2014 January/February

JANUARY/FEBRUARY 2014 | VOLUME 20 | NUMBER 1

2014 New Health Laws PLUS:

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66486 (1/14) Copyright 2014 Mercer LLC. All rights reserved.

Mercer Health & benefits Insurance Services LLC • CA Ins. Lic. #0G39709 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com

2 | THE BULLETIN | JANUARY/FEBRUARY 2014

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

Feature Articles 8 2014 New Health Laws

CME Tracking

16 Are You Just a Photocopier Away From a $1 Million Fine?

Discounted Insurance

18 Palliative Care and POLST

Financial Services

19 POLST: Improving Patient Care in the Emergency Department

Health Information Technology

20 Electric Cars for the Rest of Us

Resources House of Delegates

26 The Dual Diagnosis of an Eating Disorder and Type 1 Diabetes

Representation Human Resources Services

Departments

Legal Services/On-Call Library

5

From the Editor’s Desk

Legislative Advocacy/MICRA

6

Message From the SCCMA President

Membership Directory iAPP for

7

Message From the MCMS President

the iPhone Physicians’ Confidential Line Practice Management Resources and Education Professional Development

12 Communication: The Glue for a Functional Accountable Care Organization 13 MICRA 14 Kudos for SCU Students 28 Member Spotlight: Seham El-Diwany, MD 32 CMA Webinars

Publications

34 Classified Ads

Referral Services With

36 In Memoriam

Membership Directory/Website Reimbursement Advocacy/ Coding Services Verizon Discount

39 Medical Times From the Past 41 Covered California 44 MEDICO News JANUARY/FEBRUARY 2014 | THE BULLETIN | 3

THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President Sameer Awsare, MD President-Elect James Crotty, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Peter Cassini, MD VP-Professional Conduct Seham El-Diwany, MD Secretary Eleanor Martinez, MD Treasurer Scott Benninghoven, 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: David Feldman, 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 Kelly O'Keefe, MD President-Elect Jeffrey Keating, MD Past President John F. Clark, 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 2014 by the Santa Clara County Medical Association.

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CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD

John Jameson, MD

E. Valerie Barnes, MD

Jeff Keating, MD

Ronald Fuerstner, MD

Eliot Light, MD

James Hlavacek, MD

R. Kurt Lofgren, MD

David Holley, MD

AMA TRUSTEE - MCMS David Holley, MD

FROM THE EDITOR’S DESK

JOSEPH S. ANDRESEN, MD Editor, The Bulletin

Hello 2014!

By Joseph S. Andresen, MD Editor, The Bulletin Hello 2014! So long to 2013! Congratulations to all of us who continue to ride this steep, difficult wave of change in our profession and in our changing world. ACOs, EMRs, Big Data, HIE (Health Information Exchange), and Covered Lives were the buzzwords in 2013. Get ready for “High Outlier,” MSPB (Medicare spending per beneficiary), PROs (patient report outcome), Narrow Networks, and the “Choosing Wisely” campaign in 2014.

We all are now beginning to understand the profound changes that health reform is bringing to our patients and medical practice. Millions of Americans now have access to health insurance that can no longer be denied coverage due to pre-existing conditions. There is renewed interest and funding for preventative medicine and primary care services. Innovative ways of reimbursement for quality of care are being examined.

Along with the many benefits, many pitfalls still remain. What will stem the continued rise of insurance premiums? Will millions fall through the cracks in states that do not expand Medicaid? Are recent CBO revised projections of job losses and economic impact from the Affordable Care Act accurate? Or do they just reflect the fact that we are no longer tied to our jobs to qualify and retain our health insurance?

At a time of great challenges, the following questions should be asked: Where have we been? Where are we now and where are we headed? Three lessons of human endeavor illustrate our potential to meet these challenges.

In a 1916 expedition, Sir Ernest Henry Shackleton, an Irish explorer, attempted to be the first to cross the Antarctic continent from sea to sea.

The expedition failed with dire consequences when his ship was caught and crushed in ice. Leaving 22 of his crew behind, he set off to sail 800 miles in the Southern Ocean in a covered lifeboat to South George Island.

There, Shackleton was able to summon help and rescue without any loss of life. The vision, stamina, and courage of this historic rescue are vividly portrayed in the reenactment attempted in 2012 using traditional equipment of that era: http://shackletonepic.com/2013-expedition/.

“Shackleton’s key message was people putting aside differences, pulling together and achieving a goal against very difficult odds,” stated Tim Jarvis, expedition leader.

One of the greatest thinkers of all times, Stephen William Hawking was recently portrayed in a biographical sketch. His father, Frank, studied medicine and became the head of the division of parasitology at the National Institute for Medical Research. Stephen’s life has and continues to be one punctuated by the most brilliant achievements in theoretical physics and cosmology, as well as daunting health challenges and disability.

During his college studies, he was diagnosed with motor neurone disease and given just two years to live. It was his relationship with Jane Wilde that gave him the will to live and continue his studies. They became engaged in October 1964. Many years later, in the middle of writing “A Brief History of Time,” Stephen became critically ill and it was recommended that he be removed from life support. Jane refused, he ultimately recovered, and once again she saved his life. Today at age 72, Stephen Hawking continues to push the boundary of human knowledge and is an inspiration for people the world over.

“Researchers turn adult cells back into stem cells,” reads the recent headline in the press. This discovery unlocks a remarkably simple and unexpected way to create stem cells that can become any of the diverse type of cells in the body. This frontier will revolutionize transplant medicine.

The third story of human inspiration is that of Dr. Charles Vicanti creating the future of medicine that we are yet to discover. An anesthesiologist by training at Brigham and Women’s Hospital, he and his brother, Dr. Joseph Vicanti, are two of the original researchers in the area of tissue engineering. Dr. Vicanti envisions his work as not necessarily growing whole new replacement organs, but rather augmenting the function of existing failing organs to the point of adequate function. There is a vast ocean of ideas and answers yet to be discovered.

This month’s Bulletin has a great collection of interesting and informative articles: • Travel with one of our physicians on a Médecins Sans Frontières (Doctors Without Borders) medical mission in South Sudan.

• Learn about the importance of POLST (Physician Orders for Life-Sustaining Treatment) from Drs. Frank Mueller and True McMahan.

• Dr. Ken Yew makes an environmental and health perspective case for why your next car should be an electric or hybrid.

• Q&A with Ovidio Bermudez, MD, and Jennifer Sommer, MS, RD, Eating Recovery Center, on the dual diagnosis of eating disorder and Type 1 Diabetes.

• How can we better coordinate patient care with technology that improves communication?

• Could use of the leased copier in your office result in a milliondollar HIPAA fine!?

• What are the new health laws in 2014?

Read on, tap into your inner resources, push your boundaries, and find new ways to contribute, while creating your own future!

Joseph S. Andresen, MD, is the editor of The Bulletin. He is board certified in anesthesiology and is currently practicing in the Santa Clara Valley area.

JANUARY/FEBRUARY 2014 | THE BULLETIN | 5

MESSAGE FROM THE SCCMA PRESIDENT

SAMEER V. AWSARE, MD, FACP President, Santa Clara County Medical Association

A Community-Based Approach to Advance Care Planning

By Sameer V. Awsare, MD, FACP President, Santa Clara County Medical Association

and Bradley Stulberg Over the past 150 years, death in America has migrated from the home, to hospitals and nursing homes, where approximately 80% of deaths occur today. Death has been taken from the hands of family members and placed under the watch of physicians and other health care professionals.

A story that many of us know too well is of a patient who declines faster than expected, and loses the ability to speak for him or herself, leaving loved ones to make decisions on their behalf. Advance care planning — always too early, until it is too late — never occurred, and with no record of conversation or advance directive for health care on file, a family finds themselves stuck between a rock and the hardest place. There are never right answers in this situation, only guesses that have dire consequences for those that are forced to make them. To that end, research has shown a significant increase in the prevalence of depression and post-traumatic stress disorder in surviving family and friends when they are forced to make life or death decisions on behalf of their loved ones in the absence of prior and well-documented advance care planning conversations.

Unfortunately, this scenario is not uncommon. According to the CDC, only 30% of patients prepare advance directives in an effort to maintain autonomy during periods of incapacity or at the end of life. In addition, the support trial showed that even when a patient had an advance directive on file, about 50% of the time the patient’s wishes were not followed at the point of care. This could be for many reasons, from a lack of necessary information systems to a cultural bias to extend life at all costs, or from the patient’s health care agent not clearly understanding the patient’s wishes. While having a legally-appointed health care agent to speak on a patient’s behalf can help counteract these issues, an even smaller number of people are likely to have had meaningful conversations with their health care agent that would prepare that individual (i.e., their health care agent) to make a decision, if necessary.

In addition to the consequences for patients and families illustrated above, a lack of advance care planning impacts the health care system as a whole. A significant portion of health care’s high costs can be attributed to end of life care, where the price of long and drawn out ICU stays and aggressive life-prolonging treatments are extremely high. It would be one thing if we were certain that everyone wanted this type of care, but generally speaking, we have no real idea what people want, and the little that we do know suggests most people do not want the most aggressive care.

6 | THE BULLETIN | JANUARY/FEBRUARY 2014

The vast majority of Americans say they want to die at home, yet a recent survey of California residents shows that only 32% do.

The current state of making health care decisions in the midst of acute crises, often guessing what a loved one would want, and defaulting to the most aggressive treatment is suboptimal and carries a great risk of delivering care that is not in agreement with a patient’s wishes. It also yields high costs for care that may be of no value to patients (or in some cases, of negative value). The good news is that it doesn’t have to be this way and there are already places in America where comprehensive advance care planning is the norm.

A glimpse of this can be found in La Crosse, Wisconsin, where Gundersen Health System pioneered a program called Respecting Choices, which is a systematic approach to advance care planning that is built upon: • Detailed conversations with patients and their health care agents • Highly trained facilitators to guide the conversations • Structured and easily accessible documentation Respecting Choices has been adopted by much of the health care community in La Crosse, and as a result, the majority of the population in La Crosse receives care that is aligned with their documented preferences.

A recent review of the deaths that occurred in La Crosse showed that an astounding number of the patients (96%) had either a written advance directive or a Physician Order for Life-Sustaining Treatment that identified the patient’s choices about medical treatments at the end of life. These were readily available to the patient’s family and health care professionals; hence, there was a 99% consistency between decisions made on behalf of patients and their expressed wishes. Sure, La Crosse, Wisconsin, is just one small Midwestern town, but the approach and its proven record of success are replicable. For instance, a large group of health care providers in the Twin Cities has started working on their commitment to implementing this type of coordinated approach to advance care planning.

If any geography is capable of developing a more integrated approach to advance care planning, you’d think it would be right here in Silicon Valley! While there are various ways to ensure an advance directive and an activated health care agent, once those elements are in place, the final step to facilitating appropriate care is that clinicians have this information available to them at the bedside. Against that backdrop, we should harness the technological know-how right here in our own backyard to develop a system that would allow all of us to have the knowledge needed to do

Continued on page 39

Sameer V. Awsare, MD, FACP, is the 2013-2014 president of the Santa Clara County Medical Association. He is a board certified internist and is currently practicing with The Permanente Medical Group in Campbell.

MESSAGE FROM THE MCMS PRESIDENT

KELLY R. O'KEEFE, MD President, Monterey County Medical Society

Information Overload: Techniques For Physicians to Handle It

By Kelly R. O’Keefe, MD President, Monterey County Medical Society As I was reading the November/December issue of The Bulletin, one of the articles made me think about information overload and the ways physicians manage it. Information overload is an every day companion for all practitioners of medicine. Just typing, “information overload medicine” in a search engine yields more than two-and-a-half-million hits, including scholarly articles, problems arising from, and strategies for coping with information overload. Typing in the more general term, “keeping up with medicine,” produces more than 28 million hits.

The magnitude of information resulting from the growth of medical knowledge is difficult to visualize. A hint of that magnitude is given by the fact that we have chosen to change technologies during the past few years just to access the fruits of that growth. The Index Medicus was the technology used for over a century to give access to, and incidentally to track the growth of, that knowledge. Many of you probably used that in your training; I know I did. The Index was a comprehensive index of medical journal articles that was published for 125 years and that was a cornerstone of many medical libraries. In 2004, the National Library of Medicine stopped publishing the Index Medicus. It had grown to an unwieldy collection of volumes estimated to weigh more than 150 pounds, and the corresponding electronic database of the medical literature, PubMed, had become widely available by then. In five years, PubMed contained information on more than 18 million citations from the medical literature and was adding over two-thirds of a million new entries per year. Today, at 23 million entries and counting, even PubMed has become so large that most physicians look for more efficient ways to keep up with the medical literature and medical knowledge. It may be difficult to decide if the technologies for keeping up with new information are really part of the solution, or just another part of the problem.

In addition to this enormous volume of biomedical literature, physicians have become increasingly aware of other domains of knowledge and expertise that have direct bearing on the wider practice of medicine: informatics, computer science, and engineering in the technical arena, economics and business, and law and politics, among others. And I believe we have individually sought to find a balance of our investment of time and money to efficiently access knowledge in the domains that seem important to us.

Many of us start with CME, because it is a required element of our professions, but that selection still allows us many choices of method;

journal-based CME, conferences, on-line courses, and more. The choices come with a price tag of free to a few thousand dollars, but they all call for an investment in time. Each of the domains of knowledge, in which we are interested, calls for some combination of costs for knowledge acquisition.

There are many online CME courses or tutorials in non-medical domains that are free of financial costs; they just take time. Of course, we can take a college-level course or two with a commensurate cost in money and time.

Recently, massively open online courses (MOOCs) have become popular ways to access college-level courses relatively inexpensively and with good time flexibility. They might be a good option if we are among the 10% or so who complete the typical course. With a more demanding goal in mind, we might even invest four nights a week for four years, plus study time, plus tuition for a law degree, assuming we decided that taking three years away from practice would put us even further into medical “information overload” when we tried to catch up. Or we could invest Fridays and Saturday stays in San Francisco for two years, plus a little less than $200,000, for a prestigious executive MBA. I could go into overload just sorting out the options.

How is all of this relevant to an article I was reading in The Bulletin?

The article was the 2013 California Medical Association’s Legislative Wrapup. When I read that article, I thought about the enormous investment in time that would be required on each of our parts if we wished to add federal and California legislative and regulatory domains of knowledge to our already “information overloaded” lives – to track all the legislative and regulatory activities that allowed a focus on the 50 or so bills that were called out in the article. I considered the financial burdens if we were to attempt to influence these domains individually, and if that would even be possible. I also realized how much more efficiently we manage those tasks as organized medicine rather than individually, how a small investment of our time in providing input to our chapters, societies, and associations, and perhaps a slightly larger investment in leading them for a time, and how the financial investment we make in supporting these organizations pays enormous dividends. Being a part of organized medicine certainly seemed the efficient choice to me.

Kelly R. O’Keefe, MD, is the 2013-2014 president of the Monterey County Medical Society. He is a board certified pathologist and is currently CEO of Adaptive Clinical Solutions, Inc. JANUARY/FEBRUARY 2014 | THE BULLETIN | 7

8 | THE BULLETIN | JANUARY/FEBRUARY 2014

The California Legislature had an active year passing many new laws affecting health care. Below are highlights of the new laws likely to impact physicians this year and beyond. For more details, see “Significant New California Laws of Interest to Physicians for 2014,” in the California Medical Association’s online resource library at www.cmanet. org/resource-library.

ALLIED HEALTH PROFESSIONALS

AB 1000 (Wieckowski) – PHYSICAL THERAPISTS: DIRECT ACCESS TO SERVICES (CMA Position: Support / Co-Sponsor) Allows physical therapists to treat patients for 45 days or 12 visits without first seeing a physician. Requires a physical therapist to refer a patient to a physician if the condition is beyond the therapist’s scope of practice or if the patient is not progressing, to disclose to the patient any financial interest he or she has in treating the patient, and with the patient’s authorization, notify the patient’s physician that the physical therapist is treating the patient. Specifies that professional corporations, including medical corporations, are not limited to employing those licensed professionals that are listed in Corporations Code §13401.5.

AB 1308 (Bonilla) – MIDWIFERY Removes physician supervision over licensed midwives.

Specifies conditions of a normal pregnancy and childbirth and requires a licensed midwife to refer clients who do not meet these conditions to a physician for examination. Requires Medical Board to adopt regulations specifying those certain conditions.

Authorizes a licensed midwife to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing, and receive necessary reports consistent with the scope of practice. Requires disclosure to prospective clients of the specific arrangements for referral of complications to a physician and surgeon, and to obtain consent of those disclosures.

CONFIDENTIAL INFORMATION

SB 46 (Corbett) – PERSONAL INFORMATION: PRIVACY Amends existing law that requires notification to individuals whose unencrypted computerized personal information was, or is reasonably believed to have been, acquired by an unauthorized person due to a breach of security of a computerized system or data. Revises certain data elements included within the definition of personal information by adding certain information that would permit access to an online account. Imposes additional requirements on the disclosure of a breach of security of the system or data in situations where the breach involves personal informa-

tion that would permit access to an online or email account.

SB 138 (Hernandez, E.) – CONFIDENTIALITY OF MEDICAL INFORMATION Specifies the manner in which a health care service plan or health insurer would be required to maintain confidentiality of information regarding the treatment of an insured, including a requirement to accommodate requests to receive requests for confidential communication of medical information in situations involving sensitive services, including requests by dependents insured under a health insurance policy held by another person, or situations in which disclosure would endanger the individual.

Authorizes a health care provider to communicate information regarding benefit cost-sharing arrangements to the health care service plan or health insurer. Prohibits health plans from conditioning enrollment in the plan or eligibility for benefits on the waiver for certain rights provided for in the bill.

DRUG PRESCRIBING AND DISPENSING

AB 635 (Ammiano) – DRUG OVERDOSE TREATMENT: LIABILITY (CMA Position: Support) Authorizes a licensed health care provider, who is permitted by law to prescribe an opioid antagonist and is acting with reasonable care, to prescribe and subsequently dispense or distribute an opioid antagonist for the treatment of an opioid overdose. This is permitted to treat a person at risk of an opioid-related overdose or a specified person in a position to assist a person at risk of an opioid-related overdose. Authorizes these licensed health care providers to issue standing orders for the distribution of an opioid antagonist.

SB 809 (DeSaulnier) – CONTROLLED SUBSTANCES: REPORTING (CMA Position: Support) Funds the Controlled Substance Utilization Review and Evaluation System (CURES) for the electronic monitoring of the prescribing and dispensing of controlled substances by assessing an annual fee on practitioners authorized to prescribe, order, administer, furnish, or dispense controlled substances, non-governmental clinics and non-governmental pharmacies. Establishes the CURES Fund within the State Treasury. Requires the Medical Board to periodically develop and disseminate education materials relating to the assessment of a patient’s risk of abusing or diverting controlled substances and information related to CURES to physicians and general acute care hospitals. Eliminates notarization requirement for application process and requires health care practitioners and pharmacists to apply to obtain approval to access CURES after January 1, 2016. Requires the Department of Justice in conjunction with the Department of Consumer Affairs and relevant licensing boards to develop a streamlined applicaContinued on page 10 JANUARY/FEBRUARY 2014 | THE BULLETIN | 9

2014 New Health Laws, from page 9 tion and approval process to access CURES and enable health care practitioners and pharmacists with access to CURES to delegate their authority to order reports from CURES.

HEALTH BENEFIT EXCHANGE

SB 28 (Hernandez, E.) – CALIFORNIA HEALTH BENEFIT EXCHANGE Requires the California Major Risk Medical Insurance Board to provide the California Health Benefit Exchange (Covered California) with specified information to assist in conducting outreach to subscribers to notify them that they may be eligible for coverage through the Exchange or Medi-Cal. Implements various provisions of the Affordable Care Act relating to determining eligibility for the Medi-Cal program. Requires the Department of Health Care Services (DHCS) to authorize individuals to select Medi-Cal managed care plans via the California Healthcare, Enrollment, and Retention System.

CA SBX1 3 (Hernandez, E.) – HEALTH CARE COVERAGE: BRIDGE PLAN Requires the California Health Benefit Exchange (Covered California), by means of selective contracting, to make a bridge plan product available to specified eligible individuals, as a qualified health plan (QHP). Exempts the bridge plan product from certain requirements that apply to QHPs, relating to making the product available and marketing and selling to all individuals equally (guaranteed issue) outside the Exchange and selling products at other levels of coverage. Requires the Department of Health Care Services to include provisions relating to bridge plan products in its contracts with Medi-Cal managed care plans. Requires Covered California to evaluate three years of data from the bridge plan products, as specified.

HEALTH CARE COVERAGE

SB 161 (Hernandez, E.) – STOP-LOSS INSURANCE COVERAGE (CMA Position: Support) Prohibits a stop-loss insurer from excluding any employee or dependent on the basis of specified actual or expected health status-related factors. Establishes regulatory requirements for stop-loss insurance policies for small em-

ployers, including requiring a stop-loss insurer to renew all stop-loss insurance policies at the option of the small employer and prohibiting setting individual attachment point of $40,000 or greater and an aggregate attachment point of the greater of $5,000 times the total number of group members, 120% of expected claims, or $40,000 for a policy year or providing coverage for an employee or his or her dependents. Exempts small employer stop-loss insurance issued prior to September 1, 2013, from these attachment point requirements.

CA ABX1 2 (Pan) – HEALTH CARE COVERAGE (CMA Position: Support if Amended) Establishes health insurance market reforms contained in the Affordable Care Act specific to individual purchasers, such as open enrollment, prohibiting insurers from denying coverage based on preexisting conditions, insured claims experience as part of a single risk pool, the use of certain factors in determining individual plan rates, insurance advertising and marketing, small employer enrollment periods and coverage effective date and premium rates, a risk adjustment program, insurance data reporting, and insurer disclosure requirements; and makes conforming changes to small employer health insurance laws resulting from final federal regulations.

HEALTH CARE FACILITIES AND FINANCING

AB 980 (Pan) – PRIMARY CARE CLINICS: ABORTION Imposes the same licensing and building standards to all primary care clinics, including those that provide abortion services. Grants the Office of Statewide Health Planning and Development emergency regulatory authority to implement these provisions and requires the Department of Public Health to repeal certain regulations relating to abortion services in primary clinics by July 1, 2014.

AB 1202 (Skinner) – OCCUPATIONAL SAFETY AND HEALTH STANDARDS (CMA Position: Support) Requires the Occupational Safety and Health Standards Board to adopt a standard for the handling of antineoplastic drugs, primarily

10 | THE BULLETIN | JANUARY/FEBRUARY 2014

cancer drugs, in health care facilities regardless of the setting. Requires the standard to be consistent with and not exceed specific recommendations adopted by the National Institute for Occupational Safety and Health for preventing occupational exposures to those drugs in health care settings.

SB 191 (Padilla) – EMERGENCY MEDICAL SERVICES (CMA Position: Co-Sponsor) Extends the operative date to January 1, 2017, of existing law that establishes the Maddy Emergency Medical Services Fund, which authorizes each county to establish an emergency medical services fund for reimbursement of costs related to emergency medical services and funding for pediatric trauma centers, and authorizes county boards of supervisors to elect to levy an additional penalty upon fines, penalties, and forfeitures collected for criminal offenses.

Makes technical, non-substantive changes to the provisions.

MEDI-CAL

SB 94 (Senate Budget and Fiscal Review Committee) – MEDI-CAL: MANAGED CARE: LONG-TERM SERVICES AND SUPPORTS (CMA Position: Oppose) Amends existing law regarding the Coordinated Care Initiative (CCI) and separates CCI provisions to allow the mandatory enrollment of Medi-Cal and Medicare beneficiaries (dual eligibles) into Medi-Cal managed care, the integration of long-term supports and services into managed care plans, and the commencement of the In-Home Supportive Services Statewide Public Authority, to proceed separately from the CCI Duals Demonstration Project (now called Cal MediConnect).

SB 494 (Monning) – HEALTH CARE PROVIDERS (CMA Position: Support ) Increases the number of beneficiaries assigned to the panel of a full-time equivalent primary care physician under a Medi-Cal managed care plan. Requires a health service plan to ensure that there is at least one full-time primary care physician for every 2,000 enrollees. Authorizes the assignment of up to an additional

1,000 enrollees to the primary care physician for every full-time non-physician medical practitioner supervised by that physician. Requires the Medi-Cal program to evaluate the location, hours, and language capabilities of practitioners and adds non-physician medical practitioners (physician assistant or a nurse practitioner) to the definition of a primary care provider.

MEDICAL EDUCATION

AB 94 (Committee on Budget) – EDUCATION FINANCE: HIGHER EDUCATION Higher education budget trailer bill that allocated $15 million dollars to the Regents of the University of California, Riverside School of Medicine.

AB 565 (Salas) – CALIFORNIA PHYSICIAN CORPS PROGRAM (CMA Position: Sponsor) Amends the Steven M. Thompson Physician Corps Program to require the guidelines for the selection and placement of program applicants to include criteria that would give priority consideration to program applicants with experience providing health care services to medically underserved populations or in a medically underserved area. Gives priority to applicants who agree to practice in those areas and serve a medically underserved population, and give priority consideration to applicants from rural communities who agree to practice in a physician owned and operated medical practice.

Amends the definition of “practice setting” to include a physician owned and operated medical practice setting that provides primary care located in a medically underserved area.

PROFESSIONAL LICENSING AND DISCIPLINE

AB 1288 (Perez, V.) – STATE MEDICAL BOARDS: LICENSING: APPLICATION PROCESSING (CMA Position: Sponsor) Requires the State Medical Board and the Osteopathic Medical Board of California to develop a process to give priority review status to the application of an applicant who can demonstrate that he or she intends to practice in a medically underserved area or serve in a medical underserved population.

SB 304 (Lieu) – HEALING ARTS: BOARDS This bill is the sunset extension bill for the

Medical Board containing statutory and technical changes to provisions relating to Medical Board review by appropriate legislative committees, issuance of a license to a physician and surgeon who has acquired any part of his or her education from an unrecognized medical school who has held licensure in another state or Canada, reporting an electronic address to the Board, licensed midwives, adverse event reporting, fines for failure to provide health care records by a facility, and Medical Board investigations.

SB 670 (Steinberg) – PHYSICIANS AND SURGEONS: DRUG PRESCRIBING PRIVILEGES (CMA Position: Support) Authorizes the Medical Board, in any investigation that involves the death of a patient, to inspect and copy the records of the deceased patient without authorization of the beneficiary or personal representative of the deceased patient or a court order to determine the extent to which the cause of death was the result of the physician and surgeon’s violation of the Medical Practice Act, if the board provides a written request to the physician that includes a declaration that the board was unsuccessful in locating or contacting the deceased patient’s beneficiary or personal representative after reasonable efforts.

Revises definition of unprofessional conduct to include repeated failures by a licensee who is the subject of an investigation, in absence of good cause, to attend and participate in an interview by the board. Clarifies the authority of the administrative law judge to issue an interim order limiting the authority to prescribe, furnish, administer or dispense controlled substances.

PUBLIC HEALTH

AB 446 (Mitchell) – HIV TESTING (CMA Position: Support) Requires a medical care provider or a person administering a HIV test to provide a patient with information about risk reduction strategies and information regarding test results. Requires oral or written informed consent as specified for the HIV test except when a person independently requests an HIV test from an HIV counseling and testing site and requires the person administering the test to document the person’s independent request for the test. Exempts clinical laboratories from the informed consent requirements. Requires an HIV test to be offered to any patient having blood drawn at a primary

care clinic and consents to the test. Authorizes disclosure of HIV test results by secure Internet website posting.

REPRODUCTIVE ISSUES

AB 154 (Atkins) – ABORTION (CMA Position: Support) Allows nurse practitioners, certified nurse midwives, and physician assistants to perform an abortion by medication or aspiration techniques in the first trimester of pregnancy if he or she completes training and validation of clinical competency and is working pursuant to specified standardized procedures that specify the extent of physician supervision, and procedures for transferring patients to the care of a physician or a hospital, obtaining assistance and consultation of the physician and providing emergency care until physician assistance and consultation is available. Deletes references to nonsurgical abortions.

AB 460 (Ammiano) – HEALTH CARE COVERAGE: INFERTILITY (CMA Position: Support) Requires that health care service plan and health insurer coverage for the treatment of infertility be offered and, if purchased, provided without discrimination on the basis of age, ancestry, color, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex, or sexual orientation.

SB 460 (Pavley) – PRENATAL TESTING PROGRAM: EDUCATION (CMA Position: Support if Amended) Requires the Department of Public Health to include prescribed information regarding environmental health in the California Prenatal Screening Program patient educational information and to post that information on the department’s website. Requires the Department of Public Health to send a notice to all distributors of the patient educational information that informs them of that change and encourages obstetrician-gynecologists and midwives to discuss environmental health with their patients.

These are just a sampling of the new laws impacting health care in 2014 and beyond. For a complete list, see “Significant New California Laws of Interest to Physicians for 2014,” in the California Medical Association’s online resource library at www.cmanet.org/resource-library.

JANUARY/FEBRUARY 2014 | THE BULLETIN | 11

PRACTICE MANAGEMENT

Communication: The Glue for a Functional Accountable Care Organization

By Tracey Haas, DO, MPH Imagine your grandmother is hospitalized after suffering a heart attack. To everybody’s relief, she receives state-of-the-art medical care in a top-notch hospital a mere 10 miles from home.

On discharge day, she is sent home with a long list of instructions, new medications, and a recommendation she follow-up with her primary care doctor within the week.

A few days pass and she notices her feet begin to swell, even a little shortness of breath.

She calls her doctor and books an appointment in three days – the soonest her doctor can see her. Not two days later, however, her breathing becomes more labored. Not knowing what to do, she calls 9-1-1 for an ambulance trip back to the ER, where she is diagnosed with congestive heart failure, a complicated illness to treat.

What’s the moral of the story? It’s that this situation, while fictitious, has happened and continues to happen to thousands of Americans. And the root cause is much less about a failure of one person’s heart as opposed to the failure of a very procedure-oriented and highly disconnected medical system.

Enter the Accountable Care Organization, or ACO, which is considered by some to be the medical system of choice in the (near) future.

In an ACO, the same grandmother is given the same level of hospital care, but this time her primary care doctor is notified upon her release and given a brief synopsis of her hospital course and new medications. Courtesy of a secure communication platform used by physicians and support staff, the hospitalist even receives a “read” notification to ensure the message gets through to the primary care doctor.

The next day, the primary care doctor’s office schedules a follow-up for 48 hours later.

At the appointment, her doctor notices a slight swelling of the feet, something the untrained eye might miss. Her medication is immediately altered, and a home nursing visit is scheduled for the next day, and three times per week for the next two weeks.

Using the same mobile communication platform as the hospital and family care doctor, the home health nurse sends timely updates about your grandmother’s new vital signs,

weight, and other changes to her condition.

Your grandmother is now able to start an inhome rehabilitation program. Even better, she has avoided a costly return to the hospital and prolonged illness.

With just one mobile message and a single face-to-face visit, the primary care doctor was kept at the center of her care. What’s more, previously unreimbursed costs like the hospitalist and primary care physician providing transitional care from the hospital to home are now billable thanks to new CPT codes, making nonface-to-face patient care financially sustainable for a family practice physician.

The bottom line is that an ACO network must be able to communicate timely to coordinate care across loosely-affiliated health care organizations, if it hopes to ensure optimal patient outcomes and lower health care costs for patients and providers alike.

This win-win-win scenario is actually already happening – the hospitals and payers save money by avoiding a readmission, the primary care doctor gets rewarded for good care, and most importantly, the patient is kept healthy.

The key to this success is deceptively simple: communication.

In my experience, doctors are always motivated to do the right thing for their patients – but without good communication, they are simply not armed with all of the information needed to help their patients.

Solving the problem of poor communication between health care professionals is a huge task, but with solutions like DocbookMD, intuitive, simple steps like bringing hospitalists and primary care doctors together through a trusted, secure communication community can be done today with a few taps on your mobile device.

If communication is the “glue” that can help ACOs operate successfully, then DocbookMD is helping connect disparate health care companies like the good old Elmer’s glue we all grew up with in grade school.

For more information about DocbookMD and its recent launch of Docbook Enterprise for hospitals and groups, please visit us at: http:// docbookmd.com.

Tracey Haas, DO, MPH, is Chief Medical Officer and Co-Founder of DocbookMD, a HIPAA-secure communication solution for physicians, hospitals, and groups. Dr. Haas is Board Certified in Family Medicine and is passionate about helping physicians and their medical staff use technology to help them save time, money, and lives. Learn more at docbookmd.com.

12 | THE BULLETIN | JANUARY/FEBRUARY 2014

Prevent Costs.

ProteCt ACCess.

Protect Access to Quality Health Care and Patient Privacy – Oppose the Costly MICRA Measure

This November, these trial attorneys will ask voters to weigh in on “The Troy and Alana Pack Patient Safety Act,” which would make it easier and more profitable for lawyers to sue doctors and hospitals. This measure, according to California’s independent Legislative Analyst, could increase state and local government malpractice and health care costs by “hundreds of millions of dollars annually,” ultimately placing the burden of this additional cost on all of us.

As it stands now, county and state hospitals have to pay medical malpractice awards out of the budgets they receive from taxpayers. If medical malpractice awards increase, government costs will increase too. Somebody has to pay, and that will be taxpayers through higher taxes and California citizens through higher health care costs.

Additionally, this measure would vastly increase the number of lawsuits filed in California. That’s why the independent Legislative Analyst says that county and state hospitals will see costs of tens of millions of dollars that taxpayers will have to pay.

newsletter article

You may be aware of a trial attorney-sponsored ballot measure that would undermine the protections afforded to patients across California as part of the Medical Injury Compensation Reform Act (MICRA).

The California Medical Association (CMA) has joined a broad coalition of doctors, community health clinics, hospitals, local governments, public safety, business and labor to oppose the proposed November ballot proposition. Visit www. cmanet.org/micra for more information about what CMA is doing in this fight and how to get involved.

Not only would this measure cost patients across the state, it’s a misleading measure intended to fool voters. Written by trial attorneys, the measure makes it easier and more profitable for lawyers to sue doctors and hospitals — even if that means higher health costs for the rest of us. Our health laws should protect access to care and control costs for everyone, not increase lawsuits and payouts for lawyers.

You’ll hear a lot of rhetoric from the proponents of the measure but really, this is another example of a special interest trying to fool the voters into thinking this is about something that it’s not. The authors of this proposal purposely threw in non-MICRA provisions, like drug testing doctors, to disguise the real intent, which is to increase the limits on medical malpractice awards so that trial lawyers make even more money. The main proponent of the measure was recently quoted in the Los Angeles Times, saying, “The drug rules are in the initiative because they poll well, and the backers figure that’s the way to get the public to support the measure. ‘It’s the ultimate sweetener.’”

This measure also requires a government database with personal information on patients’ prescription drug history.

Hackers have already managed to access personal information from millions of Target customers and even the Pentagon, and another big database will only make our information more vulnerable.

Physicians take an oath to protect patients – and this dangerous initiative would put patients at risk of losing access to quality medical care.

Community health care clinics, like Planned Parenthood, say this measure will raise insurance costs that will cause specialists, like OB/GYN’s to reduce or eliminate services to their patients. Finding doctors to deliver children in rural areas and community clinics is already difficult and reducing services will make a bad situation worse.

Over 1,000 groups have joined together in support of MICRA and in opposition to this dangerous, costly measure. Be part of the effort to protect patients by visiting www.cmanet.org/micra today!

MICRA Toolkit 2014

8

JANUARY/FEBRUARY 2014 | THE BULLETIN | 13

KUDOS FOR SCU STUDENTS The medical community and alumni of Santa Clara University can be proud of a select group of students devoted to the service of humanity.

Spring break is generally a time to relax and rejuvenate, and perhaps raise a bit of mischief, but not for these. They spend their time administering medical aid to the poor in foreign countries. In preparation, the Bronco students work at least two jobs during the school year to pay for their own transportation and living expenses for their chosen foreign assignment. This coming spring break will be spent in Ghana. Photos are from last year’s assignment in Ghana. For a description of a past assign-

14 | THE BULLETIN | JANUARY/FEBRUARY 2014

ment in East Panama, please access the following website: http://www.scu. edu/fyi/blog.cfm?.

There is a current plea for donations of money and medical supplies (excluding medications), which they must bring with them. To donate, please contact Mike Wallace at SCU by email at mjwallace@scu.edu or phone at 650/799-8436. For any questions, contact Mel Russi, MD, by email at mfrussi@comcast.net.

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3803 S Bascom Ave Suite 200, Campbell, CA 95008 JANUARY/FEBRUARY 2014 | THE BULLETIN | 15

Do you or your staff scan patient health records on a leased copy machine? You might be violating the Health Insurance Portability and Accountability Act (HIPAA), putting private patient data at risk and opening yourself up to massive fines and other penalties. Many of these copy machines have an internal memory that, unless proper safeguards are in place, may allow unauthorized people to access patient data.

The U.S. Department of Health and Human Services (HHS) recently released new regulations that made important changes to the privacy and security requirements under HIPAA. These new regulations, known as the HIPAA Omnibus Rule, implement many of the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The new rules took effect in March and physicians had until September 23, 2013, to update practice policies and procedures to comply with the new regulations. Are your policies and procedures up-to-date?

While the copier infraction is not new, it does illustrate how physicians and medical office staff must think about potential risks to protected patient health information and identify and improve privacy and security vulnerabilities in office business practices.

In this instance, a New York health insurer called Affinity Health Plan really got a shock when it was informed by CBS Evening News that, as part of an investigatory report, it had purchased a photocopier previously leased by Affinity that still contained protected health information (PHI) for over 300,000 patients.

In August 2013, the federal Office for Civil Rights (OCR), which is charged with enforcing the HIPAA privacy laws, settled with the plan for a $1 million. The investigation revealed that Affinity failed to incorporate the electronic PHI stored on the photocopier hard drives in its analysis of risks and vulnerabilities as required by the HIPAA security rule and failed

16 | THE BULLETIN | JANUARY/FEBRUARY 2014

to implement policies and procedures for securing or deleting that data when returning the photocopiers to its leasing agent.

If you think that you are too small a practice to run afoul of HIPAA, think again. Small practices are not exempt from the HIPAA requirements and any physician practice that uses electronic means to engage in designated transactions, including any of the following: health claims, remittance or payment advice, claim status inquiries, eligibility inquiries, enrollment and disenrollment, referral certification and authorization, coordination of benefits or health plan premium payments, the physician is a covered entity and must comply with HIPAA or be subject to enforcement actions.

BUT WILL OCR COME AFTER THE LITTLE GUYS?

OCR has initiated enforcement actions on practices big and small.

Last year, a small cardiac surgery practice in Arizona agreed to pay a $100,000 settlement fine after it was found to have been sending PHI through an unsecured web-based email program. In addition to using unsecured email to send PHI, the practice was also posting patient appointments on an Internet-based calendar, which was publicly accessible.

With a careful assessment of their business practices and risks, physicians should be able to implement HIPAA compliance plans in their practices to protect patient information and reduce their risks of violating HIPAA and state privacy and security laws.

WHAT’S NEW?

Some of the key changes made by the HIPAA Omnibus Rule include, but are not limited to, an updated definition of a business associate, new rules surrounding certain permitted uses and disclosures of PHI, such as

the sale of PHI and the use of PHI for fundraising and marketing, and rules controlling how patients can obtain medical records that are kept by a physician electronically. It also made significant changes to the PHI breach notification rule.

Physician offices will, at minimum, need to review and update their business associate agreements, office privacy and security policies and notice of privacy practices in order to bring their offices into compliance with the new rule.

In the end, your practice doesn’t have to be locked down like Fort Knox, but you must be able to demonstrate that your practice has taken “reasonable” measures to protect the privacy and security of PHI. Each practice will differ in some detail. As doctors and staff learn more about HIPAA, your staff should be able to determine what you need to do if you have not already implemented your safeguards.

This means using appropriate and reasonable administrative, technical, and physical safeguards for all health information. Every staff member has an obligation to protect this information. This includes keeping doors properly locked, keeping computer passwords secret, securely transporting, and using portable and mobile computers and devices that access PHI, and speaking softly when discussing medical information in publicly accessible areas. The law also requires every practice to designate a Privacy and Security Official, whether it is the physician, an associate, or staff member, to oversee the practice’s HIPAA compliance plan. This person will be key to developing and implementing policies and procedures, receiving complaints, knowing where documentation of your processes are kept, responsible for thinking ahead about compliance and can help or

lead your office through an audit.

This person needs to understand computers, but does not have to be a “techie.” They will, however, require some education and some support.

Information technology (IT) is involved, but this is NOT an IT project.

Keeping your practice in compliance with HIPAA will ultimately require the whole organization’s cooperation and support.

WHERE CAN WE GET HELP?

The California Medical Association (CMA) has a number of resources that are useful in understanding and for getting medical practices practice up to par on the HIPAA rules. These and other resources are available at http://www.cmanet.org/hipaa.

Sample Documents: For more information and for an updated sample notice of privacy practices and business associate agreement, see the California Medical Association’s (CMA) On-Call documents #4101 “HIPAA ACT SMART: Introduction to the HIPAA Privacy Rule” and #4103 “Business Associates.” These documents are available free to members. Nonmembers can purchase documents for $2 per page.

On-Demand Webinar: CMA recently hosted a webinar, “HIPAA Compliance: The Final HITECH Rule,” available for on-demand playback at your convenience.

Frequently Asked Questions: CMA has produced a brief resource document, “HIPAA Omnibus Rule Compliance Frequently Asked Questions,” which answers common questions about the new HIPAA regulations.

HIPAA Compliance Toolkit: The CMA/PrivaPlan HIPAA Toolkit is a comprehensive online resource to assist physicians in complying with the HIPAA privacy and security rules and California law. It contains detailed sample forms, policies, procedures for compliance tailored for California physicians, training materials and resources to help physicians with implementation and planning. CMA members can purchase the toolkit from PrivaPlan by calling 877/218-7707 or visiting PrivaPlan’s website, http://www.privaplan.com. The cost is $325 per practice for members or $495 for nonmembers. Annual updates to this program cost $75 for CMA members. A coupon code is required to access this discount. Visit http://www.cmanet.org/benefits or call CMA’s member service center at 800/786-4262 to obtain the code.

HIPAA Training Tool: PrivaPlan also offers an online HIPAA Training Tool that is an easy and affordable way to train staff. This comprehensive course can be taken online at anytime, anywhere. It features videos and online quizzes to help just about anyone understand HIPAA and what policies and procedures must be put into place. CMA members can purchase the HIPAA Training Tool at $129 for CMA members or $169 for nonmembers.

For more information and resources, visit http://www.cmanet.org/ hipaa.

Palliative Care and POLST

By Frank Mueller, MD Palliative care services help improve the quality of life of seriously ill patients, improve patient and family satisfaction, and reduce lengths of stay and readmission rates. Currently, there are active palliative care programs in more than 50% of United States hospitals – and the number is growing. Palliative care units could be in place in 84% of U.S. hospitals by next year. Palliative care programs are proving to be useful for helping patients and families, while at the same time resulting in effective cost savings for the health care system. Medicaid patients who received palliative care incurred $6,900 less in hospital costs than matched controls receiving no palliative care.

The goal of palliative care, according to the Center to Advance Palliative Care (CAPC), is to match the patient’s goals of care with a medicallyeffective treatment plan. Palliative care: • Addresses the physical, emotional, spiritual, and social concerns that arise with advanced illness.

• Is appropriate for patients in all stages of illness.

• Uses consultants who often co-manage patients in active, life-prolonging treatment along with oncologists and other specialists, taking an active role in relieving suffering and controlling symptoms.

• Helps prepare patients and families for the tough decisions that will face them and for the outcome that disease portends: the changes in performance status and quality of life, and in some cases, the specter of death from the illness.

• Emphasizes continued care when cure may no longer be possible.

Palliative care programs are associated with improved symptom control, increased family satisfaction, and transitioning patients to the appropriate level of care. Several studies now show that patients receiving palliative care early in their illness lived longer and with better quality of life, including decreased depression.

One tool used in palliative care that helps to ensure that the patient’s wishes for care are followed is the Physician Orders for Life-Sustaining Treatment (POLST) form. POLST states what kind of medical treatment patients want toward the end of their lives, and is a document that, with the participation and signature of the physician, transforms the patient’s goals into a physician order. For patients who have been diagnosed with a terminal illness or who have less than one year to live, the POLST form is an appropriate way to record the patient’s wishes and goals of care in an immediately actionable physician order.

Here is an example of POLST at work in a palliative care setting.

John, 73, has advanced COPD, and presented to the emergency room in respiratory failure. He is on day five in the ICU and on the ventilator for the fifth time, now with bilateral pneumonia, and is fully vent-dependent.

Consent must be obtained for a tracheostomy. The intensivist and surgeon are ready to proceed, but have asked the palliative care consultant to see John and his family. The consultant arrives, sedation is withheld, and John is alert. At the time of his last hospitalization, John’s doctor helped him to understand and fill out a POLST form. At the bedside family meeting, John’s wife tearfully reports that after his last time on the vent, John told her “never again.” John hears this and confirms the decision he made in 18 | THE BULLETIN | JANUARY/FEBRUARY 2014

his POLST form for comfort measures only. The palliative care consultant counsels the family, talks with the intensivist and surgeon, and is able to assure them all that this is what John really wants. The consultant arranges for control of pain, anxiety and dyspnea, comforts the family and supports the staff, while the withdrawal of life support protocol is carried out.

Thirty minutes later, John dies peacefully and comfortably with his family at his side.

Palliative care and the POLST form combined can assure that a seriously ill patient’s wishes will be followed at the end of life and that they will get the care that they want and deserve.

The California Medical Association (CMA) publishes a POLST kit, available in English and Spanish, which includes legal forms and wallet identification cards, and answers many of the most frequently asked questions about end-of-life issues. These kits are available in CMA’s online resource library at http://www.cmanet. org/resource-library.

For more information on palliative care and POLST, visit http:// www.coalitionccc.org and http://www.capc.org.

POLST: Improving Patient Care in the Emergency Department

By True McMahan, MD Emergency department (ED) physicians are a very diverse group of providers. Some of us are cavalier, shooting from the hip as called for by the situation at hand. Others are meticulous and obsessive planners, taking no chances, and casting a wide net of differential diagnoses. But MOST, if not all of us, work in a daily melee of balancing a multitude of patients with emergency medical conditions, all the while putting out administrative fires and juggling family and visitors. Is it any wonder, then, that we crave simplicity? Why not have one less decision, one less stack of nursing home records and advance directive jargon to sift through? That is the beauty of the bright-pink POLST form that I have come to know and love.

POLST stands for Physician Orders for Life Sustaining Treatment.

Since 2010, when I first learned of this initiative to simplify and standardize end-of-life wishes, I have been a passionate supporter of its implementation. My hope is that by the end of this article, a few more physicians will

be persuaded to join with me in promoting this valuable tool.

First of all, what is it? POLST is a doctor’s order that delineates specific medically-appropriate measures desired by the patient or his/her surrogate decision maker should the patient become seriously ill, mostly what we ED physicians and providers call “code three” patients. It is a single piece of paper and is bright pink so that it is easily recognized in a stack of medical records. When used correctly, the POLST follows the patient from acute care to primary care. Stories of its utility include EMS finding it hanging from a patient’s refrigerator when neighbors called 9-1-1 and the patient lived alone, and designated health care agents having electronic versions and emailing or faxing a copy to the ED while they are en route.

I challenge all providers in the ED and acute care setting that as physicians we not only have a duty to treat, but to only treat as the patient’s dignity and health goals require. Paternalistic medicine serves to help no one. Non-beneficial care leads to more emotional pain and financial devastation than we realize. As for the ED practitioner, taking a few seconds to find that POLST form, even if hidden in the stack of papers brought in by the paramedics, may mean the difference of peace for patients and their survivors or end-of-life trauma and havoc.

Because the POLST form requires the patient or family to have the courageous conversation about end-of-life wishes BEFORE the crisis, it allows that moment of crisis to be expected, allows us emergency providers to be facilitators of thoughtful care, while taking the guesswork out of hectic, desperate situations. For me, finding that pink POLST form brings calmness to the gathered team of resuscitators. As I read aloud the wishes delineated on that form, I am able to provide care as if I had just consulted the patient and family, and I can perform that care under the grace of the Hippocratic Oath and with the grace of a doctor who cares about what the patient or family would want.

JANUARY/FEBRUARY 2014 | THE BULLETIN | 19

By Ken Yew, MD The Tesla Model S has been a game-changing vehicle that has finally popularized fully electric cars and captured the public’s imagination. Unfortunately, the base price of $62,400, which includes the $7,500 federal tax credit, is too steep for many buyers. In addition, while new charging stations are being built everyday, there is considerable concern over being able to go anywhere you want, even with the 300 mile range of the top performing model.

As a practical matter, does it make sense to spend the money on an electric car? Are there less expensive options that still let you save on fuel costs and reduce car emissions?

While not as sleek as the Tesla, hybrid cars have a backup gas engine that allows you to drive anywhere, and can still give the type of fuel economy that can translate to significant savings.

TOYOTA PRIUS: THE FIRST SUCCESSFUL HYBRID

According to Toyota, the name “Prius” is a Latin word meaning “to go before” and was chosen because it came before environmental awareness in cars became an issue.1 When Prius was first marketed in 1999, the average fuel efficiency of light-duty vehicles in the U.S. was 21.4 mpg.2 The Prius, boasting an mpg of 50 mpg, was truly ahead of its time.

The latest version of Prius has been through three generations of refinement and offers 134 horsepower and a relatively spacious interior. Base price starts at $23,215. U.S. News & World Report ranks it 11th out of 22 affordable midsize cars and named the 2013 model the Best Hatchback for Families.3 While not particularly thrilling to drive, the ride is comfortable and storage space in the hatchback compartment and the interior is generous. For those looking for a versatile hatchback with excellent fuel economy and low cost, the Toyota Prius is a winner.

How much do I spend on gasoline? I drive about 350 miles before filling up again, which translates to my filling up the 10-gallon tank every other week. This costs me a little over $30.

20 | THE BULLETIN | JANUARY/FEBRUARY 2014

CHEVY VOLT: PLUG-IN WITHOUT ANXIETY

The Volt is powered by two electric motors with a backup gas engine that powers the motors when the battery is depleted. Despite its use of electric motors, the car is very responsive and provides enough power for all possible driving situations.

Its biggest advantage compared to the Prius, however, is the battery power which allows the Volt to travel 40 miles on a single charge. The average American travels about 30-40 miles a day, usually to and from work and around town.4 So for daily needs, a Volt driver can easily get around town without accessing the gas tank at all. The battery takes four hours to charge with a special 240-volt car charger that you can have installed in your home, or ten hours with a standard 120-volt outlet.

The backup gas engine uses a nine gallon tank that gives an extra 300 miles of range once the battery is depleted. Eliminating range anxiety is a big feature of the Volt compared to other electric cars.

For the first few months after purchasing the Volt, I didn’t fill up the gas at all. Then I depleted the battery just to make sure that the gas engine would work. There was no feeling of transition, when the power switched over. The motor behaved the same, with the same power and handling.

The ride remained very smooth and responsive. I filled up the tank after using one gallon, which cost a few dollars. Then I charged the car overnight and stopped worrying.

One big criticism of the Volt, by reviewers, is the lack of interior space.5 The front seats have plenty of room, but the back has two bucket seats instead of the single “couch” that many people are used to. The dog hates this arrangement. Those of you who use the back seat as another storage area may feel restricted in this regard. Also, the trunk has enough room, but not as much as the Toyota hatchback.

ARE YOU REALLY HELPING THE ENVIRONMENT?

A recent study by researchers at MIT estimated that pollution caused by motor vehicles results in almost 6,000 premature deaths in California annually.6 About 40% of Californians live in close proximity to a freeway or other busy traffic, which is the most of any state in the U.S. This greatly increases health risks from respiratory and cardiovascular illness, as well as cancer risk.

In November, a coalition of environmental groups, public health, and community advocacy groups launched a campaign to improve California’s air quality by putting one million electric vehicles on the road within ten years. The Charge Ahead campaign’s supporters include the American Lung Association, Communities for a Better Environment, Sierra Club, and National Resources Defense Council.7 California is one of eight states that has agreed to help launch 3.3 million electric vehicles on the roads by 2025. Leaders in California, Oregon, Washington, and British Columbia signed the Pacific Coast Action Plan on Climate and Energy, which calls for scaling up the use of electric vehicles.8 Increasing the use of electric cars would not only decrease tailpipe emissions, but would also keep dollars spent on fuel within the state, instead of out of state, or overseas to purchase oil and gas. Producing those vehicles and the infrastructure needed to charge them would create over 100,000 new jobs in California by some estimates.7 So, supporting electric vehicles is probably better for the environment and for California’s economy. As they gain in popularity, the infrastructure needed for reliable public charging will develop to the point where range anxiety is no longer an issue. With long range electrics like the Tesla, there already appears to be ample public charging, as well as web pages like the one from the Alternative Fuels Data Center9 or smartphone apps like

PlugShare which help you find public chargers. As economies of scale kick in, the cost of these vehicles will, hopefully, also come down.

In the meantime, I’m keeping my Volt. I keep the Prius for the dog.

REFERENCES

1. http://www.toyota.com/about/news/product/2009/01/12-1-Prius. html 2. http://www.rita.dot.gov/bts/sites/rita.dot.gov.bts/files/ publications/national_transportation_statistics/html/ table_04_23.html 3. http://usnews.rankingsandreviews.com/cars-trucks/Toyota_ Prius/ 4. http://www.fhwa.dot.gov/ohim/onh00/bar8.htm 5. http://usnews.rankingsandreviews.com/cars-trucks/Chevrolet_ Volt/ 6. Caiazzo, F. et al “Air Pollution and Early Deaths in the United States. Part 1: Quantifying the Impact of Major Sectors in 2005” Atmospheric Environment (79): pp.198-208 7. http://www.prweb.com/releases/2013/11/prweb11335259.htm 8. http://www.pacificcoastcollaborative.org/Documents/Pacific%20 Coast%20Climate%20Action%20Plan.pdf 9. http://www.afdc.energy.gov/locator/stations/route/

JANUARY/FEBRUARY 2014 | THE BULLETIN | 21

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2930 Aborn Square Road, San Jose Neighborhood shopping center with wide array of retail tenants with Ross Dress For Less anchor.

Cupertino

3425 S. Bascom Ave, Campbell Excellent Corridor for Medical/ Dental or Professional Offices Small Atrium Suites Available with Windows, Renovated Restrooms Elevator Served.

Have you

980-1,305 SF AVAILABLE

4155 Moorpark Ave, San Jose Great medical location at Saratoga & Moorpark Ave. Convenient freeway access, excellent price!

3,318 SF AVAILABLE

743 S. Winchester Blvd, San Jose

825 Pollard Road, Los Gatos Great medical building, steps away from El Camino Hospital.

Ground floor unit, TI dollars available.

1,557-4,332 SF AVAILABLE

10353 Torre Ave, Cupertino Rare medical/dental suite available at Torre Professional Ctr. Excellent Cupertino location with EZ access to hwy 85 & 280.

Walking distance to city hall.

877 W. Fremont Ave, Sunnyvale Foothill Medical-Dental Center is a 6 plus acre medical project in the heart of Sunnyvale. Various medical and plumbed (dental) suites available. Call for best rate!

scan me to see

had your

Office Checkup?

our latest availabilities

Call us for your Office Checkup!

(408) 217-6000

Build to Suit Opportunity

14910 Los Gatos Blvd, Los Gatos Parcel: 21,400 SF. This is a BTS Opportunity . Call for more info.

PLEASE DO NOT DISTURB TENANT.

500-1,500 SF AVAILABLE

5150 Graves Ave, W. San Jose Small medical office and fully plumbed dental office space available. TI’s Available.

2,090 SF AVAILABLE

189 N. Bascom Ave, San Jose Fully plumbed dental suite available for LEASE. EZ access to Hwy 280 & 880. Space is divisible.

1,974 SF AVAILABLE

2,190 SF AVAILABLE

15215 National Ave, Los Gatos Professional Medical/Dental bldg.

Easy access ground floor unit. TI $ available for qualified tenants.

1,356-1,483 SF AVAILABLE

Rare purchase opportunity in Los Gatos. Attractive SBA Financing Avalable. Walking distance to DT.

2081 Forest Ave, San Jose Los Gatos Medical, Dental or Retail uses allowed. Great Los Gatos Boulevard location. Easy freeway access. Close to Good Samaritan Hospital Call today for the best rate and to schedule a tour.

Are you in the best location?

Are you paying too much for

BRAND NEW exterior! Located close to Willow Glen, Cambrian & Los Gatos. EZ access to 880, 17

233 Oak Meadow Drive, Los Gatos

1,300-1,806 SF AVAILABLE

15075 Los Gatos Blvd,

2242 Camden Ave, San Jose

For Lease or SALE $1.5M

14911 National Ave, Los Gatos Medical Suite Available. Great location with easy Fwy access and close to Good Samaritan Hospital.

760-5,000 SF AVAILABLE

850-1,080 SF AVAILABLE

2011 Forest Ave, San Jose

Medical Office Bldg. with established Medical Dental Suites Available. tenants located directly adjacent to Close to O’Connor Hospital. Great O’Connor Hospital. Flexible terms FWY Access. Available NOW. TI’s Available.

HealthMed Realty is a Full-Service Commercial Real Estate Firm specializing in Medical & Dental Real Estate. Put our experience on your side and we will save you time and money.

Call us today! (408) 217-6000

690 Saratoga Avenue | Suite 200 | San Jose, CA 95129 408.217.6000 T | 408.457.8803 F www.healthmedrealty.com | Lic# 01902032 ithout notice.

PRACTICE MANAGEMENT

Confused About What To Do About Your Health Insurance?

With Covered California, the Affordable Care Act, the Individual Mandate, Platinum, Gold, Silver, Bronze plans and all the changes this year, are you still confused about what you need?

Everyone has to have insurance or pay a penalty. Individuals will be able to buy their insurance from the private market or Covered California without regard to pre-existing conditions during the open enrollment period ending March 31, 2014. Individuals will also be able to purchase insurance if they lose their coverage through loss of a job or other qualifying event.

For example, if their policy is terminated on

their first policy anniversary in 2014, they can move to individual plans without regard to preexisting conditions.

Individuals with incomes below 400% of the Federal Poverty level will qualify for a tax subsidy to lower the cost of their insurance premium to an affordable level. In order to receive this tax subsidy, health insurance must be purchased through Covered California, the Statesponsored insurance exchange.

Small groups from 2 to 50 may also qualify for a tax credit and if they do, they will need to purchase their health insurance through the SHOP portion of Covered California. The vast

majority of small groups will continue to purchase their insurance through the private market. Plan designs have changed radically however, so members may need assistance to find the best plan for their practice.

We can help eliminate the confusion by working with you to find the coverage that fits your situation. Whether we help you place your individual or small group health insurance through the private market or through the Covered California exchange, call a Mercer Client Advisor today at 800/842-3761 or email CMACounty.Insurance.service@mercer.com.

You Work to Protect Your Patients…

We Work to Protect You As a physician, you probably know better than anyone else how quickly a disability can strike and not only delay your dreams, but also leave you unable to provide for your family. Whether it is a heart attack, stroke, car accident, or fall off a ladder, any of these things can affect your ability to perform your medical specialty.

That’s why the Association/Society sponsors a Group Long-Term Disability program underwritten by New York Life Insurance Company: • Benefits not tied to a practice, giving you more flexibility with potential career changes • Benefit payments that are 100% TAX-FREE — when you pay premiums yourself • High monthly benefits up to $10,000

24 | THE BULLETIN | JANUARY/FEBRUARY 2014

• Protection in your medical specialty for the first 10 years of disability With this critical protection, you’ll have one less thing to worry about until your return.

Learn more about this valuable plan today! Call Mercer for free information, including features, costs, eligibility, renewability, limitations, and exclusions, at 800/842-3761.

Underwritten by New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010. Under Group Policy No. G-29322-0 on Policy Form GMR-FACE/29322-0.

BILLING COLLECTIONS CONSULTING ACCURATE

CONSISTENT

KNOWLEDGEABLE

THE BUREAU OF MEDICAL ECONOMICS Competitive pricing and superior service for your billing, collection, and consulting needs.

HONEST FAIR ACCOUNTABLE

Committed to providing superior billing and collection services to physicians and other professional providers of health services while upholding the professional integrity of those we represent since 1947.

A rate of recovery over twice the national average.

Call (408) 998-5811 x 3034 • 1 (888) 543-7497 Email karen@bmesc.org • www.bmesc.org

Legacy Wealth Advisors

Managing the reserve investment accounts of the Santa Clara County Medical Association (SCCMA) and the Bureau of Medical Economics (BME) since 2000 1900 The Alameda Suite 510 San Jose, CA 95126 P: (408) 452-7700 F: (408) 452-7470 Email: Info@lwallc.com

Wealth Management

Legacy offers a broad range of wealth management services to SCCMA and MCMS physician members and their families. Such services include: • Financial Planning, Risk Management, Educational & Retirement Planning Projections • Liquidity Management and Cash Flow Analyses • Estate Tax and Charitable Planning • Existing Portfolio Analysis • Design and Implementation of Investment Strategies

Member Savings!

Legacy offers a one-hour complimentary financial planning check-up to Association members (this is a $500 savings). For more information, please call Lawrence Pizzella at (408) 452-7700 or email lawrence@lwallc.com

www.lwallc.com

JANUARY/FEBRUARY 2014 | THE BULLETIN | 25

The Dual Diagnosis of an Eating Q & A With Eating Disorder and Recovery Center’s Ovidio Bermudez, MD, and Type 1 Diabetes: Jennifer Sommer, MS, RD In our effort to promote education and raise awareness about eating disorders and type 1 diabetes, Eating Disorders Resource Center (EDRC) is honored to submit this article with permission of Juvenile Diabetes Research Foundation (JDRF). For more information about EDRC, including educational program for your staff, support groups, and help finding a treatment team, you may call 408/356-1212 or visit www.edrcsv.org.

26 | THE BULLETIN | JANUARY/FEBRUARY 2014

Q: What is ED-DMT1?

A: The dual diagnosis of an eating disorder and type 1 diabetes is often referred to as “diabulimia,” although this is not a medically recognized term and it is not an accurate description. This syndrome is termed among health care professionals as “ED-DMT1,” which represents this dual diagnosis in an individual with type 1 diabetes. ED-DMT1 describes the intentional misuse of insulin for weight control. This could be caused by decreasing the prescribed dose of insulin, omitting insulin entirely, delaying the appropriate dose, or manipulating the insulin itself to render it inactive. Any of these actions can result in hyperglycemia (high blood glucose levels) and glucose excretion in the urine, which causes weight loss. So, in a sense, calories are “purged” this way, which is where the term diabulimia stems from. However, a person suffering from ED-DMT1 may not be diagnosed with bulimia or have any symptoms of bulimia such as binge eating and self-induced vomiting, or only withhold insulin after they have binged (whether it be a true binge or just a larger-than-typical amount of food) as a method of purging. People suffering from ED-DMT1 may exhibit any number of eating disorder behaviors—or they may only manipulate their insulin and otherwise have normal eating patterns.

Q: How many people in the United States have ED-DMT1?

A: It is unclear exactly how many people in the United States have ED-DMT1. What is a striking statistic is the percentage of people who have type 1 diabetes who also have an eating disorder or disordered eating.

A study by Patricia Colton, MD, a psychiatrist at the Eating Disorders Program at Toronto General Hospital, found that 7%-35% of girls and women with type 1 diabetes met the criteria for what is termed a “sub-threshold” eating disorder, meaning they display symptoms of an eating disorder, but may not meet the full criteria. In that study, 0%-11% met the criteria for a full-syndrome eating disorder. These are pretty dramatic numbers when you compare them to the non-diabetic population. Rates in the general female population vary from 1%-2% for bulimia nervosa and 0.5%-1% for anorexia nervosa.

There are several factors contributing to the heightened risk of developing an eating disorder among people with type 1 diabetes compared to the non-diabetic population: • Necessary emphasis on food and dietary restraint associated with diabetes management. Carbohydrate counting and meal planning are important parts of diabetes management, and this can create an unhealthy focus on food, numbers, and control.

• Weight gain associated with the initiation of insulin treatment, which can be uncomfortable physically and emotionally.

• Psychological and emotional effects of having to manage a chronic medical condition such as type 1 diabetes. While there is no precise way to measure this impact, we do know that depression has been reported to be more prevalent in individuals with diabetes compared to the general population.

• The temptation factor—insulin manipulation is an effective, although dangerous, method of weight loss, which makes it difficult to resist if someone is struggling with eating disordered thoughts or poor body image.

Q: What are the clinical signs and symptoms of ED-DMT1?

A: The most salient clinical sign of the dual diagnosis of ED-DMT1 is weight loss. Another major sign is poor blood-glucose control, especially if the person previously had good control. People with chronic insulin

deficiency, in this case self-imposed, experience hyperglycemia, recurrent or persistent ketonuria, and these symptoms can often lead to recurrent episodes of diabetic ketoacidosis (DKA). Symptoms can also include polydipsia (excessive thirst), polyuria (frequent urination), and polyphagia (increased hunger). Other signs that clinicians look for are growth failure in adolescents, severe recurrent episodes of hypoglycemia, and higher than usual hemoglobin A1c levels (especially in spite of good blood sugar records, which may be falsified by the individual). General signs of disordered eating such as dieting, binge eating, abnormal behaviors or rituals around food, or refusal to eat in the presence of others, as well as constant or frequent talk about weight, body image, exercise and/or food, could also be indicators of a problem.

Q: What are the complications that can arise from the dual diagnosis of ED-DMT1, and why are these complications significant?

A: There are both acute and chronic complications associated with the dual diagnosis of ED-DMT1. Both acute and chronic complications can be serious and even deadly. Insulin deficiency leads to hyperglycemia.

Hyperglycemia, in turn, leads to damage of small vessels, so called “microvascular damage” and damage of nerve cells, specifically peripheral nerves. In type 1 diabetes, the rate at which microvascular disease and peripheral nerve damage occurs has been more closely correlated with the length of suffering from the disease. In the dual diagnosis of ED-DMT1, the degree of hyperglycemia allowed or induced by these patients is so significant, that the rate of onset and later progression of severity of both microvascular disease and peripheral nerve damage is greatly accelerated.

The complications most frequently seen in all types of diabetes are retinopathy, nephropathy, and cardiopathy and these are related to microvascular disease. The other frequently seen complication is peripheral neuropathy which can manifest with pain, tingling, and numbness of hands and feet.

Another serious concern is the increased mortality risk – in one study, the risk of death for the dual diagnosis of ED-DMT1 was 17-fold compared to type 1 diabetes alone and seven-fold compared to anorexia nervosa alone.

Q: How is ED-DMT1 treated?

A: As with the treatment of all eating disorders, a multidisciplinary team approach is necessary. A medical doctor, therapist, and registered dietitian (preferably all with expertise in the care of this condition) would be the minimum needed to manage ED-DMT1. The first step is medical stabilization, which in severe cases will require hospitalization. The goal of any treatment approach is to normalize the use of insulin, normalize blood glucose levels, normalize the patient’s weight, and avoid acute and chronic complications of insulin deficiency and hyperglycemia. If the patient is engaging in other destructive behaviors such as excessive exercise, or purging, or suffering from co-occurring psychiatric conditions like anxiety or depression, then these must be interrupted and treated as well. Severely underweight patients with ED-DMT1 may be at risk for refeeding complications including re-feeding syndrome. Patients with an eating disorder, including those with ED-DMT1, should be assessed for psychiatric risk including that of suicide as the clinical scenario indicates.

These patients often understand the risks that come from their manipulation of insulin, so efforts to increase their education about risks of poorly managed diabetes alone are not an effective deterrent. In our experience, sustainable recovery is possible and usually attained by those who, after interrupting the symptoms, embark on a process of identifying their personal values and life priorities.

JANUARY/FEBRUARY 2014 | THE BULLETIN | 27

MEMBER SPOTLIGHT

Picture with the kala-azar inpatient group

My MSF Mission at Yida Refugee Camp in South Sudan October/November 2013

By Seham El-Diwany, MD This was my fifth mission to Africa and the second with Médecins Sans Frontières (MSF), also known as Doctors Without Borders. Prior missions were to Kenya, Zambia, the Congo (DRC), and Egypt, my native homeland. Each mission lasted four weeks on average. Despite the similarities in the medical problems, each mission brought new experiences and exposure to new cultures. Sadly, however, after my MSF missions, there was renewed violence either close by or in the very same region 28 | THE BULLETIN | JANUARY/FEBRUARY 2014

Examining an infant’s ear in outpatient clinic

where the MSF mission was located. From my daily interactions with staff and patients, there were no indications that conflicts were brewing and that violence would erupt at any moment.

My MSF mission in South Sudan was at the Yida Refugee Camp, which is located in Unity State at the very north of South Sudan, near the borders of Sudan. The camp housed approximately 70,000 refugees who came primarily from the Nuba Mountains and South Kordofan which are part of Sudan. The camp occupied approximately 3,000 acres. The MSF facility consisted of an outpatient department (average 10,000 consultations per month), a 50-bed inpatient department, and a mobile clinic for outreach in case of outbreaks of epidemics. MSF is also involved in water supply and latrine construction in the refugee camp. The Yida Camp has been designated by South Sudan’s government as a transit site not suitable for hosting

A child with hand burn presenting to outpatient clinic

With IRC midwives after finishing the resuscitation training workshop

Our modest kitchen refugees over a prolonged period of time, which limited the range of services that aid workers can offer to refugees. I was primarily involved in the outpatient clinic, with call duties every other night, covering the emergency room tent and the inpatient department. Besides pediatric patients, I also looked after adult patients, which I haven’t done since my flexible internshiptraining year.

Arabic (with a heavy local dialect) is the prevailing spoken language in the refugee camp.

English is also widely spoken, but mostly as a second language, with widely varying degrees of proficiency. The majority of patients spoke only Arabic. My language skills in Arabic, English, and French were highly prized – much to the surprise, and probably shock of many patients, that someone in MSF speaks to them directly in their native language. Scaling down the lan-

Attending our weekly medical meeting with our cat, Crest

Continued on page 30 JANUARY/FEBRUARY 2014 | THE BULLETIN | 29

My MSF Mission at Yida Refugee Camp, South Sudan, from page 29 guage barrier made it much easier to train the clinic staff, who also spoke English, and to teach a two-day neonatal resuscitation course to the midwives of IRC (International Rescue Commission) of the UNHCR (United Nations High Commissioner for Refugees) in charge of 80% of the deliveries in Yida.

A typical day started at 8:15 a.m., with signout rounds and clinic at 8:30 a.m. The outpatient clinic resembled an emergency room with all sorts of infections: pneumonia, bloody diarrhea, and UTI, STI, ear and skin infections, in addition to seizures, hypertension, diabetes, asthma, and dehydration. Schistosomiasis, kala-azar, filariasis, and malaria are prevalent in this area of Africa.

Friday was the TB clinic day for patients in initial intensive or

Our high-tech shower with open roof

Waiting area in outp

Brunch on a Sunday, with MSF colleagues 30 | THE BULLETIN | JANUARY/FEBRUARY 2014

atient clinic

in remission phases. Patients with chronic conditions return once a month to refill their medication and for a quick check-up. Vaccination of children and adults was a top priority for MSF in Yida Refugee Camp. The clinic had eight outpatient consultants that are basically local nurses trained to evaluate and treat uncomplicated cases. All complicated cases are discussed with the outpatient physician. I was also in charge of screening all cases before they could be admitted, and wrote their admission orders to assist with the inpatient work flow during the day. Before my arrival to Yida, a Hepatitis E epidemic outbreak had peaked among the refugees and I continued to see about three to five cases each week. These cases were managed together with the community health worker, who would take the newly-diagnosed patients from the clinic back to their tents and educate them about all precautions to prevent further transmission of the disease.

Among the interesting cases was a case of rheumatic fever returning to the clinic for follow-

ing t Examin

nt clinic utpatie o in y le famil he who

up, walking and smiling after she was treated with an IM dose of penicillin and aspirin orally. Another case was of a middle-aged woman brought by the community health worker because the husband expressed concerns about her mental health deterioration. She

National nurse weighing a premature baby

Tending to

a patient

with an a bscess

wa s diagnosed with pellagra (dementia, diarrhea, and dermatitis.)

It was remarkable to see how oral treatment with nicotinamide was what she needed for recovery. It was not uncommon to see toddlers presenting with severe burns from the fire pits used for cooking. I learned to do the initial treatment of these burns under procedural sedation. I also learned to I&D abscess – including breast abscess, get sutures done, even on lips, and to cast broken bones after using my x-ray vision (no x-ray machines were available).

Despite the long hours and being on-call every other night, life in the evening in the MSF compound was quite interesting and relaxing. There were socializing events from time to time with MSF staff, the UN, and other NGO staffs. These included a Halloween costume party, a movie night once a week, and nice brunches on Sundays. French was the socializing language mostly spoken among the expats within the compound, in addition to English.

Mental illness, such as PTSD, is not uncommon among the refugees after many years of war. This is not always a priority compared to physical wounds, but MSF is taking steps to approach mental health of the refugees in a meaningful way.

It has been my privilege to work with so many dedicated physicians and support staff at the MSF Yida Refugee Camp. I admire their courage and perseverance in working under such stressful conditions for such prolonged periods of time. My hopes and prayers are for their safe return after completing their mission.

A child admitted with malaria JANUARY/FEBRUARY 2014 | THE BULLETIN | 31

February 26: Fraud and Abuse: Dangers & Defenses DHCS• 12:15-1:15p.m.

Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the importance of documentation, present suggestions for implementing internal controls, and increase awareness of preventive measures to protect your practice from fraud or abuse.

March 5: HIPAA Security Risk Analysis-How to Make Sense of This Requirement David Ginsberg• 12:15-1:15p.m.

Conducting a HIPAA Security Risk Analysis is a requirement of the HIPAA Security Rule. It is also a CORE Meaningful Use (Stage 1 and 2) measure to earn EHR incentives and avoid Medicare penalties! This webinar reviews what is required to properly fulfill this compliance obligation and at the same time secure your patient's health information. Failure to conduct a Risk Analysis or conducting an insufficient one are among the most common deficiencies found during compliance investigations!

March 26: Physician Practice Options – Self Employment or Group Affiliation Debra Phairas•12:15-1:15p.m.

April 30: Stage 2 Meaningful Use – the 2014 Edition – What You Need to Know!

David Ginsberg• 12:15-1:15p.m.

Many changes are in order for the 2014 edition (Stage 2) of Meaningful Use. This informative webinar will assist you in understanding these changes and how they impact your workflows and use of electronic health records (EHR).

May 14: Merging Practices – Strategies to Remain Independent Debra Phairas• 12:15-1:15p.m.

June 18: Power of the Pen (Prescribing) DHCS• 12:15-1:15p.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 and referring, and increase awareness of fraud and abuse in prescribing and referring.

July 16: Recipe for Financial Success Debra Phairas• 12:15-1:15p.m.

Physicians and office managers need business management skills, particularly in the financial area. This workshop will teach critical skills in analyzing the practice profit/loss statement, accounts receivable ratios and staffing patterns and how to access specialty comparison norms. At least one source of comparison data specific to your medical specialty will be given to each participant.

July 30: What to Expect From Medi-Cal Audit DHCS• 12:15-1:15p.m.

Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the role of utilization oversight and claims monitoring, increase understanding of the audit process and possible outcomes, and understand common problems and methods to improve documentation.

32 | THE BULLETIN | JANUARY/FEBRUARY 2014

Rev.on 1/21/14

September 10: HIPAA Update – Are You Compliant with the Final Omnibus Rule?

David Ginsberg• 12:15-1:15p.m.

The Final HIPAA Rule went into effect in 2013. There are so many changes to HIPAA Privacy, Security, Breach and Enforcement that this rule is referenced as an "Omnibus Rule." Many changes have profound impact on medical practice workflow. Changes are also relevant if you use an electronic health record. This webinar provides an overview of the HIPAA changes and key steps medical practices can take to comply with HIPAA. HIPAA enforcement penalties can be severe for medical practices who are not compliant!

September 17: Managing Difficult Employees and Reducing Conflict in the Practice Debra Phairas• 12:15-1:15p.m.

Very few medical or business schools teach hands-on human resources management skills and techniques.

This information-packed workshop will teach you the secrets of how to lead, coach, and manage difficult employees; set practice values; and reduce conflict in the practice. You will learn how to: • Adopt the strategies, techniques and approaches used by “superstar leaders” to lead, manage and motivate the workers in your practice.

• Set the three values that employees must perform to obtain a raise or risk termination.

• Retain your star performers while weeding out your non-performers.

• How to avoid the most common mistake by adhering to the chain of command.

• How to implement basic conflict resolution skills.

October 1: Family Medicine, Frontline of Care DHCS• 12:15-1:15p.m.

Family Medicine specialists are often gatekeepers under many payor models, and face competing pressures from the patients to gain access, the payors to control cost, and potentially third-party vendors (e.g. durable medical equipment providers) that may offer to help by providing completed referral forms etc. that are not in the physician’s best interest. This webinar will review strategies to help the provider take a pro-active approach to dealing with these external pressures, as well as review basics in documentation, prescribing, referring, and practice management.

October 8: Protect & Preserve Patient Relationship DHCS• 12:15-1:15p.m.

Presented by the Department of Health Care Services (DHCS), this webinar will help you increase understanding and awareness of the impact of fraud, waste and abuse on patient care, and discuss methods to prevent abuse and ways to preserve the integrity of the physician/patient relationship.

October 29: Managing Up! For Managers Debra Phairas• 12:15-1:15p.m.

Managers, Administrators and CEOs in medical practice positions need to successfully learn to supervise staff or manage down, but also to achieve results by influencing their physician bosses by managing up.

Learn techniques from Debra Phairas, President Practice & Liability Consultants, who has worked with over 1700 practices and recruited over 100 Medical Practice Administrators. Topics Include: Qualities Physicians Want in a Manager, Coaching Physicians Toward Productive Meetings, Importance of Strategic Planning, Data Analysis, Cost Benefit, 5 Steps for Presenting Recommendations, and the Toughest Issues for Managers to Mediate with Physicians.

November 19: Medicare: 2015 Changes Michele Kelly(CMA)• 12:15-1:15p.m.

Rev.on 1/21/14

JANUARY/FEBRUARY 2014 | THE BULLETIN | 33

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 OFFICE SPACE TO SHARE • SUNNYVALE

Convenient location. One large private office plus one exam room, shared waiting room and front office. Newly built, total 1,280 sq. ft. Available now. Please call 408/438-1593.

MEDICAL OFFICE SPACE TO SUBLET • MTN VIEW

Mountain View medical office space to sublet. 1,100 sq. ft. Available three days a week.

In large medical complex, behind El Camino Hospital. Basement storage, untilities included.

Large treatment rooms, small lab space, BR, private office, etc. Call Dr. Klein at cell 650/2691030.

MEDICAL OFFICE SPACE FOR LEASE/ SALE • SAN JOSE

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.

Luxury modern 1,300 sq. ft. turn-key office with minor surgery OR. Prime Good Samaritan/Bascom Avenue at Highway 85 location in multispecialty building. Interior amenities and terms negotiable. Email am.1960@yahoo.com.

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE

PERFECT SATELLITE OFFICE • MTN VIEW

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

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.

OFFICE FOR RENT • SAN JOSE

2395 Montpelier Dr #5, San Jose 95116. Rent $2,000 per month. Lease required. Owner pays triple net and monthly H/O dues. Two doctors set up. Three examination rooms. Approximately 1,100 sq. ft., furnished or unfurnished, adequate parking, walk to Regional Med Ctr. Close to X-Ray and lab. Previous tenant doctor retired. Call Marie at 408/268-2040.

Beautiful medical office across from Palo Alto Medical Foundation. Professional office with vaulted ceilings, new interior, digital x-ray, natural light, and Wi-Fi. Trained receptionist to schedule patients, make reminder calls, collect paperwork and insurance info. Rent exam room one to five days per week, excellent office – low overhead. Call 650/814-8506.

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 $1.25/sq. ft. Rent is $1,544/month. Contact Steven Gordon at 831/757-5246.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY

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

We are currently looking for several knowledgeable and progressive primary care and spe34 | THE BULLETIN | JANUARY/FEBRUARY 2014

cialty 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.

INTERNAL MEDICINE PHYSICIAN NEEDED

We are looking for an internal medicine physician for our multi-specialty group. Please email your CV to kaajhealthcare@gmail.com.

FAMILY PRACTICE/URGENT CARE PHYSICIAN WANTED

Currently hiring experienced primary care physician to join two other physicians in well established busy Family Practice/Urgent Care Center in south San Jose. Position is approximately 20 hours a week and offers excellent compensation. No hospital work or call required. Additional hours and partnership possible. No buy in.

Please fax CV to 408/281-4106.

PRACTICE MANAGER

Salinas Pediatric Medical Group, Salinas – seeks an experienced Practice Manager with Accounting/Finance, HR, and Office Administration experience. Degree, plus five years relevant work experience required, including supervision of staff. Great stable work environment, competitive comp, including bonus potential.

Email resume and cover letter, including salary expectations to lauralj@tpohr.com.

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

FOR SALE MEDICAL OFFICE SPACE FOR LEASE/ SALE • SAN JOSE

Luxury modern 1,300 sq. ft. turn-key office with minor surgery OR. Prime Good Samaritan/Bascom Avenue at Highway 85 location in multispecialty building. Interior amenities and terms negotiable. Email am.1960@yahoo.com.

UNIQUE BRAZILIAN ROSEWOOD EXECUTIVE DESK FOR SALE

Tracy Zweig Associates A

REGISTRY

&

PLACEMENT

FIRM

Physicians

Nurse Practitioners ~ Physician Assistants

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Help Create an AIDS-Free Generation Include routine HIV testing for all patients, regardless of their risk status, starting at age 13.

HIV screening is recommended for all patients in all healthcare settings. Persons at high risk for HIV infection should be tested at least annually.

S.C.C.M.A.

8-12-08 For more information and to view a video on how to incorporate routine testing into your practice, please scan the QR code or visit http://bitly.com/bundles/prxinc/2.

JANUARY/FEBRUARY 2014 | THE BULLETIN | 35

In Memoriam Rives C. Chalmers, MD Frederick S. Armstrong, MD Rives C. Chalmers, MD May 13, 1947 - November 16, 2013 SCCMA Past President 2012-13 Frederick S. Armstrong, MD April 9, 1929 - February 2, 2014 SCCMA Past President 1977-78 Fill not your hearts with pain and sorrow, but remember me in every tomorrow.

Remember the joy, the laughter, the smiles, I’ve only gone to rest a little while.

Although my leaving causes pain and grief, my going has eased my hurt, and given me relief.

So dry your eyes and remember me, not as I am now, but as I used to be.

Because, I will remember you all, and look on with a smile.

Understand in your hearts, I’ve only gone to rest a little while.

As long as I have the love of each of you, I can live my life in the hearts of all of you.

36 | THE BULLETIN | JANUARY/FEBRUARY 2014

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38 | THE BULLETIN | JANUARY/FEBRUARY 2014

MEDICAL TIMES FROM THE PAST

Pioneer Physician of Santa Clara Township

By Gerald Trobough, MD SCCMA Leon P. Fox Medical History Committee

DR. HENRY H. WARBURTON (1819 – 1903)

The first physician to establish a practice in Santa Clara Township was Dr. Henry Hulme Warburton. Born in Staffordshire, England in 1819, Dr. Warburton received his medical training in England. He was part of a medical family, as his father and six brothers were all physicians.

For seven years, he practiced with his father, before coming to America in 1844. He practiced medicine in New York City for one year, before moving to New London, Connecticut to become a surgeon on board a whaling ship (The Corea) from 1845 to 1847. In 1847, he landed in Yerba Buena (San Francisco) and set up practice in Woodside, before moving to Santa Clara in 1848. He bought a home near the Santa Clara mission.

During the Gold Rush, Dr. Warburton worked the mines for seven months. Upon his return to Santa Clara, he purchased 320 acres of

farmland. In 1855, he married Catherine Pennell of San Francisco. They had seven children; two of whom died in childhood.

During the cholera epidemic of 1850, Dr. Warburton and a mission physician, Dr. Espinosa, treated many patients. Dr. Espinosa contracted cholera and was successfully treated by Dr. Warburton. As the story goes, Dr. Warburton consumed a lot of brandy during the epidemic, which prevented him from developing cholera.

In the 1850s, Dr. Warburton’s reputation earned him a large practice that included the Washington and Oregon territories. One time, when riding his horse south of San Jose, he wandered into the hideout of a bandit named Joaquin Murietta. The surprised Murietta was about to shoot Dr. Warburton, when one of the bandit’s lieutenants recognized the doctor as the man who had saved his child from diphtheria.

Murietta agreed to spare Dr. Warburton if he promised not to divulge the hideout location.

The doctor happily agreed.

Dr. Warburton attended to the Vasquez family in Santa Clara numerous times. When

the notorious bandit Tiburcio Vasquez was shot and captured in Southern California in 1874, he was brought back to San Jose and was hanged.

The Vasquez family pleaded with Dr. Warburton to treat the bandit’s broken neck in an effort to save his life.

On a trip back to England in 1870, Dr. Warburton convinced one of his brothers and other relatives to move to California. James P. Warburton, MD, arrived and established a practice in San Francisco and Alameda.

The Warburtons built an office and home at 716 Main, in Santa Clara, in 1886. The first floor was his office and the first pharmacy in town; the second floor was their residence. In 1966, his office was relocated to History Park in San Jose.

In February, 1903, while rushing back to his office from a house call, Dr. Henry Warburton collapsed and died at age 83. He had practiced in the area for 56 years, the longest of any physician on the West Coast. In Dr. Warburton’s honor, a street was named in his memory. The Santa Clara Civic Center is currently located on Warburton Avenue.

SCCMA President's Message, from page 6 right by our patients. It is our individual responsibility to develop comprehensive advance care planning programs to elicit our respective patient’s wishes for care. It is our joint responsibility to design a system that will allow us to honor them, whether patients present in your hospital or mine.

I believe that our Santa Clara County Medical Association has a critical role in making community-based advance care planning a reality in our county. SCCMA’s Bioethics Committee, which has representation from every hospital in our county, and which has a culture of innovation (evidenced by the development of Non-beneficial Treatment & Un-

befriended Patient Policies that were adopted in our county and in other areas of our state and nation) would be a perfect place to further study and lead on this issue by spearheading its implementation in our county. Our County Alliance members are also crucial to champion this cause. I want to challenge the physicians, health care professionals, and hospitals in our county to match the performance of La Crosse, Wisconsin, so that the wishes of all of our patients are honored if they are no longer able to speak for themselves.

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PRACTICE MANAGEMENT

COVERED CALIFORNIA ENROLLMENT TOPS 600,000

Covered California (www.coveredca.com), the state’s health benefit exchange, has released new enrollment numbers. As of December 31, 500,108 Californians had officially purchased insurance covered through a plan offered on Covered California’s online marketplace. Of that figure, roughly 85% are eligible for some level of government subsidy.

Additionally, when preliminary numbers from the first two weeks of January are added, the total rises to slightly more than 625,000, according to exchange officials.

“We are pleased that Californians – many for the first time – are getting quality, affordable health insurance to protect themselves and their families,” said Peter Lee, the exchange’s executive director.

Many enrollees in Covered California health insurance plans who paid their first month’s premium by January 15 received health care retroactive to January 1, while Anthem Blue Cross and Health Net exchange enrollees will have until January 31 to pay their first month’s premium.

Enrollees submitting payments after the first month premium deadlines will get coverage starting February 1. The initial open enrollment period continues through March 31.

In addition to those purchasing coverage through the exchange, the state’s Department of Health Care Services also enrolled more than 1.2 million Californians in the state’s expanded Medi-Cal program. Of these enrollees, roughly 630,000 are transitioning directly from an existing Low Income Health Program, while an additional 584,000 are those that were deemed “likely eligible” for Medi-Cal during the Covered California enrollment process.

While exchange officials have touted these figures as a success for the state’s new insurance marketplace, many observers note that enrollment in key demographic groups continues to lag.

Of the roughly 400,000 consumers who responded to questions re-

garding ethnicity, less than 20% identified as Latino. Meanwhile, Latinos make up roughly 46% of the population believed to be eligible for subsidized coverage, as well as more than half of the state’s seven million uninsured residents.

Additionally, nearly half of all those purchasing coverage on the exchange fall in the 45-64 age group, while that group accounts for only 25% of the state’s overall population. This has raised concerns among many that the risk mix of the exchange population will be poor, necessitating significant premium rate increases for next year.

California physicians with questions regarding participation in Covered California are encouraged to visit the California Medical Association’s exchange resource center, which includes a guide to navigating the first months of the exchange. The resource center can be found at www. cmanet.org/exchange.

CMA DEVELOPS SIMPLE TOOL TO IDENTIFY PHYSICIAN PARTICIPATION STATUS IN EXCHANGE PLANS

It is critical that physicians and their staff have a clear understanding of their exchange plan participation status so they can communicate this information to patients before scheduling. It’s equally as important that practices understand the reimbursement rates and other terms associated with the plans with which they are contracted.

Even if you did not intentionally contract with any exchange plans, the California Medical Association (CMA) urges physicians to check their participation status. It is very possible that physicians may be unaware they have been opted into an exchange plan network due to the way that major insurance plans have structured their provider agreements.

If you’ve attempted to look up your exchange plan participation status on the Covered California website, you know that it’s not a straightfor-

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Covered California, from page 41 ward process. Because it is critical that physicians know what plans they are contracted with, CMA has created a quick and easy tool to look up your exchange plan participation status in just a few clicks.

The tool, available to members only, requires simply your first and last name and middle initial and it will tell you which plans list you as a contracting physician (based on data from Covered California as of September 2013, the most recent data released by Covered California). To access the tool, visit www.cmanet.org/exchange-lookup.

Furthermore, because the data currently supporting the CMA search tool is from September 2013, practices should verify their participation status with the respective health plans if the participation information seems incorrect or may have changed since September. Covered California is in the process of issuing December 2013 directories and has updated its online search tool for those plans that have submitted December data.

CMA will update its search tool soon after those directories are made public.

Please note: You will be required to login with a member account. If you have not already activated your web account, visit www.cmanet.org/activate. If you need assistance activating your account, contact CMA’s member service center at 800/786-4262 or memberservice@cmanet.org.

For more information on Covered California, visit CMA’s exchange resource center at www.cmanet.org/exchange. Physician members and their staff also have free access to CMA’s practice management experts at 888/4015911 or economicservices@cmanet.org.

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TEN COVERED CALIFORNIA TIPS FOR PHYSICIANS IN 2014

California’s health benefit exchange, Covered California, is now in full swing. As of January 14, Covered California reports that 625,564 individuals have enrolled, accounting for nearly a quarter of all exchange enrollments nationwide.

For those unfamiliar, Covered California is not itself an insurer.

Rather, it is an online marketplace for health insurance products, where individuals can purchase health insurance products that qualify for the federal premium subsidies. Because Covered California is a marketplace, products offered through it should generally be thought of as commercial health insurance products – as opposed to “public” coverage, like MediCal, where there is a set fee schedule.

Covered California, however, has also taken on the role of active purchaser, meaning that it will behave much like a large employer negotiating coverage terms (e.g., premiums and patient cost-sharing) on behalf of its employees. This, coupled with requirements in federal and state law, has led to a number of important considerations for physicians when contracting with an exchange plan.

Whether your practice is participating or nonparticipating with one or more exchange plans, here are 10 pointers as Covered California takes root in 2014: 1. Verify your participation status and information on Covered California’s central provider directory. Though the directory has improved significantly, the California Medical Association (CMA) continues to find errors in the data. Physicians have reported errors in participation status, board certification, languages

spoken, address, and specialty. To verify your information in the Covered California directory, follow the directions found in CMA’s physician guide, “Surviving the First Month of Covered California” or visit http:// www.cmanet.org/exchange-lookup to use the quick and easy CMA lookup tool.

2. Review any contracts or contractual amendments for exchange participation. If you are participating in Covered California, it may be helpful to undertake a review of any exchange-specific contract provisions, such as exchange-specific rates and policy manuals that may be incorporated by reference. If questions arise, contact the plan-specific contact listed in “Surviving the First Month of Covered California.”

3. Be aware of the off-exchange products that utilize exchange plan networks. Every plan offered in the exchange must also be offered outside of the exchange, using the same network. This has resulted in a number of practices unknowingly seeing patients out-of-network for commercial products that use an exchange network, as these ID cards will not have the Covered California logo on them. For instance, a Blue Shield card may read “individual PPO” in the upper right and list “enhanced PPO” as the product, but only upon further investigation will it show the network as “IFP off exchange,” which is an exchange network.

4. Know who can help patients get more information on exchange plan eligibility and enrollment. For practices getting exchange enrollment questions that they are unprepared to answer, printing out a list of nearby certified enrollment assisters may be helpful. These can be found on the Covered California enrollment assistance website, “Find Help Near You ” (www.coveredca.com/enrollment-assistance).

5. Assess your practice’s policies on extending credit to and collections from patients. Some exchange plans will impose high cost-sharing burdens on patients. Furthermore, the currently-evolving situation of the first month’s premium due date and delays in enrollee welcome packets may make eligibility verification difficult for some patients. Practices should consider their strategies for protecting themselves against such potential financial risks. Please refer to “CMA’s Got You Covered: A physician’s guide to Covered California” for more information.

6. Be prepared for exchange patients in grace period coverage limbo. Exchange enrollees receiving subsidies, currently 85% of those in Covered California, will be allowed three months of premium delinquency before being terminated for non-payment. If a practice renders services to these patients in the latter two months of the three-month grace period, the plan has the option to suspend payment on those claims and deny them if the patient is terminated for non-payment. California will require exchange plans to represent coverage as inactive for those patients in months two and three of the grace period and give notice to certain physicians of record as to the patient’s status. Practices should have a policy in place for when they encounter patients in this period of uncertain coverage. Please refer to “CMA’s Got You Covered: A physician’s guide to Covered California” for more information.

7. Know the participation status of physicians, facilities, and other providers that you refer to or use on a regular basis. Covered California plans will require that physicians provide advance notice to patients if they are being referred to an out-of-network provider or an out-of-network provider is included in their treatment plan. If, however, the provider shows as participating in the plan’s directory, the practice cannot be held liable for the inclusion. Please refer to “CMA’s Got You Covered: A physician’s guide to Covered California” for more information.

8. Be aware of the patient cost-sharing across exchange plans. Covered California will expect participating plans to encourage physicians to consider patient cost sharing when developing a treatment plan. Furthermore, physicians should consider that high out-of-pocket costs for things like brand name drugs, imaging, and specialty care could impact treatment compliance. More information may be found in the Covered California benefit summaries.

9. Let no envelope from a health insurer go unopened too long. Exchange plans are continually developing critical details as to how these plans will operate, especially in the areas of claims and billing. Many of these details are likely to come via policy manual amendments, which could be in a small envelope or email that is easy to overlook. Stay up to date on such significant changes by subscribing to the CMA Practice Resources (CPR) newsletter at www.cmanet.org/cpr.

10. Stay current on significant developments of Covered California that may impact your practice. Stay up to date with exchange developments impacting physicians by subscribing to CMA Alert and CMA Reform Essentials, free newsletters available to both members and nonmembers. See CMA’s newsletter subscription page at www.cmanet.org/ newsletters for more information.

For more information on Covered California and CMA’s exchange resources, visit www.cmanet.org/exchange.

CMA RELEASES FACT SHEETS REGARDING COVERED CALIFORNIA GRACE PERIOD, UPDATES TOOLKIT

Recognizing the Affordable Care Act’s “grace period” provision to be one of the most confounding provisions of the law, the California Medical Association (CMA) has published an FAQ sheet dedicated entirely to helping physicians make sense of the issue.

The fact sheet, “Covered California: Understanding the Grace Period for Subsidized Exchange Enrollees,” is available through CMA’s exchange resource center at www.cmanet.org/exchange.

Federal law allows Covered California enrollees who receive financial subsidies to keep their health insurance for three months, even if they have stopped paying their premiums. This is known as the “grace period.”

The first month of this grace period will be treated normally, and plans must pay for services rendered. In months two and three, however, the health plan may suspend payment for any services provided to these enrollees – and deny the claims if the enrollee’s coverage is terminated for non-payment of premiums at the end of the third month.

In California, health plans will be required to suspend a subsidized enrollee’s coverage if the enrollee has not paid his or her premiums for more than a month. The health plans also will generally be required to notify the enrollee’s physician that the enrollee has entered month two of the grace period.

In addition, CMA’s comprehensive toolkit on Covered California: “CMA’s Got You Covered: A physician’s guide to Covered California, the state’s health benefit exchange” was recently updated to reflect key developments in the exchange including the grace period, how plans are building their exchange networks, how to check physician participation status on the Covered California website (www.coveredca.com) and steps physicians can take if they disagree with their participation status in the exchange plans.

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MEDICO NEWS

SGR payment reform bill moves to full Congress On February 7, the three congressional committees announced a final joint bipartisan, bicameral agreement on the Medicare sustainable growth rate (SGR) repeal and payment reform legislation, H.R. 4015. The agreement of the House Energy Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee reflects the overwhelming support in Congress for eliminating the flawed SGR payment formula and establishing a new more stable Medicare payment system that will protect access to doctors for California’s seniors.

The California Medical Association (CMA) applauds the House and Senate negotiators for their perseverance in moving this legislation forward. The committees were receptive to CMA’s issues, giving small practices more time and funding assistance to transition to the new payment models and ensuring that physicians are involved in the development of the quality measures, clinical projects, and alternative payment models.

And CMA is most grateful that the committees included the Californiaspecific language that will update our state’s outdated Medicare payment localities, while holding the rural localities harmless from cuts.

The bill provides a 0.5% automatic payment update every year for five years during the transition to new payment models. The new system will allow physicians to select from two payment tracks—a fee-for-service

track and an alternative payment model track. The fee-for-service track with the existing quality, meaningful use and value modifier performance programs will provide physicians with potential bonuses of up to 9%. The alternative payment model track will pay 5% annual bonuses and require physicians to accept some financial risk, except for patient centered medical homes.

Most important, the bill eliminates the flawed Medicare SGR once and for all. While the bill is far from perfect, it is a reasonable agreement that was developed in an extremely difficult fiscal and political environment. CMA, the American Medical Association, and organized medicine have fought for a workable framework on which we can continue to improve and build-upon in future years.

However, the bill is not over the finish line. Congress must now marry the policy to the funding sources. It is estimated that Congress will need to find up to $150 billion to fund the bill. There is much work ahead to meet the March 31 deadline. CMA will continue to be involved in every aspect of the bill to ensure its final passage.

We must keep the momentum going to get this bill to the President’s desk.

(CMA Alert, February 10, 2014 issue)

CMS to conduct ICD-10 testing in March On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets.

To help physicians prepare for this transition, the Centers for Medicare & Medicaid Services (CMS) has announced a limited national testing week for current direct submitters (providers and clearinghouses) from March 3 - 7, 2014.

This testing week will give trading partners access to the Medicare Administrative Contractors (MACs) and Common Electronic Data Interchange (CEDI) for testing with real-time help desk support. While participants will not

be able to conduct true end-to-end testing at this time, they will be able to test whether the contractor received a claim and learn whether it was accepted or rejected. The testing will not allow participants to determine whether the claim will be paid or if payment will be reduced.

Billing experts advise physicians to start preparing for the ICD-10 transition now, if they haven’t yet done so. Steps to take include upgrading software systems, testing those updated systems, training staff, and updating payer contracts and fee schedules. The American Medical Association (AMA) offers free educational

resources that can help physicians get started.

The California Medical Association has also partnered with AAPC to provide various ICD10 training courses to members at a discounted rate. For more information, visit www.cmanet. org/aapc.

Registration for the March ICD-10 testing will be required, but currently neither Noridian nor CMS have registration information available. More information is available on both Noridian’s and CMS’s websites (see links at http:// www.cmanet.org/news).

(CMA Alert, January 27, 2014 issue)

Reminder: SLR not accepting 2014 meaningful use attestations until April The California Department of Health Care Services reminds physicians that the State Level Registry (SLR) will not be accepting 2014 meaningful use attestations for the Medi-Cal Electronic Health Record (EHR) Incentive Program until April 1, 2014.

This restriction only applies to 2014 meaningful use attestations.

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adopting, implementing, or upgrading (AIU) to a certified EHR, rather than demonstrating meaningful use, can submit 2014 AIU attestations beginning January 1, 2014.

For more information, visit www.medi-cal.ehr.ca.gov.

(CMA Alert, January 13, 2014 issue)

MEDICO NEWS

Making sense of Medicare payment changes With the new 2014 fee schedule, the temporary halt to the sustainable growth rate (SGR) cut and an interim .5% payment increase, Medicare physicians are understandably confused about what impact these changes will have on their practices. Below is a quick summary of the various Medicare payment changes facing physicians in 2014: 2014 Fee Schedule: While the 2014 Medicare fee schedule contains a 3.7% conversion factor increase, the overall fee schedule is budget neutral due to myriad relative value unit (RVU) changes. These changes will impact providers differently depending on their specialty, codes billed, and geographic region. The revised 2014 fee schedule is available from California’s Medicare contractor, Noridian, at https://med. noridianmedicare.com/web/jeb/fees-news/feeschedules/mpfs.

Sustainable Growth Rate: Congress re-

cently passed a law stopping the 24% Medicare physician payment cut called for under the SGR for three months, and instead provides a 0.5% update through March 31, 2014. The three months gives Congress time to finalize the larger Medicare payment reform legislation.

Sequestration: There is no additional sequestration cut for 2014. However, the 2% sequestration cut that took effect in April 2013 is still in effect. That cut is expected to remain in place until Congress adopts an alternative deficit reduction framework. As it was last year, the cut will be applied to all fee-for-service (Part A and Part B) claims after determining coinsurance, any applicable deductible, and any applicable Medicare secondary payment adjustments. The cut will also be applied to Medicare Advantage plans.

E-Prescribing Penalty: Physicians and group practices who were not successful elec-

tronic prescribers under the 2012 or 2013 Medicare eRx Incentive Program will be subject to a negative payment adjustment of 2% in 2014 on all Medicare Part B claims paid under the physician fee schedule.

How will these changes affect me?

It is important that physicians understand how a fee schedule can affect their practice’s bottom line, so that they can make informed decisions about participation. The California Medical Association (CMA) has developed a simple worksheet to help physicians analyze the impact fee schedule changes may have on their practices based on commonly billed CPT codes. CMA’s Financial Impact Worksheet is available free to members in CMA’s online resource library at http://www.cmanet.org/resource-library.

(CMA Alert, January 13, 2014 issue)

Senate pro tem considering MICRA legislation As both sides inch closer to a seemingly inevitable ballot war over California’s Medical Injury Compensation Reform Act (MICRA), a key figure in the legislature may be looking to step in before voters can weigh in on the issue. Earlier this month, Darrell Steinberg, president pro tem of the Senate, said that he was “thinking” about carrying a MICRA-related bill during the 2014 cycle. While Steinberg has previously stated that he wanted to see negotiations take place to avoid a costly ballot war between trial lawyers

and physicians, the fact that he would be interested in personally carrying a bill is significant.

The legislature’s renewed attention toward MICRA comes after Consumer Watchdog, a trial attorney-backed group that has made its public mission to scuttle MICRA, submitted ballot language that would put the issue before voters in November 2014. Among the provisions of Consumer Watchdog’s proposal is a nearly fivefold increase of MICRA’s cap on noneconomic damages.

As of now, there has been no MICRA bill introduced by Steinberg or any other member of the legislature. CMA’s lobbying team, however, has already mobilized to strengthen the resolve of our legislative allies. If a bill is introduced we will intensify that mobilization.

For more information on CMA’s fight to defend MICRA, or to contribute to the ongoing defense effort, please visit www.cmanet.org/ micra.

(CMA Alert, January 27, 2014 issue)

Medical board will collect CURES fees beginning April 1 The Medical Board of California announced it will soon begin collecting an additional $6 per year on physician license applications and renewals to fund the Controlled Substance Utilization Review and Evaluation System (CURES). The fees, authorized by SB 809, provide funding for ongoing maintenance and staffing of CURES. Physicians can expect to see an additional $12 ($6 per year) added to their licensing fees beginning April 1, 2014.

CURES is an online database that al-

lows authorized users, including physicians, pharmacists, law enforcement, and regulatory boards, to access information about a patient’s controlled substance prescription history. The new law will provide roughly $1.5 million annually to maintain the database. The bill builds on funding provided through the 2013 budget to upgrade the system. With proper funding, maintenance, and privacy safeguards, CURES has potential to benefit the public and physicians, assisting physicians in making informed

prescribing decisions and helping to control drug diversion in the state.

The new fees will be assessed on physicians and other licensees authorized to prescribe, order, administer, furnish, or dispense controlled substances, including dentists, pharmacists, veterinarians, nurses, physician assistants, and veterinarians. For more information on SB 809, go to http://www.leginfo.ca.gov.

(CMA Alert, January 13, 2014 issue)

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MEDICO NEWS

Gov. Brown’s proposed budget eliminates retroactive Medi-Cal cuts Governor Jerry Brown last month announced that the State of California would not be moving forward with retroactive collection of a 10% cut to the Medi-Cal program, a win for physicians and patients in California. The announcement came as part of the governor’s 2014-2015 fiscal year budget proposal.

“The Governor’s budget demonstrates a clear understanding of the importance that California’s Medicaid (Medi-Cal) program has for the state’s poorest and most vulnerable patients,” says Richard Thorp, MD, president of the California Medical Association (CMA). “After voicing a commitment to expand Medi-Cal eligibility and ensure that the rollout of the Affordable Care Act in California be a success, restoration of the retroactive cut is a huge step in the right direction.”

Unfortunately, the budget does not stop the 10% cuts moving forward.

Although elimination of the retroactive cut is a huge step in the right direction, an additional 10% cut will only cement California in the position of having the lowest Medicaid rates in the nation. While this budget will provide some relief to physicians who may have otherwise been forced to stop taking new Medi-Cal patients altogether, it does not go far enough.

CMA is part of an unprecedented coalition of physicians, dentists, health care workers, and hospitals that will continue working to stop the cuts. The coalition, called “We Care for California,” includes the largest statewide organizations representing physicians, dentists, hospitals, and health care workers, as well as health plans, first responders, caregivers, and other health providers. CMA and the We Care for California coalition will continue to push for full restoration of the cuts moving forward.

“As the rest of the nation looks to California for an example of health

reform success, we simply cannot move forward with a 10% prospective cut to the Medi-Cal program while simultaneously adding new patients to the program,” says Dr. Thorp. Under the Affordable Care Act, more than 3 million patients are expected to enter Medi-Cal over the course of the next two years.

“CMA and our stakeholder partners will look toward reforms that will result in real access to care so that health reform is more than an empty promise of an insurance card,” says Dr. Thorp.

In March of 2011, the California Legislature passed and Governor Jerry Brown signed AB 97, which included a 10% reimbursement rate cut for physicians, dentists, pharmacists, and other Medi-Cal providers. The cuts were enjoined for two years while the matter was being argued in a CMA-filed lawsuit.

Despite earlier favorable rulings, a three-judge panel of the Ninth Circuit Court of Appeals cleared the way for implementation of these rate reductions. CMA requested a rehearing from the full Ninth Circuit Court of Appeals, which was denied. In September 2013, CMA filed a petition with the United States Supreme Court, asking them to review the appeals court ruling. The Court has not yet ruled on this petition.

Even before the cuts, California’s Medi-Cal provider payment rates were the lowest in the nation. Low reimbursement rates have forced many of California’s providers to stop seeing Medi-Cal patients. As a result, 56% of Medi-Cal patients report difficulty finding a doctor. If these cuts are not stopped, Medi-Cal will become nothing more than a broken promise of access to care.

(CMA Alert, January 13, 2014 issue)

HHS extends Stark exception and safe harbor rule for EHR donations The U.S. Department of Health and Human Services Office of the Inspector General (OIG) and the Centers for Medicare and Medicaid Services (CMS) issued final rules revising and extending, through 2021, the Stark Law exception and fraud and abuse safe harbor permitting physicians to accept electronic health record (EHR) donations. The exceptions, originally scheduled to sunset on December 31, 2013, are intended to facilitate physicians’ adoption of EHR technology. According to the agencies, the extension is necessary because EHRs have not yet been universally adopted nationwide, and continued adoption remains an important goal.

The new rules extend the ability of hospitals and certain other health care entities to subsidize the bulk of EHR costs (up to 85%) for physicians without violating federal self-referral and anti-kickback laws. The exten-

46 | THE BULLETIN | JANUARY/FEBRUARY 2014

sion brings welcome relief for physicians as they continue to adopt EHRs and struggle with the high cost of implementation. The rules also made several other notable changes: • Excludes labs from the types of entities that may donate EHRs • Updates the definition of what type of software is considered interoperable for the purposes of subsidies/donations • Clarifies the requirement prohibiting any action that limits or restricts the use, compatibility, or interoperability of donated items or services • Removes from the exception the requirement related to electronic prescribing capability (CMA Alert, January 13, 2014 issue)

We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of “Books for Botox®” community outreach program, benefitting the libraries of underfunded public schools

800-252-7706 www.CAPphysicians.com

San Diego orange LoS angeLeS PaLo aLTo SacramenTo

For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like San Francisco facial plastic surgeon Corey Maas, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

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.

We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.

JANUARY/FEBRUARY 2014 | THE BULLETIN | 47

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