JANUARY / FEBRUARY 2013 | Volume 19 | Number 1
Private Practice Strategies: Retaining Independence PLUS: Have Legal Issues? Contact the
CMA Legal Information Line Tips for Steering Clear of Problems With Pain-Med Prescribing
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2 | THE BULLETIN | JANUARY / FEBRUARY 2013
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 Billing/Collections CME Tracking Discounted Insurance Financial Services Health Information Technology
Feature Articles 8 Private Practice Strategies: Retaining Independence 12 Tips for Steering Clear of Problems With Pain-Med Prescribing 17 Not Sure About the Law? Contact the CMA Legal Information Line
Resources House of Delegates Representation Human Resources Services
Departments 5 From the Editor’s Desk
Legal Services/On-Call Library
6 Message From the MCMS President
Legislative Advocacy/MICRA
7 Message From the SCCMA President
Membership Directory iAPP for
14 CMA Webinars At-A-Glance
the iPhone Physicians’ Confidential Line
22 Lucile Packard Children’s Hospital’s Pediatric Weight Control Program
Practice Management
24 Member News
Resources and Education Professional Development Publications Referral Services With
26 Welcome New Members 26 In Memoriam 28 Public Health News: HIV Screening
Membership Directory/Website
29 Classified Ads
Reimbursement Advocacy/
30 MEDICO News
Coding Services Verizon Discount
34 Medical Times From the Past 36 DocBookMD Case Study JANUARY / FEBRUARY 2013 | THE BULLETIN | 3
The Santa Clara County Medical Association Officers President Rives C. Chalmers, MD President-Elect Sameer Awsare, MD Past President William S. Lewis, MD VP-Community Health Cindy Russell, MD VP-External Affairs Howard Sutkin, MD VP-Member Services Eleanor Martinez, MD VP-Professional Conduct Seham El-Diwany, MD Secretary Scott Benninghoven, 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: Imtiaz Qureshi, MD Good Samaritan Hospital: Richard Newell, MD Kaiser Foundation Hospital - San Jose: Seema Sidhu, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Richard Kline, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Michael Champeau, MD Santa Clara Valley Medical Center: Richard Kramer, MD
AMA Trustee - SCCMA James G. Hinsdale, MD
CMA Trustees - SCCMA Thomas M. Dailey, MD (District VII) Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)
BULLETIN
THE MONTEREY COUNTY MEDICAL SOCIETY
Printed in U.S.A.
OFFICERS
Editor
President John F. Clark, MD President-Elect Kelly O'Keefe, MD Past President James Ramseur, Jr, MD Secretary Patricia Ruckle, MD Treasurer Steven Vetter, MD
THE
Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
Joseph S. Andresen, MD
Managing Editor Pam Jensen
Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising. 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 2013 by the Santa Clara County Medical Association.
4 | THE BULLETIN | JANUARY / FEBRUARY 2013
CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.
DIRECTORS Paul Anderson, MD
David Holley, MD
E. Valerie Barnes, MD
John Jameson, MD
Jose Chibras, MD
Jeff Keating, MD
Ronald Fuerstner, MD
Eliot Light, MD
James Hlavacek, MD
R. Kurt Lofgren, MD
AMA Trustee - mcms David Holley, MD (Alternate)
FROM THE EDITOR’S DESK
Joseph S. Andresen, MD Editor, The Bulletin
Control vs. Rights... By Joseph S. Andresen, MD Editor, The Bulletin Since our last Bulletin, much has happened in the world. President Obama was reelected to another four-year term. Syria, Afghanistan, Egypt, North Africa, and the Middle East teeter between the promise of democracy and the tyranny of violence. Our own economy continues to show signs of slow recovery. Immigration reform is now being openly debated in Congress. The Affordable Care Act marches forward toward full implementation in 2014, but not without continued controversy. However, it was the Newtown, Connecticut massacre that shocked us as a nation and renewed the debate over gun control vs. Second Amendment rights. I just listened to Dr. William Begg’s testimony during the final hearing of the Connecticut legislature’s Bipartisan Task Force on Gun Violence and Children’s Safety: http://www.youtube.com/ watch?v=9WPKo5Q8n-s. Dr. Begg was working the emergency room on December 14, when the massacre at Sandy Hook Elementary happened. He gave some sobering statistics: Between 1996-2010, there were 20 mass murders in the U.S. vs. 1 in the U.K. In 2010, the U.S. had 32,000 gun deaths vs. the U.K. with 155. Gun owners or a family member are significantly more likely to die by an unintentional gun death than those who don’t own a gun. “… What I’m asking for is (that) you consider a stronger assault weapons ban, elimination of the sale of semi-automatic weapons, restrictions on the size of magazine clips, number of rounds, extend background checks, and also please let us do some gun research that’s real… Allow me as a medical doctor, when I see a patient or when my colleagues see a patient, when I educate them on the effects of alcohol or tobacco, safe sex, motor vehicle accidents, can I please talk to them about the risks of gun violence? Please?” “In 20 years in the ER, I’ve never broken a tear, but this has affected me.” An emotional Begg ended his testimony telling the families of those who were killed in the massacre, “On behalf of ER, we tried our best. We tried our best.” In further reading on the aftermath of this tragedy, I came across an article entitled, “I Am Adam Lanza’s Mother,” A Mom’s Perspective on the Mental Illness Conversation in America: http://www.huffingtonpost.com/2012/12/16/i-am-adam-lanzas-mother-mental-illnessconversation_n_2311009.html. Liza Long writes about her 13-year-old son, Michael, and I share her own words with you: “A few weeks ago, Michael pulled a knife and threatened to kill me and then himself after I asked him to return his overdue library
books….That conflict ended with three burly police officers and a paramedic wrestling my son onto a gurney for an expensive ambulance ride to the local emergency room…..I am sharing this story because I am Adam Lanza’s mother. I am Dylan Klebold’s and Eric Harris’s mother. I am James Holmes’s mother. I am Jared Loughner’s mother. I am SeungHui Cho’s mother. And these boys—and their mothers—need help. In the wake of another horrific national tragedy, it’s easy to talk about guns. But it’s time to talk about mental illness….When I asked my son’s social worker about my options, he said that the only thing I could do was to get Michael charged with a crime…..No one wants to send a 13-year-old genius who loves Harry Potter and his snuggle animal collection to jail. But our society, with its stigma on mental illness and its broken health care system, does not provide us with other options. Then another tortured soul shoots up a fast food restaurant, a mall, a kindergarten classroom. And we wring our hands and say, ‘Something must be done.’ I agree that something must be done. It’s time for a meaningful, nationwide conversation about mental health. That’s the only way our nation can ever truly heal. God help me. God help Michael. God help us all.” As physicians, our patients’ health and well-being is our major concern. We diagnose and treat diseases with the goal of maintaining the quality of life and one’s independence. However, we can be most effective by supporting and adopting strategies that prevent disease, injury, or death. To that end, we have a moral and professional responsibility to educate our patients in their lifestyle choices, to participate in the national debate on gun control and safety, and to seek much needed support for the improvement of mental health services.
Joseph S. Andresen, MD, is the editor of The Bulletin. He is board certified in anesthesiology and is currently practicing in the Santa Clara Valley area. JANUARY / FEBRUARY 2013 | THE BULLETIN | 5
MESSAGE FROM THE MCMS PRESIDENT
John f. clark, MD President, Monterey County Medical Society
The Patient and the People By John F. Clark, MD President, Monterey County Medical Society In President Obama’s inaugural address, among several overarching themes, he made a trenchant argument for the vital role of government in American life. To a large degree, he was responding to the current polarization in American politics, the philosophic underpinnings of which can be understood as a conflict between the idea opined by President Ronald Reagan that “Government is not the solution to our problems. Government is the problem,” – and what Obama stated in his address, “The commitments we make to each other – through Medicare, and Medicaid, and Social Security – these things do not sap our initiative; they strengthen us.” At a deeper level, these two views express an inherent tension that exists between the needs of promoting individual welfare and the needs to promote the general welfare; between advocating for individual freedom and championing collective responsibility; ultimately, between the principle of liberty and that of justice. Both perspectives are accurate, necessary, and timeless, and we can both err in supporting the people (through the surrogate of governmental authority) over individual autonomy, as well as in supporting individual freedom over the responsibility to the commons. In health care, the field in which this conflict plays out is in the issues of publicly-funded health care, Medicaid and Medicare. Upon this field, the conflict in part pits the needs of the patient against the needs of the people. The patient is best served by unlimited access to effective medical therapies, while the needs of the people are best served by maximizing efficient use of limited public resources. That government plays a vital role in health care is self-evident. Currently, 60% – 65% of health care expenditures are paid for directly through taxation. This reality is an expression
of the fact that the provision of modern health care is a classic market failure. A market failure is a situation in which the free market is incapable of providing a necessary service efficiently. It is generally felt that access to health care is not a privilege, but falls under the general constitutional guarantee of the right to life, liberty, and the pursuit of happiness. As Obama phrased it, “We, the people, still believe that every citizen deserves a basic measure of security and dignity.” Thus, by implication, we consider the provision of a basic package of health care as a necessary right of the people. However, our modern technologically-intense health care services have become priced well beyond the means of a large segment of the American citizenry. Monthly medical costs for such common disorders as diabetes are conservatively estimated as $350 – $500/month and can impair access to basic human needs such as food and shelter for poor and middle income Americans. A single hospitalization can cost a small fortune and can easily lead to bankruptcy on the part of a patient paying out of pocket. Thus, in order to address this market inefficiency, we as a people have instituted a public health care safety net to fill in the breach and ensure basic health care services to ourselves, in the case of adversity. These are not, as is often thought, individually generated benefits that the government accounts for on our behalf. In the case of Medicare, since the Medicare payroll tax is but a fraction of Medicare expenditures, and since any worker doesn’t pay nearly enough in payroll taxes to pay for the expected benefit, this program functions as a general risk sharing pool for the collective. In other words, through publicly-funded health care, we support each other. There is currently no credible proposal to entirely abolish the right to access such a benefit. As with the protection of any right, the provision of it comes with inherent responsi-
John F. Clark, MD, is the 2012-2013 president of the Monterey County Medical Society. He is a board certified family medicine physician and is currently practicing with Salinas Valley PrimeCare Medical Group, Inc. 6 | THE BULLETIN | JANUARY / FEBRUARY 2013
bility. On the part of the people, their representative, government, has a responsibility in the health care field to use public resources efficiently to maximize the provision of the benefit to the patient. Ronald Reagan’s comments are essentially an expression of a lack of trust in the ability of government to be so efficient. Such a critique embodies a sober and necessary wariness against the injustice represented by misspent public resources. Governments, despite being the principle advocate for the people, can fail at efficiently providing necessary services to them just as markets can. However, there is, of necessity, inherent inefficiency in any public endeavor required to ensure responsiveness to the desires and needs of the people and, thus, avoid the callous efficiency accomplished through oligarchy and dictatorship. With regards to health care, great strides are being made of late to improve efficiency with regards to Medicaid and Medicare. The American Recovery and Reinvestment Act of 2009 has devoted considerable funds to assist physicians to achieve meaningful EMR usage, in part, for the express purpose of better monitoring and improving efficient allocation of public funds. The 2010 Affordable Care Act includes provisions for supporting evidencebased comparative outcomes research in order to limit resource allocation to inferior medical therapies. CMS reported a record $4.1 billion was recouped in Medicaid and Medicare fraud in 2011. The people are thus endeavoring to be responsible to the patient. Yet, analogous to the responsibilities of the people to the patient, there is in our publicly funded health care system an inherent responsibility of the patient to the people. In light of the fact that most of us will need to avail ourselves of limited public resources to maintain our health at some point in our lives, it follows that patients, too, have a responsibility to utilize these resources efficiently. This responsibility comes in several forms. First and foremost, the patient is responsible to try and maintain as optimal of health as possible and partner with physicians and the health care
MESSAGE FROM THE SCCMA PRESIDENT
Rives C. Chalmers, MD President, Santa Clara County Medical Association
Is It Just Me? By Rives C. Chalmers, MD President, Santa Clara County Medical Association Is it just me, or are others upset by the extreme violence we all see in the movies, video games, and TV? I saw my two-year-old granddaughter in rapt attention before Nemo and Pinocchio. She absorbs it all and begins to talk about the characters and situations. Is there a correlation between pervasive media violence with the gun violence at Newtown and with Gabrielle Gifford’s in Casa Adobes, Arizona? In every case this is free speech in an attempt to entertain. It sells tickets. But I believe that our society is lowering the bar for mentally immature or flawed minds to choose violent acting-out to solve social dilemmas when frustrated or angry, conditioning new generations of children and young adults. I agree that certain gun control laws, preserving Second Amendment rights, are one appropriate response. But the media portrayal of extreme violence is much more pervasive and far reaching in our society. The motion picture industry has long applied standard ratings of violence, sexual, and language content as warnings to parents. While valuable, these certainly do not deter adolescents and many parents of younger children who view these programs.
We are a free people and must preserve First Amendment rights of free speech. Each recent gun tragedy is slightly different, but one common thread has been the constant exposure to media violence. I would advocate INCREASING SELF CENSORSHIP BY THE INDUSTRIES THEMSELVES. The pendulum has swung too far in 40 years and, in my view, needs a nudge toward self control and peaceful solutions to frustration and anger. There should be more admiration of social norms and the rule of law. Last week, I watched the trailers for ten movies before Zero Dark Thirty. I saw ten apparently violent films I will never see and will urge my family to avoid. As a part of the national conversation regarding our social response to these gun tragedies, I would include consideration of self-censorship by the industries supporting the present out-of-control gun violence seen by our children. Note: Dr. Chalmers is a disabled veteran of the Vietnam Era. Rives C. Chalmers, MD, is the 2012-2013 president of the Santa Clara County Medical Association. He is a board certified orthopaedic surgeon and is currently practicing in the Los Gatos area.
The Patient and the People, from page 6 system to avoid preventable illness. Hence, such demonstratively unhealthy lifestyles such as smoking, lack of exercise, and overeating become a breech of the patients’ public responsibility. Engaging in disease prevention activities such as regular health screening and cancer prevention become not only a personal, but a public duty. Patients also have a responsibility to be as informed as possible concerning their own health and their own illnesses, in order to develop appropriate expectations concerning the effectiveness of treatments and minimize seeking such clearly worthless therapies as antibiotics for simple viral upper respiratory tract infections or MRI scans for uncomplicated low back pain. Providing low cost equivalent alternatives to designer medications is often presented to patients by insurers and should be embraced with patriotic fervor for those on
Medicaid and Medicare. While American rugged individualism may chafe at being saddled with such a perspective, in as much as the patient is the ultimate decision maker concerning their own health and health care, the people have a justifiable expectation of the patient to endeavor to be prudent in the utilization of current and future public resources. This last expectation, while vital, is rarely a point of discussion in part because illness is a state during which we generally do not want to burden those already suffering. Further, patients may not have the medical sophistication to make such clinical judgments. The health care community and, in particular, physicians are in a key position to be facilitators in discussions of efficiency on behalf of their patients, as well as on behalf of the people through education and the judicious evidence-based ordering
of diagnostics and therapeutics. Such a dual role is relatively new to the medical profession and a role forced upon it by the challenges presented by stark limitations in resources relative to the cost of high-tech care. Fortunately, the needs of the patient and those of the people are, for the most part, aligned. Health maintenance and effective treatment of illness benefits all. Through the evidence-based execution of the practice of medicine and the avoidance of unnecessary treatments, the physician, thus, also displays patriotism in the service of both the patient and the people by facilitating the efficient use of the commons. Together, the patient, the people, and their physicians must work together responsibly to maximize the benefits that our modern health care system can provide to us all.
JANUARY / FEBRUARY 2013 | THE BULLETIN | 7
Private Practice Strategies > Part 1
Retaining independence while embracing accountability: care coordination and integration strategies for small physician practices (Part I)
PHYSICIANS THROUGHOUT THE COUNTRY ARE TRYING TO FIGURE OUT HOW TO BEST ACHIEVE THEIR PROFESSIONAL GOALS IN THE CHANGING HEALTH CARE delivery environment. Physician payments are increasingly being structured in a way that incentivizes quality and cost effectiveness over volume, and many place physicians at financial risk. In addition, public reporting of physicians’ performance will now be the norm, rather than the exception, with Medicare’s expansion of its Physician Compare website in 2013. Will physicians need to be employed by a hospital or a large medical group or health system in order to provide the quality and manage the costs that these payment and reporting systems require and take advantage of the emerging opportunities resulting from health system reform? Not necessarily. While some physicians may ultimately decide that formal alignment with a large medical group or hospital system is their best option, others are actively working to integrate new care coordination and accountability capabilities into their smaller 8 | THE BULLETIN | JANUARY / FEBRUARY 2013
practices. Indeed, there are a number of avenues that physicians in smaller practices can take that will allow them to retain their independence while also achieving the new capabilities they will need to succeed in this new environment. Developing new capabilities to coordinate care and improve results AMA has published a new resource to assist physicians in small and solo practice in taking advantage of the opportunities presented by the changing health care delivery environment, entitled “Retaining independence while embracing accountability: care coordination and integration strategies for small physician practices,” available at www.ama-assn.org/go/ACO. This resource identifies the core capabilities physician practices will likely need to enhance to be successful in the future and describes how small physician practices can attain these capabilities, which are summarized briefly below. The resource also discusses options small practices may have to collaborate with other physicians and to obtain financing for practice enhancement, which will be covered in a subsequent article.
Three steps to improve quality There are at least three things
• Lowered the number of emergency room referrals for its patients;
that even the smallest of practices can do to improve care:
• Reduced hospital admissions for its patients;
• Standardize care through the use of accepted guidelines, policies and procedures;
• Increased the number of patients seen within 24 hours of a telephone call five-fold.
• Facilitate better coordination and interaction among all the parties involved with the care, including the patient; • Develop and analyze data to change behavior, produce better outcomes, and provide care more efficiently.
One practice’s success story For example,
in “Achieving Clinical Integration with Highly Engaged Physicians,”1 the authors point to Consultants in Medical Oncology and Hematology (CMOH), a ten-physician independent hematology practice in Delaware County outside of Philadelphia. These physicians were dissatisfied with their inability to contract on acceptable terms with managed care plans, and therefore began collecting their own data that would demonstrate the practice’s value by measuring performance on issues such as keeping their patients out of the hospital, and producing high satisfaction scores. They implemented an electronic health record to track their patients’ utilization of services and provided standardized approaches to care. With collaboration among its clinical support teams, the practice adhered to evidence-based guidelines, provided enhanced patient access to care through same day/next day visits, and educated patients to improve medication, evaluation, and treatment compliance, etc. According to the study, the results of these efforts were impressive, as the practice: • Increased its financial margin by lowering its full-time employee staffing requirements by 10%;
• By 2010, the group’s clinical integration program resulted in it receiving the first oncology patient-centered medical home designation by the National Committee for Quality Assurance. (Id. at 10-11.)
Tools for small practices Tools are available for
physicians to help them make changes to their practices and manage patient referrals and transitions necessary to support coordinated care. For example, the Institute for Healthcare Innovation, funded by the Commonwealth Fund, has provided a toolkit entitled “Reducing Care Fragmentation” that introduces four key concepts for enabling change, and offers activities, model documents, and other tools to support their implementation. This toolkit is available at www. improvingchroniccare.org. Similarly, there are a number of tools that small physician practices can use to aggregate and evaluate their data efficiently:
FLOW SHEETS. The American Medical Association-convened Physician Consortium for Performance Improvement (PCPI) has developed prospective data collection flow sheets for a number of clinical conditions that incorporate evidence-based performance measures. See
www.ama-assn.org/ama/pub/physicianresources/clinical-practice-improvement/ clinical-quality.page. These prospective data sheets can serve as a reminder checklist to ensure that all care team members know what needs to be done when the patient is in the office. REGISTRIES. The ability to generate and use registries, that is, lists of patients with specific conditions, medications, or test results, is also considered a proxy for high quality health care.2 Such registries help office staff identify patients who are overdue for recommended services and facilitate contacting them and arranging for office visits, lab monitoring, referrals and other needed care. Some registries can even be developed using free software. The AMA has provided guidance on patient registries, including information on how to create them. See “Optimizing Outcomes and Pay for Performance: Can Patient
Registries Help?” a copy of which can be found at www.ama-assn.org/ama1/x-ama/ upload/mm/368/pt_registries_102005. pdf. In addition, the California Health Care Foundation’s resource “Chronic Disease Registries: A Product Review,” available at www.chcf.org may also be helpful. ELECTRONIC HEALTH RECORDS. Electronic health records (EHR) can also assist with care coordination. Physicians in smaller practices may be particularly interested in investigating some of the newer, cheaper cloud-based EHR systems.
JANUARY / FEBRUARY 2013 | THE BULLETIN | 9
care services. For example, in 2000, “U.S. patients were much more likely—three or four times the benchmark rate—than patients in other countries to report having had duplicate tests or that medical records or test results were not available at the time of their appointment.”4
“CLOUD COMPUTING” refers to a number of technology solutions that: (1) operate over the Internet; (2) use shared resources such as storage, processing, memory and network bandwidth with (and more patients). Private third-party other users; and (3) are “on-demand,” payers have ranked physicians for years. meaning capabilities such as network And now, Medicare has gone into the storage can be adjusted virtually, “quality reporting” business by launching eliminating the need for on-site IT staff. a Medicare Physician Compare site which, For more information on health information technology, including the Medicare/Medicaid EHR OPPORTUNITY incentive programs, go to the AMA’s website at Preventing hospital readmissions www.ama-assn.org/go/ HIT.
Improved “profiles”
attention, and (3) better branding opportunities.
Increased financial benefits. The National
Priority Partnership, convened by the National Quality Forum, has identified four activities which require physician involvement that reduce costs substantially and improve quality. The opportunity for estimated savings can be summarized as follows: See www.nationalprioritiespartnership.org.
SAVINGS . . . . . . . . . . .$25 billion Improving patient medication adherence . . . . .$100 billion Reducing emergency department overuse . . . . $38 billion Preventing medication errors. . . . . . . . . . . . . . .$21 billion
CLAIMS DATA. Another potentially valuable source of information is claims data. AMA has published a toolkit to help physicians use these data for practice improvement activities, whether they are received from health insurers associated with their physician profiling reports or directly from a physician’s practice management system or clearinghouse. This helpful resource, “Taking Charge of your Data,” is available at www.ama-assn. org/go/physiciandata.
Potential benefits
Finally,
this resource outlines the benefits which accrue from engaging in quality measurement programs and using practice data to monitor, report, and improve:
Increased quality.
Measurement drives behavior.3 Measurement can result in both improved outcomes for patients and lower health care costs generally due to the avoidance of duplicative and/or unnecessary health
starting in 2013, will include Physician Quality Reporting System (PQRS) results based first on the 2012 reporting year.5 Increasingly, anyone who has access to a website can find out information about his or her physician, and how that physician “compares” to other physicians. While many physicians have been concerned about such public ranking, physicians who are acknowledged as recognized providers in these programs have gotten more patients to treat than non-recognized physicians and often get the opportunity to participate in more networks.6 Consequently, despite their drawbacks, performance measures can mean that those who score well will be in a better position to obtain: (1) higher payment; (2) increased consumer
10 | THE BULLETIN | JANUARY / FEBRUARY 2013
Thus, not only is performance measurement likely to improve patient care, it may also serve as a foundation for financial incentive and reward programs in value-based purchasing strategies. In California alone, since 2004 approximately $400 million dollars have been distributed to physicians by certain health plans participating in a pay for performance initiative.7 See Results of Integrated Healthcare Association Pay for Performance Program, at www.iha.org. In the end, physician practices that enhance their competency with respect to the three core areas outlined above, (1) standardization, (2) care coordination, and (3) data evaluation, will likely perform better, both clinically and financially.
Access AMA resources online “Retaining independence while embracing accountability: care coordination and integration strategies for small physician practices,” is available as part of the AMA resource, ACOs, CO-OPs and other options: A how-to manual for
physician’s navigating a post-health reform world, at www.ama-assn.org/go/ACO. Stay up to date with all of the new resources from the AMA, by signing up to receive the free AMA Practice Management Alerts emails at www.ama-assn.org/go/pmalerts. The AMA Private Sector Advocacy Unit created “A Physician’s Guide to Evaluating
Physicians’ and Dentists’ Confidential Line Substance Abuse Depression Career Burnout Stress
About the hotline: We are a confidential service dedicated to assisting physicians and dentists who may feel overwhelmed by aspects of their personal or professional lives. Our goal is to help our colleagues before their lives and practices are in jeopardy. How it works: All calls are completely confidential. Callers are quickly connected to a physician or dentist with extensive experience in helping health professionals having problems with stress, substance abuse or mental health issues. Callers receive the support and referrals needed to better manage whatever issues with which they may be struggling. Who should call: If you’re a physician or dentist looking for help with substance abuse or a psychological or emotional problem, we’re here to help. If you’re a colleague, family member or friend of a physician or dentist in need of assistance, please don’t hesitate to call.
While you’ll be there for your patients, we’ll be here for you. Northern California: 650.756.7787 • Southern California: 213.383.2691
Incentive Plans” that physicians can use to evaluate such plans for their financial and patient care implications http://www. ama-assn.org/resources/doc/psa/x-ama/ pfp_brochure.pdf.
(1) See Alice G. Gosfield, JD, and James L. Reinertsen, MD, “Achieving Clinical Integration with Highly Engaged Physicians,” a copy of which can be found at http:// www.wsma.org/files/Downloads/ PracticeResourceCenter/Achieving _ Clinical_Integration_GR.pdf. (2) See Fleurant, et al., “Massachusetts e-Health Project Increased Physicians’ Ability to Use Registries, and Signals Progress Towards Better Care,” Health Affairs, July 2011, 30:7. (3) Asch, McGlynn, et al., “Comparison of Quality of Care in the Veterans’ Health Administration and Patients in a National Sample,” Ann.of Int.Med. Vol. 141, No. 12, December 21, 2004, pp. 938-345. (4) The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008, The Commonwealth Fund, July 2008. http://www. commonwealthfund.org/Publications/FundReports/2008/Jul/Why-Not-the-Best-Results-from-the-National-Scorecard-on-US--Health-System-Performance--2008.aspx. (5) See 42 U.S.C. §280j-2. Further, although the PQRS was once voluntary, if eligible professionals do not satisfactorily submit data on quality measures for covered professional services for the quality reporting year beginning in 2015, the Medicare Fee Schedule amount for such services will be reduced. (42 U.S.C. §1395w-4.) (6) See Berry, Emily, “Narrow Networks: Will You Be In or Out?” AMedNews, Oct. 4, 2010.
The Physicians’ and Dentists’ Confidential Line is a project of the California Medical Association and the CMA Alliance, with additional support from the California Dental Association. JANUARY / FEBRUARY 2013 | THE BULLETIN | 11
Managing Professional Risk
Tips for Steering Clear of Problems With Pain-Med Prescribing By Karen K. Davis, MA, CPHRM Risk Management NORCAL Mutual Insurance Company and the NORCAL Group The following tips will help you prescribe narcotics/opioids appropriately to patients in chronic pain: Obtain a thorough history and determine the specific cause of pain. Patients who request pain treatment should receive a comprehensive assessment aimed at finding a specific physical process to explain their pain. Stephen Richeimer, MD, Chief of Pain Medicine at the University of Southern California, says, “Assessment is a key issue. The history and physical examination provides the information that allows the physician to judge if the patient is legitimately in pain or if the patient is improperly seeking drugs.”1 Document well. Explanations in the patient’s medical record demonstrate that the patient was carefully evaluated and is being appropriately managed. Documentation verifies what modalities have been used to minimize pain, what is working, and what the overall plan of care is. Richeimer asserts: “Good record keeping is part of good medicine, and it is also your best protection from frivolous lawsuits.”1 Ask chronic-pain patients to agree to use a single pharmacy. Discussing pain treatment with the patient and getting the patient to agree to certain parameters associated with long-term pain management are mutually beneficial strategies: they help you avoid inadvertently supplying medication that might be diverted for street sale, and they reassure the patient in pain that he or she can count on obtaining needed medication. An especially useful rule is that the patient will use a single pharmacy for all pain medications. Make use of a written pain medication agreement with chronicpain patients. A signed agreement by the patient that he or she will follow rules for obtaining pain medication will improve the likelihood of appropriate behavior by the patient. It discourages patients from seeking an unlimited supply of medication and helps staff members verify the legitimacy of refill requests. Monitor patients over time on their needs for and use of pain medication. Richeimer observes that patient trustworthiness “can only be assessed by monitoring the patient over time.”1 Berland and Rodgers recommend that all patients using opioids for chronic pain management “undergo urine drug testing before opioid therapy is initiated and then at 12 | THE BULLETIN | JANUARY / FEBRUARY 2013
least yearly unless patient behavior suggests the need for more frequent testing.”2 If you keep controlled substances in your office, establish a reliable process for safeguarding and reconciling such medications and for tracking their distribution. The federal Drug Enforcement Administration (DEA) requires physicians who administer or dispense controlled substances from their offices to have effective controls to guard against theft and diversion. Controlled substances must be stored in a securely locked, substantially constructed cabinet. Using a controlled substances inventory log can help you account for each and every dose of medication that goes through your office. These strategies are aimed at fostering appropriate pain management within the limits of professional practice. Furthermore, they can help physicians and staff consistently meet regulatory requirements on the management of pain medications.
References 1. Richeimer S. Opioids for pain: risk management. California Society of Anesthesiologists Online CME Program. Available at: http://www. csahq.org/cme2/course.module.php?course=3&module=12 (Accessed January 11, 2013). 2. Berland D, Rodgers P. Rational use of opioids for management of chronic nonterminal pain. American Family Physician. 2012;86(3):252258.
JANUARY / FEBRUARY 2013 | THE BULLETIN | 13
2013 Education Series MAR 6
March 6: Fraud and Abuse: Dangers and Defenses DHCS • 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the importance of documentation, present suggestions for implementing internal controls, and increase awareness of preventive measures to protect your practice from fraud or abuse.
MAR 6
March 7: Essentials for ICD-10-CM: Part 1 AAPC • 7:45 – 8:45 a.m. or 12:15 – 1:15 p.m. Continued on March 14 and 21. This three-part series gives your staff a high-level overview and fundamental knowledge of ICD-10. You’ll learn documentation challenges, the differences with ICD-9, and how ICD-10 will affect each business area of your practice.
MAR 13
March 13: Utilizing the New State Disability Insurance (SDI) Online System Employment Development Dept. • 12:15 – 1:15 p.m. SDI is a California state-mandated, employee-funded benefit that provides partial wage replacement. SDI is transitioning to a system with online capability for your patients and you. This webinar will show you how to create an SDI online physician’s account, authorize representatives to assist in completing the doctor’s certificates, and learn how to complete the new online doctor’s certificate.
MAR 14
March 14: Essentials for ICD-10-CM: Part 2 AAPC • 7:45 – 8:45 a.m. or 12:15 – 1:15 p.m. Continued from March 7 and ends March 21. This three-part series gives your staff a high-level overview and fundamental knowledge of ICD-10. You’ll learn documentation challenges, the differences with ICD-9, and how ICD-10 will affect each business area of your practice.
MAR 20
March 20: EHR Selection – Top 10 Tips for Success David Ginsberg • 12:15 – 1:15 p.m. The past several years have seen a tremendous increase in the adoption of electronic heath records (EHR) systems by California physicians. Not all selections and implementations, however, have been successful. This webinar is designed to teach the top 10 selection tips for a successful purchase and implementation. Determine the best EHR for your practice, how to correctly select an EHR, and contract negotiation dos and don’ts.
MAR 21
March 21: Essentials for ICD-10-CM: Part 3 AAPC • 7:45 – 8:45 a.m. or 12:15 – 1:15 p.m. Continued from March 7 and 14. This three-part series gives your staff a high-level overview and fundamental knowledge of ICD-10. You’ll learn documentation challenges, the differences with ICD-9, and how ICD-10 will affect each business area of your practice. The above webinars are being hosted by the California Medical Association. Please register at www.cmanet.org/events. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar. Questions? Call the CMA Member Help Line at (800)786-4262.
Please note that this calendar does not include CMA’s ICD-10 training courses to be offered in 2013.
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MAR 27
March 27: Successful Medi-Cal Provider Enrollment for Physician Providers DHCS • 12:15 – 1:45 p.m. Physicians must re-enroll in Medi-Cal as one of the provisions of the Affordable Care Act (ACA). This training will cover basic instructions and guidelines on the proper way to complete a Provider Enrollment Application Package. We will discuss the importance of reviewing and understanding program requirements and how to avoid common mistakes when completing enrollment forms. We will also cover specialized physician enrollments, important changes to the program due to ACA implementation, and where to find additional program information and PED contact information.
APR 3
April 3: Strategic Planning From Vision to Action - A Self-Guided Process Rachel Smith • 12:15 – 1:15 p.m. Learn how simplified strategic planning and personal coaching can get you, your practice or your organization where you want to go. In this interactive webinar you will get to develop your own vision and strategic plan with tools to ensure you can walk away with immediate items, tools you can use again and how to obtain coaching support to implement the remaining steps of your plan.
APR 10
April 10: Preparing for EHR Implementation and Conversion David Ginsberg • 12:15 – 1:15 p.m. Many EHR system implementations fail or stumble due to common mistakes made during implementation. This webinar will review common pitfalls, what you should insist your vendor provide (project plans, timelines), setting up files (order sets, pick lists, etc.), the importance of all stakeholder involvement, the danger of scanning paper charts, and resources to support you.
APR 17
April 17: Valuing, Selling, Buying or Transitioning a Practice Debra Phairas • 12:15 – 1:15 p.m. Considering retirement? Selling or wanting to buy a practice? Making this transition requires planning and sufficient time to accomplish this effectively for your patients, staff and family. California has a high cost of living, which makes it more difficult for physicians to sell, transition, start, or purchase a practice. Learn creative strategies to help you accomplish your goals. This seminar will discuss the options, including: bringing in an associate, recruiting or selling the practice. Included is the latest information on valuation methodology for selling, divorce or estate planning.
APR 24
April 24: California’s Health Benefit Exchange: How it Will Impact Your Practice and Change Commercial Insurance Brett Johnson • 12:15 – 1:45 p.m. Beginning in 2014, California’s private health insurance market will never look the same – individuals and small employers will be able to purchase health insurance coverage through the state’s health insurance exchange, now named Covered California. It is estimated that by the end of 2016, over one in five Californians will get their health insurance through the Exchange. Furthermore, with the selection of exchange plans occurring no later than April of 2013, payors are likely to begin reaching out to physicians regarding exchange products soon, if they have not already (e.g., Anthem Blue Cross and Blue Shield of California). In this presentation, you will learn more about California’s exchange and what it will mean for physicians. You will also gain an understanding of some of the risks and benefits of contracting to provide services to exchange enrollees.
MAY 1
May 1: The Power of the Pen – The Physician’s Responsibility in Prescribing and Referring for Medi-Cal Patients DHCS • 12:15 – 1:15 p.m. Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the importance of documentation, understand the physician’s role in prescribing/ordering/referring, and increase awareness of fraud and abuse in prescribing and referring.
MAY 8
May 8: Time Management – How to Quickly Make Decisions on What Matters Most Rachel Smith • 12:15 – 1:15 p.m. Learn how to value what matters most and achieve your goals by understanding what you are giving away and practicing simple tools to find solutions (not excuses) to get what matters most checked off the list. This interactive webinar will provide live one-on-one coaching to illustrate and use the techniques taught in this session.
MAY 15
May 15: Enforcement Provisions of the Medical Practice Act Medical Board • 12:15 – 1:15 p.m. Presented by the Medical Board of California, this webinar will describe basic facts about physicians licensed by the Board, including residence, age and specialties. Additionally, learn about laws regarding the Medical Board’s enforcement program, including the factors that can get a physician into trouble (most common mistakes, complaints and actions); the process from complaint receipt to adjudication; and why there is a physician interview and the benefits to fully responding. The webinar will also cover the sunset review process and the issues that are being discussed at the legislative level to enhance the law for consumer protection.
MAY 16
May 16: Essentials for ICD-10-CM: Part 1 AAPC • 7:45 – 8:45 a.m. or 12:15 – 1:15 p.m. Continued on May 23 and 30. This three-part series gives your staff a high-level overview and fundamental knowledge of ICD-10. You’ll learn documentation challenges, the differences with ICD-9, and how ICD-10 will affect each business area of your practice.
JANUARY / FEBRUARY 2013 | THE BULLETIN | 15
16 | THE BULLETIN | JANUARY / FEBRUARY 2013
12
SAN JOAQUIN PHYSICIAN
SUMMER 2012
WE ARE HERE TO HELP
HELP
NOT SURE ABOUT THE LAW? Contact the CMA Legal Information Line When a patient’s family member asked José A. Arévalo, M.D., to intervene at the skilled nursing facility where his patient was living, he wasn’t quite sure what the patient’s rights werea under the law.
“There was new leadership at the facility,” explained Dr. Arévalo, a board-certified family physician and Senior Medical Director of Sutter Independent Physicians since 2003. “The patient was told that she would only be able to see the medical director for the facility, instead of her established physician.” Dr. Arévalo called the California Medical Association (CMA) Legal Information Line because he was uncertain about what rights the patient had in choosing a doctor in a skilled nursing facility and had concerns about continuity of care. A CMA member for 20 years, Dr. Arévalo had used the Legal Information Line before. “This is a tremendous resource. I knew they would have an answer for me.” The Legal Information Line and its staff will research and provide information to address
just about any legal-related question from a CMA member. A WEALTH OF INFORMATION Every day, CMA member physicians and their staff contact CMA’s Legal Information Line with a wide range of legal issues they face in their practices, such as the formation of physician practice models, medical staff and peer review, managed care, reimbursement and office staff issues. The Legal Information Line is staffed by CMA’s Center for Legal Affairs, which assists members by providing them with resources and information on applicable laws. Many of the inquiries can be answered with information available in CMA’s health law library, CMA ON-CALL. CMA ON-CALL is a comprehensive legal resource that is
By listening to member inquiries, asking questions, doing research and contacting outside resources, including other health organizations and government agencies, the Legal Information Line staff works hard to address members’ questions. Whether the questions are simple or complex, “We always try to find the right information to best address our members’ questions,” Pellón said. “Do they need to talk to their professional liability carrier or a state agency? We try to direct them to the right resource if we cannot address a question.” Pellón adds that should a member need specific legal advice about a particular situation, “we also maintain contact information for physicianfriendly attorneys” in various physician-related legal issue areas. The CMA Legal Information Line is a free resource for members. You can access this member benefit by calling (800) 786-4262 or e-mailing legalinfo@cmanet.org.
JANUARY / FEBRUARY 2013 | THE BULLETIN | 17
updated annually by CMA attorneys and available free to members at the CMA website, www.cmanet.org/cma-oncall. It contains information on current laws, regulations and court decisions related to medical practice. For example, a common question on the Legal Line is: “How long do I have to keep a patient’s medical record?” CMA staff can e-mail or direct a member to a CMA ONCALL document that discusses statutory record retention requirements, recommended retention periods, options for record management, as well as record destruction requirements. See CMA ON-CALL document #1160, “Retention of Medical Records.” Some Legal Line inquiries, however, are more complex.
were happy to provide information.” She said networking with other health associations in the state allows the associations to track issues that may affect their members.
ONLINE PHARMACIES AND THE LAW
With the ease of e-commerce and patients’ desires to save money, the Legal Information Line has received numerous questions about the use of foreign internet pharmacies. When a county medical society contacted the Legal Information Line on behalf of a member physician about a patient who wanted to buy prescription medicine from an online pharmacy in Canada, CMA legal counsel Lisa Matsubara not only provided the physician with a CMA ON“We were recently updated that one member CALL document was able to get back over $20,000 from the discussing the risks of obtaining settlement fund after accessing and using our drugs from a advocacy resources.” foreign country (CMA ON-CALL document #0511, “Drug Prescribing: Drugs from Other Countries”), but she also “Many of these questions are not straightforward,” said researched several websites for Canadian pharmacies. Samantha Pellón, CMA’s health law information specialist “On behalf of the patient, the Canadian online who has staffed the Legal Information Line for the past pharmacy faxed the physician a prescription form four and a half years. “I will often ask a lot of questions and asked that the physician fill it out and return the to get enough information about a certain situation so I prescription form to the pharmacy,” Matsubara said. can refer members to the right resource or do more in“The physician wanted information on the legality depth research.” Pellón, who is set to begin a Masters in of prescribing and importing drugs from a Canadian Public Health at the University of California Berkeley pharmacy.” Matsubara, who has staffed the Legal this fall, adds that although CMA cannot give individual Information Line for over two years, reviewed the websites legal advice to members, “we try to research and provide and found policies and disclaimers that conflicted with enough information as possible to help members with federal and state laws. their legal questions.” Although she was unable to give individual legal advice, This includes pulling in CMA attorneys with Matsubara provided the county medical society with knowledge in a specific issue area to help locate the pertinent information on the applicable laws, as well as relevant law. When Dr. Arévalo asked about the legal guidance from the Food and Drug Administration and the rights of his patient at a skilled nursing facility, CMA California Board of Pharmacy about the potential liability legal counsel Alicia Wagnon got involved. Wagnon, risks associated with the importation of drugs from foreign who previously worked as a litigator in private practice countries. defending doctors in medical malpractice and employment law, called her contacts at the California CMA HELPS MEMBERS RECOUP Association of Health Facilities (CAHF). Wagnon was THOUSANDS OF DOLLARS IN able to get a clear answer from CAHF quickly and pass on CLASS ACTION LAWSUIT useful guidelines to Dr. Arévalo. “Associations are always Inquiries to the Legal Information Line also inform looking for trends (in their area of specialty), so they CMA attorneys about the need for certain advocacy 18 | THE BULLETIN | JANUARY / FEBRUARY 2013
resources. In 2000, the American Medical Association along with other health care provider and patient groups, filed a class action lawsuit against UnitedHealth Group, alleging that United conspired to defraud consumers by manipulating out-of-network reimbursement rates and shortchanging physicians and patients by hundreds of millions of dollars over 15 years. “We had a lot of questions from our membership about filing a claim for reimbursement after the settlement,” Pellón said. To help physicians understand the settlement and what they need to do to claim their share, CMA’s Director of Litigation, attorney Long Do, created a settlement guide for CMA members. The guide discussed key provisions of the settlement and provided information on how to qualify and submit claims to the settlement fund. In addition, the CMA legal center put together a resource page with links to settlement forms, the settlement claims administrator website, and AMA resources. See United/Ingenix Settlement Guide. Pellón says that the settlement guide, resource page and staff assistance helped CMA member physicians recoup thousands of dollars. “We were recently updated that one member was able to get back over $20,000 from the settlement fund after accessing and using our advocacy resources.”
HOW TO RESPOND TO NEGATIVE ONLINE REVIEWS
Another issue that is the subject of numerous calls to the Legal Information Line is how to handle negative comments on consumer review and rating websites. Such websites are a concern for physicians because inappropriate negative comments can
damage a physician’s reputation and affect his or her practice. “With more and more websites inviting patients and other members of the public to rate and review physicians, we were receiving phone calls from physicians asking about what their options were with regard to negative online reviews of their practice,” said Matsubara. In response, Matsubara
authored a CMA ON-CALL document addressing member concerns and providing information on identifying online reviews, responding to negative online comments and possible legal remedies for physicians who find themselves the subject of such reviews. See CMA ON-CALL document #0822, “Online Consumer Review and Rating Sites.”
SCCMA Annual Awards Banquet and Installation Tuesday, June 11, 2013 6:15 pm Social 7:00 pm Dinner & Program The Fairmont Hotel, San Jose Installation Sameer V. Awsare, MD, SCCMA President 2013-14 Honoring Rives C. Chalmers, MD, SCCMA President 2012-13 Award Honorees to be announced in the March/April Bulletin. Formal invitations will be mailed end of April.
JANUARY / FEBRUARY 2013 | THE BULLETIN | 19
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HOSPITAL NEWS
Lucile Packard Children’s Hospital Pediatric Weight Control Program: Alberto’s Story Alberto Hidalgo has the broad, generous smile you might expect to see on someone who has won the lottery. But 15-year-old Alberto hasn’t won anything, and his smile hasn’t come without effort. Alberto has made—and continues to make—small but important choices over and over again, several times a day, and the result is this: a very healthy, happy teen. More than a year ago, Alberto weighed 235 pounds. “I didn’t have any confidence at all. I was always thinking about what people were going to say about me.” Alberto loved to swim, but avoided it because it meant taking his shirt off in front of other people. But self-consciousness alone wasn’t enough to change his habits. “Both of my grandmothers suffer from diabetes. When I had a blood test that showed I was at risk for diabetes, they were really upset, yelling at me and my parents that we had to do something.” Alberto’s mother, Cecilia, saw an article in the newspaper about weight loss that mentioned Lucile Packard Children’s Hospital’s Pediatric Weight Control Program; she talked to Alberto about signing up. Alberto’s interest in starting the program was the most important factor. In order to start kids on a lifetime of good choices, Packard’s Pediatric Weight Control Program insists that it be the child’s decision to start the program. Teamwork is the key to the program’s success; at least one parent or guardian must enroll with their child. But no matter how enthusiastic a parent may be about the program, only children who are willing to make the commitment themselves are allowed to enroll. “In the beginning, it was hard,” says Alberto. “The program was great, but weekend dinners with our extended family were tough.” Like many families, the Hidalgos enjoy big family dinners as a time of togetherness and bonding. But having to say “no” to
some menu items can make loved ones feel rejected or insulted. “The program teaches creative ways to say no without making people feel bad,” explains Alberto. “It also teaches you how to control portions, especially when your choices are limited.” These lessons helped Alberto adjust to a new eating style in any situation. “We soon found out that every place you go has healthy food, you just have to look harder for it.” The program taught them how to read labels and understand nutrition and exercise. In the six-month, behavior-based Pediatric Weight Control Program, patients and family members meet in a group with two behavior coaches trained in a curriculum developed by pediatricians, psychologists, dietitians, and health educators. It wasn’t long before Cecilia noticed a change in Alberto’s weight, and also his outlook. “Once he started to see results, the choices became easier and easier. He was feeling the reward of his commitment.” Alberto and his mother both benefited from the program. During the time that Alberto was enrolled in the program, he lost 30 pounds. In the year that followed, Alberto practiced the skills and knowledge that he had gained and went on to lose almost 40 additional pounds. Cecilia changed her cooking style and lost 12 pounds. “I feel great,” Alberto says. “The program was a whole lifestyle change for me. It’s not like a diet or a plan; it changed the way I will eat for the rest of my life.” Alberto and his parents moved to the Bay Area from El Salvador in 2002. On their most recent visit to El Salvador, Alberto recalls, “My relatives were shocked. My cousin said, ‘Who is this person?’” Going into his junior year in high school, Alberto is looking forward to a 10-day school trip to France and doing his best to be ready for college. In
22 | THE BULLETIN | JANUARY / FEBRUARY 2013
fact, he’s looking forward to a lot of things. “I don’t feel so self-conscious anymore. I can forget about that and focus on all the things I want to do.” For more information about the Packard Pediatric Weight Control Program, please contact 650/725-4424 or visit their website at pediatricweightcontrol.lpch.org. Families can also call them directly to find out group times and payment options.
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MEMBER BENEFIT news
The Supreme Court’s Decision Didn’t Change One Thing! You still need to make important financial decisions about rising health insurance premiums. So what can you do? • 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 2013, with individual only coverage, you are eligible to contribute up to $3,250 to your account, or $6,450 with family coverage, on a federally tax-deductible* basis. Members between the ages of 55 and 64 are eligible to add an additional $1,000 per year ($4,250 and $7,450 totals respectively) to 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 (RAFs) for you to change health plans. This can help offset higher premiums. • Members who purchase group (2–50 members and employees) health insurance through Marsh/Seabury & Smith Insurance
Program Management are provided with Mercer Select HRKnowHow, which helps you stay current on group health and employee benefit issues. Access to this resource is included at no charge. Also included is 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. With the upcoming changes due to health care reform, a Marsh Client Advisor at 800/842-3761 can help provide the information you need. And, depending upon where your group health insurance is placed, we may also be able to save you 15% off your workers’ compensation insurance. *Marsh and the Association/Society do not provide tax, investment, or legal advice. Please consult with your professional advisors for guidance on these issues.
A Total Disability Can Want More Than Stop Your Income in $1,000,000? a Split Second Make sure you have a reliable financial plan in place that includes long term disability income protection. Members can turn to the Association/Society sponsored Group Long Term Disability Insurance Plan that protects members in their medical specialty.
Important features of this plan include: • A monthly benefit of up to $10,000 if you become totally disabled. Members age 50–59 are eligible to apply for up to $6,000 per month. • A 10-Year Medical Specialty Definition of Disability defined as the inability to work in your own medical specialty for the first 10 years after the waiting period (a very important distinction vs. many plans with a broad “inability to do ANY job” definition). • Your monthly benefit payments are not taxable when you don’t take your premium as a tax deduction under current tax law. That’s not necessarily the case for employer-provided plans where you could lose up to 40% of your benefit to taxation. (Always consult your tax advisor.) • Group rates are negotiated exclusively for SCCMA/MCMS members. Learn more about this valuable plan today, including: plan features, cost, eligibility, renewability, limitations, and exclusions. Please call a Marsh Client Advisor at 800/842-3761 or email CMACounty.Insurance@marsh.com. 24 | THE BULLETIN | JANUARY / FEBRUARY 2013
Travel assistance** and funeral planning and concierge services*** included at no additional charge to you. When SCCMA/MCMS/CMA members apply for up to $1,000,000 of 10- or 20-year term life insurance coverage underwritten by ReliaStar Life Insurance Company, a member of the ING family of companies, they get a few things non-members don’t. • Access to special member-only rates. • Premium savings, since rates remain level for the first 10 or 20 years of coverage.* • Each plan also includes a travel assistance service for medical emergencies when you are traveling away from home ** and a funeral planning and concierge service*** at no additional charge to you. You may also insure your spouse or domestic partner, and your eligible employees, for up to $1,000,000. Call Marsh/Seabury & Smith Insurance Program Management for more information at 800/842-3761, email CMACounty.Insurance@ marsh.com or visit www.CountyCMAMemberInsurance.com to download a brochure and application.
*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the policy with 60 days advance written notice. Underwritten by ReliaStar Life Insurance Company. Home Office: Mpls, MN Policy form LP08GP. **ING Travel Assistance Services provided by Europ Assistance USA, Bethesda, MD 20814. This product is not available in all states. ***Funeral Planning and Concierge Services provided by Everest Funeral Package, LLC, Houston, TX 77056. This product is not available in all states.
NEED HELP WITH CLAIMS?
TRY SCCMA/MCMS’s SPECIAL MEMBER BENEFIT: REIMBURSEMENT ADVOCACY PROGRAM If you need help in evaluating disputes between insurance companies and patients concerning fees and medical services, and need assistance in resolving disputes directly with the involved parties, contact Sandie Becker, CMC, Coding/Reimbursement Specialist. Phone: 408/998-8850 or 831/455-1008 or Email: sandie@sccma.org.
JANUARY / FEBRUARY 2013 | THE BULLETIN | 25
membership
Welcome 54 New MCMS Members Welcome Monterey Peninsula Surgery Center Physicians (29 New Members and 24 Existing) Monterey County Medical Society Name Richard Alexander II David Awerbuck Jon Benner Mary Kay Brewster Jeffrey Carter Christopher Carver Peilin Chang Gary Chang Ronald Chaplan Christopher Clevenger Richard Dauphine Erwin Deiparine Zoltan Denes Dragan Dimitrov Albert Doornik William Falor, Jr. David Flemming Ronald Friedman Richard Garza Peter Gerbino Donald Goldman Sohrab Gollogly Gus Halamandaris Alexander Holmes Mark Howard Roger Husted Jeffrey Hyde
City Specialty Monterey OBG Monterey OTO Monterey GS Monterey OBG Monterey OSP Monterey NS Monterey AN Monterey AN Monterey ORS Monterey ORS Monterey ORS Monterey PMR Monterey GS Monterey NS Salinas OSP Monterey OTO Monterey U Monterey OPH Monterey GS Monterey ORS Monterey U Monterey OSP Monterey NS Monterey OPH Monterey ORS Monterey OPH Monterey GS
Name Gerard Issvoran Scott Kantor Jennifer Keir-Garza Michael Klassen James Lin Christopher Meckel Steven Moore David Morwood Philip Penrose James Ramseur Richard Ravalin Richard Revis Howard Rosen Leland Rosenblum Gregg Satow Michael Scannell Emile Shaheen John Shaheen Michael Stuntz Douglas Sunde William Verlenden Steven Vetter Mark Vierra Charles Whisler Geoffrey White Don Williams Willard Wong
City Specialty Monterey FM Monterey OSP Monterey OTO Monterey ORS Salinas OSP Monterey OSP Monterey OSP Monterey PS Monterey OPH Monterey OBG Monterey OSP Monterey AN Monterey PMT Monterey OPH Monterey ORS Monterey AN Monterey AN Monterey U Monterey GS Monterey PS Monterey GS Monterey OTO Monterey GS Monterey OPH Monterey OPH Prunedale ORS Salinas ORS
US - Unspecified
In Memoriam Arthur W. Anderson, MD
William A. Johnson, MD
Thomas W. McDonald, MD Jean-Pierre Williams, MD
*Orthopaedic Surgery 8/14/27 – 1/13/13 SCCMA member since 1956
*General Surgery 6/13/23 – 10/3/12 SCCMA member since 1954
Internal Medicine 1953 – 10/7/12 SCCMA member since 2003
Stanley D. Harmon, MD
Alfred S. Maida, MD
Conor O’Malley, MD
*Orthopaedic Surgery 4/16/27 – 9/7/12 SCCMA member since 1978
Internal Medicine 5/24/27 – 1/24/13 SCCMA member since 1956
*Ophthalmology Retinal Surgery 5/21/30 – 11/30/12 SCCMA member since 1962
26 | THE BULLETIN | JANUARY / FEBRUARY 2013
*Orthopaedic Surgery 1/1/34 – 2/20/11 SCCMA member since 1967
Welcome 98 SCCMA Members Santa Clara County Medical Association Name City Specialty Snehal Adodra San Jose R P Yolanda Agredano de Moreno San Jose Beena Anantharaman San Jose P Eric Anderson Stanford US Arash Anoshiravani San Jose PD Linda Barman San Jose IM Patricia Barreto San Jose PD Ryan Basham Los Gatos OPH, PTH Kjshonija Batchu San Jose IM Ingrid Bossen San Jose OBG Lee Botkin San Jose PD Lynne Bui San Jose ON, HEM Jennifer Burkham San Jose RHU Angela Bymaster San Jose FM Xiao Cai San Jose IM Sarah Casper San Jose FM Julie Celebi San Jose FP Antonia Charles San Jose PD Angela Chen San Jose PD Luhua Cheng San Jose IM Rae-Pei Cherng San Jose OBG Bina Choi Palo Alto US Lindsay Croker San Jose FP Nancy Cuan San Jose IM Korina De Bruyne San Jose IM Jennifer Djafari San Jose PD Tuyet-Linh Doan San Jose PD, NPM Kenneth Gee San Jose P Bo Yoon Ha San Jose R Sandra Han San Jose D Kei Hanafusa San Jose R Amy Hennessy San Jose OPH Cheryl Ho San Jose IM Amy Hockenbrock San Jose FP Lea Hoff San Jose FP Anna Hui San Jose FP Susan Imamura San Jose P Olivia Jee San Jose FP Jason Jeffery San Jose IM Amanda Johnson San Jose ORS Archana Kayastha Mtn View PD Carolyn Kerr San Jose OBG Ashna Khurana San Jose PD Yeuen Kim San Jose IM Richard Knudsen San Jose CHN Abha Kumar San Jose GS, OPH Joann Laiprasert-Tantisira San Jose OBG Stephanie Le San Jose FP Katie Lemieux San Jose OBG
Name Chi-ling Lin Constance Lo June Lugovoy Cazmo Lukrich Frank Luo Malini Madanahalli Sofia Mahari Suzanne Mendez Daniel Morgan Daniel Moring-Parris Sarah Namath Sudha Rani Narasimhan Danielle Nelson Longhang Nguyen Tammy Nguyen Maria Ofreneo Rajul Pandit John Pham Teri Pham Anisa Rangwala Sreelakshmi Ravula Rejia Rawle Angela Ritz Dana Romalis Amelia Sattler Leslie Schmidt Sarah Jane Selig Veronika Sharp Benjamin Smith Jessica Smith Gerardo Solorio Deepak Sreedharan Marlene Sturm Amy Sturt Sharla Sundberg Rachel Sutherland Caroline Temmins Vinh Thai Liliana Tomona Yamashiro Susan Tran Jeffrey Tseng Adrienne Valesano Shawn Van Bockel Shirley Wang Kelly Welsh Ben Wong Enoch Yoon Brian Young Akbar Zikria
US - Unspecified
City Specialty San Jose US San Jose IM San Jose IM, NEP San Jose IM San Jose IM, NEP San Jose IM, GER San Jose FP San Jose PD San Jose FP San Jose FP San Jose AN San Jose PD, NPM Milpitas IM San Jose IM San Jose FP San Jose PP San Jose US San Jose FP San Jose IM San Jose IM San Jose PTH San Jose FP San Jose FP San Jose IM San Jose FP San Jose IM San Jose FP San Jose IM, RHU San Jose FP San Jose FP San Jose IM Los Gatos PMT, AN San Jose PD San Jose US San Jose GS San Jose FP San Jose PTH San Jose P San Jose LM San Jose FP San Jose R San Jose HOS San Jose R San Jose OBG San Jose FP San Jose IM San Jose FP San Jose IM, NEP San Jose FP
JANUARY / FEBRUARY 2013 | THE BULLETIN | 27
To My Santa Clara County Medical Colleagues Since 2006, the Centers for Disease Control and Prevention have recommended including routine screening for HIV for all our patients, regardless of their risk status, starting at age 13. Specifically, the guidelines read: For patients in all healthcare settings •
HIV screening is recommended for patients in all healthcare settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
•
Persons at high risk for HIV infection should be screened for HIV at least annually.
•
Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.
•
Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in healthcare settings.
The importance of making HIV screening a matter of course can’t be overstated. Study after study has shown that early screening and treatment are key to preventing spread of the HIV virus. But the stigma attached to HIV testing remains, largely because the test has not become routine as tests have for other conditions, like tuberculosis. We can erase the stigma by making this test routine. Join me in becoming a part of the first “AIDS-free generation.” Some helpful resources on this issue can be accessed using your smartphone to capture the QR code, or by visiting http://bitly.com/bundles/o_60gppaph19/1. •
Implementation of Routine HIV Testing in Health Care Settings: Issues for Community Health Centers
•
AIDS Education and Training Centers National Resource Center (AETC NRC)
•
U.S. Preventive Services Task Force draft guidelines for routine HIV testing
And please don’t hesitate to contact me with questions or thoughts on how to achieve universal routine HIV testing – Marty.Fenstersheib@phd.sccgov.org or 408.792.3798. Regards,
Martin Fenstersheib, MD, MPH Health Officer, Santa Clara County
28 | THE BULLETIN | JANUARY / FEBRUARY 2013
CAREER OPPORTUNITY
Classifieds office space for rent/ lease MEDICAL SUITES • LOS GATOS – SARATOGA Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking. Located next door to Los Gatos Community Hospital. Both units currently available. Call 408/355-1519. MEDICAL OFFICE 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. 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/DENTAL/PROFESSIONAL OFFICE SUITE AVAILABLE Second story of professional building. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $1.25/sq. ft. Rent is $1,543/month. Contact Steven Gordon at 831/757-5246. 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.
Make San Jose State University Your University of Choice
MEDICAL OFFICE TO SHARE • LOS GATOS Available now! To share with two primary physician Internists. Two rooms assigned personally for office use. To share four fully equipped exam rooms, EKG machine, waiting room, and two bathrooms. Price negotiable. Call 408/209-6556. MEDICAL OFFICE SPACE FOR RENT • LOS GATOS Medium size, newly established Podiatry Practice in Los Gatos, near Good Samaritan and Silicon Valley Surgery. Renting: office, exam rooms with access to Procedure/ surgery room, utility room, storage, cabinet space, and break room. Email losgatospodiatry@gmail.com.
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. INTERNAL MEDICINE PRACTICE FOR SALE • WATSONVILLE Internal Medicine practice for sale. Ideal for general internist, cardiologist, pulmonologist, endocrinologist, or rheumatologist to get started, or to build an excellent practice in a lovely coastal community in Monterey Bay – close to everything, with outstanding mild weather year round. Call 831/345-9696.
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 physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We CONTINUED ON PAGE 31
Job Title: Staff Physician Job ID: 22486 Category: Health Care Full/Part time: Full-time Regular/Temporary: Regular Department: Student Health Center Classification: Physician Salary Range: $10,477/month - $17,275/ month Please note: Applicants interested in LESS THAN FULL-TIME EMPLOYMENT are highly encouraged to apply. About the Position The Student Health Center provides a variety of medical services, which are similar to the outpatient care provided in a physicians’ group practice. These services for students include primary and urgent/acute care, evaluation, treatment, and guidance for individual health problems, family planning services, public health prevention programs, and health education. In addition, the SHC provides limited initial care for work injuries of employees, and if necessary, assists in referring such persons for ongoing care. The SHC may also provide first aid to campus visitors. Reporting to the Medical Chief of Staff, the Physician provides a variety of medical outpatient services in accordance with the overall operation of the SHC. Working independently, the Staff Physician performs medical, diagnostic, treatment, and counseling activities, which require a licensed physician and are within the scope of the program established by the Board of Trustees. The incumbent has the added responsibility of providing highly specialized and/or broad clinical duties that include planning, coordinating, and evaluating ongoing medical care of students. Collaboratively supporting student success is the bottom line purpose of this and all SHC positions. Essential duties and responsibilities include but are not limited to the following: Clinical duties; Non-clinical duties; Administrative duties; and other duties as assigned. Application link: http://apptrkr.com/303603
JANUARY / FEBRUARY 2013 | THE BULLETIN | 29
medico news
CMA files request for en banc review to stop Medi-Cal cuts The California Medical Association (CMA) filed a request for an en banc review by the Ninth Circuit Court of Appeals to stop the State of California from implementing a 10% cut to Medi-Cal provider reimbursement rates. Last month, a three-judge panel of the Ninth Circuit ruled that the state could move forward with the rate cuts, passed by the Legislature in the spring of 2011, despite an earlier district court ruling that found that the cuts would irreparably harm the millions of patients who rely on Medi-Cal for health care. CMA and the other plaintiffs in the case are requesting a rehearing from the full Ninth Circuit Court of Appeals. Following the reversal, Governor Jerry Brown issued his 2013-2014 budget proposal, which includes a 10% Medi-Cal reimbursement cut, retroactive to January 1, 2013. CMA and the other plaintiffs in CMA et al. v. Douglas et al. – California Hospital Association, California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation, and American Medical Response – argue that reducing
payments in the Medi-Cal system will force providers out of the program at a time when millions of new patients will be diverted into the Medi-Cal system. If the state moves forward with these cuts, access to care will be devastated, not only for the existing Medi-Cal patients, but also the 900,000 kids moving from the Healthy Families program into Medi-Cal in 2013 and the millions of patients that will be newly eligible for Medi-Cal under the Affordable Care Act in 2014. “Cutting payment to Medi-Cal providers by 10% will have a huge impact on patient access to care,” said Paul R. Phinney, MD, CMA president. “The state is in much better fiscal shape now than when these cuts were initially proposed in 2011 and with millions of new Medi-Cal patients entering the program under the Affordable Care Act, we simply cannot continue to cut resources and expect successful implementation of health reform in California.” The lawsuit to prevent the cuts was originally filed by CMA in November 2011. (CMA Alert, January 28, 2013 issue)
HHS makes sweeping changes to HIPAA privacy and security rules The Department of Health and Human Services (HHS) Office for Civil Rights has released a final rule implementing a wide range of changes to the Health Information Portability and Accountability Act’s (HIPAA) privacy, security, enforcement, and breach notification rules. The long-awaited “omnibus” final rule is based on statutory changes mandated by the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act and the Genetic Information Nondiscrimination Act of 2008. The rule provides patients with increased protection and control of their protected health information, expands the HIPAA privacy and security requirements to business associates, and increases enforcement authority and penalties. “Much has changed in health care since HIPAA was enacted over 15 years ago,” HHS Secretary Kathleen Sebelius said in a news release coordinated with the posting of the 563-
page rule in the Federal Register. “The new rule will help protect patient privacy and safeguard patients’ health information in an ever-expanding digital age.” The rule expands individuals’ rights to receive electronic copies of their medical records and provides patients the right to instruct health care providers to restrict disclosure of information to health plans in certain circumstances for treatment that is paid for out-ofpocket and in-full. It also sets new limits on the use of patient information for marketing and fundraising purposes and prohibits the sale of health information without their permission. Additionally, the final omnibus rule clarifies when breaches of unsecured health information must be reported to HHS, makes business associates directly liable under HIPAA, and increases penalties for noncompliance to a maximum penalty of $1.5 million per violation.
30 | THE BULLETIN | JANUARY / FEBRUARY 2013
“This final omnibus rule marks the most sweeping changes to the HIPAA Privacy and Security Rules since they were first implemented,” said Leon Rodriguez, director of the Office for Civil Rights at HHS. To comply with the new rule, physician offices will need to make significant changes to their Notice of Privacy Practices, business associate agreements, as well as their privacy and security policies. The California Medical Association (CMA) will be developing and updating resources, including model agreements and policies, in the coming months to help physicians comply with the new rule. Official publication of the new rule in the Federal Register is scheduled for January 25. The final HIPAA omnibus rule is effective March 26, 2013. Covered entities, including most physicians, and business associates must comply with applicable requirements by September 23, 2013. (CMA Alert, January 28, 2013 issue)
medico news
Classifieds, from 29
Palmetto loses protest for Medicare contract
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 riflovin@allianceoccmed.com for additional information.
On January 18, the U.S. Government Accountability Office (GAO) announced that it had denied Palmetto GBA’s protest and awarded the Medicare contract for Jurisdiction E (previously referred to as J1) to Noridian Administrative Services. The Centers for Medicare & Medicare Services (CMS) first announced in September 2012 that Noridian has been named the new Medicare Administrative Contractor for Medicare Parts A and B in California, Nevada, and Hawaii, as well as the U.S. territories of American Samoa, Guam, and the Northern Mariana Islands (Jurisdiction E, previously called Jurisdiction 1). Jurisdiction E includes over 3.5 million Medicare fee-for-service beneficiaries, 500 Medicare hospitals, and 86,500 physicians. MACs process Part A and Part B claims and perform other critical Medicare operational functions, including enrolling, educating and auditing Medicare providers. Noridian and Palmetto are awaiting further direction from CMS on the transition plan, including a transition date. The California Medical Association (CMA) will work closely with the two companies to ensure a smooth transition. Until further direction is received, members should continue with business as usual. (CMA Alert, January 28, 2013 issue)
EMPLOYMENT OPPORTUNITY Physician/Locum tenens for Family/Internal Medicine. Office based practice only. Coverage mostly needed during vacation. Parttime, must have excellent communication, interpersonal and clinical skills. Please fax CV to 408/356-6676.
FOR SALE OPHTHALMOLOGY PRACTICE FOR SALE OR PARTNERSHIP Office is 11 years old. PPO, Medicare, and cash. Take over very low rate payment on office loan plus a small amount of cash. Call 408/871-6800.
MEDICAL BILLING SERVICES
California’s exchange receives approval Covered California, the state’s recently named health benefit exchange, has received conditional approval from the federal Department of Health and Human Services, according to a statement released last month. The approval, which was also granted to six other states, comes as a result of significant progress made on the part of planning entities responsible for establishing state-run or federal partner exchanges across the nation. Approval is contingent upon the states being able to meet deadlines coming before October 2014, when exchanges will begin pre-enrollment. “States across the country are working to implement the health care law and build a marketplace that works for their residents,” wrote Kathleen Sebelius, federal secretary of health and human services. “In ten months, consumers in all 50 states will have access to a new marketplace where they will be able to easily purchase affordable, high quality health insurance plans, and today’s guidance will provide the information states need to guide their continued work.” To date, a total of 20 states have received conditional approval from the federal government. While California has been a leader in implementation of the Affordable Care Act (ACA), several recent actions taken by Covered California’s Board of Directors have caused considerable concern for the California Medical Association (CMA) and the state’s physician workforce as a whole. These actions include a flawed system of monitoring network adequacy, a continued favoring of two-tiered networks, and failure to address major issues with the law’s “grace period” provision. These issues, along with several others, have been covered at length in CMA Reform Essentials, a regular publication dedicated to the ACA implementation in California. Subscription details and more information can be found at http://www.cmanet.org/cma-reform-essentials/. (CMA Alert, January 14, 2013 issue)
MEDICAL BILLER SEEKS MD CLIENTS Medical Biller for workers’ comp seeks MD clients. Contractor, carries own business insurance and tax ID. 12 years experience with treating physician reports, QMEs, AMEs, and IMEs. Based in Los Altos. References available. Contact msavitri@hotmail.com.
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Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website www.metromedicalbilling.com
JANUARY / FEBRUARY 2013 | THE BULLETIN | 31
medico news
Obama says physicians can ask patients about guns without fear of breaking the law President Barack Obama last month clarified language in the 2010 Affordable Care Act (ACA) that many health providers had taken to mean a ban on discussing gun ownership with patients. Medical groups across the nation had expressed concerns about whether they could discuss gun safety with patients because of the littlenoticed section of the ACA that prohibits the collection of gun ownership data by the Department of Health and Human Services (HHS). It also restricts wellness and disease prevention programs run by insurers from requiring the collection of data on individuals’ guns. “Doctors and other health care providers also need to be able to ask about firearms in their patients’ homes and safe storage of those firearms, especially if their patients show signs of certain mental illnesses or if they have a young child or mentally ill family member at home,”
Obama said during last month’s press conference unveiling his new gun control plan. “The Affordable Care Act does not prohibit or otherwise regulate communication between doctors and patients, including about firearms,” the president’s gun-control plan notes. Obama also ordered the HHS to “conduct or sponsor research into the causes of gun violence and the ways to prevent it.” He directed HHS to begin by identifying the most pressing research questions with the greatest potential public health impact and assessing existing public health interventions being implemented across the nation to prevent gun violence. (CMA Alert, January 28, 2013 issue)
CMS distributes $1.2 billion for EHR meaningful use in December 2012 December 2012 saw the largest national monthly payout of electronic health record (EHR) meaningful use incentives in the program’s history, this according to the Centers for Medicare & Medicaid Services (CMS). Bonuses totaling $1.2 billion were paid to eligible hospitals and physicians, bringing estimated payout to $10.3 billion for the year. Of this total, physicians’ incentive payments for Medicare were $175 million and for Medicaid, $80 million. In addition, some 2,000 eligible professionals filed
claims for EHR incentive payments on January 2, 2013. Meaningful use is the set of criteria on which physicians must report in order to receive federal incentive payments for EHR adoption. Under the Medicare EHR Incentive Program, physicians can receive incentive payments as high as $44,000; under the Medicaid program, physicians can receive up to $63,750. Meaningful use is also the necessary foundation for all impending payment changes
involving patient-centered medical homes, accountable care organizations, bundled payments, and value-based purchasing. For more information on the meaningful use bonuses, see CMA’s fact sheet, “Federal EHR Incentive Programs: Stage 2 of Meaningful Use and Changes to Stage 1,” available free to members in CMA’s online resource library, http://www.cmanet.org/resource-library. (CMA Alert, January 28, 2013 issue)
Medi-Cal primary care rate hikes delayed Medi-Cal primary care physicians will have to wait to receive the higher reimbursement rates that were set to go into effect on January 1, under the Affordable Care Act (ACA). The delay has been caused by a state health plan amendment that must receive federal approval. It is not yet known when the federal approval process will be completed, but the California Department of Health Care Services (DHCS) has said the earliest it would be able to implement the increase is summer 2013. DHCS has been unable to provide any detailed information regarding the reason for the lengthy delay. This 100% federally-funded increase was intended to recruit more physicians to treat low-income patients who will be newly eligible for health coverage under the ACA. With the increase, primary care physicians should see their reimbursement rates raised to Medicare levels in 2013 and 2014. According to the Centers for Medicare and Medicaid Services (CMS), states must also incorporate the increased payment rates into their contracts with managed care plans so that primary care 32 | THE BULLETIN | JANUARY / FEBRUARY 2013
physicians contracting with Medi-Cal managed care plans see the higher rates. California is not alone in this delay; several other states are in the same boat as well. The final federal regulations governing the two-year primary care physician rate hike were released on November 1, which did not give the state much time to write and submit the necessary plan amendments. DHCS has indicated that regardless of when it is implemented, the increase will be retroactive to January 1, 2013. However, they have been unable to tell us exactly when we can expect the rate increase and exactly how retroactive payment will function, apart from saying that physicians will not be required to resubmit claims. The California Medical Association will provide members with additional information, as it becomes available. (CMA Alert, January 14, 2013 issue)
medico news
Nine new California Medicare ACOs approved by CMS In early January, the Centers for Medicare & Medicaid Services (CMS) announced the selection of 106 new Accountable Care Organizations (ACOs) to participate in the Medicare Shared Savings Program. This includes nine new ACOs with California service areas. The new California ACOs brings the state’s total to 24. ACOs are organizations formed by groups of physicians and other health care providers who have agreed to work together to coordinate care for Medicare patients. The Medicare Shared Savings Program, and other initiatives related to ACOs, was made possible by the Affordable Care Act. The 106 ACOs announced last month bring the total number of organizations participating in Medicare shared savings initiatives to 250. According to CMS, the new ACOs include a diverse cross-section of physician practices across the country. Roughly half of all ACOs are physician-led organizations that serve fewer than 10,000 beneficiaries. Approximately 20% of ACOs include community health centers, rural health clinics, and critical access hospitals that serve low-income and rural communities.
The nine newest California ACOs include Accountable Care Clinical Services PC, San Diego Independent ACO, Affiliated Physicians IPA, Akira Health, Inc., APCN-ACO, Cedars-Sinai Accountable Care, Meritage ACO LLC, National ACO, and the UCLA Faculty Practice Group. Fifteen of the new ACOs qualified to be “Advance Payment ACOs,” a model designed especially for solo and small group physician practices or hospitals and doctors that work in remote rural areas—entities who would benefit from greater access to up front capital to invest in staff, electronic health record systems, or other infrastructure required to improve care coordination. Medicare will recoup advance payments over time through future shared savings. Golden Life, located in Sacramento, is the only California ACO participating in the Advanced Payment Model. For a list of the 106 new ACOs announced, visit https://www.cms. gov. The next application period for organizations that wish to participate in the Shared Savings Program will be this summer. More information about the Shared Savings Program is also available at https://www.cms.gov. (CMA Alert, January 28, 2013 issue)
CMA publishes updated analysis of Blue Cross Prudent Buyer Contract
CMA board chair named to exchange advisory body
The California Medical Association has published an updated analysis of the Blue Cross Prudent Buyer Contract. It is available free to members at http://www.cmanet.org/resource-library. CMA offers members free access to objective analyses of several health plan participating provider contracts. While these analyses are not intended to be exhaustive, they are designed to draw a physician’s attention to issues that may warrant further inquiry or clarification. As a reminder, CMA cannot make recommendations as to whether a physician should sign a particular contract, or whether a specific contract is good or bad. Our goal is to provide enough information for physicians to make educated decisions before signing contracts. CMA urges physicians to carefully review and understand the vast range of legal and practical implications associated with the execution of any contract for the delivery of medical services, as well as the associated management and administrative implications. For additional information on evaluating and negotiating complex managed care contracts, see CMA’s contracting toolkit, “Taking Charge: A step by step guide to evaluate and prepare for negotiations with managed care payors,” also available in the CMA resource library. (CMA Alert, January 14, 2013 issue)
California Medical Association (CMA) Board Chair, Steven Larson, MD, has been appointed to a newly formed advisory committee designed to assist in the implementation of the Affordable Care Act (ACA) in California. Dr. Larson also serves as the CEO of Riverside Medical Clinic. The Plan Management and Delivery System Reform Advisory Group is made up of members of medical groups, health insurers, and health policy organizations from across the state. The group will advise the Board of Directors of California’s newly named health insurance exchange, Covered California, on medical, technical, and financial aspects of the ACA as it is implemented in the state. The group, which held its first meeting last month, is currently tackling such subjects as the selection of qualified health plans, plan benefit designs, and delivery system reforms. It is expected to begin making recommendations to Covered California’s Board of Directors in the coming weeks. Beginning in 2014, Covered California is set to serve as the state’s online insurance marketplace, allowing consumers to compare and purchase subsidized health plans offered as part of the ACA. Implementation of the ACA, especially the design of the digital insurance marketplace, is an ongoing issue in California and across the nation, one which will continue to be followed closely by CMA’s regular health reform publication, CMA Reform Essentials. Subscription details can be found at http://www.cmanet.org/newsletters. (CMA Alert, January 28, 2013 issue) JANUARY / FEBRUARY 2013 | THE BULLETIN | 33
MEDICAL TIMES FROM THE PAST
Agnews State Hospital By Michael A. Shea, MD Leon P. Fox Medical History Committee During the Gold Rush of 1849, psychiatric patients were locked up in ships (e.g. Ephemia) that had been abandoned in San Francisco Bay. Station houses (jails) were also used to confine these patients. By 1850, the San Francisco Marine Hospital was in use for the mentally ill. As California’s population increased, the state authorized the first insane asylum to be constructed. It was built in Stockton in 1851. This was followed by Napa State Hospital in 1876. Overcrowding at these two facilities led to the decision that a third hospital was needed. In 1855, the State purchased 323 acres of land from Abram Agnew, a seed farmer, located seven miles north of San Jose. Construction began in July 1866 and on October 30, 1888, 75 patients were transferred to this facility from Napa State Hospital. The name of the Agnew facility was The California Hospital for the Chronic Insane. The following year, the hospital’s name changed to The State Insane Asylum at Agnews. (This was done in order that the hospital could accept acute, as well as chronic cases.) In 1897, the name changed, again, to Agnews State Hospital. Architect Jacob Lenzen and son, Theodore, designed the first buildings on the site. The design was based on the Kirkbride Plan. This plan was named after Dr. Kirkbride, who wanted asylums to be conducive to the humane and moral treatment. The main building consisted of a fourstory central administration section with two wings, each three stories high. In addition, a separate building housed a kitchen, bakery, laundry, carpenter shop, and a morgue. Grazing fields for dairy cattle, vegetable gardens, and fruit tree orchards filled the remaining 276 acres. Seven artesian wells supplied water for drinking and irrigation. Landscaping with shade and ornamental trees completed the project. Treatment of patients mirrored the treatment in most parts of the country. Restraints, such as straight jackets, were used at times. Morphine, tonics, and stimulants were also employed as needed. In 1890, Dr. F. W. Hatch (medical director) initiated a social program that involved live music and dancing. It was held every Friday evening with one-third of the patients allowed to attend. Guests were invited from surrounding towns. Although they were warned to be careful, Dr. Hatch told one visitor, “Do not offend the unfortunate persons you meet, and if they ask you to dance, do not refuse the request.” The inpatient population at Agnews continued to grow, and by 1906, there were over a hundred people employed and a total of 1,073 patients. April 18, 1906, at 5:12 A.M., a 7.8 – 7.9 (moment magnitude scale) earthquake struck the San Francisco Bay Area. At Agnews, the major34 | THE BULLETIN | JANUARY / FEBRUARY 2013
ity of the buildings were destroyed and 117 staff and patients lost their lives. Under the guidance of Dr. Leonard Stocking, hospital superintendent and medical director, the facility was rebuilt by 1911. It was done in the Mediterranean Revival style of tile roofs, decorative tile patterns, rustic wooden balconies, porch columns, and banisters. It was a layout resembling a college campus, consisting of two-story buildings and abundant lawns. The present clock tower building, however, copied closely the original administration and treatment building of 1888. Agnews was a small self-contained town, including a multitude of construction trade “shops,” a farm which raised pigs, chickens, and vegetable crops, a steam generating power plant for heating the buildings, a fire and police department, bakery, cannery, butcher shop, commissary, laundry, post office, and hospital. Under Dr. Stocking’s supervision, Agnews took on the characteristics of a progressive hospital as it was intended to be a “cheerful” place, with its decentralized buildings for different treatment purposes and different types of patients. He also instituted other programs for the inpatients such as civil war enactments, parades, camping excursions, and plays with patients as the actors. In 1932, an expansion of Agnews resulted in a 424-acre East Campus known as the “colony.” This would result in more buildings for patients and more land for farming. In 1966, Agnews established the first program for individuals with developmental disabilities, consisting largely of mental retardation. The first patients consisted of 534 transfers from other facilities. Due mainly to the emergence of neuro-pharmaceutical drug therapy, the 1971 Lanterman Act returned the mentally ill to the community or other facilities. In 1972, Agnews officially became The Agnews Developmental Center. Agnews now housed only patients with developmental disabilities. Activities and events such as Agnews Awareness
Agnews State Hospital (1888 time period)
Agnews State Hospital (1966 time period) Days encouraged interaction between patients and the general population. The rise of new values and programs that promoted individual growth and development, independence, and choices meant more patients could live in the community. In the mid 1990s, modern training sites were added on the smaller East Campus and the patients relocated to it. Agnews West Campus was declared surplus by the State in April 1996, and the 295-acre site was put up for sale. Community interest helped retain a 14acre portion of the property that preserved the historic core. In 1997, Sun Microsystems purchased 82.5 acres of the West Campus for its corporate headquarters and R&D campus. Sun agreed to restore four of the historic buildings (the auditorium, the clock tower, the superintendent’s villa, and the administration building), some of which would be available for public use. Local historical groups worked with Sun to establish a history museum alongside the Historical Agnews Cemetery, where 300 former residents of Agnews are buried. Sun was acquired by the Oracle Corporation in 2010; the campus continues to be used as an Oracle R&D facility and conference center. The Martinson Child Development Cen-
ter and the Emergency Housing Consortium’s Family Living Center occupy facilities on another portion of the Agnews property. The latter uses cottages that were moved from the former hospital complex. The Rivermark Planned Development Master Community stands on the remaining portion of the State surplus land. It consists of nearly 3,000 housing units, a li-
brary, shopping center, hotel, and other commercial and civic services. The last developmentally disabled patient left the East Campus on March 26, 2009. Thus ended the 121-year history of Agnews State Hospital as a treatment center for the mentally ill and the developmentally disabled.
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