2013 March/April

MARCH / APRIL 2013 | Volume 19 | Number 2

If Congress Is the Doctor, What’s Happening to Health in Washington?

PLUS: CMA Looks Ahead

Act Now to Avoid Medicare Penalties in 2015 Transitioning From Paper to Electronic Medical Records

The Supreme Court’s Decision Didn’t Change One Thing You still need to make important decisions now about rising health insurance premiums.

So what can you do?

• Enroll in a qualified High-Deductible Health Plan and open a Health Savings Account. This provides significant premium savings that can help fund your HSA account. 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 taxdeductible* basis (members age 55–64 are eligible to contribute another $1,000).

• Investigate RAF Sales Health plans offer incentives through discounts off their risk adjustment factors (RAFs) for you to change health plans. Instead of large rate increases this

year, we might be able to help you offset some of that increase.

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* Marsh and the Association/Society do not provide tax, investment or legal advice.

Please consult with your professional advisors for guidance on these issues.

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d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 • CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 2 | THE BULLETIN | MARCH / APRIL 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 Resources House of Delegates Representation

Feature Articles 8 If Congress Is the Doctor, What’s Happening to Health in Washington?

14 CMA Looks Ahead 20 Act Now to Avoid Medicare Penalties in 2015 22 Transitioning From Paper to Electronic Medical Records 28 Tips to Help Prevent an Employment Claim

Human Resources Services

Departments

Legal Services/On-Call Library

5 From the Editor’s Desk

Legislative Advocacy/MICRA

12 CMA Request for Annual Nominations

Membership Directory iAPP for

26 Volunteer to Serve on SCCMA Committees

the iPhone Physicians’ Confidential Line

30 MEDICO News

Practice Management

34 Member Benefit News

Resources and Education

36 Thank You Members of Over 30 Years!

Professional Development

42 Classified Ads

Publications

44 Medical Times From the Past

Referral Services With Membership Directory/Website Reimbursement Advocacy/

45 Save These Dates 46 CMA Webinars At-A-Glance

Coding Services Verizon Discount MARCH / APRIL 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 | MARCH / APRIL 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

Salt-Sugar-Fat!

By Joseph S. Andresen, MD Editor, The Bulletin Salt-sugar-fat! The “bliss point” is the optimum amount of sugar in a product that will give us that euphoria with each bite. “Mouth feel” is the pleasure-center rush we get when biting into a gooey, warm piece of cheese or crisp, fried chicken laden with fat. Did you know that kosher salt is shaped like a pyramid with flat sides that enable food to stick to it?

The real secret is that it is hollowed out, dissolves three times as fast as regular salt and allows more of your saliva to come in contact with it. This is what causes the “flavor burst,” that is, the intense stimulation of your taste buds that transmit sensory input directly to your brain’s pleasure center. “Crave-ability” and “allure” are favored words to describe these phenomena, while the word “addiction” is never mentioned. Pulitzer Prize winning investigative reporter Michael Moss’s new book, “Salt Sugar Fat” describes his revealing journey exploring the $1 trillion food industry through interviews with top industry executives from Kraft to Coca-Cola, as well as top industry food scientists.

A recent article entitled “The Extraordinary Science of Addictive Junk Food,” by Michael Moss, describes a meeting held on April 8, 1999, in Minneapolis. James Behnke, a

55-year-old executive at Pillsbury arranged the gathering of 11 men, who controlled America’s largest food companies including Nestle, Kraft, Nabisco, General Mills, Proctor and Gamble, Coca-Cola, and Mars. Mr. Behnke hoped the 11 executives could adopt a common goal of combating America’s growing obesity epidemic. At that time, nearly one-quarter of the adult population, a total of 40 million, were clinically obese. Unfortunately, the good intentions of the organizer were rebuffed. Yoplait, the recently introduced yogurt dessert, with twice as much sugar as General Mills Lucky Charms, had just topped $500 million in annual sales.

“Don’t talk to me about nutrition… talk to me about taste and if this stuff tastes better, don’t run around trying to sell stuff that doesn’t taste as good,” was the response by one CEO attendee.

Over the past two decades, modern medi-

cine has made tremendous advances. Likewise, so has food science. The precise ability to manipulate the key ingredients of salt, sugar, fat, that keep products flying off the shelves for leading manufacturers, is driven by ingredients that experts say are every bit addictive as some narcotics. This is fueled by Wall Street’s demand for ever higher financial returns.

In March 2013, Gitanjali Singh of Harvard School of Public Health presented a study at the New Orleans American Heart Association scientific conference. His research calculated that 180,000 obesity-related deaths from sweetened soft drinks, fruit juice, or sports beverages occurred in 2010 worldwide as a result of diabetes, cardiovascular disease, and cancer.

Americans accounted for about 25,000 of the obesity-related deaths. Middle and lower income individuals bore the brunt of these out-

Continued on page 6

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.

MARCH / APRIL 2013 | THE BULLETIN | 5

Salt-Sugar-Fat!, from page 5 food selection to reverse the growing obesity epidemic. As health professionals, we have a duty to rise to this monumental challenge so our children and our future generations will enjoy a longer life expectancy, not a shorter one ravaged by diabetes, cardiovascular disease, and cancer.

References:

comes. Another recent study from the Harvard School of Public Health attributes one in ten U.S. deaths to high sodium consumption, or one in three deaths before the age of 70. Furthermore, the burden of sodium is much higher than sugar since it is found in virtually every food product, with bread and cheese being the top two dietary contributors.

We have reached a tipping point. It is now a fact that more than onethird of U.S. adults are currently obese and this rate is predicted to rise to 42% by 2030. The public is beginning to acknowledge this epidemic with a growing demand for healthier food products. National attention brought by “Let’s Move,” with First Lady Michelle Obama and Jamie Oliver’s Food Revolution, among a growing number of mainstream media reports, are providing an opportunity for changing dietary habits.

However, targeted marketing that begins in childhood, salt-sugarfat products that are irresistibly addictive, family lifestyles that favor quick and easy convenience over home cooking, and, of course, our electronic devices that promote a sedentary lifestyle are all formidable obstacles.

What can we do as health professionals?

1. Normalize the process of obesity screening and lifestyle counseling so they are usual and expected.

2. Recognize BMI (Body Mass Index) as a fourth vital sign.

3. Utilize insurance coverage for preventative services in diabetes and obesity counseling.

4. Highlight patient incentives in reduced insurance premiums or deductibles for program enrollees.

5. Emphasize fitness, rather than dieting, as a prescription for obesity.

6. Find new resources for patients such as the pilot Wellness Club sponsored by Whole Foods in Oakland, CA, offering dietary counseling, cooking lessons, and discounts on healthy food selections.

7. Recognize new innovative tools for behavioral modification and education using web-based and social media platforms: Chrysallis, iCouch, FitOrbit, Fitocracy, and GAIN to mention just a few.

8. Join in the public health debate and support changes in legislation challenging the status quo such as New York City’s Sugary Drink Portion Rule, School Nutrition Programs, and Junk Food Laws.

It will take a concerted effort in education, lifestyle changes, and

6 | THE BULLETIN | MARCH / APRIL 2013

1. Salt Sugar Fat by Michael Moss: http://michaelmossbooks.com.

2. Why the Cheeto is the height of food engineering: http://www. thedailyshow.com/watch/tue-march-26-2013/michael-moss.

3. Jack’s Munchie Meals: http://www.latenightfoodycall.com.

4. The Extraordinary Science of Addictive Junk Food: http:// www.nytimes.com/2013/02/24/magazine/the-extraordinaryscience-of-junk-food.html?pagewanted=all&_r=0.

5. Harvard School of Public Health: Salt and Sodium: http:// www.hsph.harvard.edu/nutritionsource/salt/.

6. Worldwide sugary soft drink mortality: http://newsroom. heart.org/news/180-000-deaths-worldwide-may-be-associatedwith-sugary-soft-drinks.

7. Let’s Move: http://www.letsmove.gov.

8. Jamie Oliver’s Food Revolution: http://www.jamieoliver.com/ us/foundation/jamies-food-revolution/home.

9. How Japan’s revolutionary school lunches helped slow the rise of child obesity: http://www.washingtonpost.com/blogs/ worldviews/wp/2013/01/28/how-japans-revolutionary-schoollunches-helped-slow-the-rise-of-child-obesity/.

10. BMI as 4th Vital Sign: http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/downloads/8_ Record_Vital_Signs.pdf 11. Employer health incentives: http://www.hsph.harvard.edu/ news/magazine/winter09healthincentives/.

12. FitOrbit: http://www.fitorbit.com.

13. Chrysallis: http://blogs.rgj.com/renorebirth/2012/11/24/isreno-up-for-chrysallis-plan-to-change-the-world/.

14. Whole Foods Launches Pilot Wellness Club in Oakland Store: http://oaklandnorth.net/2011/09/22/whole-foods-launchespilot-wellness-club-in-oakland-store/.

15. National Organizations File Amicus Briefs in Support of NYC’s Sugary Drink Portion Rule: http://www.mikebloomberg. com/index.cfm?objectid=B23F5B6C-C29C-7CA2FCADAD201AE6D7FD. 16. Weight status among adolescents in states that govern competitive food nutrition content: http://www.ihrp.uic. edu/content/weight-status-among-adolescents-states-governcompetitive-food-nutrition-content.

17. State laws governing school meals and disparities in fruit/ vegetable intake: http://www.ihrp.uic.edu/content/state-lawsgoverning-school-meals-and-disparities-fruitvegetable-intake.

18. Daniel R. Taber, PhD, MPH: http://www.ihrp.uic.edu/ researcher/daniel-r-taber-phd-mph.

19. Do Junk Food Laws Curb Childhood Obesity? http://video. foxbusiness.com/v/1785595455001/do-junk-food-laws-curbchildhood-obesity/.

16th Annual California Health Care Leadership Academy

May 31 - June 2, 2013 • Planet Hollywood, Las Vegas

Welcome to the era of health reform. Increasing demand for services. Intensifying pressure for cost and quality accountability. Small practices joining larger groups seeking safe harbor. Undercapitalized medical groups sinking.

Hospitals and health plans acquiring practices in a “vertical integration” (consolidation?) of the health care market.

Can physicians control their own destiny – and the future of medical practice?

Hear from experts and leaders of change and attend a comprehensive slate of practice management seminars and workshops to position your practice for success.

Keynote: “The Future of Medical Practice” • Jeff Goldsmith, Ph.D., President, Health Futures Inc. Early-Bird and Multiple Registration Discounts Save up to $200 per person when you register before May 3!

Register at 800.795.2262 or caleadershipacademy.com MARCH / APRIL 2013 | THE BULLETIN | 7

Town Hall Meeting Summarized by Tanya Spirtos, MD

If Congress Is the Doctor, What’s Happening to Health in Washington? … the past, the present, and the future of their treatment of our profession

Elizabeth McNeil, CMA Vice-President for Federal Government Relations, spoke to a packed crowd on February 5 at the SCCMA headquarters during a Town Hall meeting. Due to her unique position, Ms. McNeil spends her days lobbying California’s senators and representatives as well as trying to educate as many others as she can about the far-reaching consequences of legislative decisions. To help her audience understand what is on the horizon for physicians, she needed to summarize the effect of the past Congress and the work facing this new group of elected officials in Washington.

Ms. McNeil began by reviewing the achievements of this 112th session of Congress. Culminating in the worst lame-duck session of any congress, it has the distinction of being the worst congress in the history of the U.S., in terms of achievements and legislative decisions: far fewer 8 | THE BULLETIN | MARCH / APRIL 2013

laws addressing problems in our country were enacted during its term.

According to Mann and Ornstein, in their book, “It’s Even Worse Than It Looks”: “We have been studying Washington for more than 40 years and have never seen them this dysfunctional.” This was an extremely unpopular group of legislators: the Gallup poll showed only 9% approval – compared to 40% for the IRS and 24% for Nixon during Watergate.

Not only was this Congress polarized with 76% of the votes party-line, but fewer public laws were enacted than ever before – and this Congress spent inordinate time and effort voting to repeal the Affordable Care Act 33 times! (without ever having a replacement strategy). Their inability to address the debt ceiling set back economic recovery within this country (measured by a dismal drop in job growth during the months of May through August) and they are responsible for the U.S. losing its credit rating. The Super Committee failed in its task and the lame-duck session resulted in: 1. Stopping the Medicare SGR cut of 26.5% for one year with a payment freeze, 2. Allowing the Bush tax cuts to expire for higher income households, 3. Adopting some spending cuts, and 4. Postponing budget sequestration cuts until March 1.

According to Ms. McNeil, this next deadline of March 1 brings 2% cuts to Medicare, while Medi-Cal is thankfully exempt by federal law.

CMA is vigorously opposing any cuts to Medicare, physician payments, and graduate medical education, as well as any cuts to public health, CDC, FDA, and NIH. Yet the biggest good news facing this Congress is that the Medicare spending growth rate (and specifically the physician spending growth rate) is the lowest in decades – to repeat the SGR now would cost Congress $138 billion vs. $238 billion one year ago!

Ms. McNeil discussed efforts that are being conducted at the AMA, with input from state and specialty societies, to formulate physician payment reform. The future of physician payments under the Medicare system (and as Medicare goes, so go the private payers) is the biggest unknown in our future: the system of paying doctors cannot, and will not, remain just the traditional fee-for-service, but no one has yet come up with an acceptable solution. “Congress is now saying: ‘Physicians, YOU develop alternative payment models and WE will eliminate the Medicare SGR’. The AMA, CMA and organized medicine are developing a transition path out of the SGR to new payment models,” and Ms. McNeil is certain that physician leaders will formulate such a unified, proactive plan later in 2013. This alternative model for physician payment reform

could/would include: 1. Physicians receiving inflation-based updates if they report on quality, e-prescribe, and adopt EHR, 2. Primary care and chronic care adjustments, and 3. Payment options based on shared savings, bundled payments for episode of care, patient-centered medical home management fee, managing risk/capitation models, as well as feefor-service. The reform would need to include patient registries, diseaserelated projects (such as cardiac or cancer), clinical variation reduction, specialty best-practice goals, as well as ACOs. Ms. McNeil outlined the joint principles inherent in payment reform (items 3 and 4). In her opinion, this Congress is giving us the unique opportunity to create physician-designed, physician-defined, and physician-led, as well as patientcentered, payment reforms with lasting impact on future physicians and the practice of medicine in the U.S. What will Congress do in 2013? The House remains in solid Republican control, with the Senate in Democratic control, under a President facing four years without an election. We can predict that the President’s Medicare plan will retain the current structure of Medicare traditional fee-for-service, as well as Medicare Advantage, with a stated preference for higher premiums for high-income seniors. He will continue to focus on ACA and delivery reform projects such as ACOs, hospital payment reforms, and the Innovation Center. His $716 billion in ACA Medicare cuts will be split: one-third to Medicare Advantage (to equalize to FFS payments, with a quality bonus), one-third to hospitals (impacting readmissions), and one-third to pharmacy (fixing the “donut hole” as well as home health, nursing home, and medical device negotiations). The much-dreaded IPAB (payment advisory board mandated to cut Medicare, if spending exceeded certain targets) has not been appointed and cuts for health care spending in the federal budget are not anticipated until 2022. While there will be no benefit cuts under Medicare, this will come with the price of higher senior premiums.

We will keep hearing about the Paul Ryan Medicare Premium Support Plan: providing seniors with a set amount ($8,000)/voucher to purchase private health insurance; while it would be risk- and income-adjusted, it would retain the current fee-for-service program, leaving seniors responsible for the balance of their care costs. Ryan predicts $700 billion in savings by changing to this defined-contribution program, but the Congressional Budget

We have been studying Washington for more than 40 years and have never seen them this dysfunctional.

Continued on page 10

Elizabeth McNeil

Elizabeth McNeil is the Vice President for Federal Government Relations at the California Medical Association overseeing all federal legislative and regulatory matters.

She has been with the CMA for nearly 20 years. Elizabeth served as the Vice President of the CMA Center for Medical Policy and Economic Services from 1997 to 2003. Prior to moving to the Policy Center, Elizabeth was one of CMA’s state legislative advocates in Sacramento for six years. Before she joined CMA, she served as a legislative aide to two Members of Congress in Washington, D.C. She is a graduate of the University of Utah and attended the Harvard Kennedy School of Government.

MARCH / APRIL 2013 | THE BULLETIN | 9

Town Hall Meeting, from page 9 Office projects that senior out-of-pocket costs would skyrocket from $6,200 to $12,500; the voucher would be indexed to GDP + 1%, not health care costs, thereby resulting in greater percentage of cost to seniors each year. The burden of collecting the portion of health care costs not covered by insurance would then fall on physician practices and hospitals – the situation in 1965 prior to passage of the Medicare Act. Whatever happens to Medicare, going forward, the CMA must ensure that reimbursement rates and premium subsidies are tied to health care cost growth and not the GDP – we have learned very painful lessons from SGR. The CMA must keep the focus on financing for graduate medical education, as there is an expected physician shortage in the decades ahead, additional residency positions are desperately needed in California (whereas a disproportionate number are funded on the East Coast), and GME financing is inextricably linked to Medicare. Also, CMA has its eye on the California Geographic Payment Locality Update (called the CA GPCI Fix): there are currently 14 counties where physicians are underpaid by 14%/year. because Medicare payment regions have not been updated since 1998. And, finally, the “My Medicare:

My Choice” private contracting- under- Medicare option remains on the table as HR 1700: patients would then be able to privately contract with physicians, Medicare would pay its portion, and physi-

PHYSICIAN PAYMENT REFORM: MEDICINE’S JOINT PRINCIPLES • Payment models must reflect the diversity in physician pracGces – by mode of pracGce, paGents, specialty, and region.

• Reward physicians for savings achieved in all parts of the Medicare Program (Part A).

• Provide exempGons and alternaGve pathways for physicians in pracGce situaGons in which making or recovering the investments in new models would consGtute a hardship.

10 | THE BULLETIN | MARCH / APRIL 2013

Terrible, Horrible, No Good, Very Bad Congress

cians could collect the balance of their charges.

Additional federal issues facing Ms. McNeil included: the J-1 visa waiver program expansion (allowing international medical graduates to stay within the U.S. after completing residency programs), dual-eligible demonstration programs (Medicare/Medi-Cal in managed-care), Medi-Cal rate increases for primary care (reimbursement raised to Medi-

care levels for 2013-2014), and palliative care end-of-life medical homes. The federal government is particularly focused on this last issue, since 30% of Medicare expenditures occur in the last year of a senior’s life and it is projected that a compassionate, coordinated care team will result in significant savings to the Medicare system. There is currently increased FDA, public and private scrutiny of prescrip-

tion drug diversion, overdose and death (witness the “Joint Forum to Promote Appropriate Prescribing and Dispensing” sponsored by the Medical Board of California and the Pharmacy Board on February 21-22). The CMA is also supporting Senator Feinstein’s Assault Weapons Ban: “The wide range of groups and individuals standing behind the Assault Weapons Ban speaks to the common-sense nature of this bill,” Feinstein said, “The American public is behind the bill, doctors are behind it, teachers, law enforcement, religious leaders, mayors – it’s time for Washington to follow suit.”

So, if Congress is playing doctor, what is happening to health? Elizabeth McNeil ended by reminding us that “Medicare, and what happens to Medicare, influences all of health care. Patients trust physicians, not government and the payers, to fix health care.”

PHYSICIAN PAYMENT REFORM: MEDICINE’S JOINT PRINCIPLES • Early Innovator Physicians • Vast majority of physicians need help moving toward value-­‐based models which promote greater accountability for quality and cost, beOer margins, professional saPsfacPon and paPent outcomes.

• Investments in physician infrastructure • PosiPve incenPves, not penalPes.

MARCH / APRIL 2013 | THE BULLETIN | 11

Request for Annual CMA Nominations

CMA’s Board of Trustees, acting as the nominating committee to the House of Delegates for appointments to CMA councils and committees, is seeking your recommendations for CMA physicians who are interested and willing to work on the projects the Association will undertake in 2013-2014. Current appointments expire at the conclusion of the CMA House of Delegates in October 2013.

Members interested in serving on any of the following CMA Standing Councils and Committees, please email SCCMA-MCMS’s Executive Director, William Parrish, at bill@sccma.org with the nominee’s experience relevant to the council or committee to which he or she is being nominated and an executive curriculum vitae (no more than five pages).

The deadline for nominations is May 10, 2013. Thank you.

Council on Ethical Affairs

To study and make recommendations concerning evolving scientific, technological, social, and philosophical trends and issues which are of immediate or long-term concern to the medical profession, with emphasis on medical ethics, bioethics, and attendant areas. The Council generally meets via conference call one to four times a year depending upon what issues are before the Council.

Council on Information Technology

To continuously evaluate and make recommendations regarding the strategic use of information technology within both CMA and the health care system. The Council generally meets via conference call one to four times a year depending upon what issues are before the Council.

Council on Judicial Affairs

The Council on Judicial Affairs functions as an appellate body for the purpose of hearing and deciding appeals of disciplinary actions taken by component medical societies. Although it has not met for several 12 | THE BULLETIN | MARCH / APRIL 2013

years, the Council is appointed to “stand by” in the event that an appeal is brought forward; consequently, the Council is convened on an “as needed” basis.

Council on Legislation

To formulate policy recommendations to the Board of Trustees regarding sponsored legislation or positions on anticipated major legislation affecting physicians. The Council generally meets once a year, in person.

Committee on Medical Services

Committee is the singular organizational entity dealing with practice issues. To investigate and make recommendations on methods by which medical services are organized, financed, and delivered in both the private and public sectors. To maintain liaison with the health insurance industry, including county, state, and federal governments, and serve as a forum for discussion and problem solving of issues of mutual concern. To influence the structure and responsiveness of private and public third‑party payment systems in providing reimbursement to physicians. To advocate on behalf of physicians and provide advice concerning the uninsured, county health care programs, the Medi-Cal and Medicare programs (including their transition to managed care), and insurance carriers. The Committee generally meets via conference one to four times a year depending upon what issues are before the Committee.

Committee on Professional Liability

To identify, review, and make appropriate policy recommendations on all issues related to physicians’ civil liability for professional conduct, including indemnification and operation of the civil liability system.

The Committee generally meets via conference call one to four times a year depending upon what issues are before the Committee.

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CMA Sets Agenda > 2013

14 | THE BULLETIN | MARCH / APRIL 2013

loo looks ook ks k s

ahead CMA sets agenda for 2013

For more than 150 years, the California Medical Association (CMA) has fought on the frontlines of nearly every major policy, political, budgetary, societal and legal campaign affecting the state’s physicians. The shared challenges facing physicians are more formidable today than ever.

As California and the rest of the nation faces a time of unique budgetary challenges and monumental change in health care, it is more critical than ever before that physicians come together with a unified voice to advocate for the profession and for the health and well being of the patients we serve.

In January 2013 the CMA Board of Trustees adopted five distinct goals for the association this year.

On the following pages are details of each of those goals.

MARCH / APRIL 2013 | THE BULLETIN | 15

Grow Membership by 5%

Commitment to Public Health CMA has a rich history and legacy of demonstrating its commitment to public health.

CMA has incorporated key public health legislation in its legislative agenda every session and has maintained a high profile on public health issues. Advancing reforms in order to benefit our patients and the public has always been a priority for the association, and continues to be at the top of our list.

In 2013, CMA will be working proactively with public health leaders to track emerging trends and to strategize solutions for continuing challenges.

CMA member physicians are our most valuable asset. Without your dues dollars, CMA wouldn’t be able to do its vital work protecting the practice of medicine and ensuring access to quality medical care for all Californians.

Over the past two decades, organized medicine nationwide has seen a gradual decline in membership, and CMA was no different. In 2011 and 2012, we reversed that trend, reaching a 20 year membership high of more than 37,000 members last year.

CMA made a significant investment in membership development in 2012, increasing data analysis and ramping up recruitment and retention efforts. These efforts, along with focused recruitment achievements in select counties, resulted in a net growth of over 2 percent for the year. It may not sound like a lot, but after years of slow decline, 2 percent growth is a significant and laudable achievement.

Our goal for 2013 is to continue the forward momentum and grow membership by 5 percent by year’s end. Increased recruitment activities in 2013 will focus on “pilot projects” with select partner counties.

16 | THE BULLETIN | MARCH / APRIL 2013

We will continue to include legislation focusing on public health in the legislative agenda this year. CMA is also exploring new ways of demonstrating its commitment to public health, including providing educational briefings to legislators on public health matters and participating in health fair-type events.

Prosperity for All Physicians At no time perhaps since the creation of Medicare has the health care delivery system seen such dramatic and rapid changes. The transformation of health care in California is largely being driven by three major developments: The rise of large medical groups, integrated delivery systems and advanced analytics, health information technology and population health management.

Health care reformrelated policy changes at the federal and state levels that emphasize care coordination, accountability and paying for “value”— efficient, high quality care.

Purchasers—private insurers in California and the nascent Covered California Health Benefit Exchange—are making it very clear that physicians and hospitals need to control costs or risk being isolated or frozen out of increasingly narrower network products.

These trends will likely accelerate as cost pressures

grow, and health reform and other private sector initiatives continue to ramp up in 2013 and beyond.

These powerful forces pose particular challenges, and opportunities, for independent physicians and medical groups interested in maintaining a degree of autonomy while market and policy forces are driving the industry towards hospital-led systems. At the end of the day, the system benefits from a diverse set of providers competing to deliver highquality, high-value care.

proven to be an effective way of limiting meritless lawsuits, but has been targeted by the trial lawyers because it restricts the amount of money they can collect in damage awards.

Defend MICRA

For more than 40 years, CMA has defended this important law in the legislature, in the courts and in the court of public opinion. We have been successful primarily due to vigilance and allocation of sufficient resources on all fronts.

This year will be no different.

Over the next year, CMA will be working feverishly to help physicians in all modes of practice to not only thrive in the rapidly changing health care marketplace, but also to lead the charge towards new patient-centric, physician-led models of care.

One of the biggest challenges for physicians now and in the future is access to capital to invest in their own practices so that they can expand into different markets, adopt new technologies and care models and maximize reimbursement.

Without capital for necessary infrastructure, physicians are unable to implement systems to help them remain competitive and independent. In contrast, hospital systems and health plans are at a strategic advantage.

CMA staff are developing three distinct proposals that represent “game-changing” strategies in support of prosperity for all physicians; 1. Study and design physician-led health care delivery models and create a CMA-sponsored backbone for independent physicians and medical groups; 2. Develop and implement a quality initiative for independent practices with the goal of reducing clinical variation; and 3. Increase physician access to financial capital.

Stay tuned for additional details as these proposed initiatives evolve over the coming months.

As we all know, the trial attorneys have sought to modify or eliminate California’s Medical Injury Compensation Reform Act (MICRA) protections since the state’s landmark medical malpractice insurance reforms were established in 1975.

Under MICRA, injured patients are fairly compensated, medical liability rates are kept in check and physicians and clinics can remain in practice treating patients. MICRA has no limits on the economic damages that can be recovered by injured patients (medical costs and lost wages). Injured patients also can sue for unlimited punitive damages and recover up to $250,000 in non-economic damages (pain and suffering). In addition, MICRA includes a sliding pay scale, which ensures that more money goes to patients, not lawyers.

The $250,000 cap on non-economic damages has

Several factors make 2013 a decisive year for defending MICRA. Both houses of the legislature contain Democratic super-majorities, traditional allies of the trial attorneys. Also, nearly half of the members of the Assembly are newly elected without a voting history.

Attorneys are utilizing new and creative arguments to challenge long-standing constitutional approval of MICRA and to move public opinion. They are attempting to use heartwrenching horror stories placed with compliant media outlets in order to defeat MICRA. CMA in 2013 will focus on educating new members of the legislature on the importance of MICRA for their constituents and the role MICRA plays in patient protection and access to care. CMA’s government relations team will also be ready to jump into action at a moment’s notice should the trial attorneys try and utilize a late “gut and amend” to push an anti-MIRCRA bill through the legislature, as they did at the end of last session.

MARCH / APRIL 2013 | THE BULLETIN | 17

As always, CMA’s political action committee (CALPAC) will remain involved in the fight, amassing the financial resources that will be needed should a costly MICRA challenge emerge this session.

CMA’s legal team also continues to aggressively monitor court activity and seek out opportunities to provide guidance to courts when they are asked by plaintiff attorneys to weaken or eliminate MICRA.

Lead Change in Health Care Reform In 2010, Congress passed historic sweeping health care legislation, the Patient Protection and Affordable Care Act (ACA), which reformed the for-profit health insurance industry and beginning in 2014 will provide health insurance to most of the nation’s uninsured. The ACA also formed the CMS Innovation Center to fund myriad pilot programs to test new health care delivery and payment models.

Under the ACA, two thirds of California’s uninsured will be covered by private insurance through a health insurance exchange purchasing pool.

The remaining uninsured will be covered through a massive expansion of the Medicaid program.

Together We Are Stronger The shared challenges facing those who practice medicine may never have been more formidable than today. In this uniquely turbulent political and fiscal environment, we have redoubled our efforts to provide the support and services physicians need to be able to focus on their jobs and bring good health and happiness to the lives of millions of Californians.

Changes are coming – and CMA is poised and ready to meet the demands of the future.

CMA in 2013 will continue to monitor implementation of the ACA in California, ensuring that health care reform works for physicians and their patients. Specifically, CMA will remain engaged as Covered California, the state’s health benefit exchange, prepares to open for business. The exchange’s goal is to start pre-enrollment in October 2013. Critical federal regulations and guidance, however, still must be finalized and released.

Among the critical issues still needing to be hammered out before the exchange opens for business are: the state’s plan for monitoring and enforcing network adequacy requirements; the reconciliation of major discrepancies between state and federal grace period guidelines for premium nonpayment; and how exchange plans will handle the subject of out-of-network benefits.

While the pre-enrollment date is only months away, exchange leadership has yet to select which plans will offer products on the new marketplace, meaning that benefit design, contracting and enrollment policies will need to be developed at a breakneck pace.

CMA will also be working to make sure that physicians understand the implication of contracting with exchange plans and to ensure that doing so places minimal administrative burdens on physicians.

18 | THE BULLETIN | MARCH / APRIL 2013

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ver the past six years, the Centers for Medicare and Medicaid Services (CMS) has launched a number of initiatives that offer physicians the opportunity to increase their net revenue by participating in quality reporting programs. Until now, these programs have been voluntary and physicians have received bonuses for participating. That’s about to change. Failure to participate now means physicians could face significant penalties.

The American Academy of Family Physicians estimates that participating in these initiatives in 2013, rather than waiting until 2014, could save a physician $19,000 in avoided penalties.

To help physicians understand the bonuses and penalties associated with key Medicare initiatives, the California Medical Association (CMA) recently hosted a webinar for members, “Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties.” The webinar is now available for on-demand viewing in the CMA resource library at www.cmanet.org/webinars.

During the webinar, CMS Region 9 Chief Medical Officer, Betsy L. Thompson, M.D., discusses the major quality reporting and e-health incentive programs currently underway for eligible professionals. The session covers the basics of the Physician Quality Reporting System, the Medicare and Medicaid Electronic Health Records Incentive Programs, the Medicare EPrescribing Incentive Program and the new value-based payment modifier. The content is geared toward physicians, nurse practitioners, and physician assistants and what they need to

know, although other health care professionals and medical offices may find the information useful, as well.

If you are not already familiar with each of these programs, the time to learn about them is now.

Below is a brief summary of the programs and key dates that were discussed in the CMA webinar.

Meaningful Use

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 and Medicaid Electronic Health Records (EHR) Incentive Programs. 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.

Bonuses: For the Medicare EHR incentive program, your cumulative payment amount depends on the first year of participation. Physicians who start participating in 2013 can receive up to $39,000; physicians who start in 2014, up to $24,000. The last year to begin participation in the Medicare EHR incentive program is 2014. For the Medicaid (Medi-Cal) incentive program, physicians can receive up to $63,750.

Penalties: Physicians who do not demonstrate meaningful use by 2015 will be subject to Medicare payment penalties. These reductions increase from 1%-2% percent of total Medicare charges in 2015, to 2% in 2016, and 3%-5% percent in 2017, and beyond. Medicaid rates will not be adjusted for failure to achieve meaningful use.

Electronic Prescribing

Medicare’s e-prescribing program provides incentive payments for physicians who eprescribe and payment penalties for physicians who do not.

Bonuses: This year is the last year to receive a bonus for e-prescribing.To qualify for the 0.5% bonus in 2013, you must have successfully reported e-prescribing activity for at least 25 patient visits between January 1 and December 31, 2012.

Penalties: Starting in 2012, physicians who did not electronically transmit their prescriptions became subject to payment penalties on all Medicare-allowed charges. The penalty in 2013 is 1.5%, and in 2014, 2%.

Physician Quality Reporting System

The Physician Quality Reporting System

(PQRS) is a voluntary quality reporting program that provides incentive payments to eligible professionals who report data on quality measures for services provided to Medicare beneficiaries.

Bonuses: Physicians must report on three individual measures or one measures group to receive a 0.5% bonus. Physicians participating in a maintenance-of-certification program are eligible for an extra 0.5% bonus, for a total bonus of 1%.

Penalties: The Affordable Care Act calls for PQRS payment penalties starting in 2015.

In the 2012 Medicare Physician Fee Schedule, CMS announced that 2015 program penalties will be based on 2013 performance. Therefore, physicians who do not successfully report on at least one individual measure in 2013, or elect to participate in the administrative claims reporting option, will receive a 1.5% payment penalty in 2015. The penalty goes up to 2% in 2016, and beyond.

Value-Based Payment Modifier Program

The value-based payment modifier was mandated by Congress under the Affordable Care Act. It will adjust physician payment based on the quality and cost of the care they

provide. It will take effect in 2015, using 2013 data for groups of 100 or more physicians. By 2017, this modifier will be implemented for all physicians.

Bonuses: Participating physicians may receive bonuses based on their quality and cost scores.

Penalties: Participating physicians may be penalized up to 1% based on their quality and cost scores. Physicians who choose not to participate will be docked 1%.

Each of these programs has specific deadlines and reporting requirements, some of which are overlapping, and are not always simple to understand. CMA’s webinar will give physicians the information they need to successfully participate in each program. During the webinar, Dr. Thompson will help participants understand which programs they are eligible for, the associated incentives and penalties for each program, and the deadlines and requirements for participation.

The on-demand webinar is available free to CMA members at www.cmanet.org/webinars. Nonmembers can purchase the webinar for $99.

Contact: CMA’s member service center, 800/786-4262 or memberservice@cmanet.org.

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Managing Professional Risk

Transitioning From Paper to Electronic Health Records

By Mary-Lynn Ryan, Consulting Risk Management Specialist, NORCAL Mutual,

and Karen K. Davis, Project Manager, Risk Management, NORCAL Group Electronic health records (EHRs) hold promise for improving patient safety and decreasing medical liability exposure; however, EHRs are not error-proof, and no one can become a successful EHR user overnight. Implementation of an EHR system has many stages, including choosing a system, transitioning to its use, and then dealing with the ongoing issues that arise as technology and medical knowledge advance.

The two case studies in this article illustrate potential risks associated with the transition phase. Both cases involve a missed diagnosis that occurred while paper records and EHRs were in use (that is, while a “hybrid” medical record system — a system using both paper and electronic medical records — was in use). Diagnostic delay has been identified as a prevalent problem when transition involves a hybrid medical record system;1 yet, practices that make a clean break from paper records to EHRs also must be prepared to handle safety and liability risks that arise during transition.

Case 1

In February 2008, a group of family physicians (FPs) installed an EHR system and began the process of transitioning from paper to electronic records. The office manager had a plan that she felt was appropriate. First, all of the pre-2008 records were moved to a storage space. All of the files to be shredded (the files of adult patients who had not been seen in the office within the past seven years) were separated and piled on the far right side of the storage space. The plan was to: • hire a company to go to the storage space and shred the inactive patient records; • input the records of current (2008) patients immediately into the EHR system; • input active patient records from 2001-forward into the EHR system, as resources permitted; and • exclusively use the new EHR system for office visits starting on the “go-live” date of April 20, 2008.

After the plan was approved by the practice’s CEO, the office manager called the shredding company and directed the shredding of the records in the piles on the right side of the storage space (the inactive patient files). Unfortunately, all of the records in the storage space were shredded. Consequently, the practice group was left with less than five months of patient history. Although the transition plan called for an end to recording patient information on paper after April 20, physicians having difficulty adjusting to the EHR system were allowed to continue recording patient information on paper. In some instances, physicians would take notes on paper, later input information into the EHRs, and 22 | THE BULLETIN | MARCH / APRIL 2013

then put the notes in a box of records designated for shredding. In other cases, physicians gave their handwritten notes to the administrative staff for data entry assistance. Some of these notes were then filed away for data entry at a later time. During this period, therefore, both electronic and paper records were maintained for some patients, including the patient in this case.

Six years earlier, a 40-year-old male patient had presented to the practice complaining of headaches and dizziness. Over the intervening years, he was treated by various FPs in the group for headaches and a variety of other chronic conditions. Because his headaches were becoming increasingly severe, and he felt his treatment at the practice was not effective, he self-referred to a neurologist at a different practice in May 2008. A head CT scan ordered by the neurologist showed a brain mass.

The neurologist did not contact the patient’s FP and did not telephone the patient with the results — he wanted to discuss the findings personally at the patient’s next appointment, and he thought contacting the patient’s FP was unnecessary because the patient had self-referred. A week following the CT scan, the patient’s wife contacted the neurologist’s office. She was told by a member of the staff that the scan was normal. The patient later canceled his upcoming appointment, believing the normal result indicated it was no longer necessary to treat with the neurologist. The neurologist never followed up; therefore, the patient was not informed that he had a brain mass.

Starting in August 2008, the patient began to present to the family medicine practice on an almost bimonthly basis. His FPs believed the patient’s symptoms were caused by depression and anxiety, and they treated him accordingly. On July 10, 2009, the patient lost consciousness at home and was transported to the emergency department. A head CT scan showed a large intracerebral lesion with diffuse edema in the same location as the tumor discovered in 2008. The tumor had increased in size. A resection of the tumor was attempted, but could not be completed. The patient sustained permanent neurologic sequelae including severe motor function impairment and aphasia.

The patient’s wife filed a medical liability lawsuit against the family physicians and the neurologist, alleging delay in diagnosis and treatment. The neurologist settled for a significant amount during the early stages of the case. The case went forward against the FPs and their practice.

Discussion One problem in this case was the inadvertent destruction of the patient’s pre-2008 records, and another problem was the inability of the existing records to give a clear picture of the patient’s care. For example, the group’s electronic record indicated that the patient had complained of symptoms consistent with a brain tumor — severe headaches, dizziness, mental changes, blurry vision. However, nothing in the EHR indicated that the symptoms had been addressed. The FPs could not fully explain why brain tumor was not in the differential diagnosis, but the

assumption was that a hybrid system had been in use and that information missing from the EHR may have existed in paper form. Unfortunately, no one could find the missing information because it had either been shredded or misplaced.

The printed version of the EHR was substandard.

The record printed out with the initials of the last person who viewed the record in the system, rather than the health care professional who had originally initialed the report. Also, the EHR system had a “pullbackward� feature that inserted vital signs and lab results from 2009 into the 2008 chart entries. This made it impossible to tell who had treated the patient and what his lab values were. Thus, a poorly chosen EHR system and inadequate training had resulted in a misleading printed record. The multiple problems with the record, as well as the impression it gave of poor treatment, prompted settlement of the case.

Many health care organizations have some degree of hybridization resulting from their paper-to-EHR implementation plan. As this case shows, maintaining both types of records, particularly when not well managed, can increase the risk of patient injury and malpractice liability exposure.2 Practices with a hybrid health record may benefit from keeping a chart posted that describes the location of specific document types.

An example of such a chart can be found on the American Health Information Management Association

Continued on page 24

MARCH / APRIL 2013 | THE BULLETIN | 23

Transitioning From Paper to Electronic Health Records, from page 23 (AHIMA) website at: http://library.ahima.org/xpedio/groups/public/ documents/ahima/bok1_048419.hcsp?dDocName=bok1_048419.

Case 2

This case study is based on a medical malpractice case that was tried in the federal court system.3 It shows that inadequate office follow-up systems can cause essential patient studies to “fall through the cracks,” leading to delayed diagnoses.

A hospital network had installed an EHR system in all of its hospitals and clinics. A radiology practice in this network was in the process of transitioning from its multi-part paper reporting system to the network-wide EHR system. A transition protocol had been put in place that required radiologists to immediately telephone the requesting physician as the primary method of reporting abnormal results. Three additional safety measures were built into the EHR system to protect against abnormal results being lost or overlooked. They were: 1. All radiology test results coded as “abnormal” triggered an automatically generated e-mail message to the requesting physician advising about abnormal test results that needed attention.

2. Abnormal results triggered a general notification of pending test results that appeared whenever the requesting physician logged on to his or her computer.

3. The system generated an abnormal test result report that was automatically printed daily in the requesting physician’s clinic.

The hospital network was undertaking what is referred to as a “staged” roll-out of its EHRs. In other words, departments and clinics were converting to EHRs at different times. When the patient in this case was treated, the radiology department had been trained on the EHR system and was using it, but the family practice clinics in the network had not yet started EHR training.

A patient presented to the radiology department for a screening mammogram ordered by her FP. The mammography staff told her that the results would be sent to her FP, and that she could assume the results were normal if she did not hear anything within three to four days. The patient’s mammogram showed a 1.5 x 1.2 cm nodular density with irregular borders in the right breast. The radiologist recommended needle localization and biopsy. His report was transcribed into the network’s new EHR system.

On the same day, per protocol, the radiologist called the FP’s office to report the patient’s abnormal mammography results. Because the FP was out of the office, the radiologist told the staff person who answered the telephone to have the FP telephone him and to expect the mammography report on the EHR system. The FP never returned the call, and the radiologist never followed up. The radiologist assumed that the FP was using the EHR system, and that he would, therefore, be informed of the result by e-mail, computer notifications, and the printout. Consequently, he did not consider additional follow-up a priority. Unfortunately, the FP was not yet using the EHR system. Furthermore, the report was not printed because of an EHR malfunction. Consequently, the FP was not made aware of the abnormal results.

Meanwhile, the patient, who did not hear further about her mammogram, assumed it was normal. Five months later, while doing a selfexamination, she discovered a lump. She made an appointment with her FP. At that appointment the FP realized that he had not seen the results of the patient’s most recent mammogram. He was surprised when he found the abnormal mammogram report in the EHR system. The FP 24 | THE BULLETIN | MARCH / APRIL 2013

ordered another mammogram, which again identified the suspicious lesion, now almost double in size. The patient was ultimately diagnosed with infiltrating carcinoma of ductal origin. She had a lumpectomy and axillary nodes removed. Of the twelve lymph nodes removed, four were positive for metastatic disease.

Discussion The patient filed a medical liability lawsuit, alleging delayed diagnosis of breast cancer. She argued that, during the EHR transition period, the hospital network failed to have a procedure in place that ensured that physicians ordering radiological reports would receive the results in a timely manner. The hospital network eventually prevailed in this lawsuit, but not until after significant effort and expense had been expended in its defense.

This case illustrates how a seemingly well-thought-out transition protocol may not be fail-safe. When transitioning from a paper to an EHR system, it is important to have carefully crafted policies and protocols in place that are designed to minimize patient safety risks. [Note: this case study derives from a 2000 federal court case. When the treatment took place, the Mammography Quality Standards Act (42 U.S.C. § 263b), which requires direct patient notification for mammography results, had not yet been passed into law. Today, a mammography patient is not told to assume results are normal if she is not notified. Although other radiological tests do not require direct patient notification, it is good risk management practice to do so.]

A Sample Checklist for EHR Transition

The unique needs of each practice make planning and research critical to the successful conversion from paper to electronic records. Using tools such as checklists and grids can help provide structure during this complex process. The following checklist is a sample of a planning tool a practice can use to begin tackling the transition to EHRs. This list is not meant to be all-inclusive; it is a place to start and should be customized to apply to your practice.4,5,6

Create a Transition Team to Guide the EHR Implementation Process • Identify a “physician champion” who has strong rapport with the administrative and clinical staff and can communicate transition goals while generating excitement about the process and outcome.

• Identify a team manager who will oversee the transition team and keep the process moving forward.

• Have the team manager and physician champion form committees to create policies and procedures to manage and review the EHR implementation from start to finish. ȧȧ Address individual responsibilities. ȧȧ Create an action plan that includes definitive dates for implementation milestones and “go-live” dates. ȧȧ Plan activities to obtain and maintain buy-in from the EHR end-users (for example, give demonstrations of the EHR system and send out update notices that give information about implementation milestones). ȧȧ Assign designated “IT champions” — practice personnel whom team members can contact to bring up their concerns and questions. These champions can then relay new and unresolved issues back to EHR technical support

people for assistance in finding appropriate solutions.

Complete a Workflow Analysis to Ensure Successful Adoption of EHRs • Determine how the transition to EHRs will affect work flow in both the administrative and clinical environment by visualizing and diagraming each step of office transactions. ȧȧ Continuously ask “What if?” to facilitate the discovery of important work flow issues during the planning stage. ȧȧ Identify any barriers to the optimal use of EHRs (for example, length of office visits, computer terminal placement, lack of physician buy-in). ȧȧ Consider assigning a “scribe” to a physician who either cannot or will not use an EHR system.

• Determine whether conversion to EHRs will be centralized (using a designated team of scanners/data entry people) or decentralized (using staff at multiple locations throughout the practice). ȧȧ Use a sufficient number of appropriately trained individuals.

• Determine when historical records will be entered into the system (for example, some practices enter information patientby-patient, prior to their appointments; other practices convert all records at once). ȧȧ If some offices/departments in your network will use paper records during a staged roll-out, determine how these offices/departments will access information entered into the EHRs during the time they are still using paper.

• Determine how paper records from outside the practice/facility will be entered into the EHRs after the go-live date.

• Ensure that transition information will be adequately communicated to any health care professional who treats patients at your facility or refers patients to your facility.

• Determine how long the paper records will be available after the transition period. ȧȧ Retain records for the number of years required by law if portions of the paper record have not been converted to EHRs. ȧȧ Clearly communicate a paper-record destruction plan and timeline throughout the practice.

Choose What Information to Include in EHRs • Determine which historical patient information will be transitioned to the EHRs. ȧȧ Balance work flow demands with patient safety — scanning too much can overwhelm resources, while failing to scan crucial information can increase patient injury and liability risks. ȧȧ Decide which information will be scanned and which will be entered as data.

■■ Keep in mind that leaving particular patient information out of EHRs is a clinical decision that should be evaluated by someone with clinical decisionmaking capacity.

■■ Use data entry for information that needs to be crossreferenced in the clinical decision support system (for example, for inserting patient allergies into each EHR).

• Provide an environment where all physicians and staff feel comfortable with requesting assistance.

• Have a technical support person from the vendor on-site when the practice goes live.

Establish EHR Policies and Procedures • Develop standard procedures for EHR correction, amendment, validation, and completion of documentation (e.g., how will a supervising physician know that he or she needs to sign a treatment plan and how will the system notify the involved providers that the record is complete?).

• Define access restrictions — who will be able to view what information in the EHR? • Develop printing policies — who can print records from the system and under what circumstances may they be printed?

• Establish a policy that no one may write patient information on printed records from the EHR system or in an old paper chart after the go-live date.

• Create appropriate back-up procedures and test them — don’t wait until the system crashes to test the back-up system!

Conclusion

The transition from paper to electronic records is complex and exposes a transitioning practice to unique patient safety and liability risks.

The checklist for each practice’s transition to an EHR system will vary.

However, focus should never stray from ensuring that the quality and integrity of health records remain intact during the transition process.

There is no standard approach for solving the issues that may affect the transition, but physicians, staff, and institutions have a duty to make this process as safe as possible. Transition policies, protocols, checklists, and work flow analyses can help a practice make the change from a paper to a full-functioning electronic system in the safest and most efficient manner possible.

References

1. Mangalmurti SS, Murtagh L, Mello MM. Medical malpractice liability in the age of electronic health records. New England Journal of Medicine. 2010;363(21):2060-2067.

2. AHIMA. Managing the Transition From Paper to EHRs. Available at: http://library.ahima.org/xpedio/ groups/public/documents/ahima/bok1_048418. hcsp?dDocName=bok1_048418.

3. Smith v. United States of America. 119 F. Supp. 2d 561 (DSC 2000).

4. AHIMA. Migrating From Paper to EHRs in Physician Practices. Available at: http://library.ahima.org/xpedio/ groups/public/documents/ahima/bok1_048372. hcsp?dDocName=bok1_048372.

5. Notte C, Skolnick N. Teamwork is key to a successful transition. BNet Health Publications. Available at: http:// findarticles.com/p/articles/mi_hb4365/is_12_43/ai_ n55113546/.

6. Goldberg DG, Kuzel AJ, Geng LB, et al. EHRs in primary care practices: benefits, challenges, and successful strategies.

American Journal of Managed Care. 2012:18(2):e48-e54.

Provide Adequate Training and Technical Support • Plan for appropriate training for all staff; as training continues, conduct audits and follow up on identified weaknesses by providing additional training.

MARCH / APRIL 2013 | THE BULLETIN | 25

700 Empey Way, San Jose, CA 95128 (408) 998-­‐8850 FAX (408) 289-­‐1064

2013-2014 SCCMA COMMITTEE RESPONSE FORM

Listed below are the current SCCMA committees—all meet at the Medical Association building. Omitted are those where membership is by election (e.g., Council and Executive Committee), bylaw consideration, and/or existing protocol (e.g., Awards, Membership, Physicians’ Well-Being, and Professional Standards/Conduct).

SCCMA committees help recommend policies for the Association, standards for practice in Santa Clara County, and aid in the development of important relationships with governmental and public service organizations. Committee service commences on July 1, 2013. The majority of the committees will not meet during July and August, however.

In accordance with SCCMA bylaws, committee appointments are made each year by the President and state that, “The terms of office of the chairs and members of all committees shall be at the discretion of the President, and, in any event, shall end with the term of office of the President by whom they were appointed…” Therefore, the terms of fiscal 12-13 committee members and chairs, having been appointed

by Rives Chalmers, MD, will officially end with his term of office — June 30, 2013.

Name:

(Please Print)

Specialty:

Phone:

Fax:

Members currently serving, who seek reappointment, are also asked to return this form.

❏

Bioethics (4 times a year, dinner) To educate its committee members regarding bioethical decision making and to discuss bioethical issues and cases.

❏ ❏ ❏

Environmental Health (Bi-monthly, dinner) To study and address environmental and occupational health concerns.

External Affairs To review and influence legislation and regulations relating to the delivery of medical care and public health.

Leon P. Fox Medical History (Bi-monthly, 3rd Thursday, dinner) To identify, collect, and preserve archival material, memorabilia, and artifacts representing the medical history of Santa Clara County.

26 | THE BULLETIN | MARCH / APRIL 2013

❏

❏ ❏

Medical Review Advisory (Monthly, 3rd Thursday, dinner) To serve as a consultant to the attorneys for professional liability carriers by providing review and advice on malpractice claims.

High School Outreach Program (Yearly) To speak about your specialty before local high school students at the annual program, which is designed to pique the students’ interest in becoming a physician in our community.

Medical Student Mentor Program (Yearly) To volunteer as a mentor to a Stanford medical student. Students can “shadow” practicing physicians to learn about their specialties and modes of practice.

FAX form to 408/289-1064 or mail to SCCMA by 7/15/13.

06/12

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• Dementia Therapeutics focuses on more than just memory. The program targets the five primary cognitive domains: executive functioning, attention, language, visual-spacial perception in addition to memory. Interventionists also teach and promote lifestyle changes to positively influence the aging process and overall health.

• Dementia Therapeutics provides consistent care. Consistent participation in the program over time is key. Since our program is designed and led by experts, we are able to provide consistent, continuous care that meets the evolving needs of the client.

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650-213-8585

www.DementiaTherapeutics.com MARCH / APRIL 2013 | THE BULLETIN | 27

insurance tips

Tips to Help Prevent an Employment Claim*

By Roy S. Lyons, Managing Director, Marsh Let’s face it. A current, former, or prospective employee can sue you at any time.

And whether the claim is frivolous or not, it could cost your practice tens of thousands of dollars to defend. Although you can’t control whether an employment-related lawsuit happens, you can help minimize the risk.

These tips will help you find potential risks within the management of your workplace. Once you know what your exposures are, you can take measures to reduce your risk of an employment-related claim.

Do you have an employee handbook in place and does each employee have a copy of it?

A written document, such as an employee handbook, helps define the workplace environment, including hours of operation, dress code, holidays, employee benefits, safety procedures, and policies. Should an employee sue you, the court takes into consideration any written documentation in place. For example, what if a female employee sues you because she believes your hours of operation discriminate against her because she has children she needs to pick up from school before the end of the work day? Having a written document of expected hours of operation would minimize this potential claim situation. Employers should retain copy of employee’s acknowledgment of receipt of employee handbook.

Do you have any antiharassment/ discrimination policy in place and are all employees aware of it?

Having a strong antiharassment/discrimination and compliance procedure in place provides documentation of appropriate and inappropriate behavior in your work environment. With a written policy, your practice is also armed with an important affirmative defense, which may actually bar an employee’s lawsuit if the employee did not use the internal complaint procedures.

Do you have formal training in employment practices?

Most physicians go to medical school to become a doctor, not to manage employees. Most are not trained in employment practices.

Without formal training on what is appropriate and what is not, it leaves you at risk of potentially making a mistake with an employee, resulting in a claim. Training on basic Equal Opportunity (EEO) compliance principles can reduce this risk.

Do you have written employee job descriptions?

Each employee should have a clearly defined job description. With-

28 | THE BULLETIN | MARCH / APRIL 2013

out a written description, it leaves your practice exposed to a potential lawsuit if you decide to terminate an employee for failing to do his/her job and clear documentation on what the job actually entailed is not available. Job descriptions should be reviewed by a lawyer every two years.

Do you document all hiring, promotional, disciplinary, and discharge decisions?

The more frequently you make employee “moves,” the more likely the affected employees may feel discriminated against. They say, “A picture is worth a thousand words,” and so too is it critical to have documentation that shows an employer’s thought process for any employment decision. The importance of documentation cannot be understated.

Do you have written interview questions and other hiring procedures in place?

By having written interview questions, applications, and other hiring materials in place, it reduces your risk of potentially discriminating against a prospective employee. For example, if you don’t have written interview questions and just ask questions off the cuff, you’re more likely to ask a question that could be considered discriminatory, such as “Are you planning to have children?” or “Are you married?,” etc.

Have you reviewed your employment application?

Ensure that your employment application is legally sound and adequately protects your interests. Review your company’s employment application to see that it contains no improper questions (especially in light of the Americans with Disabilities Act (ADA) as well as other federal, state, and local employment discrimination laws) and includes all the necessary legal protection.

Do you have written training procedures or manuals in place for new hires?

A written list and training on essential job functions is important for all new hires. Without such written criteria, your practice may be exposed when an employee’s performance is called into question.

Do you perform background and reference checks on all employees?

If so, do you base hiring decisions on them?

Although background and reference checks are typically part of most job situations, it’s important that best management practices are followed when conducting them. Depending on the job responsibilities and what is discovered during the background check, you may not be able to use the information with respect to your hiring decision. For example, if you discover a prospective employee has a misdemeanor con-

viction from years back, depending on the nature of the offense and the type of position you are filling, you may not be able to use this information in the hiring decision.

Do you provide accurate written evaluations to employees on a standard basis?

Providing accurate written evaluations of employees on a regular basis is an important resource for demonstrating an employee’s job performance and behavior. This will help reduce your risk in “failure to promote” or “wrongful termination” situations.

Do you provide written offers of employment to prospective new hires?

It’s important to provide a written offer of employment to your prospective new hire that includes salary, title, reporting, and other general job duties. Having a clearly written document alleviates any misunderstanding about the core elements of the individual’s employment. Employers should be sure to include a statement in the written offer stating that the offer does not create a contract of employment, and that the employee’s employment will be at will.

Do you send written letters to all rejected applicants informing them of your decision not to hire them?

Sending a written letter of “rejection” to all applicants that provides

a simple explanation of why you hired someone else — for example, “we’ve found a more qualified candidate” — helps minimize the risk of applicants suing you. It’s also a best practice to inform candidates so they do not have “false hopes” or are not waiting on your decision as they consider other possibilities.

Do you have Employment Practices Liability Insurance?

Employment Practices Liability Insurance (EPLI) specifically protects your practice against employment-related lawsuits including discrimination, harassment, slander, defamation, failure to promote, among others. Most general and professional liability policies exclude employment practices from their policies. A good EPLI policy should have broad coverage, be price-competitive, include front-loaded claims handling, and include risk management tools such as training, a toll-free help line staffed by employment attorneys and sample employment policies. The Santa Clara County Medical Association- and Monterey County Medical Society-sponsored EPLI policy includes all of these benefits.

For information on how to protect your practice with Employment Practices Liability Insurance, call Marsh at 800/842-3761, email CMACounty.Insurance@marsh.com, or visit www.CountyCMAMemberInsurance.com. *Marsh and the Association/Society do not provide legal advice.

Please consult with your personal legal counsel on any of these issues.

MARCH / APRIL 2013 | THE BULLETIN | 29

medico news

CMA announces 2013-14 sponsored legislation The California Medical Association (CMA) has placed its legislative focus for 2013 on increasing the numbers of physicians in the state and fighting the proposed 10% Medi-Cal provider rate reduction. These are the bills CMA will sponsor for 2013-14: UC Riverside Medical School (SB 21 and AB 27) – These bills would provide $15 million a year in funding for the recently accredited University of California Riverside School of Medicine. According to a 2010 report by the California Health Care Foundation, the Inland Empire has the lowest ratio of primary care physicians and specialists of any region in the state, with barely half of the recommended number.

The UC Riverside School of Medicine is the first UC medical school accredited since the 1960s.

GME Funding (SB 488) – This bill would augment the amount of graduate medical education (GME) funding that California receives in order to increase the number of resident physicians in California.

Medi-Cal Cuts (SB 640) – This bill is the vehicle for a proposed rollback of the 10% Medi-Cal provider rate reduction contained in the 2011-12 state budget. CMA is building a coalition of different providers who have been impacted by the cuts or who, like CMA, are still in court over their implementation. This bill would both eliminate the retroactive cuts, as well as stop them going forward, helping to provide needed stability to the Medi-Cal system as the state prepares for full federal health

reform implementation in 2014.

Therapeutic Substance (AB 670) – This bill would close a loophole in the law that lets pharmacists receive financial incentives each time they recommend a therapeutic switch (a chemically different drug) from the drug prescribed by the physician.

Physician Workforce: Medically-Underserved Communities (AB 1288) – This bill will serve to create additional residency slots across California and develop a stronger pipeline for physicians to serve in California’s medically-underserved communities.

Employment of Physical Therapists (AB 1003) – Since 1990, the Physical Therapy Board of California has explicitly allowed physical therapy services to be provided by medical corporations. In 2010, the board rescinded this policy, threatening to disrupt the lives of hundreds of physical therapists who work for medical corporations, hospitals, home health care services, and nursing care facilities. This bill will clarify existing law to explicitly authorize medical corporations to hire persons licensed under the Business and Professions Code, the Chiropractic Act, or the Osteopathic Act. For more information on these and other bills of interest to physicians, subscribe to CMA’s Legislative Hot List at www.cmanet.org/newsletters.

(CMA Alert, March 25, 2013 issue)

CMA tells court juries must consider amounts paid when calculating economic damage awards In response to an invitation from the California Court of Appeals, the California Medical Association (CMA), together with the California Hospital Association and the California Dental Association, recently filed an amicus letter brief regarding evidence that is admissible in court for determining future medical damages and noneconomic damages.

The court solicited input on the following issue: “To what extent, if at all, evidence of the amount billed for medical expenses is admissible and relevant to the issues of future medical expenses and/or noneconomic damages.”

These specific issues were left unresolved by the California Supreme Court’s 2011 decision in Howell v. Hamilton Meats, where the court held that an injured person can only recover reasonable amounts actually paid or incurred 30 | THE BULLETIN | MARCH / APRIL 2013

for past medical care, not undiscounted provider bills that were never paid by or on behalf of the injured person.

The trial attorneys are arguing that the jury for the purposes of determining damages for future medical expenses should hear evidence about the reasonable value of and/or the amounts billed for past medical services, not the amounts actually paid. In other words, the trial attorneys want to limit the Supreme Court’s opinion in Howell v. Hamilton Meats solely to past medical expense damages.

CMA told the court in this case, Corenbaum v. Lampkin, that in determining the reasonable cost of future medical expenses, the jury may consider how much medical expenses plaintiffs actually incurred in the past for medical care. However, evidence of the amount that

plaintiffs were billed in the past for medical care is not relevant to determining what medical expenses plaintiffs will incur in the future.

CMA also told the court that to award compensation for noneconomic damages, juries should be instructed that the amount plaintiffs’ were billed in the past for medical care cannot be used to calculate the plaintiffs noneconomic damages. The brief went on to explain that there is no fixed standard for deciding the amount of noneconomic damages, which includes pain, suffering, inconvenience, physical impairment, disfigurement and nonpecuniary damage, and the jury must use its judgment instead of a formula based on medical bills to decide reasonable compensation.

(CMA Alert, March 25, 2013 issue)

medico news

New breast density notification law goes into effect April 1 On April 1, 2013, California’s new breast density law takes effect, requiring health facilities that perform mammography to provide patients who have “heterogeneously dense breast or extremely dense breasts” with the following notice, in addition to the other findings of their mammogram: “Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer.

This information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor. Together, you can decide which screening options are right for you. A report of your results was sent to your physician.”

The categorization of what constitutes dense breasts is based on the Breast Imaging Reporting and Data System established by the American College of Radiology and can be somewhat subjective.

The new law does not create a new duty of care or legal obligations beyond the duty of the health facility performing the mammography to provide the notice. The California Medical Association (CMA), however, remains concerned that such a notice places physicians in the position of counseling patients regarding breast density when there are no medical guidelines or scientific data to help interpret the report or to determine what, if any, additional testing should be done for patients with dense breast tissue.

While the intent of the law (SB 1538) is to give women more power and control over their health, CMA is concerned that it may impose undue cost burdens on the patient. Because high breast density is not currently by itself a risk factor for cancer in medical guidelines, in cases where prior authorization is required for additional screening, the tests may not be covered by their insurance.

If a patient inquires about breast density after receiving the mandated notification, physicians should provide patients with information regarding breast density and discuss their

lifetime personal risk of breast cancer and appropriate screening and diagnostic tools specific to their needs. A brochure to help patients understand breast density is available on the American College of Radiology website (http:// bit.ly/ACRDensityBrochure).

For more information, see CMA OnCall document #3112, “Cancer Information Requirements.” This document, available in CMA’s online health law library, is available free to members at www.cmanet.org/cma-oncall. Nonmembers can purchase this and other documents for $2 per page.

Physicians can find information and guidelines on breast density on the American College of Radiology website (www.acr.org) and the California Academy of Family Physicians website (www.familydocs.org/practicemanagement-news). More information on breast cancer screening can be found on the American Congress of Obstetricians and Gynecologists website (www.acog.org).

Contact: Scott Clark, 916/551-2887 or sclark@cmanet.org.

(CMA Alert, March 25, 2013 issue)

Blue Shield follows Blue Cross’s lead to require physicians to notify patients before referring out-of-network On March 15, Blue Shield announced that it would soon begin requiring contracted physicians to notify patients in writing before making out-of-network referrals. Effective, May 15, physicians will be required to notify patients in writing using a form provided by the payor when referring a patient to an out-of-network provider. The policy does not apply to emergencies.

This change comes on the heels of a similar change recently implemented by Anthem Blue Cross.

While existing language in Blue Shield provider contracts had placed limitations on referrals to out of network providers for patients with HMOs, EPOs, and/or Medicare Advantage plans, those limitations did not apply to patients with PPOs. That will change effective May 15.

According to Blue Shield, the policy is not intended to dissuade patients from utilizing their out-of-network benefits. Rather it is intended to help patients understand the impact of their decisions and to “maximize the benefits” available to them.

According to Blue Shield, the completed form must be filed in the

patient’s medical record and be made available to Blue Shield within five business days, if requested. The notice does not provide details on how Blue Shield intends to enforce this provision. The California Medical Association (CMA) has asked for clarification on this issue and will publish an update when available.

California law states that if a physician objects to a material contract change, such as this, he or she has the right to terminate the contract prior to implementation of the change. According to the Blue Shield contract, physicians who object to a material change may terminate the agreement with 60-days written notice. If a termination notice is submitted within 60 days of receipt of the notice, the proposed changes will not apply during the 60-day termination period.

Physicians with concerns are encouraged to contact the Blue Shield Provider Liaison Unit at 800/258-3091.

Contact: CMA’s reimbursement helpline, 888/401-5911 or economicservices@cmanet.org.

(CMA Alert, March 25, 2013 issue) MARCH / APRIL 2013 | THE BULLETIN | 31

medico news

AMA presents webinar series on opioid prescribing As part of an ongoing effort to address abuse and misuse of opioids, the American Medical Association is hosting a free webinar series about responsible opioid prescribing. The 12-part series will help physicians enhance their knowledge about safely prescribing opioids for the millions of Americans who suffer from chronic pain and may need these medications to function in their day-to-day lives.

“Prescription drug abuse is a serious epidemic that cannot be ignored, and any action we take to prevent it must ensure that patients who are suffering from chronic pain get the treatment they need,” said AMA President Jeremy A. Lazarus, MD. “The AMA is pleased to offer a series of webinars to help physicians combat prescription drug abuse while promoting responsible pain management.”

While overuse and misuse of prescription drugs is a serious problem, a great deal of human pain and suffering remains inadequately treated. According to a 2011 Institute of Medicine report, 100 million Americans suffer from chronic pain.

The first three webinars from this series are available free on demand. The first webinar explains how to identify patients who are ap-

propriate candidates for opioid therapy and how to monitor and evaluate their response. Presenter Lynn R. Webster, MD, president-elect of the American Academy of Pain Medicine, shares eight tested principles for managing pain while avoiding misuse of prescription opioids.

The second webinar features speakers from the Centers for Disease Control and Prevention gives an overview of the epidemiology of prescription drug overdoses and deaths. The webinar also explains the factors associated with an increased risk of unintentional overdoses from opioids as well as public policy and clinical practice strategies to promote responsible opioid prescribing.

The third webinar entitled “Improving Safety Through Opioid Rotation: Reducing Dosing and Extending Rotation Schedule,” is presented

by Lynn R. Webster, MD, president-elect of the American Academy of Pain Medicine.

For more information on the AMA webinar series, visit http://eo2. commpartners.com/users/ama/series.php?id=1214.

(CMA Alert, March 25, 2013 issue)

CMA legal counsel to argue peer review case before California Supreme Court This week the California Medical Association’s (CMA) legal counsel will testify before the California Supreme Court in the case of ElAttar v. Hollywood Presbyterian Med. Ctr. In this case, the hospital board at Hollywood Presbyterian Medical Center ignored and overrode the medical staff executive committee’s (MEC) recommendation to reappoint a physician on staff. When the physician invoked his right to a joint review committee hearing to challenge the hospital’s termination of his privileges, the hospital unilaterally appointed the hearing officer and members of the review committee. Under the medical staff bylaws, however, only the MEC has authority to determine the joint review process, including the appointment of the hearing officer and joint review committee members.

CMA, represented by CMA legal counsel and director of litigation Long Do, will argue that the medical staff bylaws, in this case, must be strictly enforced in order to uphold the systemic safeguards of a fair and just peer review system. Under California and federal laws, the professionals on the medical staff have primary responsibility for all of the functions necessary 32 | THE BULLETIN | MARCH / APRIL 2013

to ensure patient safety and the competence of practitioners at a hospital. These functions, which include peer review, fall within the medical staff’s right to self-governance and independence. Hospital governing bodies have oversight authority, but cannot unnecessarily interfere with the medical staff’s self-governance functions, including peer review.

He will explain why the hospital in this case tipped the balance too far in its favor and how the court’s ruling can have a huge negative impact on medical staff self-governance if it were to accept the hospital’s arguments.

Last year, a California court of appeal had agreed with CMA’s arguments and held that the hospital was wrong to unilaterally terminate the physician and then usurp the MEC’s authority to appoint the hearing officer and members of the joint review committee when the physician invoked his right to an appeal.

The court relied on CMA’s model medical staff bylaws to understand the strict requirements of the medical staff’s bylaws. It also warned against the danger of sham peer reviews directed by hospital governing bodies.

(CMA Alert, March 25, 2013 issue)

CMA publishes toolkit on the health benefit exchange In 2010, Congress passed historic sweeping health care legislation, the Patient Protection and Affordable Care Act (ACA), which reformed the for-profit health insurance industry and, beginning in 2014, will provide health insurance to most of the nation’s uninsured.

Under the ACA, two-thirds of California’s uninsured will be covered by private insurance through a health insurance exchange purchasing pool. The exchange’s goal is to start preenrollment in October 2013.

CMA has developed a new toolkit titled, CMA’s Got You Covered: A physician’s guide to Covered California, the state’s health benefit exchange, to educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting.

The toolkit is available free to members only at www.cmanet.org/exchange.

Contact: CMA’s reimbursement help line, 888/401-5911 or economicservices@cmanet. org.

(CMA Alert, March 11, 2013 issue)

medico news URGENT: Providers who refer, Department order, or prescribe for Medi-Cal of Justice beneficiaries must enroll with DHCS to decide

The Department of Health Care Services (DHCS) made changes in January to its Medi-Cal provider enrollment requirements as a result of the Patient Protection and Affordable Care Act (ACA). One of the changes now requires all providers who order, refer or prescribe (including but not limited to physicians, NPs, and PAs) be enrolled in the Medi-Cal program. Previously, providers needed to enroll only if they wished to furnish (and bill for) covered services for Medi-Cal beneficiaries.

If an ordering and/or referring provider (ORP) is not enrolled in Medi-Cal, the “filling providers” (for example, the pharmacy that is filling the patient’s prescription or the specialist you are referring a patient to for treatment) will not be paid. As a result, patients may not receive needed items or services if the “filling providers” refuse to accept orders or referrals from providers who are not enrolled in Medi-Cal. Although the new requirement took effect January 1, 2013, DHCS established a grace period to allow more providers to enroll before claims are denied. The grace period could end at any time and ORP providers are encouraged to complete the enrollment process as soon as possible.

ORP providers are providers who enroll for the sole purpose of ordering, referring, or prescribing to covered beneficiaries and who do not directly submit claims for their services. Please note that this type of enrollment does not allow the Medi-Cal program to reimburse the ORP-only provider for services provided directly to Medi-Cal beneficiaries.

Providers who are already enrolled in Medicare or Medi-Cal under their individual (type 1) National Provider Identifier (NPI) number do not also have to enroll as ORP providers.

The providers that may be affected by this change include individual physicians or physicians employed by physician groups, federally qualified health centers, rural health clinics, critical access hospitals, the Department of Veterans Affairs, Department of Defense TRICARE program, and the Public Health Service.

For more information, or to enroll as an ORP provider, visit the DHCS website. The ORP enrollment form is “DHCS 6129.”

For questions regarding enrollment as an ORP provider, please contact the DHCS Provider Enrollment Division at pedcorr@dhcs.ca.gov or 916/323-1945.

(CMA Alert, March 25, 2013 issue)

Medi-Cal extends 2012 EHR attestation deadline to April 30 Xerox, the vendor in charge of the Medi-Cal electronic health record (EHR) incentive payments has resolved the technical difficulties that were complicating some providers’ ability to complete their 2012 attestations. Specifically, the Medi-Cal State Level Registry was not properly allowing some providers who have been designated as members of groups to inherit and utilize the group’s information. As of Friday, March 15, the system is fully functional.

Because of the difficulties and resulting attestation delays, the California Department of Health Care Services (DHCS) has received federal authorization to extend the 2012 attestation deadline to April 30, 2013. This deadline extension applies to all eligible professionals, not just those affected by the group attestation problem.

Despite this extension, groups and providers are urged to submit their applications for 2012 as soon as possible. DHCS also recommends that group/clinic representatives do not begin the 2013 attestation process until their providers have received their 2012 payments.

For more information, visit www.medi-cal.ehr.ca.gov or call Xerox’s EHR Program at 866/879-0109.

Contact: CMA reimbursement help line, 888/401-5911 or kmarck@cmanet.org.

(CMA Alert, March 25, 2013 issue)

Medicare MAC contract protest

The Centers for Medicare & Medicaid Services (CMS) announced in September 2012 that Noridian has been named the new Medicare Administrative Contractor (MAC) for Medicare Parts A and B in Jurisdiction E (previously called Jurisdiction 1). Two protests were filed, challenging the award.

On January 18, 2013, the Government Accountability Office denied the two protests. As permitted by law, both protestors (Palmetto GBA and CGS) subsequently filed complaints with the U.S. Court of Federal Claims, challenging the Jurisdiction E MAC contract award. The protests were filed on February 1, 2013. The Department of Justice is representing CMS before the court.

For at least the next several months, Medicare providers in Jurisdiction E (California, Hawaii, Nevada, and the Pacific territories) will continue to file their Medicare claims with the incumbent Palmetto GBA. CMS will notify affected Medicare providers about the situation, including any implementation dates, following the Court of Federal Claims review.

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.

Contact: CMA member service center, 800/786-4262 or memberservice@cmanet.org.

(CMA Alert, March 25, 2013 issue)

Medico News continued on page 43 MARCH / APRIL 2013 | THE BULLETIN | 33

member benefit

A Member Prescription for Savings!

“When I found out how much money I could save on the sponsored workers’ compensation program, I joined CMA. The savings paid for my membership and then some. Now I have access to everything CMA offers.”

– Nicholas Thanos, MD, CMA Member Did you know that CMA/SCCMA/MCMS members can save 5% on their workers’ compensation insurance? And, they may save even more than that, up to 15%, depending upon their group medical carrier.

It’s true. CMA/SCCMA/MCMS members receive a 5% discount on workers’ compensation insurance policies provided through Employers Compensation Insurance Company. This discount is available exclusively through Marsh/Seabury & Smith Insurance Program Management, the sponsored broker and administrator.

As rates are increasing for this mandated coverage, don’t wait until the last minute. Contact Marsh today to get a workers’ compensation premium quote, so you’ll be prepared in the event your rate increases

on renewal.

If you have any questions, or would like to get an immediate indication of your potential savings, please call a Marsh Client Advisor at 800/842-3761 or email CMACounty.Insurance@marsh.com.

Why choose between national resources and local clout?

In California, The Doctors Company protects its members with both.

With 73,000 member physicians nationwide, we constantly monitor emerging trends and quickly respond with innovative solutions, like incorporating coverage for privacy breach and Medicare reviews into our core medical liability coverage. Our 20,000 California members also benefit from the significant local clout provided by long-standing relationships with the state’s leading attorneys and expert witnesses, plus litigation training tailored to California’s legal environment.

This uncompromising approach, combined with our Tribute® Plan that has already earmarked over $106 million to California physicians, has made us the nation’s largest medical malpractice insurer.

To learn more, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293, or visit us at www.doctorsagency.com.

We relentlessly defend, protect, and reward the practice of good medicine.

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

344258_BulletinOfSantaClara_MarApr2013.indd | THE BULLETIN | MARCH /1APRIL 2013

Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts. For additional details, see www.thedoctors.com/tribute.

2/4/13 9:14 AM

2013 Physician Membership Resource Directory NOW AVAILABLE! ORDER YOUR COPIES TODAY There are a lot of updates and changes in the new 2013 edition.

Make sure to order enough copies for you and your staff!

Contact Maureen Yrigoyen at 408/998-8850 today!

MARCH / APRIL 2013 | THE BULLETIN | 35

membership

CONGRATULATIONS and THANK YOU to the Following Physicians Who Have Been SCCMA Members for a THIRD OF A CENTURY and Longer!

SCCMA Member Physician's Name, Years of Membership

Thomas Abel Robert B Abington Arthur J Abrams Georgia K Abrams Aubrey L Abramson Fuad Abuabara Geoffrey David Adamson Robert E Adler A Richard Adrouny Edward J Ahmann Daniel Santiago Alegria Richard P Alexander Donald L Allari Michael V Altamura Taki N Anagnoston Emil A Anaya Barrett C Andersen John Noel Anderson Mark Arthur Anderson Robert Walter Andonian Glorietta Zapata Angfonte Frank Lloyd Annis Robert Aptekar Robert W R Archibald Frederick S Armstrong Marsha F Armstrong Robert W Armstrong Walter L Arons Lawrence Aronson Stephen H Astor Joseph C Avakoff Kenneth E Averill Bernard J Axelrad Joseph M Badame Robert B Baer

33 38 41 50 35 32 34 35 31 41 30 40 40 37 49 36 39 43 32 32 33 34 37 36 43 41 42 37 55 33 35 47 42 37 50

36 | THE BULLETIN | MARCH / APRIL 2013

Michael E Baggett Keyvan Bahadi George W H Bailey Rodney L Baker Amara Balakrishnan Davis W Baldwin Ralph A Baldzikowski Joseph Carl Barbara Thomas J Barclay John Earle Barnes Charles Lee Barrett Krikor Barsoumian David W Barton Arthur Alden Basham Charles W Bass Sr. Clayton Woodward Bavor H Glenn Bell Jr. Alvin D Benjamin Bronson M Berghorn David H Berkeley R Laurence Berkowitz Gerald Berner Alex Bernyk Frank D Berry Gerald Besson Alan E Bickel Arthur Adolph Biedermann Armond R Bigler Paz Quezada Bilkey Roderick Biswell William C Blair Barbara G Blancke Douglas John Blatz Richard Alan Bobis Arthur M Bobrove

44 34 33 45 35 52 38 39 32 38 38 33 36 31 43 34 33 36 39 33 32 40 35 37 41 42 40 35 30 45 45 32 31 38 34

Edwin Eastland Boldrey Lawrence Paul Bonaldi Samuel C Bonar William R Bonnington Charles A Borgia Richard A Borrison Niels E Brandstrup Robert L Bratman Alan Paul Brauer David L Breithaupt Calvin D Brenneman Ross D Bright Melvin Creed Britton Jr. Marie Bernadette Britz Robert F Bronstone Charles J Brooks Seymour Bross Philip Anthony Brosterhous Arthur M Brown C Walter Brown J Sewall Brown Jeffrey Hilliard Brown Peter Watson Brown Robert Calvert Brown III Wendell E Brown Brent R Browning Gerald A Bruce Barry D Brummer Charles S Brummer Carl D Brunsting William Maxwell Buchholz Sara J Bunting Emiro Burbano Roger J Burkhart Robert D Burnett

38 33 48 39 48 34 35 39 30 42 37 39 42 34 43 43 39 33 39 36 38 31 37 39 42 38 38 36 40 37 34 31 35 31 57

Michael Dane Butcher Alfred N Butner Edward L Cahn Michael S Cahn Richard F Cain Jerry Lester Callaway Kenneth G Campbell Dale Andrada Capulong Robert A Carlin Alan F Carpenter Brian James Carrie R Kemp Carter Joseph M Casey Rives Coleman Chalmers Michael T Charney Richard S Cherlin Gregory G Cheung Sydney C Choslovsky Shingsan Chou Martin F Choy John R Christensen II Wayne S Chronister Theodore Jenwen Chu Sandy F Chun Joseph Benjamin Cirone Richard A Cirone Dean T Clark Gordon R Cohen Ronald Hershel Cohen Stephen Cohen Theodore Cohen Richard Carter Colbert Sara Louise Colby Harold E Coleman John Vincent Collin John Peter Colman Jr. John K Colwell George W Commons Jr. John D Condie Michael W Condie Robert S Condie Miles Robert Congress Donald J Conlon W Stroud Connor Robert T Constantino Arthur L Cooley Norman S Coplon Mario Nestor Cordero-Gamez Richard Joseph Corelli James D Corfield Jr. Victor F Corsiglia Jr. Diane Eline Craig James D Crane Don C Creevy William P Creger Kalman A J Cseuz James M Cuthbertson Robert L Dale Peter R Dalena

36 39 44 49 33 35 38 33 32 34 31 38 36 31 39 36 34 38 34 45 41 39 41 31 32 40 44 31 38 42 36 38 30 36 38 33 37 36 33 32 39 35 48 36 42 40 34 32 34 34 44 30 42 48 53 37 41 40 44

Anthony J Damore John C Damron Robert W Danielson John H Davis Mary Donaldson De Figard Philip A M Debrincat Lawrence T Debusk Joseph H Decker Victor J Defino John A Delfiugo Angelos Dellaporta Charles C Delong Michael S Denenberg Richard Derby Karen B Devich Richard R Dewey Thomas J Diamond John T Differding Raymond H Dimarco David P Discher Leonard Doberne John C Doiron Jr. Kenneth V W Dole Bock L Dong Raymond W Donovan Jr. Douglas E Downey Henry R Drinker Jr. D Jeffrey Duckham David H Eby Jr. Jack P Edelstein Saul Eisenstat Franklin R Elevitch Hugh W Elliott Edward L Ellsworth Robert Scott Elmore Richard S Eng Leo V English Jr. Thomas G English Lawrence A Epstein Hans J Ernst Philip P Ernstrom Orval M Eshelman Robert K Evans Stanton L Eversole Jr. Molly Fainstat Theodore Fainstat Gilbert S Farfel Henry Jordan Fee Jr. Anthony S Felsovanyi John Austin Field Joseph H Field Stanley Finkel Solon I Finkelstein Elliot M Finkle Norris B Finlayson Stanley E Fischman George H Fish Martin L Fishman Violeta R Fojas-Vitug

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Allen Gary Fong Keith Bradley Ford Steven S Fountain William C Fowkes Jr. Keith Edward Fraker S Robert Freedman William A Frey Gary A Fry Ivan S Fucilla Peter Chun-Chung Fung Constantino T Gallo Myron Gananian Leroi B Gardner Jr. J Kent Garman Frank E Garrett Jr. Don Gartman J Richard Gaskill Michael William Gaynon John W George Allan J Gherini Frank J Giansiracusa Richard Alan Gilman Alan Harvey Gladman John P Glathe Harry R Glatstein Jr. David Robert Godley Abraham A Goetz Michael Martin Gold Leonard M Goldberg James B Golden Nelson E Goldschneider David P Goldstein Mark Ira Golod Hayman Gong Roger B Goodfriend Frederick K Goodill William E Goodrow Jr. Saroja Gopalan Elsa L Gordon William M Gould Philip A Granieri David Jay Graubard Foy W Green Jr. Stephen Eliot Green Richard Arthur Greene Alan E Greenwald Frank C Griffin Monroe A Gross Philip A Grossi Melvyn L Grossman William Edward Grove III F Carl Grumet A Maynard Guderian Hrair P Gulesserian C Desmond Gunatilaka Sterling Joel Haidt Dexter H Hake Arthur W Halliday

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Continued on page 38 MARCH / APRIL 2013 | THE BULLETIN | 37

30-Year SCCMA Members, from page 37 Glen Gordon Halliday Roger P Halliday David Douglas Hammons Eric A Hansen Jerry Alan Hanson Richard W Hardy Douglas M Harper David R Harris Donald G Harris Harry E Hartzell Jr. John E Hasson Barbara Jane H Hastings John E Hauser Lewis Lee Haut Artyce L Hawman Ronald Stuart Hay Roger M Hayashi Kenneth Hayes Marshall D Heller Elizabeth Ann Herb John A Herman Robert M Herman Maie K Herrick Robert A Hersch Eva H Hewes George R Hewes Oakley Hewitt Robert L Hill David S Hirschfeld Tin Tin Hla William H Hoag Thomas A Hodge Armin C Hofsommer Jr. Halsted R Holman Arthur H Holmboe Gordon R Hondorp Jeannette A Hovsepian Charlotte Hu Eng H Huan Frank Fang-Chi Huang John Y Huang Frazier Olander Hubbard Alfred C R Hughes Gerald Edward Hughes Jr. James A Hull Johan V Hultin David D Hunt Alfred Lewis Hurwitz Bruce W Hutchinson Bruce Hyman Anthony C Iantosca Joseph A Ignatius Stephen T Imrie Paul David Indman Martin I Inkelas William H Irving

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Paul M Jackson Stephen H Jackson George P Janetos Herbert E Jang Robert A Jelinek Gregory Lee Jenkins Grady Lynn Jeter Bert D Johnson Merlin J Johnson Robert W Johnson William W Johnson Charles L Johnston Jr. Ronald Joseph Janardan S Joshi Jack Kabak Chris J Kachulis Herbert K Kain Cornelius F Kalman Barry Martin Kaminsky Eugene W Kansky Ernest N Kaplan Henry Paul Kaplan Robert W Karch Bill Gust Karras Eugene D Kates Gordon Eric Katske Gary R Katz Ronald L Kaye Jonathan Merrick Kelley Leo A Keoshian K Theodore Keyani Ronald G Kite Michael Alan Klass Martin Klughaupt Harvey E Knoernschild Francis Henry Koch Harrison J Kornfield Barbara L Korthamar Jon C Kosek Margaret S Kosek John Kersten Kraft Allan C Kramer David Kramer Richard Jay Kramer Bela Kraus Kerry Dean Kravitz Larry H Kretchmar Rayna Jacobs Kroman Thomas Alexander Kula Jr. Michael Charles Kushlan Cynthia A Lacy Philip A Lahr Bart C Lally Jr. James B Laroy Harvey Lash Alan L Lasnover

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Donald B Lathrop Donald R Laub Larry L Lawrence William L Lawrie Robert D Leasure Ping-cheung Lee R Hewlett Lee Robert Q Lee Peter J Leeson John Edward Lenahan Henry F Lenartz Thomas F Leo Gordon S Leonard Elliot Charles Lepler Donald Y Lesser Edward N Levin Gordon Leonard Levin Martin B Levitt Henry T Lew James E Lewis Sherwin D Lewis Robert S Lichtenstein Michael C Liebermann Thomas Tsu Hsiung Lin William R Linder Philipp M Lippe Harold P Lipton Dorson Norman Liss Hunter L Little Christine A Litwin-Sanguinetti Frederick Lloyd David Andrew London John Deforest Longwell Jr. Herman A Lorberbaum James A Losito Robert Marshall Lowen Leon Lubianker Morgan L Lucid Andrew D Lucine Robert G Maclean William R Macmaster Sr. Richard A Mahrer Alfred S Maida Elisabeth A Mailhot William J Majors Robert A Mallison David B Mark James W Markham Stuart Alan Markovitz Stanley L Markowski John E Marlow Michael Francis Martin Robert Jay Marx M Richard Maser Robert John Masi Nancy Elizabeth Mason

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Stuart Irwin Mass Robert Coleman Master Robert Steven Mastman Larry Michio Matsumoto Herbert M Matthews Robert B Matthews Anthony G Matukas Nancy S McCall Don Earl McCleve Reginald V S McCoy David Wesley McCullough Cyril J McDonald Benson R McGann Kirk C McGuire Thomas J McGuire William D McKee William T McLaughlin Douglas E McNeil James Ian McNeill Hamid Moradali Mehdizadeh August W Meier James R Meier Helmut W Meisl Alan C Merchant William S Michael Howard Elliott Michaels David Craig Miller Kenneth Ames Miller Philip D Miller Robert J Miller Paul Joseph Mills Albert K Mineta Richard T Mitchell Robert Lee Mitchell Jamal Modir Robert W Moncrieff Rodolfo Antonio Morales David Morgan Joe L Morgensen Elliot Morrison Peter Simon Moskowitz Jerold David Moss Richard Lewayne Muller Eileen Mullin Carter V Multz Saylo Munemitsu Vincent T Murphy William E Murphy Sadri Musavi Thomas M Nachbaur Michael R Nagel Shaku Nagpal Robert N Naughten Suresh R Nayak Emeka J Nchekwube Norman R Nedde Thomas S Nelsen Lionel M Nelson Anthony J Nespole Jr.

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William B Ness James W Newell Andrew B Newman Walter Simon Newman Jr. Jonathan Ting Ng Michael Alan Nierenberg Vincent F Nola Harold W Nolen Jr. David William Noller Norman Nomof F Richard Noodleman Jerrod Normanly Harold R Novotny D Brendan O'Donnell Conor C O'Malley Richard M O'Neill Robert J O'Neill Robert A O'Reilly Harry A Oberhelman Jr. William G Odom Irving W Olender Wesley E Olson James M Orth Hans I Orup Stephen Francis Osborn John G Pace Parviz Pakdaman Louis Pang Malcolm R Parker Jr. Harlan S Parks Jonathan B Parmer Richard Mark Parrish Roy E Paulsen Jr. Donald H Paulson Samuel Nelson Pearl James Michael Pellegrin Dennis Israel Penner Frank Allan Perlroth Ronald F Perry Barbara Ann Peters Kenneth Scott Peters C David Petersen Vincent J Philbrick Ralph Pietrobono Abe Piramoon Edward Anthony Plonka Michael David Podlone James H Poppy David Y Porter Howard R Porter Martha S Porter Klaus Joachim Porzig Jagdip Singh Powar Richard W Poytress Donald J Prolo Richard L Provines Munir Pualuan Gurdon S H Pulford Douglas B Pulley

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Merlin S Puterbaugh James H Quakenbush Jr. John B Quick Jr. William W Quisenberry Jay Singh Raju Richard Allen Raley Paulita Regalado Ramos Virginia Raphael Michael Lee Rappaport James W Ratcliff Robert A Ratshin Donald J Rawson Gordon Robert Ray Clark G Reed Marshall W Reed Willard D Regester Henry H Reily Jr. Charles L Rennell Jr. James S Reynolds Norman Thomas Reynolds Albert P Ribisi John C Richards John Richards IV William Bassett Ricks Patrick J Riley Lawrence Allen Rinsky Karl W Robinson Martin C Robinson Bruce L Robison William M Rogoway John Steven Rollins K G Romine Marshal Del Rosario Paul J Rosen Howard L Rosenberg Lynn B Rosenstock David M Rosenthal Lawrence A R Ross Robert F Ross Ronald Mark Rossen Jude Thaddeus Roussere Martin Donald Rubenstein Leonard Rush Melvin F Russi Jr. Alvin B Rutner Susan Heekyung Ryu Bruce Marshall Saal Harmeet Singh Sachdev Virender K Sachdeva Harvey Joel Sachs David E Safir C John Samios Wallace I Sampson Patricia Celia Samson Francis S San Filippo Pacifico C Santos Walter Saphir Jagat Bushan Satia

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Continued on page 40 MARCH / APRIL 2013 | THE BULLETIN | 39

30-Year SCCMA Members, from page 39 J Robert Schauwecker Jonathan P Schechter Francis H Schipfer Frederick Schlichting John F Schmaelzle Marvin H Schwartz Frederick W Schwertley Raymond L Schwinn Dudley O Scott Jr. Philip L B Scott Boyd W Seaman Mark Melvyn Segall Vincent K Seid Robert S Seipel Carmelo Salvatore Sgarlata Lee Shahinian Jr. Jerome R Shapiro Lawrence Edward Shapiro Michael A Shea Richard D Sheehan Gerald M Shefren Robert B Shelby Charles Sheptin Theodore Shiff George L Shoptaw Jack Stephen Siegel Joel I Siegel Richard Henry Sieve Donald Clendennin Silcox W James Silva Jack H Silveira Gary M Silver Gerald D Silverberg David Steven Silverstein Barry Slater Richard Jay Slavin David Edward Smith Gilbert I Smith Hershel D Smith John Philip Smith Mansfield F W Smith Roy C Smith Mark Alan Snyder Richard L Sogg Keith C Soper Randall B Spencer Alfred P Spivack Donald Anthony St Claire John F Stahler Richard W Starrett William Robert Stearns David Emil Torres Stein Stuart L Stein Gary W Steinke Donald William Stemmle Laura Sue Stemmle

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Lawrence D Stern G Melvin Stevens Donald R Stewart William A Stocker Barbara Stofer M Lee Stone John Stoner III Eric Strauss William Eugene Straw James Cooper Stringer Leo D Stuart Francis L Stutzman John H Sullivan Lewis E Sullivan R Lawrence Sullivan Jr. Reinhold Sundeen Rahnea L Sunseri Katherine K Sutherland Paul N Swartz Kambuzia Tabari Ben Z Taber Joseph B Tanner Ralph W Tanner Linda Anne Teagle Gordon J Thenemann Craig Woodrow Thomas David Vernon Thomas Ernest M Thomas Jr. Donald E Thompson Noel P Thompson Steven Mark Tilles George Oscar Ting G James Tobias Shirley K H Tom Norman Jay Tong Richard J Trevino Martin Trieb Gerald E Trobough Michael L Trollope Donald Tsang Victor W H Tsang Wallace Tsang Charles F Tuffli Jr. D Thomas Urban Ronald R Uyeyama Nora Valdez Valin-Ancheta Eduardo A Vergara Nilda Vergara Fernando G Vescia Paul J Vincent Allan S Vishoot Jr. Virgil H Voss Gordon J Vosti Stephen R Voydat Murray K Walker Samuel Ray Walker

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Hugh Glynn Walsh Joseph F Walter Jr. Brian Ward Phillip O Warner Richard W Warren William Samuel Warshal Saul Wasserman William Waterfield Jr. Robert E Watson James W Weatherholt Alan Weber Ellis Weeker Charles L Weidner John F Weigen Robert L Weinmann Myron H Weisbart Robert L Weisman Edward Arthur Weiss Gerald A Weiss Waldemar Hall Wenner Emory G West Richard P Wheat Kevin Ross Wheaton Frank R Wheeler Harry G Whelan Jr. Patrick Edward Wherry Charles R Whitney Francis M Whittaker Bruce George Wilbur James H Williams Robert L Wilson James D Wolfe Harry C Wong John B Wood Jr. Ralph H Wood Norman P Woods John M Wortley Carleton J Wright Hossein Askariyah Yazdy Peter Y Yee Takashi Yoshida John V Young Kou Ping Yu Chiu J Yuan Alejandro A Zaffaroni Louis C Zanger Leslie M Zatz John C Zauner Paul J Ziegler Richard W Ziegler J Kirk Zimmer Sheldon A Zitman Warren Walter Zodrow Richard C Zug

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membership

CONGRATULATIONS and THANK YOU to the Following Physicians Who Have Been MCMS Members for a THIRD OF A CENTURY and Longer!

MCMS Member Physician's Name, Years of Membership John A Anderson Milton L Baker John N Baldwin Jon Winston Benner Jeffrey I Berman Robert L Black Ronald L Branson William L Breneman Heinrich Alfons Brinks Dale K Buche Donald Anthony Catalano Ronald Norman Chaplan Martin H Chester Byron M Chong Craig E Christensen David A Clark John W Curtis Frank P Cusenza Richard Tierney Dauphine James J Debartolo Emma Dong Giles Anthony Duesdieker June H Dunbar Thomas S Elliott Theo D Englehorn Jr. William Henry Falor Duke D Fisher John J Forbush Jacob J Foster Ronald C Fuerstner W Reid Giedt-Paredes Jr.

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William C Goenne Jr. 34 Melvin F Gorelick 39 Joseph Byron Greene 33 Norman L Halfpenny 47 Takashi Hattori 36 Robert A Helfrich 37 David R Holley 41 Glenn E Hudgens 41 Duane F Hyde 40 Jeffrey H Hyde 30 Albert B Janko 44 Rolf E Johnsen 42 Steven Grant Johnson 36 Samuel I Johnston 33 Hisashi Kajikuri 45 Thomas A Kehl 32 William J Keller 36 Edward J Kennedy 42 William J Kennedy 39 Don Reese King 33 Edwin John Kingsley 32 Ramakrishna Subrahmanya Kochi 32 James A Kowalski 37 William H Lawler Jr. 47 Marc Lieberman 30 R Kurt Lofgren 34 Chas B Macglashan Jr. 48 Paul E Messier 42 L Bruce Meyer 44 Frank M Morgan 62 Richard L Murtland 44

Spencer W Myers Jr. Norman Dorr Nelson Thomas J O'Neill Jerry M Parker George H Penn II Joseph Celestino Petrini John P Phillips Richard A Pirotte Howard Press James A Pretzer Barbara Lois Rever James E Rheim Jr. Benjamin T Richards John F Rinderknecht James M Rodda Alan Harris Rosen Donald M Scanlon John Wallace Schatz Robert W Selle Frances E Shields Roger Shiffman Anthony (Jon) Smith Michael Richard Smith Charles R Snorf William Charles Vogelpohl John D Wagner Stephen C Walker B Sanders Watkins Geoffrey G White

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MARCH / APRIL 2013 | THE BULLETIN | 41

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 408/3551519.

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. Time-share also available. Call Betty at 408/848-2525.

newly established Podiatry Practice near Good Samaritan Hospital with after hours Health Care Urgent Care facility and Health Diagnostics (MRI/CT) imaging center downstairs. Excellent for a Primary Care Physician, Cardiologist, Dermatologist, Rheumatologist, Orthopedic Surgeon, or an Endocrinologist. 5 newly remodeled treatment rooms equipped with brand new ADA compliant chairs and in-office digital x-ray, access to state of the art minor procedure room, utility room, storage, cabinets, and break room. Call 408/358-2250 or email: losgatospodiatrygroup@gmail.com.

MEDICAL/DENTAL/PROFESSIONAL OFFICE SUITE • SALINAS

Second story of professional building across from SVMH. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $1.35/sq. ft. Rent is $1,667.25/month. Contact Steven Gordon at 831/757-5246.

OFFICE FOR LEASE • SAN JOSE

Medical, 1,000+ sq. ft., Vietnam town, east side, San Jose. Please call 408/396-7311.

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE

EMPLOYMENT OPPORTUNITY

2,300 SQ FEET MEDICAL SPACE

OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY

Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/644-9800.

2,300 sq. ft. surgicenter; eligible for Medicare approval. Or Medical-Dental office space by Good Samaritan Hospital. Rent negotiable. Call Gloria Wu, MD at 408/356-5553 or Jeff Petulla at 408/888-4859.

PRIME MEDICAL OFFICE FOR LEASE • SAN JOSE

Excellent location. Westgate area. 1,584 sq. ft.

West Valley Professional Center, 5150 Graves Ave., Suite 2/stand-alone unit. Private office, reception area, exam rooms with sinks. Available 2/1/11. Call owner at 408/867-1815 or 408/2217821.

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 408/2096556.

MEDICAL OFFICE TO SHARE • LOS GATOS

Available now! 1,800 sq. ft. to share with a 42 | THE BULLETIN | MARCH / APRIL 2013

Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage.

We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or email riflovin@allianceoccmed.com for additional information.

EMPLOYMENT OPPORTUNITY

Physician/Locum tenens for Family/Internal Medicine. Office based practice only. Coverage mostly needed during vacation. Part-time, must have excellent communication, interpersonal and clinical skills. Please fax CV to 408/3566676.

EMPLOYMENT OPPORTUNITY

Immediate opening for an Internist, Family

Practice physician, Nurse Practitioner, or Physician Assistant to take over a solo Internal Medicine practice in South Salinas. Position open through May, 2013. Call 831/424-4886.

GREAT EMPLOYMENT OPPORTUNITY

Family Practice office located in Los Gatos is currently looking for a physician to join our group. Malpractice Insurance is provided with competitive salary and benefits. Please contact Kim Hayes at 408/377-3130.

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 408/8716800.

MEDICAL EQUIPMENT FOR SALE

Used Lightsheer ET Diode laser and SkinScape microdermabrasion system manufactured by Lumenis. Well maintained and in excellent condition. Price negotiable. Call 408/691-1800.

MEDICAL BILLING SERVICES 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.

EXPERT BILLING SERVICE, A FULL SERVICE MEDICAL BILLING COMPANY

Our company is dedicated to helping health care practices and physicians maximize profits and reduce the cost, time, and effort associated with billing, leaving you, the provider, more time for your practice. We invite you to visit our website at www.ExpertBillingService.com for details about our service offerings. For a free consultation call 805/452-2525 and learn how we can help you achieve the peace of mind you deserve!

METRO MEDICAL BILLING, INC. • • • • • •

Full Service Billing 25 years in business Book Keeping ClinixMIS web based software Training and Consulting Client References

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website www.metromedicalbilling.com

medico news, from page 33 CMS releases sequestration guidance for providers On March 8, the Center for Medicare & Medicaid Services (CMS) released guidance for provider billing under the Budget Control Act of 2011, or sequestration. According to CMS, the 2% Medicare cuts will be applied to fee-for-service (Part A and Part B) claims with dates-of-service or dates-of-discharge on or after April 1, 2013. The claims payment adjustment will be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare secondary payment adjustments.

Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will also be reduced by 2% for claims with dates-of-service on or after April 1, 2013.

Though beneficiary payments for deductibles and coinsurance are not subject to the 2% payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2% reduction. CMS encourages Medicare physicians who bill claims on an unassigned basis

to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.

Across-the-board federal budget cuts were triggered on March 1, because Congress failed to come to an agreement on how to reduce the federal deficit. The 2% “sequestration” cuts to Medicare are part of the $1.2 trillion in cuts required by the Sequestration Transparency Act, part of a deal worked out to end last year’s debt-ceiling crisis. The cuts are evenly split between defense spending – with spending on wars exempt – and discretionary domestic spending. Medicaid is exempt from the cuts. The mandatory Medicare cuts will result in a savings of $11 billion in 2013. For more information, see “Sequestration FAQ,” available in CMA’s online resource library at www.cmanet.org/resource-library.

Questions about reimbursement should be directed to your Medicare claims administration contractor.

Contact: Michele Kelly, 213/226-0338 or mkelly@cmanet.org.

(CMA Alert, March 11, 2013 issue)

CMA joins briefs challenging Prop. 8 and DOMA in U.S. Supreme Court

Covered California launches consumer website

On February 28, the California Medical Association (CMA) joined the American Medical Association (AMA) and dozens of health care provider organizations across the country in filing an amicus brief in the United States Supreme Court challenging California’s Proposition 8, which denies state recognition of same-sex marriages. Additionally, CMA will also join a second amicus brief in the U.S. Supreme Court challenging the federal Defense of Marriage Act, which denies benefits to same-sex partners of federal employees.

“CMA strongly supports efforts to reduce health care disparities among members of same sex households, including measures to afford such households equal rights and privileges to health care, health insurance, and survivor benefits,” said Paul R. Phinney, MD, CMA president. “We also recognize that denying civil marriage contributes to poorer health outcomes for gay and lesbian individuals, couples, and their families.”

The brief states that the listed Amici, which includes leading mental health associations, have sought to present an accurate and responsible summary of the current scientific and professional knowledge concerning sexual orientation and families relevant to the case.

In October 2012, during CMA’s annual policy-setting meeting, hundreds of physician representatives from across the state passed a resolution calling for health care equality for same sex households. The resolution (505-12) requires CMA to work to reduce health care disparities among members of same-sex households, including minor children. It also calls on CMA to support measures providing same-sex households with the same rights and privileges to health care, health insurance, and survivor benefits afforded to opposite-sex households.

“At CMA, we’re dedicated to promoting the science and art of medicine, the care and well-being of patients, the protection of public health, and the betterment of the medical profession. That mission, along with our existing policy, leads us to join our physician colleagues in submitting these briefs,” said Dr. Phinney.

For a full copy of the Proposition 8 (Perry) brief, go to http://www.cmanet.org/news.

(CMA Alert, March 11, 2013 issue)

California’s new insurance marketplace finally has a home. In mid-February, Covered California, the state’s health benefit exchange, launched its new consumer website, www.coveredca.com, which will eventually serve as the portal for millions of Californians to purchase the subsidized health coverage promised in the Patient Protection and Affordable Care Act (ACA).

As of now, the website is not completely functional, as exchange staff and board members are still working through the process of selecting the insurance providers who will be eligible to offer products through Covered California’s new online health insurance marketplace.

The site, however, does feature a variety of fact sheets, printed in both English and Spanish, as well as a “costestimate calculator” that helps residents determine their expected premium costs, as well as what amount of federal subsidy they can expect once the marketplace goes live on January 1, 2014.

The California Medical Association (CMA) has been closely following along as the state works to launch its exchange. The latest developments are published in CMA Reform Essentials, a regular publication dedicated to the implementation of health reform in California. More information, including instructions on how to subscribe, can be found at http://www.cmanet.org/cma-reformessentials/.

(CMA Alert, February 25, 2013 issue)

MARCH / APRIL 2013 | THE BULLETIN | 43

MEDICAL TIMES FROM THE PAST

John Marsh The First American Practitioner in California

By Michael A. Shea, MD Leon P. Fox Medical History Committee Preface: The following is a quote from an old wizened woman to author George Lyman in 1930. “Over there,” said she, “in an adobe at the base of that mountain, lived the most mysterious of California’s pioneers. His name was John Marsh. He was a doctor, a hermit, a misanthrope. He hated men.”

John Marsh, a descendant of the first minister of the first Christian Church in Massachusetts, was born in 1799 in Danver, Massachusetts.

He was the eldest of seven siblings. Showing no love for farm life, he enrolled in a boarding school, Lancaster Academy, where his curriculum was classical studies, including Latin and Greek. Answering a call to the ministry, he changed schools and attended Phillips Academy. Graduating in 1819, he then enrolled at Harvard to further pursue his religious avocation. Dismissed in his second year for participating in a student rebellion, he was allowed to return one year later as a junior. At this time, he changed his major to premed. During his senior year he took gross anatomy and spent some time under the tutelage of Dr. John Dixwell, of Boston. He graduated from Harvard in 1823 with a Bachelor of Arts degree.

Needing money to go on to Harvard Medical School, he accepted a two-year obligation, teaching military dependents at Fort St. Anthony, on the Mississippi River in Michigan territory. It was here that he also studied under the post surgeon, Dr. Edward Purcell. Due to Dr. Purcell’s sudden death, he received no written confirmation of his preceptorship. While teaching at the Fort, he fell in love with a part-French, partSioux woman, named Marguerite Deconteaux. Although not married,

The Stone House

44 | THE BULLETIN | MARCH / APRIL 2013

they had a son, Charles, in 1825. Deciding not to return to Harvard for medical school, he stayed on at the Fort, where he was appointed Indian sub-agent. Several years later, Marguerite and their second baby died shortly after childbirth. This adverse event was followed by an indictment against John Marsh for selling guns to the Indians. He planned to escape his legal problem by moving west. For reasons unclear, he left his six-year-old son with a faith healer in Salem, Massachusetts, promising to return for him in a few years. This was not to be.

In 1832, the pioneer was found operating a general store in Independence, Missouri. The business failed and he was off to Santa Fe, New Mexico, just ahead of his creditors. From here, it was on to the Pueblo of Los Angeles, in California. He arrived in 1836, penniless, and finding no doctors in the area, presented his Harvard diploma to the City Council under the guise of a medical degree. As it was written in Latin, the council referred it to the Franciscan padres at San Gabriel Mission, where they unexplainably confirmed it as a medical diploma. He was, from that time on, known as Doctor John Marsh. He practiced in L.A. with very few treatment options. He had brandy and quinine for fevers, aches, and pains, and some cowpox vaccine that he used to immunize patients against smallpox. He developed quite a following for attending childbirth, although there is no known record of any training in this field. Cowhides, worth two dollars each, were the main method of payment in those times.

Selling his practice to a Boston trader for $500 dollars, he moved north to the San Jose area. There he purchased a 7,000 acre ranch, Los Meganos, 40 miles north of San Jose, at the foot of Mount Diablo. He financed his large cattle and horse ranch by practicing medicine. He was known to travel miles to see patients, but was also known for his expensive fees. He developed a reputation for rudeness and being inhospitable. This ran against the grain of most of his neighboring Californios.

Desiring security in a Mexican-run California, he wrote letters to people in Missouri, extolling the virtues of California and encouraging them to move west.

Some did make the long journey, as a result of John Marsh’s letters, including the first pioneer wagon train of the Bartleson Bidwell Party in 1841.

In 1850, he married Abigail Smith Tuck (Abby), a devout Baptist school teacher. They had a daughter, Alice, two years later. In 1855, Abby passed away from what probably was tuberculosis.

There were two California bright spots in the life of John Marsh. One was the large stone house that he built near his

SAVE THESE DATES! 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

John Marsh

adobe home. It was considered by many to be the finest example of old English architecture in the state. The second was the surprise return of his son, Charles, in 1856. It was an emotional reunion and seemed to soften the heart of father Marsh.

The sudden ending of John Marsh’s life came one day in 1856, when he was stabbed multiple times by one of his vaqueros while enroute to San Francisco. The reason was a dispute over wages paid to the worker after branding the Marsh cattle. Ten years later, son Charles found the culprit, Felipe Morena, and after a trial, he was sentenced to life in San Quentin. However, 25 years later, Governor Markham pardoned Morena.

The extensive estate of John Marsh gradually eroded away, as squatters and towns encroached upon the land. The stone house, however, remains, and is being restored at this time.

John Marsh was an enigmatic man. Wherever he went, there was action and adventure.

He was broke. He was rich. He was good. He was bad. He was loved. He was hated. Although his medical training was borderline, he was the first American to practice in California. For this alone, John Marsh will always be remembered, and like the beacon atop Mt. Diablo, his memory will endure.

Bibliography

1. Lyman, George D. John Marsh Pioneer, New York, 1933.

Honoring Rives C. Chalmers, MD, SCCMA President 2012-13 Award Honorees Sharon L. Levine, MD – Robert D. Burnett, MD Legacy Award James G. Hinsdale, MD – Benjamin J. Cory, MD Award Diane E. Craig, MD – Outstanding Achievement in Medicine Rosaline Vasquez, MD – Contribution in Medical Education Stephen C. Henry, MD – Contribution to the Medical Association Jeffrey D. Urman, MD – Contribution to the Community Congresswoman Anna Eshoo – Citizen’s Award Marita Trobough – Dedicated County Alliance Member Award Formal invitations will be mailed end of April

MCMS Annual lnstallation Dinner Thursday, June 20, 2013 6:15 pm Social 7:00 pm Dinner & Program Pasadera Country Club

Installation Kelly O’Keefe, MD, MCMS President 2013-14 Honoring John F. Clark, MD, MCMS President 2012-13 Formal invitations will be mailed in May MARCH / APRIL 2013 | THE BULLETIN | 45

CMA Center for Economic Services Webinars At-­‐A-­‐Glance 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: 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: 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: 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.

Most webinars are FREE for CMA members, $99 for non-­‐members.

CMA members are eligible for special discounts on ICD-­‐10-­‐CM Training from AAPC Questions? CMA Member Help Center: 800.786.4262 Please note: this calendar is subject to change. Visit www.cmanet.org/events for updates.

Calendar updated 3/12/13 46 | THE BULLETIN | MARCH / APRIL 2013

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CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

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MARCH / APRIL 2013 | THE BULLETIN | 47

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