2016 January/February

JANUARY / FEBRUARY 2016 VOLUME 22 | NUMBER 1

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BULLETIN THE

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

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

MEMBER BENEFITS Billing/Collections

Feature Articles 10 New Health Laws 2016

CME Tracking

18 Mandatory Reporting Requirements for Physicians and Others

Discounted Insurance

20 Telehealth and the Law: What You Need to Know

Financial Services Health Information Technology Resources House of Delegates Representation Human Resources Services Legal Services/On-Call Library Legislative Advocacy/MICRA Membership Directory iAPP for the iPhone Physicians’ Confidential Line Practice Management

Departments 5 From the Editor’s Desk 6 Message From the SCCMA President 7 Message From the MCMS President 16 You Asked For It 23 CHOMP Dr. Terry Franklin Drops a Smart, Free App 28 Other Unintended Consequences of the Affordable Care Act (ACA) 31 In Memoriam 32 Guidelines to Assess Eating Disorders

Resources and Education

34 CMA Education Webinars

Professional Development

36 Medical Times From the Past

Publications

38 Meaningful Use Hardship Exception – FAQ

Referral Services With Membership Directory/Website

42 MEDICO News 46 Classified Ads

Reimbursement Advocacy/ Coding Services Verizon Discount JANUARY / FEBRUARY 2016 | THE BULLETIN | 3

THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President Eleanor Martinez, MD President-Elect Scott Benninghoven, MD Past President James Crotty, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Anh Nguyen, MD VP-Professional Conduct Vanila Singh, MD Secretary Seema Sidhu, MD Treasurer Seham El-Diwany, MD

CHIEF EXECUTIVE OFFICER

COUNCILORS

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Ryan Basham, MD El Camino Hospital: Vacant Good Samaritan Hospital: David Feldman, MD Kaiser Foundation Hospital - San Jose: Hemali Sudhalkar, MD Kaiser Permanente Hospital: Martin Wong, MD O’Connor Hospital: Michael Charney, MD Regional Medical Center: Erica McEnery, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Health Care / Children's Hospital: John Brock-Utne, MD Santa Clara Valley Medical Center: Clifford Wang, MD

CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Tanya Spirtos, MD (District VII)

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Editor

OFFICERS

THE

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

Printed in U.S.A.

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, 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 2016 by the Santa Clara County Medical Association.

4 | THE BULLETIN | JANUARY / FEBRUARY 2016

President James Hlavacek, MD President-Elect Vacant Past-President Jeffrey Keating, MD Secretary Edward Moreno, MD Treasurer Cary Yeh, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD Valerie Barnes, MD Ronald Fuerstner, MD Gary Gray, DO Steven Harrison, MD David Holley, MD

John Jameson, MD William Khieu, MD Eliot Light, MD James Ramseur, MD Marc Tunzi, MD Craig Walls, MD

Population Health

By Joseph Andresen, MD

Editor, The Bulletin

JOSEPH S. ANDRESEN, MD

You may ask, how can this broad topic of population health help me in my day-to-day clinical practice? The development of actionable metrics may still be a few years away but being actively pursued by the Institute for Medical Quality among others.

The mandate to act in a much broader role as a physician is yet to be defined. The economics of who shall pay is still a work in process both politically and logistically. However, if we look back over our career since medical school graduation, our profession has been in a constant state of evolution. From the age of infectious disease to that of chronic illness, to preventative medicine and now population health, how can we best improve the lives of our patients and the health of our communities? Do we now look beyond cholesterol, history of smoking and blood pressure, drug or alcohol, seat belt use, and safe sex practices? Should we now ask our patient about gun ownership? Do we routinely screen for depression? Do we understand the medical home model and how to make it work? Do we take a leadership role in collaborating with physician leaders, employers, social services, local church, and community programs that promote health? Can we raise the bar beyond maintaining health to promoting wellbeing?

How does Santa Clara County measure up in ranking of the 57 California Counties?: http://www. countyhealthrankings.org/app/california/2015/ rankings/santa-clara/county/outcomes/overall/ snapshot How can we raise our counties ranking and what role can you play in this challenge? How can our profession embrace this new paradigm?

FROM THE

As we begin this New Year 2016, let us reflect on lessons learned in the year that has passed. How can our work as physicians best promote health of our patients and the community at large?

The traditional role of the physician has been treatment of disease, illness, or injury. However the goals of health care reform now guide us in a new direction: population health. What is population health? Quite simply, population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. More specifically, policies and programs produce changes in determinate factors such as health care, individual behavior, social and physical environment and genetics that produce health outcomes measured by mortality and health related quality of life.

Public health traditionally has been known as the work of state and local public health departments in preventing epidemics, environmental hazards, and encouraging healthy behaviors. Up to now, no one in either the public or private sector has had the responsibility or authority for overall health improvement. These may include factors such as health care, education, and income. However, this is now changing.

I had the pleasure of attending the 2015 Eisenberg Legacy Lecture at the University of California at San Francisco. The keynote speaker was Dr. Eugene Washington, an internationally renowned clinical investigator and Duke University’s chancellor for health care affairs and the president and CEO of the Duke University Health System.

Duke University Medical Center and School of Medicine is taking a leadership role in collaborating with community groups, physicians, employers, and payers to improve the health of North Carolina citizens. This includes new initiatives to provide medical students and primary care residents with knowledge, skills, and attitudes required to improve population health and health care. A primary care leadership tract exposes medical students to local communities and social determinates affecting the health of people in Durham. The family medicine residency builds on these earlier experiences with emphasis on public health, critical thinking, community engagement, and team skills.

EDITOR'S DESK

Physician Editor, The Bulletin

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 2016 | THE BULLETIN | 5

President, Santa Clara County Medical Association

ELEANOR MARTINEZ, MD

MESSAGE FROM THE

SCCMA PRESIDENT

The End of Life Option Act

Eleanor Martinez, MD is the 2015-2016 president of the Santa Clara County Medical Association.

She has a solo obstetrics and gynecology practice in Los Gatos.

In one of my previous President’s messages, I wrote about end-of-life-care.

I asked each of us the question “How many of us have advanced directives? How many of us have had the conversations with our loved ones and patients about the care we wish to have when confronted with dying?”

On October 5, 2015, Governor Jerry Brown signed into law The California End of Life Option Act. The law will take effect 90 days after the extraordinary session on health care is adjourned (by November 2016 at the latest). California is the fifth state in the nation to allow physicians to prescribe terminally ill patients medication to end their lives. “The End of Life Option Act” permits terminally ill adult patients with capacity to make medical decisions to be prescribed an aid-in-dying medication if certain conditions are met. This law has a very stringent detailed outline of how a patient can secure this aid in dying drug that we, as physicians, have to adhere to.

Attempts were made to overturn the law, however, opponents of Death With Dignity in California failed to gather enough signatures to have a November referendum.

Therefore, we, as physicians, are invited to familiarize ourselves with the requirements of the End of Life Option Act. The CMA Health Law Library has written a very detailed document #3459, dated January 2016, in a question and answer format elucidating the workings of this law.

Upon reviewing the document, there were takeaway points, which I have summarized below. However, I encourage everyone providing health care to take the time to review this document, as it would give us facts to help address our patient’s concerns regarding the matter.

First, the physician participation in the activities defined by The End of Life Option Act is voluntary.

Therefore, we are free to choose whether to participate or not. However, California Health and Safety Code section 442.5 requires a health care provider who diagnoses a patient with a terminal diagnosis to notify the patient about his/her right to comprehensive information and counseling regarding the legal end-of-life options; and if requested, to provide them with such information and counseling. If, by reasons of ethics, conscience, or morality the physician elects not to engage in activities to aid in dying, the law provides such exemptions. Immunity is provided to such

6 | THE BULLETIN | JANUARY / FEBRUARY 2016

physicians. It is stipulated that the patient should be referred to a health care provider that would be able to meet the request of this terminally ill patient, in accordance with the requirements defined in detail by the law.

Second, if certain steps are taken, an employer or health care provider may prohibit its employees, independent contractors, or others within such entities from participating in such activities under the Act while they are in the premises owned by, or under the management or direct control of that prohibiting employer or health care provider. The act of participation in the activities is clearly defined by the law. However, the medical provider can, without limitation, make the diagnosis of a terminal disease, and upon request of the patient for the aid in dying drug refer the patient to another provider for services under the Act. Third, there are protections and immunities for physicians who choose to participate in the End of Life Option Act. The health care provider is protected from civil and criminal liability when present during the qualified patient committing the end of life activity, as long as he/she does not assist in ingesting the aid to dying drug. This protection is in place as long as compliance with the provisions of the Act are met and executed.

Fourth, the Act does not impact insurance policies and contracts. Death resulting from self-administration of the drug to aid in dying is not suicide. This is what the Act provides. The Act prohibits insurance plans and contracts to make alterations or exclusions on patients making a request for the aid in dying drug.

The Health and Safety Code 443.13 (a)(2) defines this.

Fifth, the document I reviewed was indeed very enlightening. However, it is recommended that we, as a physician engaging in activities in The End of Life Option Act should have a legal opinion concerning the specific situations we may encounter.

In summary, for information regarding the matter on The End of Life Option Act, I urge you to read the California Physicians Legal Handbook (CPLH) which provides a comprehensive law and medical practice resource containing legal information that affect medical practice in California. The CMA Center for Legal Affairs wrote and regularly updates this valuable resource. The document pertaining to The California· End of Life Option Act is document #3459.

The hospital libraries should have this eight volume softbound compendium.

President, Monterey County Medical Society

JAMES M. HLAVACEK, MD

Technology must be user-centered and support physicians, which sounds to me like more and more electronic health records speak. Mr. Slavitt stresses that there must be more interoperability, which means different health systems need to be able to share information more easily and cheaply. Again, stay tuned for details.

The election year will see all three incumbent Monterey County Supervisors challenged. Assemblyman Luis Alejo, and Salinas City Councilman Tony Barrera are running against Supervisor Fernando Armenta. Former Mayor of Salinas Dennis Donohue is challenging Supervisor Jane Parker. Mary Adams, former CEO of United Way Monterey County is running against Supervisor Dave Potter. In addition, Sam Farr’s retirement has brought two candidates forward for his seat, Casey Lucius and Jimmy Panetta.

Carina Alejo is running for her husband’s Assembly seat against former Salinas Mayor Anna Cabellero. It should be an entertaining spring, summer, and fall, as the candidates debate the issues.

The Level 2 Trauma Center at Natividad Medical Center is now one year old. This milestone achievement was barely mentioned in the media’s Year in Review. The quiet success is due to the leadership of CEO Dr. Gary Gray, Trauma Director Dr. Alex Di Stante, and the dedication of the doctors, nurses, and support staff at NMC. Two other items, which got almost no news coverage, were the failed recall initiatives against the End-of-Life Bill, and against Senator Dr. Richard Pan, lead author of SB 277, the Immunization Bill.

As I enter my final months as your President, I want to encourage all of you to be active in promoting membership in the Monterey County Medical Society. We need more doctors to be involved in the continuing reforms and reshaping of the health care landscape. CMA is our advocate and needs the strength of our members. CMA will host its Annual Legislative Advocacy Day on April 13th in Sacramento. This is an excellent opportunity to see government in action. It is open to all members and there is no charge.

Finally, our Annual Membership Dinner is scheduled for June 16th at Corral de Tierra Country Club. We will be sending out ballots for the Physician of the Year, and also for Board of Director members.

We also need to elect a new President.

Happy New Year everyone! Let’s hope 2016 is a great year!

MESSAGE FROM THE

It is 65 degrees, the sun is shining, the hills are green, Toro Creek behind my house is flowing, and we wonder why we ever left Nebraska!

2016 has started off with a bang in the wrong direction. The stock market has tanked, and the world economy is shaky. In the middle of this is the presidential election. Who will prevail is anyone’s guess.

“The Donald” certainly keeps the press entertained.

Can he become President Trump? We’ll find out. “Because 2016 is a presidential and congressional election year, Congress is not expected to have a productive year” – this is a quote from Elizabeth McNeil, CMA Vice President for Federal Governmental Affairs.

Why does this not surprise me?

The medical issues for 2016 can be summed up in a couple of words, MACRA, and the end of Meaningful Use. MACRA is the Medicare Access and Children’s Health Insurance Reauthorization Act. This legislation is being hailed as the biggest achievement for CMA since the protection of MICRA. MACRA will create new payment pathways, which should simplify and increase payments to physicians. It will create new alternative payment models. It will pay for value, defined by four criteria: quality, cost, use of technology, and practice improvement. There will be a merit-based incentive program to increase reimbursement. Let’s hope the new program actually does what is promised. One thing is certain, with the input of CMA, the AMA, and other state Medical Societies, we have a chance to have something that works for everyone.

The other CMA victory is the California Medicare Geographic Payment Locality Reform, known as the California GPCI fix. Finally, counties like Monterey will see an increase in reimbursement!

The end of Meaningful Use in its current form is the other big news. Andy Slavitt, Acting Administrator of CMS, in a speech on January 11, laid out the platform for a new and more workable solution for the government’s payments to physicians. Mr. Slavitt came to CMS from the private sector. He has degrees from Wharton and The Harvard Business School. He was an executive with United HealthCare. I recommend you read his speech, which shows he is willing to simplify government and work with organized medicine. Let’s hope so!

Mr. Slavitt’s focus will be to reward outcomes.

Providers (not physicians?) will be able to customize goals so tech companies can build around individual practice needs, and not the needs of government.

MCMS PRESIDENT

2016

James Hlavacek, MD, is the 2015-2016 president of the Monterey County Medical Society. He is an Anesthesiologist and is currently practicing Chief-of-Staff with Natividad Medical Center, in Monterey, and also practices at George L. Mee Memorial Hospital.

JANUARY / FEBRUARY 2016 | THE BULLETIN | 7

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NEW HEALTH LAWS 2016 Significant New California Laws of Interest to Physicians 10 | THE BULLETIN | JANUARY / FEBRUARY 2016

The California Legislature had an active year, passing more than 130 new laws affecting health care. In particular, there was a strong focus on health care coverage, public health issues, and end-of-life care. Following is a list of the most important new health laws pertaining to the practice of medicine and/or impacting physicians.

JANUARY / FEBRUARY 2016 | THE BULLETIN | 11

ALLIED HEALTH PROFESSIONALS (19 NEW LAWS) SB 337 (Pavley) – Physician Assistants Requires that the medical record for each episode of care for a patient identify the physician and surgeon responsible for supervision. Replaces medical record review provisions and requires supervising physician to use one or more of described alternative medical records review mechanisms. Authorizes a physician assistant, under prescribed supervision of a physician, to administer or provide medication to a patient, or transmit an order to furnish medication or medical device. Prohibits a physician assistant from administering, providing, or issuing a drug order to a patient for controlled substances without advance approval by a supervising physician and surgeon for that particular patient unless the physician assistant has completed an education course that covers controlled substances and that meets approved standards. Requires that the medical record of any patient cared for by a physician assistant for whom a physician assistant’s Schedule II drug order has been issued or carried out to be reviewed, countersigned, and dated by a supervising physician and surgeon within seven days.

SB 407 (Morrell) – Comprehensive Perinatal Services Program: Midwives Amends the Comprehensive Perinatal Services Program. Authorizes a health care provider to employ or contract licensed midwives for the purpose of providing comprehensive perinatal services. Provides that, upon effective date of regulations adopted by the board, a licensed midwife shall be eligible to serve as a “comprehensive perinatal provider,” as defined. Requires the State Department of Health Care Services to commence the revision of existing regulations as it determines are necessary for the implementation of these provisions.

SB 408 (Morrell) – Midwife Assistants Authorizes a midwife assistant to perform certain assistive activities under the supervision of a licensed midwife or certified nurse-midwife, including the administration of medicine, the withdrawing of blood, and midwife technical support services. Prohibits a midwife assistant from being employed for inpatient care in a licensed general acute care hospital.

Defines midwife assistant and midwife technical supportive services.

DRUG PRESCRIBING AND DISPENSING (4 NEW LAWS) AB 679 (Allen) – Controlled Substances: CURES Registration Extends provisions of existing law requiring a licensed health care practitioner authorized to prescribe, order, administer, furnish, or dispense controlled substances, pharmacist, or both, providing care or services to an individual to apply to the Department of Justice to obtain approval to access information contained in the Controlled Substance Utilization Review and Evaluation System (CURES) database regarding the controlled substance history of a patient under his or her care, from January 1, 2016 effective date to July 1, 2016.

END OF LIFE (3 NEW LAWS) ABX2 15 (Eggman) – End of Life Enacts the End of Life Option Act authorizing an adult who meets certain qualifications, and who has been determined by his or her attending physician to be suffering from a terminal illness, to make a request for a drug for the purpose of ending their life. Establishes procedures and forms for such requests. Provides immunity from civil or criminal liability 12 | THE BULLETIN | JANUARY / FEBRUARY 2016

solely because the person was present when the qualified individual selfadministered the drug so long as the person did not assist with the ingestion of the drug. Provides immunity from liability for health care providers who refuse to engage in activities authorized pursuant to its provisions.

Requires a physician to submit specified information to the State Department of Public Health after writing a prescription for an aid-in-dying drug and after the death of individuals who requested an aid-in-dying drug.

The law will take effect 90 days after the session on health care is adjourned (by November 2016 at the latest).

AB 637 (Campos) – Physician Orders For Life Sustaining Treatment Forms Authorizes the signature of a nurse practitioner or physician assistant acting under the supervision of the physician and within the scope of practice authorized by law to create a valid Physician Orders for Life Sustaining Treatment form.

HEALTH CARE COVERAGE (14 NEW LAWS) SB 145 (Pan) – Robert F. Kennedy Farm Workers Medical Plan Requires the State Department of Health Care Services to annually reimburse the Robert F. Kennedy Farm Workers Medical Plan up to $3,000,000 million per year for claim payments that exceed $70,000 made by the plan on behalf of an eligible employee or dependent for a single episode of care. Requires the Department to make the reimbursement payment within 60 days after it receives specified claims data from the plan.

SB 282 (Hernandez) – Health Care Coverage: Prescription Drugs Requires the Department of Managed Care and Department of Insurance to develop the uniform prior authorization form on or before January 1, 2017, and would require prescribing providers to use, and health care service plans and health insurers to accept, only those forms or electronic process on and after July 1, 2017, or six months after the form is developed, whichever is later. Deems a prior authorization request to be granted if the plan or insurer fails to respond within 72 hours for non-urgent requests, and within 24 hours when exigent circumstances exist.

SB 388 (Mitchell) – Health Care Coverage: Solicitation and Enrollment Relates to group health and health insurers providing a written summary of benefits and coverage under the Patient Protection and Affordable Care Act. Provides that summary constitutes a vital document and would require a plan or insurer to comply with requirements applicable to those documents. Requires the development of written translations of the template uniform summary of benefits and coverage and to make those translations available in specified languages on respective Internet websites.

SB 546 (Leno) – Health Care Coverage: Rate Review Requires large group health care service plans and health insurers to file with the respective department prior to implementing any rate increase, all required rate information for any product with a rate increase, if any, if certain conditions apply. Provides the procedures and time frames for department action on such increase requests. Requires the plan or insurer to file additional aggregate rate information with the respective department. Relates to contracting with multiple medical groups.

HEALTH CARE FACILITIES AND FINANCING (24 NEW LAWS) AB 601 (Eggman) – Residential Care Facilities For The Elderly: Licensing Amends the Residential Care Facilities for the Elderly Act. Requires the applicant for the licensure of a residential care facility for the elderly to disclose specified information upon initial application. Requires the crosschecking of specified information from the application. Provides specified grounds for the denial of an application or the revocation if the applicant knowingly withholds material information, makes or has made a false statement in regards to material fact regarding the licensure application. Requires, to the extent that the department’s computer system can electronically accommodate additional information, the department to post on its website specified information. Authorizes a civil penalty for a violation.

AB 848 (Stone) – Alcoholism and Drug Abuse Treatment Facilities Authorizes an adult alcoholism or drug abuse recovery or treatment facility that is licensed under provisions to allow a licensed physician and surgeon or other health care practitioner to provide incidental medical services, as defined, to a resident of the facility at the facility premises under specified limited circumstances, including that the resident signs an admission agreement and a physician and surgeon or other health care practitioner determines that it is medically appropriate for the resident to receive these services. Requires the department to establish and collect an additional fee from those facilities, in an amount sufficient to cover the department’s reasonable costs of regulating the provision of those services.

AB 1177 (Gomez) – Primary Care Clinics: Written Transfer Agreements Requires a primary care clinic, except as specified, to send with each patient at the time of transfer, or in the case of an emergency, as promptly as possible, copies of all medical records related to the patient’s transfer, and would require the medical records to include, among other things, current medical findings and a brief summary of the course of treatment

provided prior to the patient’s transfer. Provides that a licensed primary care clinic is not required to enter into a written hospital transfer agreement pursuant to existing law as a condition of licensure, except as provided primary care clinic that provides services as an alternative birth center.

AB 1387 (Chu) – Care Facilities: Penalties, Deficiencies and Appeals Relates to residential care facilities for the elderly. Authorizes any person to request an investigation of a residential care facility for the elderly by making a complaint to the Department of Social Services. Provides for rights of access, complaints of long-term care ombudsmen, civil penalties for death, physical abuse, or serious bodily injury, certain appeals, requests for a formal review of a finding of deficiency, and the use of moneys in the Child Health and Safety Fund for assisting families with the identification, transportation, and enrollment of children in day care centers or family day care homes.

MEDI-CAL (9 NEW LAWS) SB 4 (Lara) – Health Care Coverage: Immigration Status Requires, at the time the Director of Health Care Services determines that systems have been programmed for implementing extension of eligibility for full-scope Medi-Cal benefits, individuals under 19 years of age enrolled in restricted-scope Medi-Cal to be enrolled in the full scope of Medi-Cal benefits, if otherwise eligible, pursuant to an eligibility and enrollment plan, as specified. Requires the DHCS to provide monthly updates to the policy and fiscal committees of the Legislature as specified beginning January 31, 2016, until the director makes the above-described determination. Requires that an individual, who is eligible pursuant to these provisions, enroll in a Medi-Cal managed care health plan. Does not preclude a beneficiary from being enrolled in any other children’s MediCal specialty program that he or she would otherwise be eligible for.

SB 299 (Monning) – Medi-Cal: Provider Enrollment Exempts from notarization requirements any Medi-Cal provider that chooses to enroll electronically. Clarifies that the Department of Health Care Services is required to collect an application fee for continued enrollment. Requires DHCS to designate a provider or applicant as a high categorical risk if DHCS lifted a temporary moratorium within the previous six months for the particular provider type submitting the application.

MEDICAL MARIJUANA (5 NEW LAWS) AB 243 (Wood) – Medical Marijuana Regulations Requires specified State agencies to promulgate regulations or standards relating to medical marijuana and its cultivation, as specified. Requires various State agencies to take specified actions to mitigate the impact that marijuana cultivation has on the environment. Requires state licensing authority to charge each licensee, a licensure and renewal fee, as applicable, and would further require the deposit of those collected fees into an account specific to that licensing authority in the Medical Marijuana Regulation and Safety Act Fund, which this bill would establish. Imposes certain fines and civil JANUARY / FEBRUARY 2016 | THE BULLETIN | 13

penalties for specified violations of the Medical Marijuana Regulation and Safety Act.

SB 643 (McGuire) – Physician Prescribing of Medical Marijuana Sets forth standards for a physician and surgeon prescribing medical cannabis and requires that the Medical Board of California prioritize its investigative and prosecutorial resources to identify and discipline physicians and surgeons that have improperly recommended excessive cannabis to patients. Prohibits a recommending physician or surgeon from accepting, soliciting, or offering any form of remuneration from a licensed dispensary facility. Requires the appointment of a Chief of the Bureau of Medical Marijuana Regulation. Sets forth standards for the licensed cultivation of medical cannabis. Authorizes a county cannabis tax.

MEDICAL PRACTICE & ETHICS (8 NEW LAWS) AB 1423 (Stone) – Prisoners: Medical Treatment Establishes a process of a licensed physician or dentist to file for a

MENTAL HEALTH (13 NEW LAWS) SB 238 (Mitchell) – Foster Care: Psychotropic Medication Requires the Judicial Council to amend and adopt rules of court and develop appropriate forms for the implementation of specified provisions.

Specifies the contents of such rules of court. Requires a report on the number of such medications authorized. Requires specified related training on aspects of taking and administering such medications. Requires foster care public health nurses to receive this training.

SB 453 (Pan) – Prisons: Involuntary Medication Relates to findings of mental incompetence in criminal proceedings. Relates to withdrawal of consent for antipsychotic medication or circumstances where a treating psychiatrist determines that antipsychotic medication is medically necessary and appropriate. Authorizes a treating psychiatrist to request that a facility medical director designate another psychiatrist to act in the place of the psychiatrist for purposes of involuntary medication. Requires an examination prior to the hearing.

SB 613 (Allen) – State Department of Public Health: Dementia Guidelines Workgroup Requires the Department of Public Health to convene a workgroup to update the Guidelines for Alzheimer’s Disease Management in the State to address changes in the health care system, including changes in the federal Patient Protection and Affordable Care Act, Medicaid, and Medicare. Requires the submission of a report on the updates and recommendations to the Legislature.

OFFICE SAFETY (2 NEW LAWS) SB 225 (Wieckowski) – Medical Waste Amends the Medical Waste Management Act. Revises the definition of biohazard bag. Limits the application of the requirement that biohazard film bags used for transport be marked and certified by the manufacturer as having passed specified tests only to those bags used to transport from the generator’s facility onto roadways and into commerce to a treatment and disposal facility. Revises the requirements for such bags that are used to collect medical waste within a specified facility. Relates to tracking documents. determination as to a prisoner patient’s capacity to give informed consent and whether a surrogate decision maker should be appointed. Requires the related petition to contain specified information including the patient’s current physical condition and a description of conditions afflicting the patient. Relates to determinations by an administrative law judge to appoint a surrogate health care decision maker for an inmate patient.

MEDICAL RECORDS & PRIVACY (8 NEW LAWS) AB 964 (Chau) – Civil Law: Privacy Defines “encrypted” to mean rendered unusable, unreadable, or indecipherable to an unauthorized person through a security technology or methodology generally accepted in the field of information technology for purposes of existing law relating to the breach of security relating to the disclosure of a person’s computerized personal information.

14 | THE BULLETIN | JANUARY / FEBRUARY 2016

LICENSING AND DISCIPLINE (5 NEW LAWS) SB 467 (Hill) – Professions and Vocations Requires the Attorney General’s Office to submit annual reports on consumer complaints concerning a professional licensed under a Department of Consumer Affairs agency. It also requires the Director of the Department of Consumer Affairs (DCA) to implement “Complaint Prioritization Guidelines” for health care boards. Prioritization of disciplinary cases and specific enforcement reporting was highlighted as a concern during oversight hearings and sunset review of the DCA and licensing boards. This bill also extends the sunset for two Boards, the California Board of Accountancy and the term of the executive officer, and the Contractors State License Board and the term of the Registrar, until January 1, 2020.

PUBLIC HEALTH (11 NEW LAWS)

REPRODUCTIVE ISSUES (3 NEW LAWS)

SB 658 (Hill) – Automated External Defibrillators Provides an exemption from civil liability for a physician and surgeon or other health care professional that is involved in the selection, placement, or installation of an Automated External Defibrillator (AED).

Requires person or entity that acquires an AED to comply with specified regulations for the placement of the device and esure that the AED is maintained and tested. Requires certain notification regarding an AED location by building owners and to inform tenants regarding AED training.

AB 775 (Chiu) – Reproductive FACT Act Enacts the Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act that requires a licensed covered facility to disseminate a notice to all clients stating the State has public programs that provide immediate free or low-cost access to family planning services, prenatal care, and abortion, for eligible women. Requires an unlicensed covered facility to disseminate a notice that the facility is not licensed as a medical facility by the State. Authorizes civil penalties against facilities that do not comply.

SB 277 (Pan) – Public Health: Vaccinations Eliminates the exemption from existing specified immunization requirements based upon personal beliefs. Allows an exemption from future requirements deemed appropriate by the State Department of Public Health for either medical reasons or personal beliefs. Exempts pupils in a home-based private school and students enrolled in an independent study program and who do not receive classroom-based instruction. Provides a temporary exclusion only for a child who has been exposed to a specified disease and whose proof of status does not show proof of immunization against one of specified diseases. After July 1, 2016, prohibits a governing authority from unconditionally admitting to any private or public elementary or secondary school, child day care center, day nursery, nursery school, family day care home, or development center within the state for the first time or admitting or advancing any pupil to the 7th grade level, unless the pupil has been immunized as required by this bill.

WORKERS’ COMPENSATION (6 NEW LAWS)

AB 216 (Garcia) – Product Sales to Minors: Vapor Products Prohibits the sale of any device intended to deliver a non-nicotine product in a vapor state, to be directly inhaled by the user, to a person under 18 years of age. Exempts from the prohibition the sale of a drug or medical device that has been approved by the federal Food and Drug Administration.

AB 1124 (Perea) – Workers’ Compensation: Medication Formulary Requires the administrative director to establish a drug formulary, as part of the medical treatment utilization schedule, for medications prescribed in the workers’ compensation system. Requires the administrative director to meet and consult with stakeholders, as specified, prior to the adoption of the formulary. Requires the administrative director to publish at least 2 interim reports on the Division of Workers’ Compensation website describing the status of the creation of the formulary, until the formulary is implemented. Requires the administrative director to update the formulary at least on a quarterly basis to allow for the provision of all appropriate medications, including medications new to the market. Exempts an order updating the formulary from the Administrative Procedure Act and other provisions, as specified. Requires the administrative director to establish an independent pharmacy and therapeutics committee to review and consult with the administrative director in connection with updating the formulary, as specified.

SB 738 (Huff) – Pupil Health: Epinephrine Auto-Injectors: Liability Limitation Prohibits an authorizing physician and surgeon from being subject to professional review, being liable in a civil action, or being subject to criminal prosecution for the issuance of a prescription or order of emergency epinephrine auto-injectors to a qualified supervisor of health or administrator at a school district, unless the physician and surgeon’s issuance of the prescription or order constitutes gross negligence or willful or malicious conduct.

SB 27 (Hill) – Livestock: Use of Antimicrobial Drugs Prohibits the administration of medically important antimicrobial drugs to livestock unless prescribed by a licensed veterinarian or a feed directive. Prohibits the administration of a medically important antimicrobial drug to livestock solely for purposes of promoting weight gain or improving feed efficiency. Requires the development of antimicrobial stewardship guidelines and best practices on the proper use of such drugs. Requires gathering of related information.

Provides civil penalties for violations.

These are just a sampling of the new laws impacting health care in 2016 and beyond. For a complete list, see “Significant New California Laws of Interest to Physicians for 2016” in CMA’s online resource library at www.cmanet.org/resources-library.

JANUARY / FEBRUARY 2016 | THE BULLETIN | 15

YOU ASKED FOR IT

Common Questions Received By the Medical Board of California

By Christine Valine Public Information Analyst, MBC These questions are reprinted with the permission of the Medical Board of California, originally printed in their Newsletters from Fall 2015 and Winter 2016 issues. The following are common questions that the Medical Board of California receives. Read on and see if you know the answers too.

Q. I am a licensed California physician and I do not prescribe controlled substances to my patients. Am I required to register for CURES? A. According to the law, you are required to register for CURES if you are a California licensed physician and have a valid DEA registration that permits you to prescribe or administer controlled substances in Schedules II IV regardless of whether you actually do prescribe or administer controlled substances.

Q. I just heard the deadline for registering for the CURES program has been extended to July 1, 2016. What is the penalty if I do not register?

A. There is no penalty discussed in the bill. If the issue of non-compliance is brought to the Board’s attention, the non-compliance may be investigated and appropriate action taken. The Board’s goal is to ensure physicians are in compliance with the requirement to register.

Q. I have a patient that has requested a copy of her medical records; however, she owes me a substantial amount of money. Can I refuse to provide her with a copy of her records until she pays her bill?

A. No. California Health and Safety Code 123110(j) states you may not withhold patient records because of an unpaid bill.

Q. I was disciplined by the Medical Board in 2001 and completed probation in 2003. I do not want my disciplinary action published on the website forever. I have not received any further discipline or broken any laws since my license was placed on probation over 10 years ago. Is it possible to have this disciplinary action removed from your website?

16 | THE BULLETIN | JANUARY / FEBRUARY 2016

A. Effective January 1, 2015, Assembly Bill 1886 (Eggman, Chapter 285) amended Business and Professions (B&P) Code section 2027. The law states that the Board shall post on its Internet website certain historical information in its possession, custody, or control regarding all current and former licensees. B&P Code section 2027(b) states revocations, suspensions, or probations ordered by the Board or the board of another jurisdiction shall remain on the Board’s website indefinitely. Therefore, the information posted on the Board’s website regarding a prior probation order is in accordance with the law and cannot be removed.

Q. I am a recently licensed physician. When is it necessary for me to apply to the Board for a fictitious name permit?

A. You must apply for a fictitious name permit if you intend to practice under a name other than your own, either alone, with a partnership, in a group, or as the name of a professional corporation. You do not need a fictitious name permit if you are only adding “Inc.” to the end of your name.

Further information regarding the law and obtaining a fictitious name permit can be accessed through the following link: http://www.mbc.ca.gov/Applicants/Fictitious_Name/.

Q. I have been charged with a felony offense; however, I have not been convicted. My understanding is I do not need to report this to the Medical Board unless I am actually convicted. Is this correct?

A. No. As a physician, you are required by law to report to the Medical Board within 30 days all information regarding the bringing of an indictment or information charging you with a felony. Additionally, you are required by law to report to the Medical Board any felony or misdemeanor conviction within 30 days. (Business & Professions Code §802.1)

Q. Has the Medical Board changed its guidelines regarding pain management?

A. The Medical Board updated its guidelines for physicians in November 2014 in a publication entitled “Guidelines for Prescribing Controlled Substances for Pain.” The booklet is available on the Medical Board’s website at www.mbc.ca.gov/licensees/prescribing/pain_guidelines.pdf.

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Mandatory Reporting Requirements for Physicians and Others Reprinted with the permission of the Medical Board of California

REPORTING TO THE MEDICAL BOARD OF CALIFORNIA PHYSICIANS

• Physicians without malpractice insurance must report a Settlement (over $30,000), Judgment (any amount) or Arbitration Award (any amount) within a specific time frame. http://www.mbc.ca.gov/Forms/Reporting/enf-801.pdf (Business and Professions Code §801.01) The same holds true for attorneys representing such physicians.

• Physician Reporting - Criminal Actions: An indictment or information charging a felony or any conviction of any felony or misdemeanor must be reported within 30 days. http://www.mbc.ca.gov/Forms/Reporting/enf-802.pdf (Business and Professions Code §802.1) • Transfer to Hospital from, or Death of Patient in Outpatient Surgery Setting: Physicians performing a medical procedure outside of a general acute care hospital resulting in patient death must report within 15 days.

Physicians performing a medical procedure outside of a general acute care hospital resulting in a patient transfer to a hospital for treatment of more than 24 hours must be reported within 15 days. http://www.mbc.ca.gov/Forms/Reporting/patient_death.pdf http://www.mbc.ca.gov/Forms/Reporting/enf-2240b.pdf (Business and Professions Code §2240) • Notification of Name Change : Name changes must be reported within 30 days. http://www.mbc.ca.gov/Licensees/Name_Change.aspx (Business and Professions Code §2021(c)) • Address of Record : A change of address must be reported within 30 days. http://www.mbc.ca.gov/Licensees/Address_of_Record.aspx (Business and Professions Code §2021(b)) • Email address: Any physician with an email account is required to notify the Board of his or her email address. http://www.mbc.ca.gov/Forms/Applicants/address_change_request.pdf (Business and Professions Code §2021(d))

OTHERS

• Insurers’ report of Malpractice Settlement or Arbitration Award within a specific time frame. http://www.mbc.ca.gov/Forms/Reporting/enf-801.pdf (Business and Professions Code §801.01) • Self-insured employers of physicians report of Settlement, Judgment or Arbitration Award within a specific time frame: http://www.mbc.ca.gov/Forms/Reporting/enf-801.pdf 18 | THE BULLETIN | JANUARY / FEBRUARY 2016

(Business and Professions Code §801.01) • State or local government agencies that self-insure physicians, report of Settlement, Judgment or Arbitration Award within specific time frame: http://www.mbc.ca.gov/Forms/Reporting/enf-801.pdf (Business and Professions Code §801.01) • Peer Review/Health Facility Reporting: http://www.mbc.ca.gov/Forms/Reporting/enf-805.pdf (Business and Professions Code §805) http://www.mbc.ca.gov/Forms/Reporting/enf-805-01.pdf (Business and Professions Code §805.01) • Reporting for coroners: http://www.mbc.ca.gov/Forms/Reporting/coroner_report.pdf (Business and Professions Code §802.5) • Reporting requirements for court clerks and prosecuting agencies: http://www.mbc.ca.gov/Forms/Reporting/enf-805-01.pdf (Business and Professions Code §§803, 803.5 and 803.6) • Accredited Outpatient Surgery Settings must report adverse events to the Board no later than five days after the adverse event is detected, or, if that event is an ongoing urgent or emergent threat to the health and safety of patients, personnel or visitors, not later than 24 hours after adverse event is detected. http://www.mbc.ca.gov/Consumers/Outpatient_Surgery/outpatient_ adverse_event_form.pdf (Business and Professions Code §2216.3) • Reporting Transfer of Planned Out-of-Hospital Births: A hospital shall report each transfer by a licensed midwife of a planned out-of-hospital birth to the Medical Board of California and the California Maternal Quality Care Collaborative. http://www.mbc.ca.gov/Forms/Licensees/midwives_out-of-hospital_ delivery.pdf (Business and Professions Code §2510)

REPORTING TO OTHER ENTITIES

• Live births must be registered with the local registrar of births and deaths for the district in which the birth occurred within 10 days following the date of the event. (Health and Safety Code §102400) • Medical and health section data and the time of death shall be completed and attested to by the physician last in attendance, or, in some cases, by a licensed physician assistant. Physicians, or licensed physician assistants in certain cases, will state conditions contributing to death (except in cases to be investigated by the coroner) and the hour and day the death occurred on a certificate of death and indicate the existence of cancer. (Health and Safety Code §§102795 and 102825) • Certificates of fetal death must be completed by the physician, if any in attendance, within 15 hours after the delivery. (Health and Safety Code §102975) • Diseases reportable by physicians, physician assistants, nurses, midwives and others in California: http://www.cdph.ca.gov/HealthInfo/discond/Documents/SSS_ Reportable_Diseases.pdf Reportable to the local health officer for jurisdiction where patient resides.

(Title 17 California Code of Regulations §2500) • Injuries by deadly weapon or criminal act: http://leginfo.legislature.ca.gov/faces/codes.xhtml (Penal Code §11160) Reportable to local law enforcement.

• Child abuse: http://leginfo.legislature.ca.gov/faces/codes.xhtml (Penal Code §§11165.7(a)(21), 11165.9, 11166(a)(c))

•

•

•

•

Reportable to local law enforcement, county probation department or county welfare department.

Adult/Elder abuse: http://leginfo.legislature.ca.gov/faces/codes.xhtml (Welfare and Institutions Code §15630) Reportable to local law enforcement or an adult protective service agency.

Injuries resulting from neglect or abuse: http://leginfo.legislature.ca.gov/faces/codes.xhtml (Penal Code §11161.8) Reportable to local law enforcement and the county health department.

Lapses of Consciousness: http://leginfo.legislature.ca.gov/faces/codes.xhtml (Health and Safety Code §103900) Reportable to local health officer.

Pesticide poisoning/illness http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?law Code=HSC&sectionNum=105200 (Health and Safety Code §105200) Physicians must report pesticide illnesses to the local health officer by telephone within 24 hours.

MISCELLANEOUS REPORTING REQUIREMENTS

• Reporting requirements for lost or stolen controlled substances or prescription forms, reporting obligations for illegal use of your DEA number: http://www.mbc.ca.gov/Licensees/Prescribing/DEA_Reporting.aspx

ADDITIONAL REQUIREMENTS

Required written information physicians must provide to patients: http://www.mbc.ca.gov/publications • A Patient’s Guide to Blood Transfusion (Health and Safety Code §1645) • A Woman’s Guide to Breast Cancer Diagnosis & Treatment (Health and Safety Code §109275) • Gynecologic Cancers…What Women Need to Know (Health and Safety Code §109278) • Professional Therapy Never Includes Sex (Business and Professionals Code §728) • Things to Consider Before Your Silicone Implant Surgery (Business and Professions Code §2259) • What You Need to Know About Prostate Cancer (Business and Professions Code §2248; Health and Safety Code §109280)

MANDATORY PHYSICIAN SIGNAGE

• Notice to consumer: http://www.mbc.ca.gov/Licensees/Notices/Notice_to_Consumers. aspx (Title 16, California Code of Regulations §1355.4) • Education disclosure: http://www.mbc.ca.gov/Licensees/Notices/Education.aspx (Business and Professions Code §680.5) • Prostate cancer “Be Informed” notice: http://www.mbc.ca.gov/Licensees/Notices/Prostate_Cancer.aspx (Health and Safety Code §109282) • Breast cancer “Be Informed” notice: http://leginfo.legislature.ca.gov/faces/codes.xhtml (Health and Safety Code §109277) JANUARY / FEBRUARY 2016 | THE BULLETIN | 19

20 | THE BULLETIN | JANUARY / FEBRUARY 2016

By Brittan Durham, MD Health Quality Investigative Unit, Tustin Office Many terms – such as eHealth, telemedicine, and telehealth – have been used to describe the use of communication technology in medicine. In this article, I will use the term telehealth, defined as the use of telecommunication and information technologies in order for licensed medical care practitioners to provide clinical health care from a location that is distant from their patients. Telehealth is a tool used in the practice of medicine, not a separate form of medicine. The objective of this article is to highlight new developments in California telehealth law and review issues to consider when using this tool.

AB 415, also known as the Telehealth Advancement Act of 2011, was signed into law on January 1, 2012. This law changed the statute of California Business & Professional Code (BPC) section 2290.5 that governs telehealth services. The intent of this law

was to integrate parity of telehealth into in-person traditional medicine.

The idea is that telehealth can provide health care delivery, diagnosis, consultation, treatment, transfer of medical data, care management, and education using interactive audio, video, and data communications in a real time (synchronous) interactive medium where the patient is at the originating site and the health care provider is at a distant site. Telehealth has been shown to be beneficial to patients living in isolated communities and remote regions where they receive telehealth care from physicians or specialists from far away.

In addition, telehealth has been used by some hospitals to provide for rapid neurology consultation in patients with time-sensitive treatment such as thrombolytics for acute cerebral accident (CVA).

According to BPC section 2290.5 (b), prior to the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient that telehealth may

While other states have instituted a new category of licensure for physicians practicing telehealth, California requires physicians providing telehealth services to have an active California medical license

JANUARY / FEBRUARY 2016 | THE BULLETIN | 21

be used and obtain verbal or written consent from the patient for this use.

The verbal or written consent shall be documented in the patient’s medical record. The consent should not alter the scope of practice or standard of care.

Informed consent and privacy standards apply to all health care encounters including telehealth. A patient may receive in-person health care delivery services during a specified course of health care and treatment after agreeing to receive services by telehealth.

While other states, such as Oregon, have instituted a new category of licensure for physicians practicing telehealth from an out-of-state location, California requires physicians providing telehealth services to patients located in California to have an active California medical license. There is a limited exception for out-of-state physicians if they are in consultation with a physician licensed in California pursuant to BPC section 2060.

Even under those circumstances, the out-of-state physician using telehealth may not receive calls from patients, give orders, write prescriptions or have ultimate authority over patient care.

Under California law, a physician cannot prescribe medications (or recommend marijuana for medical purposes) without an appropriate prior examination and indications justifying the patient’s use of the drug. The Board has stated that this examination need not be in person, if the technology is sufficient to provide the same information to the physician as would be obtained if the exam had been performed face-to-face. A simple questionnaire without an appropriate prior evaluation may be a California practice violation.

The Medical Board of California (Board) has received complaints of inadequate medical examinations via telehealth. Undercover investigators posing as patients have revealed cases in which they were evaluated by Skype from a distant location.

Many of these evaluations had an inadequate history, no physical examination, and resulted in no coherent treatment plan. Many of the associated medical records were inaccurate and some were fraudulent. A telehealth evaluation must meet the same standard of care as a face-to-face medical evaluation, consistent with use of the patient history, appropriate examination, and laboratory data, to arrive at a diagnosis and develop therapeutic plans. Medical record documentation requirements remain constant for all 22 | THE BULLETIN | JANUARY / FEBRUARY 2016

health care delivery modalities.

Out-of-state telehealth practitioners have been prosecuted. The California State Appellate Court allowed California to criminally prosecute a Coloradolicensed physician for the unlicensed practice of medicine through telehealth. (Hageseth v. Super. Ct. of San Mateo Co. (2007) 150 Cal.App.4th 1399 (“Hageseth”). The patient in question, a California resident, obtained a prescription via telehealth after filling out an internet questionnaire. No physical examination took place and the physician who prescribed the medication never entered California or had contact with the patient. With this case in mind, California physicians seeking to provide telehealth services to patients located in another state, while they (the physicians) remain physically in California, must ensure compliance with that other state’s licensing and telemedicine requirements.

There are no legal prohibitions to using telehealth technology in the practice of medicine in California, as long as the practice is done by a California-licensed physician, complies with BPC section 2290.5 and other applicable codes and regulations, and the care given meets the standard of care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers such as transmission of a patient’s medical information from an originating site to the health care provider at a distant site without the presence of the patient.

This has been a brief administrative review of telehealth, which is evolving as I write this article. “Dial a Doctor” web interactive access is being marketed, diagnosis applications are available on smart phones, and digital medicine is poised to change the way patients can obtain and monitor their clinical data. For example, a home laboratory unit, which is literally a finger prick away from providing real-time data via smart phones, is already available. So stay tuned and connected, there is more to come.

California has been a major leader of medical technology innovations, and telehealth law will evolve to reflect future changes in the delivery of medical care. The Board will continue to monitor licensees to ensure the standard of care is met, which protects health care consumers by promoting responsible physician-patient relationships, regardless of technology used.

TECHNOLOGY

CHOMP Dr. Terry Franklin Drops Smart, Free App

By Mary Duan Courtesy of Monterey County Weekly, Seaside, CA, 2016. http://www.montereycountyweekly.com.

All rights reserved.

Terry “Tel” Franklin describes the state of people’s health in good news-bad news fashion.

Bad news: People are unhealthy.

Good news: It’s not their fault.

“Most diseases in the United States are preventable because most are lifestyle-oriented,” Franklin says. “But the choices we choose are not conscious. We don’t take the time to reflect and say, ‘Is this what I really need, is this in my long-term best interests?’ It’s what I call toxic hunger. It’s not from our stomach, it’s from our brains.”

But there’s better news: A little education, collaboration and motivation can do wonders for that problematic decision-making. That’s where Franklin comes in.

As a staff physician at Community Hospital of the Monterey Peninsula and medical director of the Ryan Ranch Medical Group, Franklin’s wrapped up his accumulated wisdom into an iPhone app, TelMD Level 1, released this month on the iTunes store.

Franklin is a weird hybrid of a traditional doctor and holistic healer, incorporating acupuncture, vitamin infusions, nutritional and sleep counseling and meditation into his practice. The hybrid nature of his practice is reflected in the app – it can be used by any patient, seeing any doctor. He hopes it will help people collaborate with their doctors more productively with an end goal of living healthier, more balanced lives.

The idea for the app came in 2014, when Stanford University invited Franklin to a think tank of innovators trying to figure out new ways to help people live healthier lives. “I said, ‘It should really be to change our thought process,’ and they said,

Photo credit: Nic Coury – Terry Franklin, MD, developed the TEL MD Level 1 app as a means to help patients communicate better with their doctors.

‘This is beyond the scope of what we’re trying to do.’”

Franklin said he’d be back in four months with an app. It was more like a year.

He sat in his living room with a stack of yellow legal pads, wrote out how the app should work and collaborated with a professional developer and then a designer.

“TelMD is about nutrition, taking inventory of where you are and where you want to go and life as a journey,” he says.

“Learn to eat better, learn to spend time in nature, learn to go to the chiropractor in order to stay healthier, give your body proper nutrition and sleep.”

TelMD Level 1 is available on the iTunes store.

FRANKLIN’S BASICS 1. Hydrate. Drink three big

glasses of water a day.

2. Take vitamins—iron, a fish-oil supplement and calcium.

3. Get sufficient sleep—and get help if you can’t.

4. Learn to meditate. Even 20 seconds of deep, focused breathing a few times a day is a good place to start.

JANUARY / FEBRUARY 2016 | THE BULLETIN | 23

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Stable medical office asset with diverse tenant mix, superior location and access. Land size: ±88,000 SF.

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3400 El Camino Real, Santa Clara Rare freestanding 2-story office/retail building on prominent El Camino Real location. Small suites easy to lease. One parcel totaling ±6,970 SF with additonal shared parking. Perfect for investment or owner/user. Excellent access to Lawrence Expwy & Hwy 101.

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Gain From Our Unique Perspective...

We proudly serve as the authority on healthcare real estate within the Silicon Valley. Today’s real estate investment climate is challenging and complex, and 3431-3439 De La Cruz Blvd, Santa Clara 200 N. Bascom Ave, San Jose our exclusive focus on healthcare provides a true Freestanding medical/retail Owner-user opportunity in a rare perspective of the High healthcaremulti-tenant investment landscape. building in shell condition.

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JANUARY / FEBRUARY 2016 | THE BULLETIN | 25

MCMS/SCCMA/CMA Presents:

Wednesday, April 13, 2016 CMA’s 42nd Annual Legislative Leadership Day Sheraton Grand Ballroom 1230 J Street, Sacramento, CA • •

• • • • •

Tentative Agenda 8:00 a.m. Registration/Continental Breakfast 9:00 a.m. CMA Welcome and Remarks o Steven E. Larson, MD, President, CMA o Dustin Corcoran, Chief Executive Officer, CMA 9:30 a.m. Meetings with Legislative Offices (State Capitol) 11:30 a.m. Buffet Lunch (Sheraton Grand) 12:30 p.m. CMA Keynote 1:00 p.m. Political Panel 1:30 p.m. Meetings with Legislative Offices

***In preparation for Legislative Advocacy Day, CMA’s Center for Government Relations will host a special webinar on March 23, 2016, from 7 to 8 p.m. This webinar will review in detail CMA’s list of bills to be lobbied and effective advocacy tips, as well as covering other relevant program information. Register on CMANET.ORG. “FAX BACK” 408/289-1064 RSVP TODAY! MCMS/SCCMA Student, Resident, Alliance, and Physician members are invited to attend CMA’s 42nd Annual Legislative Leadership Conference at the Sheraton Grand Hotel on Wednesday, April 13, 2016. We will meet with local legislators to discuss pending resolutions/bills that will affect the future of medicine. This is your chance to make your voice count and to see what CMA is doing for you! MCMS/SCCMA will provide transportation to and from Sacramento on a chartered bus. Breakfast and lunch also provided. (You can meet us there if you prefer.)

To RSVP for Legislative Day and/or a seat on the chartered bus, please fax RSVP no later than April 8, 2016, to Jean Boileau Cassetta, Membership Director, 408/289-1064. (We will leave from the SCCMA parking lot at 6:00 a.m. and return at approx. 6:30 p.m. Seats are limited. Agenda packets will be mailed to you prior to April 13, 2016. Any questions, call Jean at 408/998-8850 Ext. 3010 or 831/455-1008 Ext. 3010.

Name: Phone: Fax: Date: Please Circle:

I will meet you there

26 | THE BULLETIN | JANUARY / FEBRUARY 2016

Or

I will ride on the chartered bus

Hilton San Francisco Union Square

May 13 - 15, 2016

San Francisco, CA

Physicians, nurses, medical practice managers and all other health care industry professionals—Join us in the heart of San Francisco to prepare for changes affecting your profession, your practice and your economic future.

Health care power players will share strategies and resources for accelerating the shift to a more integrated, high performing and sustainable health care system. Speakers include Dr. Atul Gawande, distinguished surgeon, teacher and writer – named one of TIME magazine’s 100 most influential thinkers; Karl Rove, former Deputy Chief of Staff and Senior Advisor to President George W. Bush; and Donna Brazile, Al Gore campaign manager and Democratic National Committee Vice Chair.

800.795.2262 www.westernleadershipacademy.com JANUARY / FEBRUARY 2016 | THE BULLETIN | 27

28 | THE BULLETIN | JANUARY / FEBRUARY 2016

OTHER

UNINTENDED CONSEQUENCES OF THE

AFFORDABLE CARE ACT (ACA)

By Mark Christiansen General Manager, Bureau of Medical Economics A recent news release from a Kaiser Family Foundation/New York times survey headlined, “One in Five Working-Age Americans With Health Insurance Report Problems Paying Medical Bills.” They further reported “Among the Insured with Medical Bill Problems, 63% Report Using Up Most of All Their Savings and 42% Took on an Extra Job or Worked More Hours.” Of those who were insured when the bills were incurred, 75% say that the amount they had to pay for the insurance co-pays, deductibles, or coinsurance was more than they could afford.

People with health insurance who have problems with medical bills also report skipping or putting off other health care in the past year because of the cost, such as postponing dental care (62%), skipping doctor-recommended tests or treatments (43%), or not filling a prescription (41%).

Other findings included: claim denials and out-of-network costs (69% were not aware the provider was not in their plan’s network when they received the care).

WHAT DOES ALL OF THIS HAVE TO DO WITH THE AFFORDABLE CARE ACT (ACA) AKA OBAMACARE?

Apparently, there are a lot of people who didn’t fully understand the consequences of the ACA and its actual impact on their health care and finances as they were selecting their coverage options.

The ACA has significantly increased the number of people with health insurance coverage by overhauling the individual insurance market and expanding Medicaid, and by some estimates as many as 17 million people so far became insured through this program. This hopefully means people are seeking the preventative care they formerly chose to ignore. There are admitted benefits to many; now you cannot be denied coverage for a pre-existing condition. However, intended or

not, there are also issues that directly affect compensation for doctors such as new Medicare rules including patient outcomes and value-based medicine.

With the individual mandate that all Americans carry health insurance coverage or pay a penalty, it is expected the number of insured individuals will continue to rise. Along with the rise of insured patients come problems associated with this increase. One issue is the products being sold. To be fair, there is information out there for the general public to investigate prior to buying a product; however, how many people truly spend the time to do this? Some of the policies sold, such as the bronze plan under the ACA, can equate to a catastrophic loss policy only coming into play after a $6,250 individual deductible has been met.

There are annual out-of-pocket limits; however, for many, getting to that threshold will have already created a financial burden. The bronze plan is often the answer to the mandated health insurance coverage requirement. It can be cheaper than the penalty and individuals may assume it is efficient as they “never get sick” or can’t afford the extra premium cost anyway.

It just may be the ACA provides the illusion of coverage. Yes, you may be insured, but in most plans the out of pocket expense is very high. In view of the statistics from the Kaiser/New York Times poll, it appears that most patients presenting for care will be surprised and ill-prepared for these large out-of-pocket expenses; thus, creating a debt owed to the physician and increasing his/her accounts receivable more than ever before. Another “loan” by the practitioner until the patient is able to make payment. You don’t have to go it alone.

In addition to an increase in accounts receivable for the doctor, caused by high deductibles, co-pays, and co-insurance owed by the patients, there is also a problem with the lack of patient understanding of the basic nature of health care insurance. This problem is manifest with Medi-Cal and Medicare patients believing they are “100% covered.” As a medical revenue recovery agency, the Bureau of Medical Economics JANUARY / FEBRUARY 2016 | THE BULLETIN | 29

(BME) is seeing an increase in accounts assigned to collection where the patient believes that by paying their insurance premiums each month they have already met their patient responsibility. We have become educators of patient responsibility.

The rise in newly insured patients will continue along with your patient self-pay accounts receivable. BME is here to help your practice with its revenue recovery by providing you with medical revenue recovery professionals ready to explain to your patients the nature of the relationship between their health care coverage and their remaining responsibility to the MD. BME assists the patients by walking them through the claim process, reviewing the itemization of services with the patient and explaining items such as adjustments. BME medical revenue recovery associates also creatively assist the patient to arrive at a payment plan, so the patient can meet his/her day-to-day expenses while also repaying those responsible for their continued good health.

Doctors have always faced the difficult decision of whether or not to send an account to collections. They don’t want to write off their services as bad debt, yet they also don’t want to offend their patients. Nonetheless, you deserve compensation for your services and a patient should be held accountable for monies due and owing. In this new environment, you should use a medical revenue recovery agency that has experienced certified medical coders and billers on their staff who exclusively deal with medical bills.

THE BUREAU OF MEDICAL ECONOMICS IS HERE TO HELP.

It isn’t a crime to send accounts to a collection agency or medical recovery organization such as the Bureau of Medical Economics. However, it would be beneficial to first review any agency’s experience level in medical revenue recoveries, their exclusivity to medical recoveries, as well as other affiliations that point to a close relationship with your medical practice.

In choosing an agency, an often overlooked objective is protection from potential liability and maintaining the physician’s good reputation in the community. It is a good idea to check out the reputation of the agency 30 | THE BULLETIN | JANUARY / FEBRUARY 2016

with the Better Business Bureau and/or Yelp.

Does the agency have a relationship with the medical community? When all is said and done, does the medical community benefit by this relationship? BME meets all of these important criteria.

BME is a member benefit, for which you receive no less than a 5% discount on services. BME doesn’t charge a loading fee on your accounts. BME doesn’t harass your patients, but works with them to arrive at solutions. BME has an experienced staff and has been exclusively dedicated to medical recovery services for over 65 years. BME is a not-for-profit organization with all profits going back to our own medical community.

Most of all, there is no fee unless we collect.

With the increase in patients and patient accounts receivable, your office often doesn’t have the time or resources to pursue your revenue recovery in a meaningful way.

Traditionally, your office staff, your biller, or billing company are not trained for this part of your revenue recovery cycle; they are not usually aware of laws regarding collections; and they likely will be dealing with the added volume of patients. BME is a resource created by the Santa Clara County Medical Association, over 65 years ago, by physicians for physicians. We hope you will give BME the opportunity to help you bring some of the unintended consequences of the ACA back under control. For further information, please contact BME through our client relations director, KAREN JORGENSON, at (408) 286-6219.

Mark Christiansen is the general manager of the Bureau of Medical Economics (BME).

Mark is an attorney licensed to practice law in the State of California since 1994 and specializes in medical collections.

Mark has been counsel to BME and SCCMA for over 20 years and has been employed as the general manager of BME for the last eight years.

The Bureau of Medical Economics (BME) is a not-for-profit corporation specializing in medical collections and billing.

BME was formed over 65 years ago by physicians (SCCMA) to recover monies for valuable services rendered by physicians, as well as other members of the medical and dental communities, while maintaining the physician/patient relationship. BME is a member of the American Collectors Association, the California Association of Collectors, and has an A+ rating with the Better Business Bureau.

In Memoriam John C. Damron, MD *Anesthesiology 5/13/33 – 8/29/15 SCCMA member since 1963

Armin C. Hofsommer, MD Internal Medicine 1/1/28 – 4/1/15 SCCMA member since 1959

James A. Losito, MD

L. Bruce Meyer, MD *Orthopaedic Surgery 7/26/22 – 4/5/15 MCMS member since 1955

John D. Wagner, MD General Practice & Surgery 10/8/19 – 6/22/15 MCMS member since 1949

*Pediatrics 1/1/26 – 9/6/15 SCCMA member since 1959

YOUR PARTICIPATION CAN MAKE A DIFFERENCE! Are you looking for a new activity? IMQ is looking for physicians who may be interested in becoming surveyors for the Ambulatory Care, Corrections, or CME Review Programs. The Ambulatory Program accredits surgery centers, offices, and medical groups in California. The Corrections Program reviews the healthcare in jails and juvenile facilities, and the CME Program reviews providers of CME. All surveyors contribute directly to the improved quality of care. They interact with colleagues throughout the state, and see best practices and innovation beyond their own medical community.

The time commitment is generally 3 to 4 surveys a year.

The general qualifications for an IMQ surveyor are: 1. CMA membership is required (or other state medical association) 2. Meaningful involvement in a related program 3. Active in medicine 4. Peer recommendations 5. A letter of recommendation from the county medical society The qualities sought in an IMQ surveyor are excellent communication skills, diplomacy, efficiency, fairness, flexibility, good judgment, reliability, ability to present ideas in a constructive and positive manner, and enthusiasm for learning.

Survey travel expenses plus honorarium are paid.

Further Information For more information, please call Jill Silverman at (415) 882-5151 or email: jsilverman@imq.org Please visit our website at www.imq.org We look forward to welcoming you to IMQ! JANUARY / FEBRUARY 2016 | THE BULLETIN | 31

These guidelines are taken from the American Psychiatric Association (APA) DSM-5 as a tool to be used by health care professionals in the diagnosis and treatment of eating disorders.

The Eating Disorders Resource Center is a local non-profit that provides education and support services to physicians and families to raise awareness about eating disorders.

As a physician, you might be the first person to recognize and offer assistance regarding a patient’s eating behaviors and weight concerns. Please incorporate these questions into your patient interviews.

Although a patient may not initially disclose enough information due to stigma, your sustained interest and concern may eventually allow your patient to admit there is a problem and accept your help.

Eating disorders are real, complex, and devastating conditions that can have serious consequences for health, productivity, and relationships. They are not a fad, phase, or lifestyle choice. Eating disorders are serious, potentially lifethreatening conditions that affect a person’s emotional and physical health. People struggling with an eating disorder need to seek professional help. The earlier a person with an eating disorder seeks treatment, the greater the likelihood of physical and emotional recovery.

For more information contact 408/356-1212 or visit EDRC’s website at www. edrcsv.org.

Guidelines to Assess Eating Disorders Screening Questions • What is a typical day of eating for you? Do you go a long time between eating meals?

• Do you ever make yourself throw up, use laxatives, diet pills or diuretics?

• When was the last time you used any of the above?

• What is your exercise regimen?

• How tall are you? What do you weigh?

• How often do you weigh yourself? What has your weight range been? Has anyone ever given you a hard time about your weight?

Physical Exam • • • • • •

Weight and height Undressed, empty bladder, morning weight Measurements taken by provider Ideally a consistent scale Vital signs and temperature Full physical

Laboratory Tests: For ALL patients • EKG • CBC with differential, full chemistry • Full Thyroid panel • Urinalysis • Complete metabolic profile • Serum magnesium

For patients with <15% below ideal body weight • • • • • •

Chest x-ray Complement 3 (C3) 24 hour creatinine clearance Uric acid Echocardiogram <25% IBW Bone density scan

Review of Symptoms: • • • • • • • •

Fatigue Sleep Disturbances Dizziness/Fainting Weakness Chest Pain Shortness of Breath Depression, Anxiety Loss of muscle mass

32 | THE BULLETIN | JANUARY / FEBRUARY 2016

• • • • • • • •

Bloated/Heartburn Constipation or Diarrhea Puffy cheeks Brittle hair/nails Cold intolerance Frequent Urination Loss of Menses Broken bones

DSM - 5 Diagnostic Criteria for Eating Disorder Anorexia Nervosa - AN: Two types - Restricting & Binge Eating/purging • Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health • Intense fear of gaining weight or becoming fat • Disturbance in the way one’s weight/shape is experienced, undue influence of weight/shape on self-evaluation, or denial of the seriousness of the current low body weight

Bulimia Nervosa - BN: Two types - Purging and Non-purging (exercise)

• Recurrent binge episodes (large amount within a 2 hour period with loss of control) • Recurrent use of inappropriate behaviors to prevent weight gain (vomiting, laxatives, exercise, diet pills) • Both binging and purging occur, on average, once a week for 3 months • Self-evaluation unduly influenced by weight/shape • Does not meet criteria for anorexia

Binge Eating Disorder - BED: • Recurrent episodes of binge eating, as outlined under BN • BED also associated with 3 or more of the following: -Eating rapidly -Eating until uncomfortably full -Eating large amounts of food when not hungry -Eating alone because of embarrassment -Feeling disgusted, guilty or depressed afterwards • Marked distress regarding binge eating is present • Binge eating occurs, on average, once a week for 3 months

Other Specified Feeding and Eating Disorders (OSFED):

• Disturbance in eating behavior that does not fall into the specific category of Anorexia nervosa, Bulimia nervosa or Binge eating disorder

d e rc

Eating Disorders Resource Center

15891 Los Gatos-Almaden Road • Los Gatos, CA 95032 Ph: (408) 356-1212 • www.edrcsv.org Printing provided by Center for Discovery JANUARY / FEBRUARY 2016 | THE BULLETIN | 33

WEBINARS

EDUCATION •

SEMINARS

•

PODCASTS

•

AND MORE

DID YOU KNOW? CMA offers free webinars to its members Through its robust webinar series, CMA gives physicians and their staff the opportunity to watch live presentations on important topics of interest and interact with practice management, legal and financial experts, to name a few, from the comfort of their homes or offices. The webinars are free to CMA members and members’ staff and provide the timely information needed to help run a successful medical practice. What’s more, all webinars are available on-demand immediately following the live airing, providing an ever-growing resource library accessible at any time.

FEBRUARY

10

CMA Physician Governance - How to Get Involved in CMA’s Newly Reformed Governance Structure February 10, 2016 | 12:15pm - 01:15pm | Members Only

An educational session designed to explain CMA’s structure of physician governance and how members can get involved in the organization – especially in light of recent changes and improvements to the process. See how your voice can impact the future of the practice of medicine in California. Ideal for members who are interested in getting involved (or more involved) in organized medicine.

FEBRUARY

24

HIPAA Compliance: Key Risks All Physicians Should Know February 24, 2016 | 12:15pm - 01:15pm

Please join CMA’s HIPAA advisor, David Ginsberg, for his annual HIPAA compliance update. This webinar will summarize recent federal enforcement and what this means for every medical practice. We will also discuss the top HIPAA privacy and security gaps and risks, along with simple steps to comply.

Closing a Medical Practice MARCH

9

March 9, 2016 | 12:15pm - 01:15pm This webinar will cover some of the major practical and legal issues that may arise when closing a medical practice, and will assist physicians who are retiring or otherwise leaving their practices and/ or families or estates of deceased physicians. Issues that will be addressed in this webinar will include people and agencies to notify when a physician practice closes, medical records retention and other issues, and considerations when selling a medical practice.

PRESENTER: Theodore M. Mazer, M.D., is a board-certified otolaryngologist who has been working in a small, solo practice in San Diego for more than 25 years. He is currently serving as the California Medical Association’s Speaker of the House.

PRESENTER: David Ginsberg is Co-Founder and President of PrivaPlan Associates, Inc., a leading provider of HIPAA privacy, security and breach notification services, consulting and products for the health care and business associate industry. He has more than 30 years of experience in the health care industry.

PRESENTER: Lisa Matsubara is Legal Counsel in the Center for Legal Affairs at the California Medical Association. She also manages CMA’s legal educational resources, including the California Physician’s Legal Handbook and the legal information help line.

REGISTER ONLINE TODAY! WWW.CMANET.ORG/EVENTS *Webinars are free for CMA members and their staff ($99 for non-members).

34 | THE BULLETIN | JANUARY / FEBRUARY 2016

CMA Legislative Advocacy Day Webinar Training MARCH

23 MEMBERS ONLY

March 23, 2016 | 7:00pm - 8:00pm

CMA will host its 42nd annual Legislative Advocacy Day on Wednesday, April 13, at the Sheraton Grand in Sacramento. Attendees will also go to the Capitol to meet with legislators on health care issues. More than 400 physicians, medical students and CMA Alliance members will be coming to Sacramento to act as champions for medicine and their patients by lobbying their legislative leaders.

In preparation for Legislative Advocacy Day, CMA’s Center for Government Relations will host a special webinar. This webinar will review in detail CMA’s list of bills to be lobbied and effective advocacy tips, as well as covering other relevant program information.

APRIL

6

MACRA Implementation: A Review of the CMS Proposed Rule April 6, 2016 | 12:15pm - 01:15pm

This webinar will review the details of the proposed rule around the new Medicare Merit-Based Incentive Payment System (MIPS) implementation. We’ll also discuss any new details available regarding the Alternative Personnel Management System (APMS), and review the next steps toward implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

APRIL

20

How to Reduce Overhead Expenses and Increase Profitability April 20, 2016 | 12:15pm - 01:15pm

There are only three ways to realize increased net income: raise fees, increase productivity or decrease overhead. With managed care contracting difficulty, increased fees are difficult to achieve. The doctor/ group may already be working at maximum capacity so this may not be an option. In California, practices have higher overhead costs than national norms. The only way to assure profitability is to control and reduce overhead expenses. This webinar will provide information on how to do just that in a way that works for your practice.

MAY

4

Contract Renegotiations: How to Get Past “No” with a Payor May 4, 2016 | 12:15pm - 01:15pm

When submitting a request to renegotiate, best practice is to present a “business case” as to why the payor wants to keep your practice in the network. However, many practices fail to present a business case, which often results in a quick reply from the payor indicating that they are not in a position to renegotiate at this time. This webinar will cover steps practices can take to build their best business case and identify the uniqueness of their practice to prevent the “auto-reply” and present a thoughtful renegotiation request.

PRESENTER: Janus Norman is CMA’s Senior Vice President for Government Relations and Political Operations, and serves as CMA’s chief lobbyist. Prior to joining CMA, he served as Legislative Advocate for the American Federation of State, County and Municipal Employees (AFSCME).

PRESENTER: Ashby Wolfe, M.D., MPP, MPH is a boardcertified family physician who currently serves as Chief Medical Officer for California, Arizona, Nevada, Hawaii and the Pacific Territories for the Centers for Medicare and Medicaid Services (CMS).

PRESENTER: Debra Phairas is President of Practice & Liability Consultants, LLC, a nationally recognized firm specializing in practice management and malpractice prevention. Her background includes medical clinic administration and loss prevention management for NORCAL Mutual, a physician malpractice insurance carrier in Northern California.

PRESENTER: Kristine Marck is an Associate Director in CMA’s Center for Economic Services. With over 20 year of experience in the health care industry, she offers a unique perspective as well as a balance of working for and with physicians and a drive to assist them in difficult times.

SIGNING UP FOR WEBINARS IS AS EASY AS 1, 2, 3…

(1) Go to www.cmanet.org/events, (2) Select the webinar you would like to join and (3) Register to attend. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar. Questions? Call the CMA Member Help Line at (800) 786-4262.

JANUARY / FEBRUARY 2016 | THE BULLETIN | 35

Great Moments in Medicine

Louis Pasteur

By Michael Shea, MD Leon P. Fox Medical History Committee Louis Pasteur was born December 27, 1822, in Dole, France. His father, Jean-Joseph was a tanner, as was his father and grandfather. Louis would grow up reflecting the patience and perseverance that was characteristic of his father.

Although an average student in early school, the headmaster recognized his potential and recommended to Jean-Joseph to push for enrollment in the Ecole Normale, one of Franceâ&#x20AC;&#x2122;s most prestigious universities.

This occurred in 1843 when Louis was accepted into the science department at the Ecole Normale Superieure in Paris. His major was chemistry.

It was during these early years that Louis discovered crystals formed by molecules, a process called stereo chemistry. This advanced the study of the arrangement of atoms within molecules.

January 1849, Pasteur accepted a position as assistant professor of chemistry at the University of Strasbourg in the Alsace region of France. It was here he met and married Marie Laurent. They would spend a lifetime of 46 years together. Of their five children, three died in childhood, two of typhoid fever. This would motivate Pasteur in his later search for cures of infectious diseases.

36 | THE BULLETIN | JANUARY / FEBRUARY 2016

Louis Pasteur

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t z w ei g@ tracyzw ei g. com w w w. tracyzw ei g. com The first breakthrough as a biologist came in 1856. Through the use of the microscope, he discovered a living one celled organism, yeast, that was responsible for fermentation. He further demonstrated that some organisms in wine would cause the wine to spoil. However, when the wine was heated to a certain degree, the organisms would disappear and the wine would not spoil. Here is where he is shedding light on what would be called the germ theory. This heating process became known as pasteurization and is used with milk to the present day.

In 1874, Joseph Lister, an english physician, became aware of Pasteurâ&#x20AC;&#x2122;s work. He began using carbolic acid as an antiseptic hand-wash, surgical prep, and to sterilize surgical instruments. The surgical mortality rate in his hospital dropped from 45% to 15%.

Vaccines to prevent disease in animals and humans was the final chapter in the life of this brilliant chemist-biologist.

Using old cholera organisms, he prepared a vaccine to prevent cholera in chickens. He vaccinated some and re-injected them with fresh cholera organisms. They all survived and a group of unprotected ones all died.

Next, an anthrax vaccine was created. It was successfully tested in a famous public dem-

onstration in 1881. France and the world now fully recognized the significance of these results. (Note: the first use of a vaccine was in 1796 when an english physician, Edward Janner, used a cowpox vaccine to protect against smallpox.

However, the science behind this treatment was unknown at that time.)

The rabies vaccine was the final triumph of Pasteur. He removed the spinal cord from a rabid rabbit and preserved it for 14 days. He concocted a solution of weakened rabies from the dried out spinal cord. Healthy dogs were injected daily for two weeks with the vaccine. Next, a challenging dose of virulent rabies was injected into the dogs. None developed rabies.

July 1885, the first human was treated with the vaccine, when nine-year-old Joseph MeisSCCMA ter was bitten severely by a rabid dog. Pasteur, bravely, treated him with single daily injections 09-03-15 over 13 days. The boy survived, showing no signs of rabies.

In 1888, the Pasteur Institute in Paris opened with Louis as the director. It became the center for the treatment of rabies and for research into other contagious diseases. It continues to this day, as a world center for scientific research for the prevention and treatment of infectious disease. The Institute employs nearly

2,800 people of more than 60 nationalities. It now has 32 other branches on five continents.

On September 28, 1895, 72-year-old Louis Pasteur died. He had been weakened by a series of strokes late in his life. His final resting place is a tomb at the Pasteur Institute.

Pasteur was one of the most significant scientists of all time. He taught the world about research, experimentation, and discovery. He contributed to the understanding of the germ theory and developed the pasteurization process. In addition, he pioneered microbiology, sterilization, and immunology. His greatest achievement, however, was the vaccine. His vaccines for cholera, anthrax, rabies, and other diseases have saved millions of lives throughout the years.

JANUARY / FEBRUARY 2016 | THE BULLETIN | 37

FAQ Meaningful Use Hardship Exception Frequently Asked Questions In mid-December 2015, Congress adopted a last-minute bill that gives the Centers for Medicare and Medicaid Services (CMS) the authority to grant a blanket exemption from 2017 meaningful use payment penaltiesâ&#x20AC;&#x201D;for all eligible physicians who apply for a hardship exception by March 15, 2016. This action prevents CMS from implementing Medicare payment penalties in 2017 for physicians who failed to demonstrate meaningful use of a certified electronic health record (EHR) system for reporting year 2015.

New rules released last year state that eligible professionals (EPs) must attest that they met the requirements for Modified Stage 2 Meaningful Use for a reporting period of at least 90 consecutive days during calendar year 2015. However, the CMS did not publish the updated stage 2 regulations until October 16, 2015. As a result, physicians were not informed of the revised program requirements until fewer than the 90 required days remained in the calendar year.

CMS previously stated that it would grant hardship exceptions for 2017 payment adjustment year (2015 reporting period) if providers were unable to attest due to the late publishing of the rule, but the law at that time only authorized it to grant such exceptions on a case-by-case basis. This new law grants CMS the authority to make an automatic exception IF the provider submits a hardship exception application on or before March 15, 2016. It also streamlines the exception process, alleviating burdensome administrative issues for both physicians and the agency.

The following are answers to frequently asked questions about the blanket exceptions.

1. I think my practice will meet the requirements of meaningful use. Should I still apply for a hardship exception for the 2015 reporting period?

Practices that think they will meet the meaningful use requirements to qualify for a payment incentive must attest no later than February 29, 2016. However, CMA is encouraging ALL physicians subject to the 2015 Medicare meaningful use program to apply for the hardship exception. AMA has confirmed with CMS that applying for a hardship exception will not prevent you from receiving the incentive payment if your practice successfully attests to having met the requirements. Filing for the exception will simply prevent your practice from receiving the meaningful use penalty in 2017 (based on the 2015 reporting period).

Questions: CMAâ&#x20AC;&#x2122;s reimbursement help line, (888) 401-5911 or economicservices@cmanet.org (Rev. 02/09/16) 38 | THE BULLETIN | JANUARY / FEBRUARY 2016

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2. Which providers do not need to submit the hardship exception application?

If an EP is classified in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) as having one of the five following specialty codes as the primary area of practice, they do not need to submit the hardship application. They are automatically granted a hardship exception from the 2017 payment penalty based on their PECOS designation. The specialties include anesthesiology (05), diagnostic radiology (30), interventional radiology (94), nuclear medicine (36), and pathology (22). In addition, newly eligible professionals (EPs) who began to submit claims to Medicare in 2015 automatically receive exceptions to payment adjustments in 2016 and 2017, but will need to demonstrate meaningful use during the 2016 reporting year to avoid a penalty in 2018. Hospital-based physicians also do not have to submit the form to avoid an adjustment, as they cannot participate in the EHR program and would not be subject to the meaningful use penalties. For more information on eligible professionals, click here.

3. How do I access the application? Are there resources available to help practices complete a hardship exception application?

The hardship exception application is available on the CMS website and can be downloaded by clicking here.

Physicians who wish to apply for an exception should apply under the “extreme and uncontrollable circumstances” category by completing the following steps: •

Go to the CMS website and download an application.

•

Complete the application and under the “extreme and uncontrollable circumstances” category check box 2.2.d (“EHR Certification/Vendor Issues (CEHRT Issue)” in order to avoid a penalty under the meaningful use program.

CMS has stated it will not only broadly accept hardship exceptions because of the delayed publication of the program regulations, but also that it will refrain from auditing physicians who file under Option 2.2.d.

For more detailed instructions on completing the hardship exception application, see the American Medical Association’s fact sheet.

4. I qualify for more than one hardship exception category. Should I select more than one?

Physicians who qualify for more than one hardship exception category may select all of the applicable options; however, according to AMA, one category will suffice.

5. Do I need to apply for a hardship exception if I attest to having met the requirements under the Medicaid (Medi-Cal) EHR Incentive Program?

Medicaid physicians who do not see any Medicare patients are only eligible to participate in the Medicaid EHR Incentive Program and are not subject to the Medicare payment adjustments. However, if an eligible physician attesting under the Medicaid EHR Incentive Program is a Medicare EP and sees even one Medicare patient, they must apply for a hardship exception in order to avoid a payment adjustment.

Questions: CMA’s reimbursement help line, (888) 401-5911 or economicservices@cmanet.org (Rev. 02/09/16)

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JANUARY / FEBRUARY 2016 | THE BULLETIN | 39

6. If I apply for a meaningful use hardship exception, does that also cover the Physician Quality Reporting System (PQRS) program?

No. PQRS and meaningful use are distinctly separate CMS programs. Each program carries its own requirements for satisfactory reporting as well as its own payment penalties for unsuccessful reporting and incentives for successful reporting.

For more information on the different Medicare incentive and penalty programs, see CMA’s resource titled, “Medicare Incentive and Penalty Programs: What physicians need to know.” This document is available free to members in CMA’s online resource library at http://www.cmanet.org/resource-library.

Additional information on PQRS and meaningful use can be found on the CMS website.

7. Do I need to submit any documentation to demonstrate the hardship?

Other than the application, CMS does not require EPs to submit supporting documentation for the hardship category selected. Providers should, however, retain any documentation they may have for their own records. For more information, see CMS FAQ 14113.

8. Some of the physicians in our group did not previously participate in the meaningful use program. Should they apply for an exception?

Yes. Regardless of whether all physicians participated in the program previously, ALL physicians (except those in the five specialties listed in #2 above) who submitted Medicare claims in calendar year 2015 should apply for the hardship. Otherwise the physicians will be subject to the penalty.

9. Does each physician in the practice have to apply individually for a hardship exception?

No. This year an individual can apply for an exception on behalf of a group of physicians via a single submission. The individual may be the physician applicant or someone filling out the information on behalf of the physician group, like a practice administrator. It’s important to note that CMS will provide notice of its hardship exception decisions, which are final and cannot be appealed – to the email address provided on the hardship application.

10. What is the difference between applying for a hardship exception vs. a reconsideration?

Physicians can apply for a hardship exception for the 2015 reporting year to avoid a payment penalty in 2017.

A reconsideration is like requesting an appeal. Eligible professionals should only file a reconsideration if they received notice that they are subject to the 2016 payment adjustment (for 2014 reporting year) in error. If you are not sure whether your practice is subject to the penalties for 2014 reporting year, call the CMS EHR Incentive Information Center at (888) 734-6433.

Instructions to apply for a payment adjustment reconsideration for payment adjustment year 2016 are available on the CMS website. The deadline to request a reconsideration for the 2016 payment adjustment year (based on the 2014 reporting year) is February 29, 2016.

Questions: CMA’s reimbursement help line, (888) 401-5911 or economicservices@cmanet.org (Rev. 02/09/16) 40 | THE BULLETIN | JANUARY / FEBRUARY 2016

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11. What are the options for submitting my hardship exception request?

CMS “strongly recommends” submission by email to ehrhardship@provider-resources.com. If that is not feasible, the application must be completed in blue or black ink only, printed out and submitted by fax to (814) 456-7132. Do not use pencil.

12. I have heard about multiple different deadlines. Can you clarify each of the different deadlines?

February 29, 2016 – deadline to attest to meeting meaningful use requirements for 2015 reporting year (2017 payment adjustment year).

February 29, 2016 – deadline to request a reconsideration of 2014 reporting year results for those that did not meet the requirement (2016 payment adjustment year).

March 15, 2016 – deadline to request a hardship exception for 2015 reporting year (2017 payment adjustment year) using the blanket exception option (Option 2.2.d). Remember, even if you have attested to meeting the meaningful use requirements by the Feb. 29 deadline, you should still apply for a blanket exception, just in case. Applying for a hardship exception will not prevent you from receiving the incentive payment if your practice is able to successfully meet the requirements and attests.

July 1, 2016 – deadline to request a hardship exception for 2015 reporting year (2017 payment adjustment year) for any reason other than the blanket exception. Note, these exception applications will be approved on a case-by-case basis, as opposed to the blanket exception, after review by CMS.

Questions: CMA’s reimbursement help line, (888) 401-5911 or economicservices@cmanet.org (Rev. 02/09/16)

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JANUARY / FEBRUARY 2016 | THE BULLETIN | 41

CMA Alert, February 8, 2016 issue

CMA endorses marijuana ballot initiative to regulate and monitor substance The California Medical Association (CMA) has formally endorsed the ballot measure known as the Control, Regulate and Tax Adult Use of Marijuana Act. CMA does not as a matter of policy encourage the use of marijuana and discourages smoking. But, ultimately, its physician members believe that the most effective way to protect the public health is to tightly control, track, and regulate marijuana and to comprehensively research and educate the public on its health impacts – not through ineffective prohibition.

Consistent with the organization’s historic White Paper of 2011 urging legalization and regulation of cannabis to allow for greater clinical research, oversight, accountability, and quality control, CMA has endorsed the Adult Use of Marijuana Act so: • First, the impacts of marijuana in California can be monitored, researched, tightly regulated and, where necessary, mitigated to protect the public health; and • Second, improper diversion by non-symptomatic patients into California’s medical marijuana system can be reduced.

“The California Medical Association believes the Adult Use of Marijuana Act is a comprehensive and thoughtfully constructed measure that will allow state officials to better protect public health by clarifying the role of physicians, controlling and regulating marijuana use by responsible adults and keeping it out of the hands of children,” said Steven Larson, MD, MPH, CMA president.

“Medical marijuana should be strictly regulated like medicine to ensure safe and appropriate use by patients with legitimate health conditions and adult-use marijuana should be regulated like alcohol. This measure – along with the recently-passed medical marijuana bills – will ensure the state of California does both – with the public health and public interest being paramount concerns.”

The Adult Use of Marijuana Act is a consensus measure based on rec42 | THE BULLETIN | JANUARY / FEBRUARY 2016

ognized best practices and recommendations from engaged citizens and organizations representing local government, health and policy experts, environmental leaders, small farmers and business owners, worker representatives, and social justice advocates.

It includes safeguards for children, workers, local governments and small businesses, as well as strict anti-monopoly provisions and the toughest warning label and marketing-to-kids laws in the nation.

The initiative provides hundreds of millions of dollars in annual funding – the highest level ever by any state in America – for youth drug prevention, education and treatment programs. It also provides significant investment into local law enforcement and environmental and water protection programs.

It also closely adheres to Lieutenant Governor Gavin Newsom’s Blue Ribbon Commission on Marijuana Policy and the new medical marijuana laws recently passed by a bipartisan majority of the Legislature and signed

by Governor Brown (SB 643, AB 266 and AB 243).

Supporters of the initiative have begun collecting signatures to place it on the November ballot.

CMA Alert, January 25, 2016 issue

Campaign to increase state’s tobacco tax launches signature-gathering drive in Sacramento The signature-gathering phase of a campaign to increase California’s tobacco tax by $2 per pack has now officially begun.

On January 21, the Save Lives California coalition held a press conference at C.K. McClatchy High School in Sacramento to kick off the next big step in the initiative’s development—procuring more than half a million valid signatures to qualify the measure for the November 2016 ballot.

Philanthropist and campaign co-chair Tom Steyer; California State Superintendent of Public Instruction Tom Torlakson; Sacramento’s state Senator Richard Pan, MD; and representatives from several coalition members, including the California Medical Association (CMA), were among those in attendance.

“There’s no way to sugarcoat it: tobacco kills,” said Steyer, who has already donated $1 million to the coalition’s efforts. “This initiative aims to save lives and stop teens from ever picking up the deadly tobacco habit in the first place.”

The California Healthcare, Research and Prevention Tobacco Tax Act of 2016 will increase the state’s tobacco tax from its current $0.87 per pack to $2.87 per pack. It will also place equivalent taxes on other products containing nicotine derived from tobacco, including e-cigarettes. “We’re here today to encourage kids to never pick up the deadly habit,” Steyer said.

“This is a very straightforward proposition.”

Only those who choose to use dangerous tobacco products will be affected by the tobacco tax, a proposal that will “help dissuade our youth from starting an insidious habit that kills 40,000 Californians a year,” Dr.

Pan told reporters.

“Smoking still costs too many people their health, and actually too many dollars for our taxpayers as well,” said Dr. Pan, who is also a CMA member. “A $2-per-pack tax [increase] will discourage our young people and our fellow citizens from a habit that causes cancer, lung disease, heart disease, and many other ailments.”

The tax would also apply to e-cigarettes, which currently threaten to undermine decades of progress in reducing teen addiction to nicotine.

Studies show that youths who use e-cigarettes are four times more likely to smoke traditional cigarettes later in life than their peers who never try ecigarettes at all. Additionally, more than a quarter of a million youth who had never smoked a cigarette before used e-cigarettes in 2013.

“Teen e-cigarette use tripled between 2013 and 2014,” Superintendent Torlakson said. “Candy-flavored products that contain nicotine derived from tobacco put teens at risk of developing a deadly, lifelong addiction to nicotine.”

“I’m pleased to join the Save Lives coalition to raise awareness among students and reduce the use of tobacco products across the state,” he added.

A roundtable discussion about the danger of e-cigarettes was held with McClatchy High School students prior to the press conference. There, the students talked about their friends’ experiences with the products— one student said a close friend’s hand was severely injured after an e-cigarette blew up during use—or gave suggestions on how they should be regulated.

“I was certainly educated about this issue,” said Jay Hansen, Sacramento City Unified School District Board of Education 1st vice president.

“Big Tobacco is targeting these students with flavors like ‘cotton candy,’ and it’s important that we continue to educate them about the dangers around not only traditional tobacco products, but the e-cigarettes that we’re hearing more about today.”

Smoking costs California taxpayers billions of dollars each year, including the $3.5 billion Medi-Cal spends annually to treat smoking-related diseases. The $2-per-pack tobacco tax increase will not only reduce these long-term health care costs, but also reduce smoking rates across the state. For more information on the California Healthcare, Research and Prevention Tobacco Tax Act of 2016, go to www.savelivescalifornia.com.

JANUARY / FEBRUARY 2016 | THE BULLETIN | 43

CMA Alert, January 25, 2016 issue

CMA publishes physician guidance for the End of Life Option Act The California Medical Association (CMA) has published new legal guidance intended to help physicians and patients understand the End of Life Option Act, which was passed in 2015 and makes physician aid-in-dying legal in California.

The document is in a question-and-answer format, and is intended to help both physicians and patients navigate the complicated law.

“As physicians, there are a lot of questions about requirements under the new law, required documentation and forms, requests for the drug, consulting physicians and so on,” said CMA President Steve Larson, MD. “There certainly will be areas that evolve as we look to best

practices in areas like which drugs to prescribe, but this is a resource to help us all navigate the new landscape.”

Throughout the 15-page document, both straightforward questions as well as those without answers yet are included, and acknowledge that the resource will evolve as the law goes into effect. CMA’s health law library is the most comprehensive health law and medical practice resource for California physicians and contains On-Call documents with up-to-date information including current laws, regulations and court decisions related to the practice of medicine. On-Call documents are generally a benefit for CMA members and are available for sale to

the public; however, On-Call document #3459, “The California End of Life Option Act,” is free through CMA’s website.

“CMA was fielding calls from not only our members, but the general public about what the End of Life Option Act means and how it will impact care moving forward,” said CMA General Counsel Francisco Silva. “This is a complicated issue and both physicians and patients should have access to answers that help further the patient-physician relationship.”

CMA removed longstanding opposition to physician aid-in-dying last May and took a neutral position on the End of Life Option Act, Senate Bill 128.

CMA Alert, January 11, 2016

New approval time frames for prescription drug prior authorizations took effect January 1 A new law took effect January 1, 2016, that requires health plans and health insurers to respond to prescription drug prior authorization requests within 72 hours for non-urgent requests and 24 for urgent requests.

The law (SB 282) deems such requests to be granted if the payor fails to respond within these timeframes. A previous law (SB 866) had required a determination within two business days or the request was deemed approved.

SB 282 also requires the Department of Managed Health Care and the Department of Insurance to create a standard electronic prior authorization request form no later than Jan. 1, 2017. Prescribers and payors will

be required to use and accept this uniform electronic prior authorization form beginning July 1, 2017, or six months after the form is developed, whichever is later. Previously, SB 866 had required use and acceptance of a paper uniform prior authorization form.

A second and related law (AB 374) requires that prior authorization for prescription drug step therapy override requests be submitted in the same manner—and using the same electronic form, when available—as a prescription drug prior authorization requests. Plans and insurer must also respond to such requests within the timeframes set forth in SB 282.

CMA Alert, February 8, 2016 issue

AMA publishes online Zika resource center for physicians This month, the World Health Organization (WHO) declared an international public health emergency as the spread of the Zika virus has moved into more than 20 countries in Latin America. This rare move by the WHO signals the seriousness of the outbreak and gives countries powerful new tools to fight it.

The WHO is concerned about a possible link between Zika virus and microcephaly, a condition that causes babies to be born with brain damage and unusually small heads. Reported cases of microcephaly have risen sharply in Brazil, where Zika is raging, rising from 150

reported cases of microcephaly in 2014 to 4,180 cases in 2016. Researchers have yet to establish a direct link.

To keep physicians up-to-date on this growing concern, the American Medical Association (AMA) has created an online Zika Virus Resource Center as a clearinghouse for timely, credible information from WHO, the Centers for Disease Control and Prevention, the Journal of the American Medical Association, and other respected sources of health information.

Providers can visit the AMA’s Zika Resource Center at www.ama-assn.org/go/zika.

44 | THE BULLETIN | JANUARY / FEBRUARY 2016

Currently available resources include: • Education for physicians about the risks and symptoms of the Zika virus • How providers can detect the Zika virus • Treatment of symptoms and effects of the virus • Continuous updating of information about the infection, with maps of Zika-infected areas • Tools for communicating clearly and factually with patients, their families, and the media about exposure risks and potential preventive measures, particularly as new evidence becomes available

CMA Alert, December 14, 2015

New law requiring accurate provider directories includes provider obligation to update information On July 1, 2016, a new law will take effect that requires plans and insurers to comply with uniform standards, and provide timely updates, for their provider directories. The law (SB 137) includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payor’s network. Specifically, the law requires: • Plans/insurers must offer an online provider directory available to the public, including physicians, without any restrictions or limitations.

• The directory must be searchable electronically by, at a minimum, name, practice address, city, zip code, license number, NPI, admitting privileges to an identified hospital, product, tier, provider language, provider group, hospital name, facility name, or clinic name, as appropriate. This provision takes effect July 31, 2017, or 12 months after the date provider directory standards are developed, whichever occurs later.

• The directory must use a consistent method of network naming, product naming, or other classification method to ensure easy identification of which providers participate in which networks for which products. This provision is effective July 31, 2017, or 12 months after the date provider directory standards are developed, whichever occurs later.

• The directory must state whether a provider is accepting new patients.

• The directory must include an email address and telephone number for providers and members of the public to report directory inaccuracies.

• The directory must not include providers who do not have a current contract with the plan/insurer. If a provider is listed as participating in error and an enrollee reasonably relied upon that information, the plan/insurer may be required to pay for covered services and to reimburse the enrollee for any amount beyond in-network cost sharing.

• Plans/insurers must promptly investigate, and, if necessary, correct any issues within 30 business days if they receive a report of a possible inaccuracy in the directory.

• Plans/insurers must update paper directories at least quarterly and online directories at least weekly.

• Plans/insurers must file an amendment with the regulator if there is a 10% change in the network size for a product in a region.

• Plans/insurers must include a contractual requirement that providers inform the plan within five business days if they are not accepting new patients or if they were previously not accepting new patients but are now open to new patients.

• Plans/insurers must have a process to ensure accuracy, and must at least once per year conduct a thorough review and update of the directory. This process must include notification to contracting providers to advise them of the information the plan has about them in the directory. Group providers will be noticed annually and other providers will be noticed every six months. The notice must include information about how providers can update their directory

information using an online interface, which must generate an acknowledgment of receipt by the plan. The notice must also include a statement that the failure to respond may result in a delay of payment.

• If the payor does not receive updates to any information or confirmation from the provider that the information is accurate, the plan is required to verify the provider’s information by contacting the provider in writing, electronically and by telephone.

The plan must document the outcome and each attempt to verify the information. If the payor is unable to verify the provider’s information, the payor may remove the provider from the directory and delay payment, after providing at least 10 business days advance notice.

• The directory must inform enrollees of their rights to language interpreter services and access to covered services under the ADA.

SB 137 Effect on Physicians The new law also establishes certain requirements for physicians. The requirements underscore the importance of ensuring that practice demographic information, including whether or not the practice is accepting new patients, is up-to-date with contracted payors and any changes to practice demographics are communicated to the plan/insurer in a timely manner. Specifically, the law requires: • Providers will be required to notify plans and insurers within five business days if they are no longer accepting new patients or, alternatively, if they were previously not accepting new patients and are now open to new patients.

• If a provider is not accepting new patients and is contacted by a new patient, the provider must direct the patient to the plan/insurer to find a provider or to the regulator to report a directory inaccuracy.

• Providers will be required to respond to plan and insurer notifications regarding the accuracy of information in the provider directory by either confirming the information is correct or updating demographic information as appropriate. Failure to do so may result in a delay in payment and removal from the provider directory. Additionally, a provider group may terminate a contract with a provider for a pattern or repeated failure to update the required information in the directories.

• For providers that have capitated payor contracts, the plan can delay up to 50% of the next scheduled capitated payment for up to one calendar month if they fail to update their provider demographics or fail to confirm the accuracy of the current information. Payments to providers who have fee-for-service contracts can be delayed for up to one calendar month, beginning on the first day of the following month.

To help physicians understanding how to update their provider demographic information, until the electronic online option is required, the California Medical Association (CMA) queried the major payors on their processes. Their responses have been compiled into a members-only resource for physicians, “Updating Provider Demographic Information with Payors,” which is available free to CMA members at www.cmanet.org/ces.

JANUARY / FEBRUARY 2016 | THE BULLETIN | 45

Classifieds OFFICE SPACE FOR RENT/LEASE MEDICAL OFFICE SPACE TO SHARE • OFFICE FOR LEASE/SUBLEASE O’Connor Hospital area with office lease/ sublease. Please contact Dr. Maggie Chau at 408/799-7842 for details.

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 408/2280454.

MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Timeshare also available. Call Betty at 408/8482525.

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/DENTAL/PROFESSIONAL OFFICE SUITE • SALINAS Second story of professional building across from Salinas Valley Memorial Hospital. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $0.729/ sq. ft. Rent is $900/month. Contact Steven Gordon at 831/757-5246.

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

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Total office size 3,000 sq. ft. Available now.

Call 408/376-3305 or marlene@svspine. com.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or e-mail riflovin@allianceoccmed.com for additional information.

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.

PRIMARY CARE PHYSICIAN FOR NONPROFIT CLINIC Catholic Charities of Santa Clara County is looking for a Primary Care Physician as a Supervising Physician for a Physician Assistant, Nurse Practitioner, and medical interns on Thursdays. Clients include homeless, mental health, and seniors. Contact jobs@catholiccharitiesscc.org.

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

FOR SALE FAMILY PRACTICE FOR SALE Family Practice for Sale. East San Francis-

46 | THE BULLETIN | JANUARY / FEBRUARY 2016

co Bay, CA. Multi-location, multi-discipline practice for the Asian community’s established residents and newcomers. Revenue $1.4 million. Seller works only half-time.

The languages spoken by physicians and staff include Cantonese, Mandarin, Punjabi, and Spanish; buyer doctor must be fluent in at least one Chinese dialect. The office also performs sleep studies. EMR in place. High profit margin, and seller will stay to train buyer in proprietary systems. Independent appraisal available. Offered at only $682,000. Excellent seller financing terms available with reasonable down payment.

Real estate also available. Contact info@ MedicalPracticesUSA.com or 800/5766935. www.MedicalPracticesUSA.com.

WELL ESTABLISHED MEDICAL WEIGHT LOSS PRACTICE IN MARIN COUNTY Fall in love with practicing medicine again.

Enjoy work-life balance and financial freedom. This all cash practice offers a flexible schedule and provides income streams besides doctor visits. In addition, this practice presents a significant growth opportunity.

This is and will continue to be an active ongoing practice. The seller will enable a smooth transition. Email now BariatricPracticeForSale@gmail.com.

FAMILY PRACTICE FOR SALE Family Medicine Practice in San Jose for sale. Practice caters to South Asians, including many tech worker families. EMR in place. Good profit margin. About $500K in revenue. Contact ntnbhat@yahoo.com or call 408/839-6564.

OTHER DONATE TUBE FEEDING SUPPLIES I have a large supply of isosource HN unflavored tube feeding, as well as irrigation and mono jet syringes, and joey pump sets.

I ended up not using any of the supplies because I was sent to a sub acute facility upon leaving Kaiser Hospital. The supplies are all in the original packing material. We would like to donate them. Please email pschummers@gmail.com.

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