprehensive and compassionate care of HIV-positive people. As primary investigator for several HIV clinical trials, he published articles on evolving new treatments and quality of life issues for people living with the virus in such journals as International Journal of STD and AIDS, Western Journal of Medicine, Journal of AIDS, and Blood. A fellow of the American Academy of Allergy, Asthma, and Immunology, and the American Academy of Pediatrics, Dr. Frascino also served as Associate Clinical Professor of Medicine, Division of Immunology, Rheumatology, and Allergy, at Stanford University Medical Center for 18 years. He was a certified member of the American Academy of HIV Medicine and a distinguished member of the executive boards of numerous state and regional associations, including past president of the California Society of Allergy, Asthma, and Clinical Immunology; the Allergy/Immunology Association of Northern California; and the Allergy, Asthma, Immunology Foundation of Northern California. Dr. Frascino crossed the line from physician to patient when an occupational exposure resulted in his testing HIV-positive. In early 1996, when his health began to fail, he gave up his HIV/ AIDS medical practice and turned his efforts to HIV education and to fundraising. In his words, “I could now speak with the knowledge and authority of a physician, but with the eyes and heart and soul of a patient.” That same year, he and Steve, both 18 | THE BULLETIN | NOVEMBER / DECEMBER 2011
concert pianists, planted the seed for what would become The Robert James Frascino AIDS Foundation (www. concertedeffort.org) by performing a piano concert benefitting HIV/AIDS, at their home in Los Altos, California. Due to its overwhelming success, the couple founded the Concerted Effort HIV/AIDS benefit concert series through which they performed classical and popular piano concerts throughout California. They raised over $1,500,000 for crucial HIV/AIDS services worldwide, ranging from hospice care in Los Angeles to a clean needle-exchange program in Washington, DC, to the provision of anti-HIV medication to HIV-positive pregnant women in Africa, thereby helping to prevent transmission of the virus to their newborns. Concerted Effort 2011, which would have been the 17th in the series, was scheduled to take place at the Mountain View Center for the Performing Arts on September 18, the day following Bob’s death. Dr. Frascino was the recipient of the National Society of Fundraising Executives’ Distinguished Honoree/Silicon Valley Philanthropy Award and the Santa Clara County Medical Association’s Award for “Outstanding Contribution in Medical Education.” In May 2002, as part of the International AIDS Candlelight Vigil in San Francisco, Dr. Frascino accepted the Bobbi Campbell AIDS Hero Award for which he received personal letters of acknowledgement and congratulations from both Governor Gray Davis and Mayor Willie Brown. Since May 2000, Dr. Frascino served as an expert in two Internet-based HIV educational forums – Fatigue/Anemia and Safe Sex/HIV Prevention – at The Body, an HIV/AIDS information resource website (www.thebody.com). He posted answers to nearly 30,000 questions over the past 11 years. In December 2010, he started a blog titled “Life, Love, Sex, HIV and Other Unscheduled Events.” Known as “Dr. Bob” to his global online community, he touched the lives of millions of people through his forums and blog. In 2005, Dr. Frascino joined the Oberlin College Board of Trustees. He served as vice chair of the board for two years, beginning in 2009. In the words of fellow trustee Stewart Kohl, “ . . . he was the shining light of our board, who on every issue – big and small – brought his keen mind, great sense of humor, appreciation for the human side of issues and an especially welldeveloped sense of fashion, relative to the rest of us schleps from Oberlin.” “Bob was a wonderful trustee and friend to Oberlin,” says President Marvin Krislov. “His leadership, dedication, and unfailingly positive spirit brightened our community. We mourn his loss. He leaves a legacy at Oberlin that we will cherish.”
CHRISTOPHER C. CHOW, MD IN MEMORIAM
It is with deepest sorrow that we announce the passing of Dr. Christopher C. Chow on August 21, 2011. Dr. Chow passed peacefully after a lengthy illness, at home, surrounded by his loving family. Chris joined The Permanente Medical Group in 1963, and his leadership acumen was quickly recognized. He was the Chief of Internal Medicine and the elected representative to the PMG Board of Directors before rising to become Physician-inChief of the Kaiser Permanente Santa Clara Medical Center, serving in that role for 16 years. Chris was a superb internist and a major strategist, and his indelible mark was left throughout the medical center. In fact, it was Dr. Chow who had the strategic foresight to purchase, in 1992, the piece of property on which the Kaiser Permanente Santa Clara Medical Center now stands. Dr. Chow’s professional accomplishments are numerous, but he was best known for his openness in leadership and democratization of the leadership process. He was also a strong patient advocate, espousing a philosophy of quality, accessibility, and affordability in medical care. Dr. Chow was the recipient of the Santa Clara County Medical Association’s Benjamin J. Cory, MD Award in 1996. Dr. Diane Craig, who had the privilege of working for him since 1985, captures the essence of the man with these words:
“He was the sort of man who could be underestimated. He did much of his work through others, always seeking to promote and encourage the development of others. He was such a kind man. Always making people feel at ease, willing to share their thoughts and concerns and to be heard. He gave direction, not orders. He walked among his colleagues, not above them. He was always fair-minded. It was never about personal gain, but what was good for the medical group.” Chris was raised in San Francisco Chinatown and Honolulu. He attended UC Berkeley, where he graduated with a B.S. degree in zoology. He earned an M.D. degree from UCSF in 1957. He did his internship in 1958 at San Francisco General Hospital. Chris trained in internal medicine at Wadsworth General Hospital and finished his training in gastroenterology at Cedars of Lebanon in Los Angeles. He served in the U.S. Air Force from 1959 to 1961, stationed at Luke Air Force Base in Glendale, Arizona. A resident of Los Altos, Chris is survived by his wife, Rowena (Sue), and his son and daughters, Janis, Craig, Suanne, Dianne, and Lani. He is also survived by eight grandchildren and his brother, Galen Chow.
A Fallen Limb A limb has fallen from the family tree. I keep hearing a voice that says, "Grieve not for me. Remember the best times, the laughter, the song. The good life I lived while I was strong. Continue my heritage, I'm counting on you. Keep smiling and surely the sun will shine through. My mind is at ease, my soul is at rest. Remembering all, how I truly was blessed. Continue traditions, no matter how small. Go on with your life, don't worry about falls I miss you all dearly, so keep up your chin. Until the day comes we're together again –Author unknown NOVEMBER / DECEMBER 2011 | THE BULLETIN | 19
CMA House of Delegates Annual Meeting Highlights Hundreds of California physicians convened in Anaheim last month for the 2011 House of Delegates, the annual meeting of the California Medical Association (CMA). 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. Visa restrictions and health care provider shortage areas (Resolution 606a-11): The delegates asked CMA to advocate for the expansion of the J-1 Visa program beyond 30 slots; and that visa waivers should be granted for six years initially and that preference should be given to physicians serving in rural and underserved areas. Hospital foundation ownership of medical groups (Resolution 207a-11): The delegates directed CMA to advocate for stronger regulatory enforcement of California’s ban on the corporate practice of medicine. Generic versus brand medications (Resolution 504-11): The delegates asked CMA to oppose the profit-motivated removal of generic medications from the market in favor of much more expensive brand products. Presumed consent for organ donation (Resolution 509a-11): The delegates asked CMA to study and develop new policy recommendations for relieving the organ donor shortage, including presumed consent. Legal prohibition of circumcision (Resolution 106-11): The delegates directed CMA to oppose any attempt to legally prohibit male infant circumcision and to refer this for national action. Regulation of electronic cigarettes (Resolution 113-11): The delegates voted to support the prohibition of the use of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids in places where smoking is prohibited by law, and to support requiring a tobacco permit for the sale of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids. Medi-Cal enrollment at point of care (Resolution 204a-11): The delegates voted that CMA support allowing eligible uninsured patients to enroll in public health programs at the time they receive care. Effect of Medi-Cal funding cuts on access to care (Resolution 205a-11): The delegates asked CMA to request that the Centers for Medicare & Medicaid Services require the State of California to provide independently verified studies and data comparing access to physician services by Medicaid and commercially insured patients in California since state cutbacks. Coverage of contraception as health insurance benefit (Resolution 403-11): The delegates directed CMA to support coverage, without copayments, of all FDA-approved contraception methods and sterilization as a mandated health benefit of all health plans. The rest of the actions of the 2011 House of Delegates are available to 20 | THE BULLETIN | NOVEMBER / DECEMBER 2011
District VII Delegates (representing counties of Santa Clara, San Mateo, Monterey, and Santa Cruz). members at http://www.cmanet.org/hod. Click on the “documents” tab.
San Diego Family Physician Elected CMA President
San Diego family physician James T. Hay, MD, took over as the California Medical Association’s 144th president at the close of the association’s annual House of Delegates. In his address to the nearly 1,000 physicians in attendance, Dr. Hay challenged the members to set out to recreate the health care marketplace “like the tech industry does.” Rather than waiting for someone to pay us for our products and services under the new health care system, he said, physicians need to be active in its creation. Physicians need to set big goals, he said. It’s time to think about the end point – a better profession, a more secure economic environment, a healthier and safer public – we need to design a way to get there. But to get there, he cautioned, physicians must stop “fighting each other for pieces of a dwindling market,” and to think about enacting plans that enhance the marketplace for patients and clinicians. Physicians know a lot about what would improve care for patients and produce cost savings, he said. For example, if we can coordinate care better and make it possible for patients to receive “treatment at home rather than in a hospital or skilled nursing facility,” this would save money and help patients. “If patient care and safety were improved this way,” we might be able to “capture 25% of the market dollars rather than the 19% we currently own.” “We have met the enemy and he is us,” Dr. Hay said, quoting Walter Crawford’s satirical cartoon character Pogo. Then he challenged CMA’s members to stop thinking like victims. “If we have the power to create
Photo Credit: Sheila Foley and David Flatter
2011 CMA House of Delegates our own problems, we certainly have the power to fix them.” A native of Philadelphia, Dr. Hay has practiced in the north county area of San Diego since 1978, when he founded North Coast Family Medical Group. He received his medical degree from Jefferson Medical College in Philadelphia and his B.A. from Duke University in North Carolina. He completed his residency at Naval Hospital, Camp Pendleton, and is board certified by the American Board of Family Medicine. Dr. Hay is a member of the San Diego County Medical Society (SDCMS) and the California Academy of Family Practice. He also has a long history of involvement in organized medicine at the local, state, and national level. He is past president of SDCMS and the SDCMS Foundation and has been on the Board of Trustees of the California Medical Association (CMA) since 1994. He has been a member of CMA’s House of Delegates (HOD) since 1986, serving as vice speaker and speaker of the HOD from 2003 to 2009, and is currently concluding a one-year term as CMA president elect. He has served as a member of the board of the San Diego and Imperial County Red Cross for six years and on the board of 211 San Diego for four years. Since 1977, he has received the AMA Physician’s Recognition Award, which is given to physicians who demonstrate a commitment to
James T. Hay, MD, CMA President.
L to R: MCMS/CMA Delegate and CMA Past President Dr. David Holley, and SCCMA/CMA Delegates Drs. Yannis Paulus and Arthur Basham enjoy the evening.
patient care through continuing medical education. Dr. Hay is active in local and state political action and enjoys running, travel, and great restaurants. Dr. Hay and his wife, Tricia, have two grown children and four grandchildren. View the video on YouTube at http://www.youtube.com/cmaphysicians. Also serving on CMA’s 2011-2012 Executive Committee are: • Immediate Past President James Hinsdale, MD, a San Jose trauma surgeon; • President-Elect Paul Phinney, MD, a general pediatrician at Kaiser Permanente Medical Group in Sacramento; • Speaker of the House Luther Cobb, MD, a surgeon in Humboldt County; • Vice Speaker of the House Ted Mazer, MD, a San Diego ear, nose and throat specialist; • Chair of the Board of Trustees, Steve Larson, MD, an internist and infectious diseases consultant in Riverside County; and • Vice Chair of the Board of Trustees, David Aizuss, MD, a Los Angeles ophthalmologist.
SCCMA/CMA Delegates Drs. Robert Gould and Cindy Russell give their comments on resolutions.
L to R: SMCMA/CMA Delegate and 2012 District VII Chair Dr. Dirk Baumann, SMCMA’s Executive Director Sue Malone, SCCMA/MCMS’s CEO William Parrish, and Sandra Baumann. NOVEMBER / DECEMBER 2011 | THE BULLETIN | 21
CMA President James Hinsdale, MD, speaks at the House of Delegates annual session.
L to R: SCCMA/CMA Delegate and District VII Chair Dr. James Crotty, SCCMA/CMA Delegate Dr. Cindy Russell, SCCMA/CMA Delegate and SCCMA President Dr. William Lewis, and SCCMA/CMA Delegate and CMA Trustee Dr. Martin Fishman.
L to R: SCCMA/CMA Delegates Drs. Cindy Russell, Jeff Coe, William Lewis (also SCCMA President), Tanya Spirtos, Thomas Dailey, and Martin Fishman.
SCCMA/CMA Delegate and District VII Chair James Crotty, MD; SCCMA Executive Assistant Sheila Foley; SCCMA/CMA Delegate and SCCMA President William Lewis, MD; and SCCMA/CMA Delegate and CMA Trustee Martin Fishman, MD.
SCCMA/CMA Delegates Drs. Amir Hadid, Richard Kramer, and Robert Gould at the District VII dinner.
MCMS/CMA Delegate Dr. Valerie Barnes poses with SCCMA/MCMS CEO William Parrish.
SCCMA/CMA Delegate and SCCMA President Elect Dr. Rives Chalmers enjoys the evening with his wife Ann.
22 | THE BULLETIN | NOVEMBER / DECEMBER 2011
2011 CMA House of Delegates CMA Past President J. Brennan Cassidy, MD, presents CMA President James Hinsdale, MD, with a proclamation from the state assembly for his outstanding contributions in leadership to the CMA.
MCMS/CMA Delegates Drs. Valerie Barnes and John Jameson, and SCCMA/ CMA Delegate Dr. Rebecca Powers at the District VII dinner.
SCCMA/CMA Delegate and CMA Trustee Dr. Martin Fishman enjoys the camaraderie with MCMS/CMA Delegate and CMA Past President Dr. David Holley.
L to R: SCCMA/CMA Delegate Dr. Yannis Paulus, SCCMA/MCMS CEO William Parrish, Luanne Parrish, and SCCMA/ CMA Delegates Drs. Arthur Basham, Jeff Coe, and Richard Kramer.
CMA Presidents Drs. James Hinsdale (2010-2011), James Hay (2011-2012), and J. Brennan Cassidy (2009-2010).
Dr. William Ricks and CMA Alliance Past President Debbi Ricks enjoy the evening.
Anita Benninghoven, SCCMA/CMA Delegate Dr. Scott Benninghoven, and MCMS/CMA Delegate Dr. John Jameson.
NOVEMBER / DECEMBER 2011 | THE BULLETIN | 23
“Without concerted action, thousands more Americans will die each year from liver cancer or liver failure…”
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Check the boxes for
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Hepatitis B: A Vital Sign for Asian Americans 1 in 12
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will die from liver cancer or liver disease without long term medical care.
Websites for further information: http://www.cdc.gov/hepatitis/HBV/TestingChronic.htm http://liver.stanford.edu A public service announcement from
24 | THE BULLETIN | NOVEMBER / DECEMBER 2011
1 in 4
Santa Clara County Medical Association and the Alliance Invite you to a
Holiday Dinner Celebrating the Medical Family
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Monday, December 5, 2011 7:00 p.m. $42 per person (children 12 & under $15) Family Style Service, No-Host Bar, 50 person limit RSVP by December 2, 2011 For further information contact: Debbi Ricks, 408-354-5613 or debbiricks@aol.com SCCMA & SCCMAA Holiday Dinner
Send paid reservations by November 28, 2011 to: Santa Clara County Medical Association • 700 Empey Way, San Jose, CA 95128 Make checks payable to : SCCMA Alliance
FAX-BACK MasterCard/Visa payments attention: Jean Cassetta, 408-289-1064 Please bill my credit card as indicated:
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hospital news
El Camino Hospital Updates GENOMICS EDUCATION PROGRAM FOR PHYSICIANS LAUNCHES AT EL CAMINO HOSPITAL First of its kind program aims to help primary and specialty physicians leverage the power of “personalized medicine” for patients. El Camino Hospital’s Genomic Medicine Institute (GMI), in collaboration with Genetic Alliance and the National Coalition for Health Professional Education in Genetics (NCHPEG), has launched a groundbreaking genomic education curriculum specifically designed to help physicians who practice there apply the principles of genetics and genomics to everyday practice. The program began on October 18. “We think our program has tremendous potential to improve physicians’ ability to prevent, diagnose, and treat a wide range of conditions,” said Eric Pifer, MD, El Camino Hospital’s Chief Medical Officer. “By providing physicians with help in applying genomic medicine in their practices, better outcomes can and will be achieved.” GMI, Genetic Alliance, and NCHPEG recognize the many formidable challenges of incorporating genomics into clinical care. In fact, El Camino Hospital’s GMI is one of the first non-academic centers in the nation that is confronting the topic head-on. “We think there is a critical need for physician education about genomics,” said NCHPEG Executive Director Joan Scott. “Despite the fact that the NIH has spent more than $30 billion on the Human Genome project— which has yielded enormous breakthroughs in knowledge about the interplay of genetics and disease—only 10% of respondents to a recent AMA survey thought they had enough knowledge to use gene tests in prescribing medicines. Nonetheless, nearly all thought such tests were useful. El Camino Hospital and its collaborative medical staff is exactly the right place for this pioneering program to take place. It will address this knowledge gap and provide a model for physicians across the country to in-
crease their genomics competency.” The curriculum consists of ten two-hour evening workshops to be held at El Camino Hospital, each presented by a subject matter expert paired with an El Camino physician. Four foundational courses focus on the use of genomics in practice, while six additional modules cover its application to a range of specific conditions such as cancer, cardiovascular disease, prenatal and pediatric disease, neurological conditions, and rare and complex diseases. Each module will include a patient video, featuring one or more individuals sharing their personal experiences with genetic testing and genomics. The videos will be designed to illustrate clinical issues relevant to each subject area, but will also serve to illustrate the human element of hope and expectations for genomics. “As important as it is to learn the science, we also have to focus on the ultimate beneficiaries, individuals, and families,” said James O’Leary, chief innovation officer at Genetic Alliance. “Surveys show that patients are increasingly looking to genomics in order to make informed decisions and to find better treatment options. Their doctors need to be able to communicate the risks and benefits of those decisions.” “Physicians hear about the science of genomics at their professional meetings and many great conferences address industry and research groups,” said Lynn Dowling, executive director of the GMI. “But no one teaches doctors how to take the science home and put it into practice tomorrow. This curriculum will give them all that, in a setting that is both familiar and convenient.” A nominal charge for each session includes dinner and course materials and access to regularly-updated on-line resources; physicians are encouraged to complete all ten courses and receive a quantity discount to do so. Both CME
26 | THE BULLETIN | NOVEMBER / DECEMBER 2011
credit and a certificate of completion are offered, and physicians who complete the course can be listed on the El Camino website.
About the National Coalition for Health Professional Education in Genetics
NCHPEG is an “organization of organizations” committed to a national effort to promote health professional education and access to information about advances in human genetics. NCHPEG members are an interdisciplinary group of leaders from more than 50 diverse health professional organizations, consumer and volunteer groups, government agencies, private industry, managed care organizations, and genetics professional societies. For more information, visit http://www.nchpeg.org.
About Genetic Alliance
Genetic Alliance improves health through the authentic engagement of communities and individuals. In this, our 25th year, we celebrate innovation on our journey toward novel partnerships, connected consumers, and smart services. For more information, visit http://www. geneticalliance.org.
About El Camino’s Genomic Medicine Institute
The GMI helps speed the translation of genomic science, from the research labs to the medical offices of El Camino Hospital physicians, for the benefit of patients and the community. For more information, visit http:// www.elcaminohospital.org/Genomic_Medicine_Institute.
EL CAMINO HOSPITAL DESIGNATED THE ONLY GYNECOLOGICAL CASE OBSERVATION SITE FOR ROBOTIC SURGERY IN NORTHERN CALIFORNIA On September 9, El Camino Hospital became the first and only Gynecological Oncology Case Observation Site for robotic surgery in Northern California. This program is intended to share the expertise and experience of our surgeons with gynecologists nationally and internationally. By offering this opportunity, the hospital will educate clinicians on best practice utilization of the da Vinci® Robot, a breakthrough surgical technology which facilitates minimally-invasive surgery. El Camino Hospital’s Mountain View and Los Gatos facilities are home to the most comprehensive robotic surgery program in Northern California, offering minimallyinvasive GYN, uterine, prostate, lung, and kidney procedures. The hospital’s surgeons have performed the most robotic gynecological surgeries in the region; Dr. Dwight Chen and Dr. Albert Pisani, GYN oncologists who will lead the hospital’s Intuitive Case Observation Site program, collectively have performed more than 750 GYN robotic surgeries in the last three years. El Camino Hospital has a dedicated Robotics Coordinator overseeing all procedures with the surgeons, and a dedicated team of nursing professionals with specialized expertise in the care necessary for this patient population. Numerous studies have shown that the ex-
perience of the hospital staff and surgeons who perform a certain procedure correlates with better outcomes. “El Camino Hospital has made a consistent commitment to our community to invest in the best technology and patient care,” said Dr. Chen, a board certified surgeon who treats women with GYN cancer and noncancerous reproductive system conditions that require complicated surgery. “The da Vinci Robot is one such technology—but it is only as good as the surgeons who use it, so we’re delighted to be able to share our expertise with other surgeons interested in being trained.” The Da Vinci Si with 3D HD vision is considered one of the most advanced platforms for minimally-invasive surgery, one which opened up new opportunities to replace high-impact open cavity surgeries with minimally-invasive, nerve-sparing procedures. Such procedures are a growing percentage of all surgeries because they tend to be much less traumatic for patients, with fewer complications (smaller incisions equal fewer chances of infection) and faster recovery. “A robot is much like a scalpel or a clamp,” said Dr. Pisani, one of the leading robotic surgeons in California with over 500 procedures performed. “Once a surgeon has mastered the technique, it becomes an extension of his or her
hands—except that now there are four hands instead of two. The robot allows a surgeon more freedom of movement than traditional laparoscopy. Because our community tends to be extremely well-informed, we’re seeing more and more patients seeking out robotics-trained surgeons for their procedures; the demand keeps on growing as people become more aware of its advantages.” Currently, there are 11 GYN surgeons at El Camino Hospital trained on the da Vinci. In addition to Dr. Pisani and Dr. Chen, they include Dr. Camran Nezhat, Dr. Barbara PhelpsSandall, Dr. Angela Pollard, Dr. Katherine Sutherland, Dr. Kirby Tran, Dr. Mary Kilkenny, Dr. Nadine Graven, Dr. Tom Margolis, and Dr. Nilima Parekhji. El Camino Hospital also offers Case Observations in complex GYN benign cases. It has three da Vinci Si Systems and has dual console capabilities for training purposes. Dr. Chen offers a Case Observation schedule every other Friday, beginning September 9. Dr. Pisani’s Case Observations are scheduled on every other Tuesday, beginning September 13. To schedule an observation, call Matthew E. Falvo, Clinical Sales Representative, Intuitive Surgical Inc., 408/892-8354.
Submissions to the “Hospital News” Section are free and encouraged. The Bulletin reaches over 3,600 health care professionals bimonthly. Feel free to use this space to promote exciting developments affecting your hospitals. To submit items, email us a Press Release or Word file to: Pam Jensen at pjensen@sccma.org. NOVEMBER / DECEMBER 2011 | THE BULLETIN | 27
28 | THE BULLETIN | NOVEMBER / DECEMBER 2011
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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. 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.
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medico news
CMA urges legalization and regulation of medical cannabis to allow for wider clinical research The California Medical Association (CMA) has adopted official policy recommending legalization and regulation of cannabis. The decision was based on a CMA white paper that concludes physicians should have access to better research, which is not possible under current drug policy. The paper, available at http://www.cmanet.org, is a thoughtful study and response to an important issue, continuing CMA’s tradition of providing guidance on public health. CMA is the first statewide medical association to take this official position. “CMA may be the first organization of its kind to take this position, but we won’t be the last. This was a carefully considered, deliberative decision made exclusively on medical and scientific grounds,” says CMA President James T. Hay, MD. “As physicians, we need to have a better understanding about the benefits and risks of medicinal cannabis, so that we can pro-
vide the best care possible to our patients.” CMA’s Board of Trustees adopted the policy, without objection, at its October 14 meeting in Anaheim. The federal government currently lists cannabis as a Schedule I drug. That classification restricts the research and ability to study the substance. Part of the policy adopted by CMA emphasizes that the drug should be rescheduled, in addition to being legalized. “There simply isn’t the scientific evidence to understand the benefits and risks of medical cannabis,” says Paul Phinney, MD, CMA Board Chair. “We undertook this issue a couple of years ago and the report presented this weekend is clear – in order for the proper studies to be done, we need to advocate for the legalization and regulation.” “We need to regulate cannabis, so that we know what we’re recommending to our patients,” says Dr. Phinney. “Currently, medical
and recreational cannabis have no mandatory labeling standards of concentration or purity. First, we’ve got to legalize it, so that we can properly study and regulate it.” Physicians, who are currently only allowed to “recommend” medical cannabis, have been stuck in an uncomfortable position, since California decriminalized the drug in 2006. “California has decriminalized marijuana, yet it’s still illegal on a federal level,” says Dr. Hay. “That puts physicians in an incredibly difficult legal position, since we’re the ones ultimately recommending the drug.” The regulation of medical cannabis will allow for wider clinical research, accountable and quality controlled production of the substance and proper public awareness. CMA also recommends the regulation of recreational cannabis so that states may regulate this more widely-used cannabis for purity and safety. (CMA Alert, October 18, 2011 issue)
FAQ: How do I comply with patient requests to restrict disclosures to a health plan? Since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, physicians have inquired about how to comply with a provision that conflicts with most health plan provider contracts. The provision gives patients the right to restrict disclosure of “protected health information” (PHI) to health plans in certain circumstances. Under this provision, physicians covered by HIPAA are required to comply with patient requests to restrict disclosure of PHI to a health plan if all three of the following criteria are met: • The disclosure would be for purposes of payment or health care operations, and not for treatment purposes; • The PHI at issue pertains solely to a health care item or service for which the individual pays out-of-pocket and in-full; and
• The disclosure is not required by law. Many physicians are contractually obligated to submit all claims to the health plans for covered services. Physicians are also often contractually prohibited from collecting any fees other than copayments, coinsurance, or deductibles for these covered services. The California Medical Association (CMA) expects final regulations for the HITECH Act, including the provision at issue here, to be published shortly. The final regulations are expected to address this conflict and clarify physicians’ obligations, under this provision. While the Office for Civil Rights continues to work on the final regulations, CMA contacted various health plans to find out how they are handling these contractual obligations in light of the HITECH provision. The plans indicated that federal law would supersede state law and any relevant contractual obligations, and that
30 | THE BULLETIN | NOVEMBER / DECEMBER 2011
they would not consider a physician to be in breach of contract if the physician is complying with patient requests to restrict disclosure of their PHI, pursuant to their rights under the HITECH Act. Physicians are urged to contact their contracted health plans with regard to this interpretation and consult with their professional liability carrier for further input into a particular situation. CMA members who encounter any problems with their contracted health plans for complying with this HITECH requirement are encouraged to contact CMA. For more information on patient requests to restrict disclosures of certain PHI, see CMA medical-legal document #1175, “Special Confidentiality Requests.” Medical-legal documents are available free to members in CMA’s online resource library at http://www.cmanet.org/ resource-library. (CMA Alert, September 6, 2011 issue)
medico news
CMA blasts CMS for approving Medi-Cal rate cuts In what will prove to be a huge roadblock for health care reform implementation in California, the Centers for Medicare & Medicaid Services (CMS) last month approved the state’s request to slash Medi-Cal payment rates by 10%. The cuts approved by CMS include: • A 10% provider payment reduction on a number of outpatient services, including physicians, clinics, optometrists, therapists, laboratories, dental, durable medical equipment, and pharmacy. • A 10% provider payment reduction for freestanding nursing and adult subacute facilities. • A 10% provider payment reduction and rate freeze for distinct part/nursing facility-B services. Exempt from the cuts are physician and clinic services for children, outpatient hospital care, home health services, and subacute nursing facility services for adults. Cuts will also not apply to any services that are enjoined by lawsuits. CMS has yet to rule on California’s other requested cuts, which include $5 co-payments for physician visits, $50 co-payments for emergency department visits, and a cap of seven office visits per year. California’s Medi-Cal rates are already almost the lowest in the nation. Currently, half the doctors in the state cannot afford to participate in the program. The gaping hole in the safety net will be further exacerbated as there will be 3 million uninsured newly-eligible for Medi-Cal, in 2014, under the federal health reform legislation. “The President built his expansion of access to care on the MediCal system, and with this decision, his administration has effectively destroyed it,” says Dustin Corcoran, CEO of the California Medical Association (CMA). “Adding three million patients to Medi-Cal, while reducing physician resources, is nothing but a recipe for disaster.” Federal law requires that Medicaid (Medi-Cal in California) patients have the same access to physicians and other health care providers as the general insured public. CMA strongly believes that even before these cuts, California is in violation of federal access law. An independent study, recently commissioned by CMA, found that 49% of Medi-Cal patients are unable to get health care when they need it, compared to just 26% of privately insured patients. CMA filed a petition with CMS asking that corrective action be taken to address current reimbursement rates and access standards. “CMS
has chosen to ignore its own law with this decision,” says Corcoran. “What we’re seeing now is that Medi-Cal patients are already having a tough time getting access to care,” says CMA President James T. Hay, MD. “With these cuts, physicians will only be reimbursed $11 per Medi-Cal patient visit, when it costs the physician several times that to provide. Physicians will be forced to reduce the number of Medi-Cal patients they accept, if they can continue to see any at all. We want to be able to treat these patients and we regret that the federal government is making it impossible.” Recent data from the California Office of Statewide Health Planning and Development, compiled by the American College of Emergency Physicians, shows that emergency room use by Medi-Cal patients increased 30% between 2007 and 2009 (most recent reporting period). This demonstrates that Medi-Cal beneficiaries are already being forced to seek necessary care in the ER when they can’t find a physician. “The approval of provider payment reductions will ensure overcrowding in emergency rooms and will absolutely mean less access to care for all Californians,” Corcoran adds. “Of course these are tough budget times, but the Department of Health Care Services and CMS are balancing their budgets on the backs of the most vulnerable Californians.” According to CMS, California “submitted extensive data demonstrating that the remaining cuts will not jeopardize Californian’s access to care and has agreed to ongoing monitoring of access to care for the affected services.” CMA is extremely disappointed in the secretive process and that this data was not shared with providers and other stakeholders. CMA and others made repeated requests for such data to support the state’s claim that the cuts will not negatively affect access to care for Medi-Cal patients. DHCS’s failure to provide the requested data prompted CMA and the California Pharmacists Association to take joint legal action under the California Public Records Act. CMA is extremely angry with CMS for approving these cuts, in light of the overwhelming access to care problems in the state’s MediCal program. The cuts will unquestionably cause irreparable harm to patients by forcing physicians out of the Medi-Cal program. CMA will continue to fight at all levels to ensure that California’s most vulnerable patients receive the care that they need. (CMA Alert, October 31, 2011 issue)
Medicare delays provider enrollment revalidation for two years The Centers for Medicaid & Medicare Services (CMS) has delayed the requirement that physicians revalidate their Medicare enrollment under the program integrity screening provisions of the Affordable Care Act. According to CMS, the revalidation effort, originally scheduled for March 23, 2013, will be pushed back through 2015. Physicians will be among the last to revalidate. Physicians who have already received revalidation notifications from Palmetto GBA should fill out the form and return it to Palmetto per the instructions in the notice. The California Medical Association is gathering more information on the next round of validation notifications and an update will be published shortly.
The revalidation requirement is necessitated by new screening criteria that were implemented this past March. Newly enrolling and revalidating providers will be placed in one of three screening categories representing the level of risk to the Medicare program. The level of risk will determine the degree of screening to be performed when processing the enrollment application. Do not do anything until you get a letter instructing you to revalidate. (This is very important to ensure an orderly enrollment process.) Physicians who are making changes (moving, closing practice, etc.) should continue to submit their changes as usual. (CMA Breaking News, October 31, 2011 issue) NOVEMBER / DECEMBER 2011 | THE BULLETIN | 31
medico news
CMS releases final 2012 Medicare fee schedule On November 1, the Centers for Medicare & Medicaid Services (CMS) released the final 2012 Medicare physician payment rule, which indicates that (absent congressional action) the Sustainable Growth Rate (SGR) formula will cut Medicare payments by 27.4% on January 1, 2012. However, in a statement accompanying the rule’s release, U.S. Department of Health and Human Services Secretary Kathleen Sebelius said she was committed to working with “legislators on both sides of the aisle to address this issue once and for all.” She stated that physicians are “the backbone of our health care system,” and noted that the “Obama administration is 100% committed to fixing the flawed Medicare payment system and protecting Medicare beneficiaries’ access to doctors.” The pattern of threatened SGR cuts, she said, and “last-minute Congressional rescues are in itself not a sustainable solution and must be remedied.” The California Medical Association (CMA) and all of organized medicine are advocating for Congress to repeal the SGR this year in the Super Committee’s recommendations.
Geographic Practice Cost Index (GPCI) becomes fairer to California physicians As a result of intense CMA lobbying, CMS adjusted the fee schedule so that an even larger percentage (3%) of the payments are adjusted for geographic differences in practice costs, which prevented large cuts in 2012 and will help California physicians enormously in future years. However, payments to physicians in several California payment localities will be reduced due to an overall reduction in rent according to the new American Community Survey database. For a chart showing the impact by county, go to http:// www.cmanet.org/files/pdf/news/medicare-feeschedule-2012.pdf. Highlights of major changes in the fee schedule include: E-prescribing CMS finalized its proposal for the 2012 and 2013 incentive, and 2013 and 2014 penalty programs. Despite continued CMA and American Medical Association (AMA) opposition, physicians will need to report 10 times during the first six months of 2012 and 2013 to avoid application of e-prescribing penalties in subsequent years. Physicians may use claims, registry or electronic health record (EHR)-based reporting methods. Improvements to the program, which CMA and AMA supported, include allowing the
use of a certified EHR to e-prescribe and making it easier to avoid the penalties by (1) not requiring physicians to link the e-prescribing codes to qualifying visits, and (2) allowing physicians to apply for additional hardship exemptions online. Physician Quality Reporting System (PQRS) In response to CMA/AMA advocacy, CMS finalized its proposal to provide interim feedback reports for physicians reporting individual measures and measure groups through claims-based reporting for 2012 and beyond. These reports will be a simplified version of annual feedback reports that CMS currently provides and will be based on claims for the first three months of each program year. The interim feedback reports will be provided to physicians during the summer of each program year. Despite strong opposition from the physician community, CMS finalized its proposal to use 2013 as the reporting period for the 2015 PQRS penalty. If CMS determines that a physician or group practice has not satisfactorily reported quality data for the 2013 reporting period, then its 2015 payments will be reduced 1.5%. The rule also redefined “group practice” under the Group Practice Reporting Option as a group of 25 or more eligible professionals.
Value modifier While acknowledging the strong opposition of CMA, AMA and others in organized medicine, CMS finalized its proposal to base payment adjustments in 2015 on yet-to-be-determined cost and quality measures to be finalized in November 2012. Quality measures for the modifiers will most likely be based on PQRS and EHR measure sets. Cost measures to be used in the modifier will be based on average total per capita cost for the physician’s patients, and per capita cost for four conditions (chronic obstructive pulmonary disease, heart failure, coronary artery disease, and diabetes). CMA will continue to oppose the value modifier payment methodology and urge Congress to withdraw it. The Patient Protection and Affordable Care Act established the value modifier, which in 2014 will pay physicians more than the Medicare fee schedule if they successfully report on quality measures and spend less than the national average per patient. It will also pay physicians less if they spend more than the national average and do not successfully report on quality measures. Multiple procedure cuts In response to comments from AMA, the
32 | THE BULLETIN | NOVEMBER / DECEMBER 2011
AMA/Specialty Society RVS Update Committee (RUC) and many specialties, CMS scaled back its proposal to apply a 50% reduction to the professional component (PC) of certain imaging services. Instead, the rule applies a 25% reduction to the payment for the PC of second and subsequent CT, MRI, and ultrasound services furnished by the same physician on the same patient in the same session on the same day.
Lab test signatures no longer required CMS has retracted the requirement for physicians to sign paper lab requisitions for clinical diagnostic laboratory tests – a policy change AMA strongly and successfully opposed. Annual wellness visit (AWV) changes CMS is increasing the payment for the AWV codes to recognize additional resources associated with adding a health risk assessment to the service’s requirements, but is continuing its policy of not covering a physical exam as part of these services. RUC In a significant accomplishment, the RUC persuaded CMS that the resources involved in hospital observation care visits and hospital inpatient visits are equivalent. CMS also accepted the vast majority of the RUC’s recommendations. However, the RUC had recommended that CMS begin paying for telephone calls, anticoagulant management, team conferences, and patient education in 2012. CMS did not announce any plans to consider payment for these services, but emphasized that the agency will continue to work with stakeholders to ensure that care coordination and primary care services are appropriately recognized. Open enrollment The open enrollment period that will allow you to change your participation status in the Medicare Program is available until December 31, 2011. Changes are effective as of the next calendar year on January 1. To learn more about Medicare participation, see medical-legal document #0151, “Medicare Participation (and Non-Participation) Options,” available in the CMA resource library at http://www.cmanet.org/resource-library. For the payment impact by specialty, go to http://www.cmanet.org/files/pdf/news/impactstable-2012.pdf. The Fee Schedule and additional information is available on the CMS website at www.cms.gov/physicianfeesched. (CMA Alert, November 14, 2011 issue)
medico news
Have you established an Injury and Illness Prevention Program as required by law? California law requires every employer, including physicians, to establish and maintain an effective Injury and Illness Prevention Program (IIPP). The program must be in writing and must provide guidelines for identifying, evaluating, and correcting workplace hazards. The program must cover all employees and all other workers the employer directs or controls and directly supervises on the job, to the extent that those workers are exposed to work siteand job-specific hazards. CMA medical-legal document #1825, “In-
jury and Illness Prevention Programs,” outlines the scope and contents of an effective program, as well as record keeping and retention requirements. There are also special enforcement provisions for “non-high-hazard” employers, such as solo practitioners or small medical offices. Cal-OSHA has prepared a model IIPP for such employers and will make copies of it available upon request. Any employer in a “non-highhazard” industry who adopts, posts, and implements this model IIPP, in good faith, will
not be subject to a civil penalty for a first violation of the regulations. Medical-legal document #1825, “Injury and Illness Prevention Programs,” as well as the rest of CMA’s medical-legal library (formerly CMA On-Call), is available free to members in CMA’s online resource library at http:// www.cmanet.org/resource-library. (CMA Alert, October 31, 2011 issue)
Palmetto conducting audits of physician claims For the past two years, Palmetto GBA has received payment error rates from the Comprehensive Error Rate Testing (CERT) Contractor that have been almost twice the national rate. A large portion of the errors are attributed to insufficient and illegible documentation, and lack of or illegible signatures. Palmetto is now taking steps to correct these errors by reviewing claims to identify potential areas for provider education. Palmetto will notify affected physicians by mail that a small sample of their claims will be selected for medical review. The notice will also provide recommended resources on documentation and coding. Physicians who are notified will receive a request for medical records in the form of an Additional Document Request (ADR) for each claim selected, along with an example of the information that should be returned. Fail-
ure to respond to these requests will result in non-payment of the claim. Palmetto may also call or make unannounced site visits to physician offices to schedule an appointment for an educational meeting. Failure to participate in this education will result in 100% pre- and post-payment audit of claims. CMA is discussing the nature of these audits with Palmetto and the disruption and burden they will be to physician offices. For more information on this and other Medicare audits, see CMA’s Medicare Audit Guide for Physicians. This guide is available free to members in CMA’s online resource library at http://www.cmanet.org/ resource-library. CMA will provide more information as it becomes available. (CMA Alert, October 31, 2011 issue)
2010 Medicare quality reporting feedback reports now available Physicians can now download the 2010 Physician Quality Reporting System’s (PQRS) feedback reports at the Centers for Medicare & Medicaid Services’ (CMS) quality reporting portal at http://cal.md/pqrs-portal. PQRS, previously known as the Physician Quality Reporting Initiative (PQRI), is a voluntary quality reporting program that provides incentive payments to eligible professionals who report data on quality measures for services provided to Medicare beneficiaries. Feedback reports are compiled at the Taxpayer Identification Number (TIN) level, with individual-level reporting by National Provid-
er Identifier (NPI) for each eligible professional who reported at least one valid e-prescribing quality-data code on a claim submitted under that TIN. Groups who utilized the Group Practice Reporting Option will only have reports at the TIN level. To access TIN-level reports, you will need to register for an Individuals Authorized Access to CMS Computer Services (IACS) account. To access NPI-level reports, you will need to submit a “communications support request.” (Go to http://cal.md/pqrs-portal and click “communications support page” in the left
sidebar.) To verify your identity, you will need to provide your legal business name (as registered with PECOS), your NPI number, and the last four digits of your TIN. NPI-level reports can also be requested from Palmetto, California’s Medicare contractor, by calling 866/931-3901. You will need to provide your individual NPI number and an email address, and can expect to receive an email containing the feedback report within 30 days of the request. (CMA Alert, October 31, 2011 issue)
NOVEMBER / DECEMBER 2011 | THE BULLETIN | 33
Summary of CMS Final Regulations on Medicare Shared Savings/ACO Program Last month, CMS released its final rule on the Medicare Shared Savings/ACO program. Also released was a new Advanced Payment initiative specifically for physician organizations, a final FTC-DOJ Policy Statement on Antitrust Enforcement for Medicare ACOs, and an Interim Final Rule on fraud waivers for Medicare ACOs. Links to all documents are at the end of this article. Based on AMA’s preliminary review, there are significant changes to the Final Rules and significant advocacy wins for the AMA and physicians. While AMA staff is now reviewing in detail, the following changes have been made to the rule that are very positive and reflect AMA comments on the proposed rules:
•
•
ACO PAYMENT AND STRUCTURE
• The standard financial model for ACOs will still be shared savings, i.e., there will be no change in the underlying payment system, and the program will function essentially as a pay-for-performance program based on total cost. However, they are creating a complementary program through the Innovation Center to provide “Advance Payments” specifically to physician organizations and rural providers that do not have the capital reserves available to finance needed changes in care processes or to cover short-term losses while waiting for shared savings payments to be made. • There will still be two different tracks for ACOs, but one will be “upside only” during the three-year contract period, i.e., the ACO will not be liable to pay CMS if costs actually increase. The second will be both upside and downside, as in the proposed rule. (The proposed rule made ACOs, even in the first track, liable to pay CMS back for cost increases in the third year.) • There will no longer be requirements to withhold shared savings payments to cover potential future cost increases. • ACOs will be allowed to share in savings beginning with the first dollar of savings
•
•
earned. The proposed rule gave ACOs a share of savings above a minimum threshold. ACOs must still meet a minimum threshold of savings, but they can earn back more of the savings they generate. There will be 33 quality measures instead of 65, and they have dropped the Hospital Acquired Conditions (HAC) measures, as we urged. There will be no flexibility, though, for different quality measures in different regions. They will have a more prospective method of assigning beneficiaries. ACOs will get a list of “probable beneficiaries” and the list will be updated quarterly. There will still not be mechanisms for beneficiaries to “sign up” voluntarily, though; the ACO will only get credit for them after the attribution methodology determines that they have had a majority of their primary care visits with the ACO. In addition, as the AMA recommended, CMS will include primary care services provided by specialist physicians in assigning patients to ACOs, and not limit the attribution method exclusively to primary care physicians. They eliminated the requirement that at least 50% of an ACO’s primary care physicians must be “meaningful users” of EHRs by year two of the program. Instead, they will double weight the quality measure “Percent of PCPs who successfully qualify for an EHR Incentive Program Payment.” ACOs only have to report a percentage and not meet a specified percentage when reporting this quality measure, and the term “qualify” covers PCPs who participate in either the Medicare or Medicaid EHR Incentive program. There will be a rolling application process, so prospective ACOs will have time to prepare without having to meet arbitrary deadlines that are too short.
ANTITRUST
FTC-DOJ has adopted two important
34 | THE BULLETIN | NOVEMBER / DECEMBER 2011
changes that the AMA requested: • They have eliminated the need for mandatory review of ACOs above the 50% threshold of the primary service area (PSA) calculation. While the agencies will still rely on the PSA calculation, eliminating mandatory review will result in significant removal of burden and cost on potential ACOs. • The statement applies to ALL collaborations among otherwise independent providers. The draft statement applied only to new entities formed after March 23, 2010. This would have placed all collaborations that existed prior to March 23, 2010 under a separate antitrust review system.
FRAUD WAIVERS
• CMS and the Office of Inspector General adopted the AMA recommendations that the waivers begin sooner so that they will apply during the process of planning a Medicare ACO, and that ACOs will be able to offer certain additional medical benefits to patients, such as care management, without having them viewed as inappropriate inducements. In addition, the agencies issued the new waivers regulation as an interim final rule, instead of a final rule, as the AMA had recommended.
Here are links to all key documents: ACO final http://w w w.ofr.gov/OFRUpload/OFR Data/2011-27461_PI.pdf Advanced Payment http://w w w.ofr.gov/OFRUpload/OFR Data/2011-27458_PI.pdf OIG waivers http://w w w.ofr.gov/OFRUpload/OFR Data/2011-27460_PI.pdf FTC / DOJ statement http://www.ftc.gov/opa/2011/10/aco.shtm
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NOVEMBER / DECEMBER 2011 | THE BULLETIN | 35
Santa Clara County Medical Association 700 Empey Way • San Jose, CA 95128 • 408/998-8850 • FAX 408/289-1064 November 2011 TO:
All Members, Santa Clara County Medical Association (SCCMA)
FROM:
Rives Chalmers, MD, Chair, 2011-2012 Awards Committee
At the 2012 Medical Association’s annual banquet, the association will honor several individuals with its perpetual awards. These awards are significant honors which reflect the respect, recognition, and appreciation of our membership. The recipients are selected from among our outstanding members who have distinguished themselves with extraordinary service to medicine in general, to the association, to the community, or to medical education. Selections are made by the Awards Committee, with the aid of input from the membership. Your suggestions for recipients for each of the awards outlined on the next page of this memo will be appreciated. Please complete the form below to submit suggestions, keeping in mind the requirements for each award as listed on the opposite page. If you would like to nominate more than one person, or for more than one award, please photocopy this form or send a letter. Suggestions must be received by January 13, 2012. Thank you for your recommendations. If you previously suggested a candidate who was not given an award, please feel free to resubmit that name. I THINK ______________________________________________________ WOULD BE A GOOD CANDIDATE FOR THE _____________________________________________________________________________________ (Name of Award) PLEASE ATTACH ALL SUPPORTING INFORMATION, INCLUDING ACCOMPLISHMENTS AND CONTRIBUTIONS THAT WILL HELP THE AWARDS COMMITTEE EVALUATE THE CANDIDATE FOR THE AWARD SELECTED. YOU MAY MAIL, FAX, OR EMAIL THE INFORMATION TO PAM JENSEN AT SCCMA. SUBMITTED BY: __________________________________________________________________________________ MD (Please print) MAIL FORM TO: SCCMA Attn: Pam Jensen 700 Empey Way San Jose, CA 95128 EMAIL: pjensen@sccma.org FAX: 408/289-1064 DEADLINE: January 13, 2012 36 | THE BULLETIN | NOVEMBER / DECEMBER 2011
Santa Clara County Medical Association
Annual Awards
ROBERT D. BURNETT, MD LEGACY AWARD
For a physician member of the Association who has demonstrated extraordinary visionary leadership, tireless effort, selfless longterm commitment, and success in challenging and advancing the health care community, the well-being of patients, and the most exhalted goals of the medical profession. The only two recipients of this award are Robert D. Burnett, MD and Philipp Lippe, MD.
BENJAMIN J. CORY, MD AWARD
For a physician member of the Association who has displayed forward-looking, pioneering ideas, enterprise, enthusiasm, and prolonged professional stature and ability.
AWARD FOR OUTSTANDING ACHIEVEMENT IN MEDICINE
For a physician member of the Medical Association who, during his/her medical career, has made unique contributions to the betterment of patient care, for which he/she has achieved widespread recognition. Consideration shall be given to research and/or the development of procedures, methods of treatment, pharmaceutical agents, or technological advances in the field of medicine.
AWARD FOR OUTSTANDING CONTRIBUTION TO THE MEDICAL ASSOCIATION
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the Association over and above that expected of the membership at-large.
AWARD FOR OUTSTANDING CONTRIBUTION IN MEDICAL EDUCATION
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more medical education activities over and above that expected of the membership at-large.
AWARD FOR OUTSTANDING CONTRIBUTION IN COMMUNITY SERVICE
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the community over and above that expected of the membership at-large.
CITIZEN’S AWARD
For an individual who is not a member of the Medical Association, who has achieved public recognition for a significant contribution in the health field. (This usually will be a nonphysician, although physicians are not categorically excluded.)
Benjamin J. Cory, MD Award 1994
Robert W. Jamplis
1995 1996
Christopher C. Chow
1997
Outstanding Contribution To The Medical Association Richard M. O’Neill
Outstanding Contribution In Medical Education John B. Shinn
Outstanding Achievement In Medicine Thomas J. Fogarty
Robert W. Andonian Ronald L. Kaye
Norman E. Shumway
David M. Rosenthal
William C. Fowkes
Thomas A. Stamey
Bernice S. Comfort
Robert J. Frascino
Outstanding Contribution In Community Service Arthur A. Basham / Arthur L. Messinger ---
Citizen’s Award Gary W. Steinke, MD / Mrs. Pamela Steinke Mr. Howard W. Pearce
Cindy Lee Russell / Minoru Yamate
Florene Poyadue, RN
Michael R. Fischetti
Suzanne Jackson, RN
1998
Mansfield F. W. Smith
Stanley D. Harmon
Howard R. Porter
Burton D. Brent
William A. Johnson
Judge Leonard Edwards
1999
Donald J. Prolo
Steven S. Fountain
C. Michael Knauer
Jack S. Remington
M. Ellen Mahoney
Rigo Chacon
2000
Sharon A. Bogerty
Stephen H. Jackson
Theodore Fainstat
Richard P. Jobe
Barbara C. Erny
Janet Childs
Roger P. Kennedy
Bert Johnson
Nelson B. Powell / Robert W. Riley
Robert Michael Gould
Tony & Brandon Silveria
Elliot C. Lepler
Allen H. Johnson
Bruce A. Reitz
David Morgan
Tom Campbell / Ted Lempert
Joseph E. Mason, Jr.
Anthony S. Felsovanyi
David A. Stevens
Martin D. Fenstersheib Michael E. & Mary Ellen Fox
2001 2002
Robert M. Pearl
2003 2004
Robert Wuerflein
Eugene W. Kansky
Barry Miller
D. Craig Miller
Elizabeth Menkin
Jayne Haberman Cohen, DNSc
2005
Harvey J. Cohen
Richard L. Miller
Gus M. Garmel
Rodney Perkins
Elouise Joseph
Doris Hawks, Esq.
Arthur A. Basham
Robert W. R. Archibald
G. David Adamson
Harmeet S. Sachdev
Edward A. Hinshaw, Esq.
2006 2007
Stephen H. Jackson Cindy L. Russell
Catherine L. Albin
John R. Adler, Jr.
Madhur Bhatnagar
Debbi Ricks
2009
Bernadette Loftus
Martin L. Fishman
George P. Kent
Thomas Krummel
Seham El-Diwany
Peggy Fleming-Jenkins
2010
Melvin Britton
James G. Hinsdale
David Levin
Gary Steinberg
Leo Strutner
Judge Lawrence Terry
Tanya Spirtos
Dennis Siegler
Robert Armstrong
Gary Silver
Kathleen King
2011
NOVEMBER / DECEMBER 2011 | THE BULLETIN | 37
managing professional risk
Hand-Offs: Which Mnemonic Is Right for You? By Mary-Lynn Ryan, Risk Management SHARED (Situation, History, NORCAL Mutual Insurance Company and the NORCAL Group Every patient hand-off is a vulnerable point in the continuum of patient care. Incorrect information can be passed on and crucial information can be lost. In fact, according to the Joint Commission, most of the sentinel events resulting from communication breakdowns occur during hand-offs.1 The primary goal of an effective hand-off policy is consistent transfer of accurate patient information to oncoming providers that results in the delivery of appropriate care. Using a mnemonic (pronounced nee-ma-nik) or memory-improvement tool during handoff provides a systematic approach that sets expectations about what should be communicated. Listed below are summarized versions of a few of the more popular hand-off mnemonics:1
SBAR (Situation, Background, Assessment, Recommendation)
SBAR is recommended by the Joint Commission: Situation: What’s happening with the patient? Background: What is the clinical or contextual background? Assessment: What is the problem? Recommendations: What can I do to correct the problem? SBAR also has extended versions: I-SBAR. I-SBARQ, and I-SBARR. “I” stands for Introduction (or Patient Identifiers), “Q” for Questions, and “R” for Read-back.
I Pass the Baton (Introduction, Patient, Assessment, Situation, Safety Concerns, Background, Actions, Timing, Ownership, Next)
I Pass the Baton can be used at shift change, and at hand-offs between departments and between facilities: Introduction: Tell the patient who you are and what your role is. Patient: What is the patient’s name, and what are the identifiers, location, etc? Assessment: What is the chief complaint, vitals, symptoms, diagnoses, etc? Situation: What is the patient’s current status, code status, recent changes, response to treatment, etc? Safety Concerns: What are the critical labs, allergies, socioeconomic factors, alerts (e.g., isolation), etc.? Background: What are the comorbidities, medications, family history, and previous episodes, etc? Actions: What was done and what still needs to be done, including rationale? Timing: What is the level of urgency; what are the priorities? Ownership: Who is responsible for what aspects of care? Next: What’s happening next? 38 | THE BULLETIN | NOVEMBER / DECEMBER 2011
Assessment, Request, Evaluate, Document)
The Joint Commission identifies the SHARED checklist as one that is particularly adaptable to hand-offs between departments and services: Situation: What are the names of patient and physician, what is the reason for transfer, etc? History: What are the admitting and current diagnoses, the medical history, etc? Assessment: What is the status of the patient’s neurological, cardiopulmonary, skin status, etc? Request: What needs to be done, e.g., labs, diagnostic studies, etc? Evaluate: Is there a need to inform other resources? Who? Document: Record communications, including assessments, test results, progress notes, consultations, etc. Mnemonic use is an important aspect of an effective hand-off protocol. Disorganized hand-offs, even if they do not result in patient injury, can add to patient dissatisfaction. As studies have shown, it is not necessarily substandard care that leads patients to file a malpractice lawsuit. In many cases, patients are simply angry about the way they have been treated.2
Sample Mnemonic Forms
Sample forms that utilize SBAR, I Pass the Baton, and SHARED can be accessed on the Association of periOperative Registered Nurses (AORN) website in its Perioperative Patient Hand-off Toolkit at: www.aorn.org/ docs_assets/55B250E0-9779-5C0D-1DDC8177C9B4C8EB/44F6B4B217A4-49A8-86F218EDBF23516A/HandOff_SampleTools.pdf (accessed 8/3/2010). These forms can also be found in Improving Hand-Off Communications, Ed. Meghan Pillow, 2007, available for a fee from the Joint Commission on its website at: http://www.jcrinc.com/Books-and-Ebooks/IMPROVING-HAND-OFF-COMMUNICATION/1225/ (accessed 8/3/2010).
References
1. Joint Commission. Improving Hand-Off Communications. Ed. Meghan Pillow. 2007. 2. Huntington B, Kuhn N. Communication gaffes: a root cause of malpractice claims Proc (Bayl Univ Med Cent). 2003 April; 16(2): 157–161. Available on the National Center for Biotechnology Information (NBCI) website at: www.ncbi.nlm. nih.gov/pmc/articles/PMC1201002/ (accessed 3/20/2010).
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MEDICAL TIMES FROM THE PAST
Origins of the Medical Societies By Gerald E. Trobough, MD Leon P. Fox Medical History Committee In the early part of the 19th century, medical education was in a deplorable state. There were approximately 450 proprietary medical schools. Their primary aim was to collect tuition from students for the privilege of attending lecture for 10 - 20 weeks. There were no entrance requirements beyond the ability to pay for the courses. There were few examinations and the resulting diploma was accepted as a license to practice medicine.
American Medical Association (AMA)
The American Medical Association was organized on May 7, 1847. This “drastic measure” was to establish standards of care and improve medical education. A program of medical ethics was introduced, as well as the promotion of public service. The first meeting was at the Academy of Natural Sciences in Philadelphia, Pennsylvania. The 250 delegates present elected Dr. Nathaniel Chapman as its first president. An initial committee of nine doctors, headed by Dr. Nathan Smith Davis, was established to develop recommendations to improve medical education. Dr. Davis was the first African-American graduate from Rush Medical School. He is often credited as the father of the AMA and was the first editor of JAMA. Despite the good intentions of the AMA, the society had no vested authority to change policy of the proprietary medical schools. However, the AMA set standards and pointed the way towards reform.
promoted medical education “and develop, in the highest degree, the scientific truths embodied in the profession.” Another goal of the society was to root-out quackery. Their first meeting was March 12, 1856, at Pioneer Hall, located on J Street in Sacramento. The first president was Dr. Benjamin Franklin Keene, from El Dorado County. Unfortunately, Dr. Keene died a few months after taking office. The second president was Dr. Elias Cooper, from San Francisco. Dr. Cooper was the head of the Medical Department of the University of the Pacific, which was California’s first medical school. Dr. Thomas Logan, a Sacramento physician, assisted in the formation of the medical society of California. He became the first president of the AMA from the west coast. He
named California Medical Association in 1923.
Santa Clara County Medical Society
The county medical society was organized on May 9, 1870, by nine physicians with a stated goal of “alleviation of human suffering by stimulating its members to acquire and perfect medical knowledge.” It was a loosely organized association. The society was reorganized along formal lines by twelve physicians on August 12, 1876. The newly stated objectives were to “discuss developments in medicine and also fight itinerant quacks and charlatans flourishing on credulous human nature.” The meetings were held on the second Tuesday of each month. For at least ten years, the meetings were held in the offices of Drs. Cory and Kelly. Thereafter, the meetings were rotated in the offices of other participating physicians. Papers were often read and discussed. Case histories were presented and commented upon by the members. The society worked hard to identify “pretenders of medical knowledge” and drive them out of the valley. The county medical society was also instrumental in establishing a City Board of Health in 1899. It exposed unsanitary conditions that affected public health. Dr. J.R. Curnow was elected health officer. He established an excellent city sewer system that practically eliminated typhoid fever and diphtheria in the county. These medical societies have helped shape medical care in the 19th and 20th centuries and will continue to do so in this 21st century.
There were no entrance requirements beyond the ability to pay for the courses. There were few examinations and the resulting diploma was accepted as a license to practice medicine.
California Medical Society (CMA)
The Medical Society of the State of California was established in 1856, behind the leadership of Dr. Elias Cooper and Dr. Thomas Logan. They wrote letters to their colleagues asking for support of a state organization that
brought the national AMA meeting to San Francisco in 1871. Logan also promoted state public health departments and he lobbied for county medical societies. His role in the California Public Health Department is legendary. Dr. Logan felt it imperative that physicians track births, diseases, deaths, and their causes. In 1870, he authored a law to establish the State Board of Health. California was the second state to have a public health board. Logan also promoted childhood vaccinations. Another important person in the early CMA history was Dr. John Frederick Morris. Dr. Morris set up the first credential committee of the CMA, in an attempt to prevent unqualified physicians from practicing in the state. He is also credited with starting the first journal of the medical society in 1873. It was called The California State Journal of Medicine. The Medical Society of California was re-
42 | THE BULLETIN | NOVEMBER / DECEMBER 2011
risk management
EHR in Medical Liability Litigation By Mary-Lynn Ryan NORCAL Mutual Insurance Company Electronic health records (EHRs) hold great promise for improving patient safety and decreasing medical liability exposure, but as EHR systems have been adopted, a variety of new medical liability litigation issues have arisen. For example, some systems cannot create a printed patient record that will be understandable to a jury; and some offices are not staffed with a person who knows how to remove privileged or irrelevant information from an EHR before it is released to the plaintiff’s attorney. EHR metadata (data about data) is a related concern. EHR system metadata shows how, when, and by whom EHR data was received, created, accessed, and modified. State courts are indicating that EHR metadata can be relevant in medical liability lawsuits, and plaintiffs have begun seeking and obtaining metadata related to their cases. Consider how valuable metadata could be to an attorney attempting to establish a failure-to-monitor or delayed-diagnosis claim. To address these emerging issues, providers are encouraged 1) to analyze their own EHR systems and determine whether they can generate understandable patient record copies and metadata reports that are appropriate for medical liability litigation, and 2) to create policies and procedures that ensure only the release of appropriate patient information as a result of a discovery request, while protecting sensitive medical information subject to special confidentiality requirements. Producing appropriate records for litigation is rarely a top marketing priority for EHR vendors, but a system’s ability to print an appropriate patient record should be an important consideration for any provider purchasing or updating an EHR system. Medical records are a primary means of showing compliance with the standard of care, and it is difficult to defend even exemplary care if records are inadequate, confusing, or incomplete. To get a sense of whether your practice is prepared for a request to release electronic health records, consider the following questions:1
What information will be disclosed upon a request for medical records? • Do you have a standard report format that can be used in all record release situations (e.g., can patient requests, billing compliance requests, research requests, and litigant requests all be satisfied with one type of medical record)? • Define the patient record of care in the system. The system needs to be programmed to generate an accurate account of a patient encounter or episode of care. The resulting document must be able to “tell the story” of a patient encounter in a way that satisfies the requirements of the party requesting the record. • Keep the patient record fluid and adaptable. The perfect
“litigation” patient record may not satisfy laws, regulations, and standards related to payers, patient safety organizations, and/or other entities that request patient information.
Does your system allow you to block confidential, sensitive medical information and privileged or irrelevant information when producing copies from the electronic record (e.g., drug and alcohol abuse, HIV, mental health, quality assurance, email from liability insurers or attorneys, etc.)? • Double check records before they are released and confirm that they do not include privileged or irrelevant information. Does someone in your organization know how to produce an appropriate record? • Ensure that staff members are appropriately trained in releasing EHR and metadata. Being prepared for the release of a patient’s medical information can mean the difference between success and failure in medical liability litigation. Because of the complexity of the EHR options available, planning and research are critical to the successful utilization of EHR. While it may take extra time and money to personalize and adequately understand an EHR system and put EHR policies in place, the added investment can yield rich benefits for patients and physicians alike. 1. Dougherty M, Washington L. Still Seeking the Legal EHR. Available on the American Health Information Management Website at: http://library.ahima.org/xpedio/groups/public/documents/ahima/ bok1_046428.hcsp?dDocName=bok1_046428 (accessed 8/3/2010). NOVEMBER / DECEMBER 2011 | THE BULLETIN | 43
Classifieds office space for rent/ lease PRIME OFFICE FOR LEASE • SALINAS 2,150 sq. ft. available January 2012 across from Salinas Valley Memorial Hospital. 1045 Los Palos; five examination rooms, laboratory, sterilization, two private offices. Call Dr. Hirasuna at 831/484-9439 or email at hi2jtsumo@gmail.com. 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. OFFICE SUITE AVAILABLE Location is highway 85 at De Anza. One suite available. Currently configured with six Tx rooms/offices, entry, large master 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. $2.00 per sq. ft. plus 3N. Located at 1196 South De Anza at Rainbow. MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA 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.
ELEGANT AND SPACIOUS LOS GATOS MEDICAL OFFICE 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. Timeshare also available. Call Betty at 408/8482525. DOWNTOWN MONTEREY OFFICE FOR SUBLEASE Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/6449800. 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. OFFICE SPACE FOR LEASE OR PURCHASE • SAN JOSE For lease or purchase. 900 sq. ft. space in a medical/dental office building opposite Regional Medical Center. Please call 408/9262182.
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. MEDICAL OFFICE FOR LEASE • SALINAS 4,816 sq. ft. Class “A” medical office for lease/ sublease – all or part. Modern professional office in sought after medical office area on Abbott Street in Salinas. The office space has nine exam rooms, two waiting rooms with two patient entrances. There is A/C, emergency power, travertine floors, and granite counters. Lease a third, two-thirds, or all. $2.75/sq. ft. Not triple net. Call 831/238-9001. 44 | THE BULLETIN | NOVEMBER / DECEMBER 2011
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 408/8671815 or 408/221-7821. SANTA CLARA OFFICE • HOMESTEAD AND JACKSON Plumbed for Dental/Medical, or other use. 1,200 sq. ft. Downtown across from post office and weekly farmers market. Excellent location! Dentist on site, please do not disturb. Don’t miss! Come see! Call 408/838-8191 or 408/741-1956.
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.
EMPLOYMENT OPPORTUNITY 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
Pajaro Dunes Beachfront Condo Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families Owners Bill & Debbi Ricks 408-354-5613
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METRO MEDICAL BILLING, INC. • • • • • •
Full Service Billing 25 years in business Book Keeping ClinixMIS web based software Training and Consulting Client References
Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website www.metromedicalbilling.com 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 Rick Flovin, CEO, at 408/228-0454 or e-mail rifl-
ovin@allianceoccmed.com for additional information. INTERNIST WANTED San Jose Medical Group has an immediate opening for a Board Certified, experienced Internist. One of our busy Internists relocated to Southern California recently, creating an opportunity for the right candidate to step into a successful growing practice. Must have excellent communication, clinical, and interpersonal skills. Excellent salary and benefits with bonus opportunities. Please fax CV to 408/278-3181 or email Tania_mcadams@ sanjosemed.com.
pital care and no obstetrics. Our state-of-the art facility includes an excellent medical and support staff, 100% EMR and outstanding specialist support. Competitive salary with excellent benefits offered. Send C.V. Attn: CEO via fax to 831/655-1829 or telmd@aol. com.
FOR SALE SL65 MERCEDES BENZ V12 Twin Bi Turbo G04 HP. Silver metallic, light grey interior. At 13,000. Original owner. Contact 408/621-4350. $80,000.
EXCELLENT PRIMARY CARE OPPORTUNITY Thriving primary care group on the beautiful Monterey Peninsula is seeking a qualified family or internal medicine physician (see www.ryanranchmedicalgroup.com for more information). Responsibilities include: light after hours call (phone only), no inpatient hos-
help2inform Discover investment strategies for a rising-tax environment Prepare your investments for future tax increases Taxes may be heading higher for a number of reasons. While this could have a significant impact on your investment portfolio and long-term goals, there are strategies that can help you address rising taxes within the context of your overall wealth management picture. As your Merrill Lynch Financial Advisor, I’ll work with you and your tax advisor to determine how to adjust your investment strategies to help meet your needs and potentially mitigate the impact of tax increases. Learn how to take advantage of strategies for rising taxes ■ Find out why taxes may be increasing ■ Understand the impact of higher taxes on your portfolio ■ Explore ways to protect your investments, retirement savings and estate from future tax hikes
I can heLP you IncorPorate tax-effIcIent Investments In your PortfoLIo. Gary McRae, AAMS® Financial Advisor 333 Middlefield Road Menlo Park, CA 94025 (650) 473-7884 http://fa.ml.com/garymcrae
Merrill Lynch Wealth Management makes available products and services offered by Merrill Lynch, Pierce, Fenner & Smith Incorporated (MLPF&S) and other subsidiaries of Bank of America Corporation. Investing in securities involves risks, and there is always the potential of losing money when you invest in securities. Neither Merrill Lynch nor its Financial Advisors provide tax, accounting or legal advice. You should review any financial transactions with your personal professional advisors. Investment products provided: Are Not FDIC Insured
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MLPF&S is a registered broker-dealer, Member SIPC and a wholly owned subsidiary of Bank of America Corporation. © 2010 Bank of America Corporation. All rights reserved.
NOVEMBER / DECEMBER 2011 | THE BULLETIN | 45
Tracy Zweig Associates A
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46 | THE BULLETIN | NOVEMBER / DECEMBER 2011
BME Headquarters 700 Empey Way, San Jose, CA. 95128 (408) 998-5811 Fax(408) 998-5850 WWW.BMESC.COM
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NOVEMBER / DECEMBER 2011 | THE BULLETIN | 47
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To make a calculated decision on medical liability insurance, you need to see how the numbers stack up—and there’s nothing average about NORCAL Mutual’s recent numbers above. We could go on: NORCAL Mutual won 86% of its trials in 2010, compared to an industry average of about 80%; and we paid settlements or jury awards on only 12% of the claims we closed, compared to an industry average of about 30%.* Bottom line? You can count on us. *Source: Physician Insurers Association of America Claim Trend Analysis: 2010 Edition.
strenghten your Practice at norcalMutual.coM Proud to be endorsed by the Monterey County Medical Society and the Santa Clara County Medical Association.
Our passion protects your practice