January/February 2019 Bulletin: HIV/AIDS and STD Prevention and Treatment

JANUARY / FEBRUARY 2019

Volume 25 | Number 1

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2

The Bulletin January / February 2019

MEMBER BENEFITS Collections CME Tracking Discounted Insurance Financial Services

New California Laws of Interest to Physicians

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Health Information Technology Resources

In This Issue

House of Delegates Representation Human Resources Services Legal Services/ Health Law Library Legislative Advocacy/MICRA Membership Directory APP for the iPhone Physicians’ Confidential Line Practice Management Resources and Education Professional Development Publications Referral Services With Membership Directory/Website Reimbursement Advocacy/ Coding Services

Feature Articles 8 Working Across Sector Lines: Santa Clara County’s Getting to Zero HIV/AIDS Prevention and Treatment Initiative 12 New Weapons in an Old Fight: HIV Pre-Exposure Prophylaxis 16 Practice Changes to Meet Rising STD Rates 28 Significant New California Laws of Interest to Physicians for 2019

Departments 5 Save the Date – CMA Legislative Advocacy Day 6 Message From the SCCMA President 7 Message From the MCMS President 21 CMA’s 2018 Year in Review 24 CMA Recoups $29 Million on Behalf of Physician Members 27 Physician Wellness 36 Medical Times From the Past 38 Classified Ads

January / February 2019 The Bulletin

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The Santa Clara County Medical Association OFFICERS

CHIEF EXECUTIVE OFFICER

COUNCILORS

President

April Becerra, CAE

El Camino Hospital of Los Gatos:

President-Elect

CMA TRUSTEES - SCCMA

El Camino Hospital:

Past President

Thomas M. Dailey, MD (District VII)

Good Samaritan Hospital:

VP-Community Health

Kenneth Blumenfeld, MD (District VII)

Kaiser Foundation Hospital - San Jose:

Kenneth Blumenfeld, MD Seema Sidhu, MD Seham El-Diwany, MD Cindy Russell, MD

Lewis Osofsky, MD Gloria Wu, MD

Vinit Madhvani, MD

Hemali Sudhalkar, MD

VP-External Affairs

Kaiser Permanente Hospital:

VP-Member Services

O’Connor Hospital:

VP-Professional Conduct

Regional Medical Center:

Secretary

Saint Louise Regional Hospital:

Treasurer

Stanford Health Care / Children's Health:

Erica McEnery, MD

Open

Randal T. Pham, MD Faith Protsman, MD Martin Wong, MD Anh Nguyen, MD

Cathy Angell, MD

Heather Taher, MD

Scott Benninghoven, MD John Brock-Utne, MD

Santa Clara Valley Medical Center:

Clifford Wang, MD

BULLETIN THE

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

Printed in U.S.A.

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 2019 by the Santa Clara County Medical Association.

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The Bulletin January / February 2019

THE MONTEREY COUNTY MEDICAL SOCIETY OFFICERS President

Maximiliano Cuevas, MD President-Elect

Christopher Burke, MD Past-President

Craig Walls, MD PhD Secretary

Alfred Sadler, MD Treasurer

Steven Harrison, MD

CHIEF EXECUTIVE OFFICER April Becerra, CAE

DIRECTORS E. Valerie Barnes, MD David Holley, MD Jeffrey Keating, MD William Khieu, MD

Walter Mills, MD James Ramseur, MD Stephen Saglio, MD

SAVE THE DATE

California Medical Association 45th Annual Legislative Advocacy Day Wednesday, April 24, 2019 Sacramento Convention Center | 3rd Floor Ballroom

Put your training into ACTION and visit your legislator!

CMA Legislative Advocacy Webinar Training Thursday, April 4 | 7–8PM Registration is FREE cmadocs.org/events

For more information, please contact Yna Shimabukuro at (916) 444-5532 or yshimabukuro@cmadocs.org.

January / February 2019  The Bulletin

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Challenging Times

President, Santa Clara County Medical Association

KENNETH S. BLUMENFELD, MD, FAANS

MESSAGE FROM THE

SCCMA PRESIDENT

W

Kenneth S. Blumenfeld, MD, FAANS is the 20182019 president of the Santa Clara County Medical Association.

He is a board-certified Neurological Surgeon with Sutter Health/Palo Alto Medical Foundation and is currently practicing with South Bay Brain and Spine. He also is adjunct clinical professor in Neurological Surgery at UCSF.

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hen it comes to health care policy, we should all be doctors – not Democrats or Republicans. The house of medicine, like California and our nation, stands divided and at odds with respect to many health care issues. Despite all the division, there remains so much that we all can agree. Cooperation, compromise and working toward the common good can go a long way.

We need to speak with one voice and, most importantly, try to regain the public trust. For too long we have let bureaucrats with little or no understanding of health care determine the fates of our profession and the patients we serve.

The Santa Clara County Medical Association (SCCMA) and California Medical Association (CMA) have more influence in Sacramento now than ever. We have built relationships, alliances and coalitions – and although I am partial, I believe we have the best lobbyist team in Sacramento, bar none. We’re not the most heavily funded, but we are powerful because we speak for doctors and patients.

With a new administration and the prospect of universal access, now is the time for constructive debate leading to rational, insightful and implementable recommendations for health care to come from California’s doctors. Rather than being reactive or playing defense, this is an opportunity to be proactive, to lead, to take control and shape the future of health care.

From my perspective, no administration has approached health care in an entirely rational fashion. The Affordable Care Act (ACA) and the California conformity laws and health care statutes that followed have achieved some laudable goals. But it was also filled with politics and concessions to special interests. It was a taxation plan sold as an individual mandate that has not been truly affordable. Many on Capitol Hill were worried it was not viable because the penalties were not high enough to convince the healthy to purchase insurance which would have brought premiums down for everyone. Not surprisingly, no political party has come up with a

The Bulletin January / February 2019

better plan.

Where do we go from here? In my opinion, we need to build on what is working, fix what is broken and leave the partisan politics at the door.

Perhaps we can agree on some basic tenants. Here are a few of my thoughts, not to be construed as representative of any organization or comprehensive in nature: 1. Everyone should have access to health care. For the sake of argument, let’s refer to the Medi-Cal safety net as universal access. As a modern industrialized country, I feel we should choose to provide these services. In making this choice we must recognize the cost. It is not free.

2. Everyone must contribute. I would like to get away from a mandate, but if there is a mandate to treat, there must be a mandate to pay. Too many have claimed they shouldn’t be forced to pay for “something they don’t want,” but the system can’t refuse to treat those in need regardless of their ability to pay. Much as someone can’t refuse to have their money go to law enforcement, fire departments or national security, all in this country and state must contribute as their means allow.

3. We need to get rid of costs that add little or no value. a. Tort reform immediately comes to mind. Although there are exceptions, medical malpractice lawsuits do little to improve the quality or safety of patient care.

More importantly, they drive medical decision-making, thereby unnecessarily escalating costs. b. How insurance companies improve health care and why anyone would think a corporation cares more about their wellbeing than a doctor is just baffling. True insurance reform needs to happen.

We can no longer afford to line the pockets of CEOs and shareholders of insurance companies. Predatory Continued on page 21

Physician Shortages

H

MESSAGE FROM THE

MCMS PRESIDENT

MAXIMILIANO CUEVAS, MD, FACOG

ment as recommended by the AAMC. How many do we need?

Increasing the number of physicians would be one approach to meeting the growing demand and reducing some of the shortage. To increase the number of physicians, we would need to make sure that the pool of available students is also increased at all levels of education. In California, the California Future Health Workforce Commission is currently working to build a future workforce with the right people, in the right places, with the right competencies, to promote health and deliver care to all Californians.

Let’s get involved with the planning for the resources needed to care for the people of California and in the United States.

A starting point then is to identify the specific number of primary care and specialty doctors needed to eliminate or reduce the medically underserved areas in rural and urban communities in the state of California that are designated as shortage and medically underserved census tracts by the federal government.

Reviewing the causes for the projected shortage, we had to ask ourselves what it is that we need to do in our communities to make sure that families are getting their students ready to pursue a career in health care.

At what level in school do we begin focusing our resources to increase the number of students that are interested in the sciences and then taking that interest to pursue a college education to prepare for medical/healthcare studies?

We met with the Superintendent of Schools for Monterey County to discuss some of the questions that we had come up with.

The data illustrating the projected physician shortage made us all work for a few hours discussing what could be done locally starting with raising awareness of the issue. Our local educators suggested that the starting point for increasing the pool of students interested in health care was to focus on middle school-aged students. Providing educational resources to more school districts for teach-

President, Monterey County Medical Society

ow do we increase the number of Monterey County students that are interested in pursuing a career in health care? This is the topic for discussion that started recently one morning while we were “in line” waiting to get started on our surgical case. My partner and I had been contemplating earlier in the week the projected physician shortage facing our communities across California especially in rural, agricultural-producing areas such as Monterey County. We reviewed the series of meetings that we had during the previous weeks with policy-makers in our community to discuss the issue of physician shortages.

The lack of primary care providers and medical specialists in the clear majority of rural and agricultural producing regions in California and the nation have been more a “talking point” than a policy point. In California, there are currently 607 federally designated Health Professional Shortage Areas (HPSA).

The preferred ratio of primary care physicians to population is 1,041 to 1. The only counties in California that meet this ratio is Orange, Sacramento and the Greater Bay Area region!

When we examine this ratio in counties in California’s central and coastal valleys and in the north, the ratios often are twice the preferred ratio. Access to medical specialists is significantly greater in these regions. Lessons learned from the implementation of the Affordable Care Act pointed out that the issue of access was a huge problem for communities with larger numbers of people that spoke a primary language other than English.

A report by the Association of American Medical Colleges (AAMC) Center for Workforce Studies projects future supply and demand for physicians and concludes that a national shortage is likely. Driven by such factors as U.S. population growth, aging population and doctors, and increased physician visits, the demand for doctors will outstrip the supply through at least 2025. If physician supply and use patterns stay the same, the United States will experience a shortage of 124,000 full-time physicians by 2030. U.S. medical schools are increasing their enroll-

Maximiliano Cuevas, MD, FACOG is the 2018-2019 president of the Monterey County Medical Society. He is currently the Chief Executive Officer at Clinica de Salud del Valle de Salinas.

Continued on page 15

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By Karuna S. Chibber, DrPH and Mia Bladin, BA John Snow Inc. A NEW MODEL FOR HIV/AIDS IS MUCH NEEDED. PERHAPS IT IS NOW TIME TO ABANDON THE IDEA THAT HEALTH CARE PROVIDERS ALONE MUST ADDRESS HIV, AND INSTEAD, BRING PROVIDERS TOGETHER WITH MULTIPLE SECTORS (PUBLIC HEALTH, SOCIAL SERVICES, HOUSING, BUSINESS, EDUCATION, COMMUNITY GROUPS ETC.) TO TACKLE HIV COLLECTIVELY AND FROM MULTIPLE ANGLES. Health care providers are well aware that HIV/ AIDS, like many other health conditions they see in their patient populations, rarely occurs in isolation (Zahner, 2014). In fact, health care professionals increasingly say that as much as 80% of patient health may be determined by what are commonly referred to as social determinants of health, or a complex interplay of individual, community, social, and structural factors (e.g. unemployment, housing insecurity, social support, toxic stress, adverse childhood experiences, addiction, physical living and working conditions, structural racism). These factors, in turn, disproportionately increase the risk of HIV for some individuals, and decrease their likelihood of receiving timely and quality health care.

Today, HIV diagnosis rates have stagnated considerably with significant advances in prevention and treatment options. This means that an HIV diagnosis is no longer considered a terminal disease when treatment can be reliably accessed.

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The Bulletin  January / February 2019

discrimination against people living with HIV (PLWH) (National HIV/AIDS strategy, 2016). Importantly, GTZ builds on many long-standing County efforts to reduce new HIV infection and improve service coordination and HIV-related outcomes. GTZ strategies also align with other County, State and National HIV/ AIDS prevention and response efforts including the statewide ‘Laying a Foundation for Getting to Zero: California’s Integrated HIV Surveillance, Prevention, and Care Plan’ (Brown, Dooley & Smith, 2016).

COLLECTIVE IMPACT Figure 1: New HIV diagnoses by race/ethnicity, 2014-2017 Yet, it is estimated that there are 3,361 people living with HIV/ AIDS in the County (Santa Clara 2017 eHars data). In 2017, there were 156 new HIV diagnoses, a 15% increase from 2016, and 20 HIV-related deaths. Importantly, despite scientific advances, in recent years, the HIV incidence rate in the County is rising among a few key sub-populations, including African Americans and Asian/Pacific Islanders, such that disparities by race and ethnicity are worsening over time. As Dr. Anthony Fauci says, the problem is “not that we don’t know how to prevent and address HIV…we already have the technology to eradicate HIV, we just need to use it effectively.”

How do we equitably address HIV/AIDS in Santa Clara County and reduce transmission and HIV-related deaths, while ensuring optimal health for people living with HIV? There is emerging consensus that working across sector lines can have greater impact when addressing complex and deeply entrenched health and social problems like HIV/AIDS (Kottke, 2016). Perhaps it is now time to abandon the idea that clinical providers, hospitals, and health systems have to singlehandedly address HIV/AIDS. Instead, by mobilizing resources and aligning strategies across multiple sectors and organizations, and bringing clinical providers together with other sectors (e.g., public health departments, social service agencies, community organizations, educational institutions, businesses, and people with lived experiences among others) we can be more effective and create the momentum necessary to impact change (Kania, 2011).

Getting To Zero (GTZ) Silicon Valley|Santa Clara County is one such multi-sector initiative, with funding allocated by the County of Santa Clara Board of Supervisors. Launched in 2017 as a four-year initiative, GTZ includes partners from the Public Health Department, health care systems, social service agencies, providers, technology sector actors, businesses, educational institutions, advocacy organizations, and LGBTQ and other community based organizations. GTZ’s goals reflect the United States National HIV/AIDS Strategy goals of zero new HIV infections, zero AIDS-related deaths, and zero stigma and

Using a Collective Impact framework, GTZ partners work together with a common agenda and shared vision for change, designing and pursuing strategies that build on each other’s efforts and are mutually reinforcing (Kania, 2011). To ensure progress and account- Figure 2: Whole Systems working ability, partners addi- together as equal partners tionally commit to collecting and sharing data routinely on a set of mutually agreed upon measures. The Health Trust serves as the “Backbone” of the GTZ initiative, coordinating strategies, partner engagement, strategic planning activities, communications, and creating an overall collective will and commitment for large-scale, countywide change. John Snow Inc. (JSI), a public health research organization, serves as the monitoring, evaluation and learning partner. Better World Advertising (BWA) designs and implements the social marketing campaigns to create awareness, address stigma, promote self-efficacy, and foster practice and behavior change. The Bill Wilson Center, a non-profit service provider, leads outreach, capacity building, and community awareness activities.

Partners. Other active partners include: AIDS Education and Training Center at UCSF; Caminar; County of Santa Clara Office of LGBTQ Affairs; Planned Parenthood Mar Monte; Roots Community Health Center; San Jose State University; Asian Americans for Community Involvement (AACI); Billy DeFrank LGBTQ Community Center; Colectivo Acción Latina de Ambiente (ALA); Community Health Partnership; Office of Community Health Stanford Medicine; Indian Health Center of Santa Clara Valley Inc., African Community Health Institute (ACHI).

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Activities Timeline

OPERATIONS AND GOVERNANCE STRUCTURE

GTZ’s activities are organized into four core areas: PrEP and PEP access, stigma reduction, guideline-based STD screening and HIV testing, and linkage to care and retention in care for HIV. A team of individuals representing different sectors and partners work together in four Action Teams focused on each of these areas. Under the guidance of a team lead, the teams pursue annual objectives and activities collectively outlined for each focus area. The Action Teams meet bi-monthly, use detailed work plans, collectively agreed upon measures, data collection and tracking tools to monitor their ongoing progress.

In addition, a Leadership Team meets monthly for goal setting and strategic planning; to oversee the activities of the Action Teams; to share emerging findings, challenges and barriers in real-time; and to ensure availability of routine reporting data to the community and Board of Supervisors regarding ongoing GTZ progress. The Leadership Team is comprised of

Focus Areas

PrEP/PEP Access Team

Enhance access to PrEP and PEP in SCC

Example Strategies: • Educate providers and staff in clinical settings about PrEP and PEP. • Design and provide tools to support consistent implementation.

• Create greater public awareness about PrEP. • Provide navigation services to help patients access PrEP. • Improve linkage and retention to PrEP services.

• Increase availability of PrEP for key populations at free or low cost.

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Guideline Based STD Screening and HIV Testing Team

Increase and improve access to STD and HIV testing services in SCC Example Strategies: • Expand routine opt-out HIV testing in health care settings.

• Expand routine STD testing per indication.

• Support establishment of Centers of Excellence in guideline based testing to increase screening.

• Provide targeted community outreach and education to support guideline based HIV and STD testing.

Linkage to and Retention in Care for HIV Team

Design and promote activities to facilitate rapid linkages and retention in care Example Strategies:

team leads from the four Action Teams, community partners, and other GTZ partners providing strategic services including the Backbone agency, the social marketing agency, and the research, evaluation and outreach partners. Another core strategy is the mini-grant program, designed to support local capacity building. Every year, the GTZ Backbone agency solicits, awards, and manages a mini-grant cycle.

A total of $100,000 is invested annually in three to five community-based groups, educational institutions, and/or community clinics to support their efforts to advance the four GTZ focus areas.

IMPACT

Over the past two years, GTZ has had significant reach, establishing new partnerships and engaging over 10,000 community members through events, meetings, and trainings.

Instead of representing their individual organizations, partners from diverse sectors come together as GTZ to conReduction of Stigma duct outreach and awareness at PRIDE and World Aids Team Day events. Key new partnerships include one with the County of Santa Clara Custody Health, resulting in PrEP access, perhaps for the first time, within the jail system.

GTZ also engaged pharmacies and identified prescription Design and support reminder services at 20 pharmacies across the County to stigma reduction activities across SCC support retention in care efforts.

Two successful social marketing campaigns were Example Strategies: launched with over 15 million impressions.

• Co-design clear and GTZ funding enabled reaching youth in a focused consistent messaging manner, and the development and provision of concise to decrease bias and stigma around and context-appropriate messaging on stigma reduction HIV/STDs. and prevention. In some youth centers, GTZ funding also • Support widespread allowed provision of free comprehensive testing. condom promotion and distribution.

Over 50 trainings have been conducted for medical • Engage community in providers, staff, students, and other community members. stigma reduction Over the first two years, a total of 136 medical providers through education,

• Disseminate information on resources available to ensure rapid linkage and retention in care.

• Improve referral systems and communications to ensure coordinated care.

• Provide education events, and outreach. and coordination for • Conduct action volunteer peer research to better navigation and identify the nature of support services. stigma surrounding • Expand provider HIV and how stigma education to affects specific improve capacity to populations. retain clients.

• Provide Technical • Identify barriers to Assistance to a range linkage to care and of providers on develop strategies to stigma reduction. address them.

The Bulletin January / February 2019

treatment for many County residents. The investment has been efficiently used to build on and leverage many of the long-standing efforts taking place around the County to reduce new HIV infections, improve service coordination, and improve HIV-related outcomes.

REFERENCES ■■ Brown, E., Dooley, D., & Smith, K. (2016). Laying a

and health professionals across 10 disciplines have been trained in PrEP and PEP. In addition, GTZ partners have developed and distributed educational materials, branded GTZ promotional materials, and safe sex supplies throughout SCC. During Year 2 alone, 3,910 flyers, pamphlets, and other educational materials were distributed, and 20,002 condoms and other safe sex supplies were distributed through GTZ efforts. Additionally, 122 PrEP/PEP toolkits were distributed to providers throughout the county. Today partners continue to take steps to ensure widespread reach and utilization of these tools and materials. This includes, for example, supporting Training of the Trainer (TOT) events to better customize and/or adapt tools to each sub-population’s unique needs.

GTZ’s laser-focused efforts to expand PrEP/PEP have yielded highly favorable results. Reach has almost doubled. In Year 1, PHD hired a PrEP navigator, developed protocols and tested a navigation system. Lessons learned from the year 1 pilot were employed to adapt and refine the PrEP referral, screening, and prescription process based on real-time learnings. Efforts in Year 2 focused on simplifying the referral process and maximizing the services provided to as many people as possible. This included getting approval for pharmacists to be providers of PrEP, and the implementation of PrEP and related services at the County STI clinic. By the end of Year 2, 256 individuals were referred for PrEP or PEP, of whom 171 completed PrEP and 18 completed PEP. The portion of PrEP referrals resulting in a prescription increased from 37% in Year 1 to 74% by the end of Year 2; a similar increase was seen among uninsured patients.

Other successes include a highly functional and acclaimed PrEP/PEP navigation program in the County, development of protocols and provider training, and availability of PrEP/PEP prescriptions through pharmacists and clinicians at the Lenzen STI clinic.

In a little over two years, the GTZ initiative has established several building blocks of a Collective Impact initiative and made substantial progress in reach, engagement, and partnerships, not to mention improved access to cutting-edge

■■ ■■ ■■ ■■ ■■ ■■

Foundation for Getting To Zero: California’s Integrated HIV Surveillance, Prevention, and Care Plan (pp.

1-101, Rep.). Sacramento, CA: California Dept. of Public Health.

Dr. Anthony Fauci, Director of National Institute of Allergy and Infectious Diseases.

Kania, John and Kramer, Mark, (2011). Collective Impact. Stanford Social Innovation Review.

Kottke TE, Stiefel M, Pronk NP (2016). “Well-Being in All Policies”: promoting cross-sectoral collaboration to improve people’s lives. National Academy of Medicine, 2016 April 14.

National HIV/Aids Strategy (2016). National HIV/AIDS Strategy. Updated to 2020.

Santa Clara County Public Health Department, eHARS, data as of May 11, 2018.

Zahner SJ, Oliver TR, Siemering KQ (2014). The mobilizing action toward community health partnership study: multisector partnerships in US counties with improving health metrics. Prev Chronic Dis. 2014 Jan 09;10:E05.

HOW CAN YOU SUPPORT GTZ?

1. TELL US what you need to ensure routine HIV/STD testing in your practices, implement PrEP/PEP and facilitate better linkages and retention in care. Call 408-792-5030.

2. LEARN more about our PrEP navigation programs, or receive training for your staff on PrEP/PEP implementation, prescriptions, and referrals by calling 408-792-3750.

3. CONDUCT routine HIV and STD screening.

4. PRESCRIBE PrEP to eligible patients.

5. ADD YOUR NAME to the PrEP provider directory. To be included in the directory of local PrEP Providers, visit: www.pleaseprepme.org/provider-resources 6. CREATE improved linkage and treatment support for your patient population through our Positive Connections Program at 408-792-5080.

7. JOIN one of our Action Teams or APPLY for a minigrant. Contact The Health Trust (THT) at candelariof@ healthtrust.org or call 408-513-8700.

8. For additional sexual health history-taking resources and training, information on Confidential Communications Request, or other sexual health resources for your patients, please contact the Santa Clara County Health Department at HIVPrevention@ phd.sccgov.org or call 408-792-3739.

9. For more information on GTZ, please visit the website at http://gettingtozeroscc.org.

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New Weapons in an Old Fight: HIV PreExposure Prophylaxis

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The Bulletin  January / February 2019

By Sarah Lewis Rudman, MD, MPH, Rodrigo Garcia-Reyes, BA and Patricia Cerrato, MPH County of Santa Clara Public Health Department, STD/HIV Prevention

I

n an era when HIV rates have stagnated, a once daily pill for prevention is now easy enough for all providers to prescribe. The Public Health Department provides additional support to bring PrEP to your practice.

Pre-exposure prophylaxis (PrEP) is an HIV prevention strategy in which antiretroviral drugs are used to protect people who do not have HIV from contracting the infection. The U.S. Food and Drug Administration approved once-daily Truvada® for PrEP in 2012. The safety and efficacy data has only improved since then. PrEP is highly effective in preventing HIV transmission and provides individuals, clinicians, and HIV prevention workers with another option for HIV prevention beyond behavioral change. According to the Centers for Disease Control and Prevention (CDC), when taken consistently, PrEP reduces the risk of HIV transmission in people who are at high risk by more than 90%. A meta-analysis presented this year showed that the risk for serious adverse events is no greater than the risk with placebo or without PrEP (Pilkington et al., 2018). PrEP should be used as part of a comprehensive HIV prevention plan that includes adherence and risk counseling and prevention education.

The CDC estimates that “1.2 million persons in the United States have risk behaviors that constitute indications for PrEP use”1 (Smith, Chang, Duffus, Okoye, and Weissman, 2018). An estimate by the California Department of Public Health suggests at least 5,000 men who have sex with men (MSM) living in Santa Clara County have an indication for PrEP (Bateman, Chibber, Greenberg, and Spezeski, 2015). From national estimates, we can extrapolate that this number may be matched by an equal or greater number of people with other indications due to heterosexual or drug-related risk factors (Smith et al., 2015).

Since FDA approval in 2012 there have been dramatic increases nationally in PrEP uptake. In 2016, there were over 77,000 PrEP users in the U.S.; a 73% increase from 2012 (Smith et al., 2018). However, every year there are new HIV cases in the County and potentially many primary care providers who are

Rate of HIV new diagnoses among males 13+ by race/ ethnicity, County of Santa Clara, 2017

not consistently offering PrEP to clients with indications. The Public Health Department also gets reports of new cases that include clients who previously sought PrEP from their primary care providers but were unable to receive it. Patients were unable to receive PrEP because their provider said they could not prescribe it for them or advised the patient not to proceed with PrEP care and choose behavioral risk reduction instead, and not in addition to, PrEP. The reasons for this “PrEP gap” are likely multifactorial, but major reasons for limited prescription may include lack of provider knowledge of the safety and efficacy data; concerns about insurance coverage of medications, labs, and visits; failure to assess clients for indications; and stigma that affects patients’ disclosure of sexual and drug history. Importantly, the Public Health Department has resources to overcome these barriers through a range of activities focused on increasing access to PrEP, including through a PrEP navigation program.

WHO MAY BENEFIT FROM PrEP? ■■ Men who have sex with men (MSM) ■■ People who inject drugs ■■ Trans women ■■ Heterosexual men and women with partners with or ■■

at risk for HIV Anyone who self-identifies a need for PrEP

MISSED OPPORTUNITY TO PREVENT HIV

Juan (name changed to protect client), a forty-year-old male from San Jose received a phone call from a former female partner to let him know that she had been diagnosed with Chlamydia and encouraging him to get tested. Juan presented to the County’s Lenzen STI Clinic on a Thursday night. Once in the examination room, the physician took a thorough sexual health history following the five P’s. (See adjoining article.)

Juan’s provider assessed that Juan had both female and male sexual partners, he used condoms irregularly when practicing anal and vaginal sex, and his last negative STD and HIV tests happened 6 months prior at a local community clinic. After the assessment, the physician discussed PrEP with Juan. Despite previously having been tested for STDs, this was the first time a medical provider had talked to Juan about PrEP, and even though he was aware of PrEP, he had been under the impression that he could not afford it due to his lack of health insurance. He was surprised to learn there were multiple support options for covering costs of care and medications, such as Gilead’s medication assistance program.

Juan’s HIV results unfortunately revealed a positive HIV diagnosis. Juan was instead directed to the Positive Connections program for linkage to HIV care. Juan was also advised according to CDC reports that if he is able to take HIV medications until his HIV viral load is undetectable, he will no longer be able to transmit HIV to his sexual partners (Siedner and Triant, 2018).

What can we learn from Juan’s experience? Had the provider who evaluated Juan 6 months prior conducted a full sexContinued on page 14

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ual history to identify Juan’s risk factors for HIV, could Juan have received PrEP as a prevention option and avoided contracting HIV? Fortunately, with medication, Juan’s health prognosis is still excellent, but his case is a perfect example of a missed opportunity. The Public Health Department aims to combat and prevent such situations with its concerted focus on increasing

mission to other sexual partners. Every step of the way, there are multiple options for patients and opportunities for us as providers to stop the epidemic while creating equitable access to better health.

REFERENCES ■■ Bateman, Chibber, Greenberg, and Spezeski (2015).

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■■

access to PrEP, including through a PrEP navigation program.

WHAT CAN MY PRACTICE DO TO MAKE SURE I DON’T MISS AN OPPORTUNITY TO PREVENT HIV? ■■ Follow CDC Guidelines for HIV and STD screening: ■■

■■ ■■

https://www.cdc.gov/std/tg2015/default.htm Report new HIV cases immediately to Public Health to facilitate immediate linkage to HIV care. New cases of HIV can be reported to HIV Surveillance at phone number (408) 792-3727 or (408) 792-3733. For linkage to HIV care call Positive Connertctions at (408) 792-5080.

Collect a sexual history from new patients and returning patients at least annually.

Prescribe PrEP for HIV prevention to those who meet guidelines or request it.

WHAT CAN THE PUBLIC HEALTH DEPARTMENT DO TO SUPPORT MY PRACTICE AND MY PATIENTS? The Santa Clara County Public Health Department can assist you with implementing interventions that support biomedical approaches to HIV prevention such as PrEP or PEP and increase patient retention in HIV care and viral suppression through our Public Health Detailing Program.

The Public Health Department can help you in identifying individuals most vulnerable to HIV while following appropriate screening guidelines and linking those with HIV to care in a timely manner. We can also help you with different prevention strategies to help your patients either remain HIV negative or achieve an undetectable viral load, so there is no risk of trans-

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The Bulletin January / February 2019

Prepped on PrEP: An Assessment of the PrEP Landscape in Santa Clara County, JSI. Pilkington, V. et al. (2018). Meta-analysis of the risk of Grade 3/4 or serious clinical adverse events in 12 randomized trials of PrEP (n = 15,678). International Congress on Drug Therapy in HIV Infection (HIV Glasgow). Glasgow, abstract O143, 2018.

Smith, Chang, Duffus, Okoye, and Weissman (2018).

Missed Opportunities to Prescribe Preexposure Prophylaxis in South Carolina, 2013–2016, (Vol. 68, Issue 1, Clinical Infectious Diseases, p.37–42).

Smith et al. (2015). Vital Signs: Estimated Percentages and Numbers of Adults with Indications for Preexposure Prophylaxis to Prevent HIV Acquisition — United States, 2015, (Vol. 64, MMWR, p. 1291-1295).

Atlanta, GA: Center for Disease Control and Prevention.

Siedner, Mark and Triant, Virgina (2018). Undetectable = Untransmittable and Your Health: The Personal Benefits of Early and Continuous Therapy for HIV Infection, (Vol. 219, Issue 2, The Journal of Infectious Diseases, p.173-176).

1 “PrEP prescriptions have been steadily increasing but are still less than 10% of those estimated to have indications for PrEP use, with marked disparities by race/ethnicity, age, transmission risk group and gender, when compared to rates of new HIV infections” (Smith et al., 2018).

CONTACT US FOR MORE INFORMATION ABOUT OUR PROGRAMS: ■■ Santa Clara County PrEP Navigation Services ■■ ■■

408-792-3750 www.sccphd.org/rxprep Santa Clara County Public Health Detailing Program 408-792-3720 HIVPrevention@phd.sccgov.org Positive Connections Program 408-792-5080 www.SCCPositiveConnections.org

HOW CAN YOU DO YOUR PART TO SUPPORT PrEP SERVICES IN SANTA CLARA COUNTY?

1. ADD YOUR NAME to the PrEP provider directory: Visit www.pleaseprepme.org/provider-resources to be included in the directory of local PrEP Providers.

2. READ the guidelines/obtain training.

3. PRESCRIBE PrEP to eligible patients.

For additional PrEP Resources, please visit www.sccphd. org/rxprep or call (408) 792-3750.

Legislative Advocacy

Reflection on CMA and Organized Medicine

By Ghida El-Banna

I

Stanford Medical Student & CMA Vice Chair of Policy

have always believed in the power of organized medicine to shape health policies and improve health outcomes for patients. I have witnessed first-hand the inadequacy of healthcare services for refugees around the world, and I have seen the consequences of bias and systematic oppression for minority populations’ health. Before starting at Stanford’s School of Medicine, I pursued a Master’s of Public Policy. Now, as a firstyear medical student, I am continuing my work in organized medicine with the California Medical Association.

I first heard about the California Medical Association through the CMA Chapter at Stanford. I heard about their work on policy resolutions such as maternity leave for female residents in surgical fields, and decided to get involved. Our voice clearly matters as Stanford medical students!

I also love our chapter leadership team and find them to be great mentors.

Motivated by my social responsibility as a future physician, I attended both CMA regional and House of Delegates

(HOD) meetings. I got the opportunity to work with medical students from across California on important topics such as health insurance costs and pharmaceutical monopolies. It was empowering to see a group of dedicated medical students meet very early on a weekend to discuss policy resolutions and provide suggestions to improve them. We also attended lectures delivered by experts on the discussed policy issues. These talks reinforced the importance of informed medical practices and well-researched policies. While we, as medical students, had intellectually heavy discussions, we also had so much fun. The HOD was a great time to make new friends, attend a Gala, and network with physicians and residents.

I am a proud member of the CMA, and I will continue to be involved in the CMA as the elected Vice Chair of Policy.

This is going to be a huge responsibility, and I am excited about collaborating with peers to craft important health policies for the future of healthcare in California.

I highly encourage my medical student peers at Stanford and other medical schools in California to get involved in the CMA. We are the future of medicine.

Sooner or later, we will all realize that we cannot treat our patients in isolation from the policies that govern their care and the social determinants of their health. It is time for all of us to actively participate in health policy work.

Physician Shortages, continued from page 7 ing the sciences could go a long way toward raising interest levels and make learning biology, chemistry, etc., more enjoyable.

During our discussions we became more aware of the need for resources such as teachers, books, computers, and more handson experiences for the students such as visiting nearby universities.

Our planning has just started. We will be developing shortterm, intermediate, and long-term ideas and strategies for approaching the issue of the projected physician shortage. We

plan to meet again to continue our discussion about our local schools and students and agreed that we will visit one of the schools where one teacher is making in-roads to making science enjoyable for students. On the short- and intermediateterm, engaging in the ongoing discussions with the California Future Health Workforce Commission will be necessary.

We ended our discussion as the operating supervisor informed us that our patient was ready. We scrubbed and got ready for surgery.

January / February 2019 The Bulletin

15

By Sarah Lewis Rudman, MD, MPH, Jim McPherson, Charisse Feldman, BSN, RN and Denise Young, MPH County of Santa Clara Public Health Department, STD/HIV Prevention

16

The Bulletin  January / February 2019

R

ising rates of STDs in Santa Clara County mean new populations are affected. Risk factor-based screening is still our best tool, but all practitioners need to be on the lookout to avoid missing cases and treatment opportunities.

Anna Bloom1 was a healthy 22-year-old woman in her first pregnancy. She entered timely prenatal care and screened negative for all risk factors for STDs except being under age 26, and initially screened negative for chlamydia, gonorrhea, syphilis, and HIV. At 31 weeks, she presented to her obstetrician with a painless, serpiginous rash on her palms and soles. The rash was initially diagnosed as a fungal skin infection given her occupation, and she was treated with anti-fungal cream and diphenhydramine. No new risk factors for STDs were identified.

At 35 weeks she returned presenting with concern for hemorrhoids and was found to have perianal warty lesions. These were initially thought to represent genital warts. But an astute PA identified these as possible condylomata lata and initiated empiric treatment for secondary syphilis with one intramuscular

injection of benzathine penicillin G 2.4 million units and resent testing for syphilis, gonorrhea, chlamydia, hepatitis B and HIV. Anna’s labs were consistent with new syphilis infection, and in retrospect her palmar rash was identified as classic for secondary syphilis. All signs and symptoms resolved within days after penicillin treatment.

At 39 weeks, Anna went into labor and delivered a healthyappearing neonate. Since delivery occurred just 4 weeks after treatment, a full evaluation of the infant was conducted in accordance with CDC guidelines, including CBC, LFTs, long bone x-rays, and lumbar puncture. The infant was treated empirically for congenital syphilis in the neonatal ICU with 10 days of intravenous aqueous crystalline penicillin G. The only positive findings on evaluation were periosteal lucencies on long-bone xrays concerning for periostitis seen in congenital syphilis, which fortunately later resolved.

Congenital syphilis is a potentially devastating disease caused by transplacental transmission during pregnancy. Adverse outcomes include: miscarriage, stillbirth, neonatal death, and lifelong disability. Over 98% of cases can be prevented with timely diagnosis and antibiotic treatment during pregnancy.

In the County, cases of chlamydia, gonorrhea, and syphilis are on the rise among all ages, genders, and racial and ethnic groups, with a near quadrupling of gonorrhea since 2010. Most alarmingly, the number of syphilis cases among females has increased 10fold since 2010, accompanied by an increase in syphilis during pregnancy and congenital syphilis. Santa Clara County received reports of 7 cases of congenital syphilis in 2017, more than had occurred in the 5 years prior, and all likely preventable had timely diagnosis and treatment occurred during pregnancy.

Syphilis has been called the great masquerader because its symptoms appear simiNumber of congenital syphilis cases and early syphilis rates among females lar to common diseases such as allergic rashes, ages 15 – 44 years, County of Santa Clara, 2010 – 2017 Continued on page 18

January / February 2019 The Bulletin

17

LOOKING AHEAD TO PREVENT CONGENITAL SYPHILIS

■■ ■■ ■■

Universal third trimester rescreening for syphilis is now recommended for all pregnancies in Santa Clara County.

Dr. Sarah Lewis Rudman, STD Controller, is available to provide training in syphilis screening, evaluation, diagnosis, and treatment tailored to your clinical site.

The Public Health Department STD/HIV Prevention & Control Program has a team of disease investigation specialists ready to assist you in syphilis lab interpretation, treatment recommendations, obtaining syphilis testing and treatment records, patient location, accessing benzathine penicillin, and referral to alternate sites for treatment.

genital warts, and herpes outbreaks. Additionally, periods of latency mean that many patients may be asymptomatic during clinical evaluation. Laboratory test interpretation is also complex, and accessing affordable treatment can be difficult for many patients. Importantly, as the rates of syphilis and other STDs rise, the Public Health Department has dedicated resources to assist with earlier detection and treatment.

What can we learn from Anna Bloom’s experience?

With the rising syphilis rates and complex nature of the clinical manifestations, risk-factor based re-screening is no longer sufficient for syphilis detection during pregnancy. According to the Centers for Disease Control and Prevention (CDC), “Effective prevention and detection of congenital syphilis depends on the identification of syphilis in pregnant women and, therefore, on the routine serologic screening of pregnant women during the first prenatal visit. Additional testing at 28 weeks’ gestation and again at delivery is warranted for women who are at increased risk or live in communities with increased prevalence of syphilis infection” (Workowski, K.A. and Bolan, G.A., 2015).

Informed by this guideline, the County STD Controller is issuing a new recommendation for routine rescreening of all pregnancies in third trimester, regardless of personal risk factors.

This recommendation is in line with CDC and ACOG guidelines that recommend rescreening in areas of high syphilis morbidity

5 STEPS YOU CAN TAKE TO IMPROVE SEXUAL HEALTHCARE

1. Take a comprehensive sexual history that includes the gender of sexual partners and anatomic sites of sexual exposure during the past year.

2. Perform syphilis and 3-site gonorrhea and chlamydia testing every 3 months for sexually active gay, bisexual and other men who have sex with men.

3. Immediately treat and report all syphilis and gonorrhea cases.

4. Screen all women <26 years old for chlamydia and gonorrhea annually.

5. Test and treat ALL pregnant women for syphilis in the first trimester, and retest at the beginning of the third trimester. If either test is missed or the patient has additional personal risk factors for syphilis, repeat screening at time of delivery.

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The Bulletin January / February 2019

such as Santa Clara County.

Had Anna Bloom been routinely rescreened at 28-32 weeks or her initial rash prompted rescreening, her infection likely would have been detected and treated early enough to prevent transmission to her infant and require only a single injection of benzathine penicillin at delivery, saving the infant an extensive medical work-up and prolonged separation from family just after birth.

Other STDs are also on the rise. Syphilis is just one of the STDs rising in Santa Clara County populations, and routine screening is critical to stop this rising trend. According to the

CDC, “Providers should make STD screening and timely treatment a standard part of medical care, especially for pregnant women and men who have sex with men (MSM). They should also try to seamlessly integrate STD screening and treatment into prenatal care and HIV prevention and care services.”

YOUR ACTIONS COUNT: START BY TAKING A SEXUAL HISTORY

Taking a sexual history is a necessary first step to risk-based screening, the best tool in our arsenal to fight the rising rates of STDs. Questions should be open-ended, appropriate to sexual orientation and gender identity, and recognize both current gender and sex at birth.

Let patients know that taking a sexual history is an important part of a regular medical exam or physical history and that California law allows any person aged 12 years and up to direct their health plan not to share sensitive information by submitting a Confidential Communications Request.2 Ask the Expert: How Dr. Sarah Lewis Rudman, County STD Controller, Takes a Sexual History The world and the medical community have evolved in our understanding of sex, gender, and sexual orientation, which affects how we talk about them. Here’s how I ask my patients about their sexual history, including some of the hardest questions.

I am going to ask you a few questions about your sexual health, which I ask all my patients. I understand that these

questions are very personal, but they are important for your overall health. Like the rest of our visits, this information is kept in strict confidence. Do you have any questions before we get started?

THE FIVE “P”S OF SEXUAL HEALTH3 PARTNERS

■■ ■■ ■■

Regardless of gender expression, medical history, marriage status, or cultural background, I ask the following questions the same way every visit and tailor additional explanation as needed: Roughly, when was the last time you had sex?

How many sexual partners have you had in the past year? (If one:) Is this a new partner since the last time you were tested for STDs? Does your partner have any other partners?

What genders are your sexual partners?

PRACTICES

■■

With these partners, have you had any oral sex? Any vaginal sex? Any anal sex? (Based on sex at birth of patient and partners, may need to clarify if vaginal and anal sex are receptive, insertive, or both.)

PROTECTION FROM STDS

■■(Based on types of sex practiced:) Any condom or barrier use with oral sex, like a dental dam?

With vaginal or anal sex, would you say you use condoms, sometimes, always, or never?

PAST HISTORY OF STDS

■■

■■ When was the last time you were tested for STDs? And did you have an HIV test then as well?

What were the results?

■■ Have you ever been treated for any STD in the past like chlamydia, gonorrhea, or syphilis?

Have you been exposed to any STDs as far as you know? For example, has a partner called you and told you they tested positive for something?

PREVENTION OF PREGNANCY Based on your patient’s sex at birth, partners and sexual practices, pregnancy may also be a risk.

If so, first determine if a pregnancy is desired. If not, include a discussion of birth control options in addition to options for reducing STD risk.

■■ Are you/your partner currently trying to get pregnant?

(If not:) What do you use for pregnancy prevention?

How is that working for you? Are you interested in another method?

Continued on page 20

4 Dx/Rx Answers

January / February 2019 The Bulletin

19

■■

(For anyone with a recent or current STD and any partners who were assigned female sex at birth:) As far as you know, are any of your partners currently pregnant?

ADDITIONAL RISK FACTOR ASSESSMENT

LEARN MORE ABOUT PARTNER SERVICES AVAILABLE TO YOUR PATIENTS

Partner Services is a free program offered by the Santa Clara County Public Health Department (SCCPHD) that helps patients determine how to best notify their sex or needle sharing partners. Let your patients know that SCCPHD Communicable Disease Investigators and Social Workers routinely work with patients diagnosed with syphilis and HIV to offer partner services.

Partners Services staff will also help confidentially contact any partners and offer STD and HIV testing, treatment, and linkage to prevention services such as Pre Exposure Prophylaxis (PrEP) and Post Exposure Prophylaxis (PEP).

Partner notification is important because treating partners can prevent reinfection and prevent further disease transmission and complications.

Call 408-792-3739 to learn more.

You will likely need to ask additional questions appropriate to each patient’s special situation or circumstances. For some patients, such as those with unstable housing, multiple sex partners, condom-less sex, suspected or prior STD, or current pregnancy, I assess additional risk factors for STDs as follows: ■■ I always ask everyone, do you use any drugs like meth, heroin, cocaine, or poppers? How often are you using when you have sex?

■■ Have you ever traded anything for sex? For example, have you ever paid someone, or been paid, or been given something else you needed like food or a place to stay?

■■ Have you ever been to jail or prison?

■■ Right now, do you have a safe and reliable place to stay? Have you ever been homeless in the past?

■■ Is PrEP or PEP something you’ve heard of before?

Have you ever been on it in the past? These are pills to prevent HIV, and if you’re interested in learning more, we can talk about it in a bit. (See adjoining article for more information.)

The answers to the questions above provide all the information I need to know about which screening tests to order, what risk reduction methods to recommend, and if any empiric treatment is needed for exposure to an STD.

HIV infection is reported using either the Adult HIV/AIDS Case Report Form (ACRF) for ages 12 years and greater, or the Pediatric HIV/AIDS Confidential Case Report for those under age 12.

Timely and accurate disease reporting not only helps provide a better understanding of our local epidemic, trends, and needs, but it helps control further spread of infection by allowing our disease investigators to ensure timely patient and partner treatment. And it affects state and federal funding the County receives for STD and HIV prevention and treatment.

CALIFORNIA’S REPORTING LAWS

WANT MORE INFORMATION?

California law requires health care providers to report cases of sexually transmitted infections to the local health department. Though rarely prosecuted, failure to report is actually a misdemeanor in California. Reporting of STDs, including HIV or AIDS, does not require patient consent and is permitted with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

STDs that must be reported: ■■ Chlamydia (including lymphogranuloma venereum (LGV)), within seven (7) calendar days of diagnosis ■■ Gonorrhea, within seven (7) calendar days of diagnosis ■■ Chancroid within seven (7) calendar days of diagnosis ■■ Syphilis within one (1) working day of diagnosis ■■ HIV infection and all CD4 and viral load test results within seven (7) working days ■■ Acute HIV infection (symptomatic, antibody-negative, or known recent exposure) within one (1) working day of diagnosis Chlamydia, gonorrhea, chancroid and syphilis can be reported by mail or fax using the Confidential Morbidity Report (CMR), available at www.sccphd.org/reporting, or electronically through the California Reportable Disease Information Exchange (CalREDIE) communicable disease reporting and surveillance system.

For more information on the CalREDIE Provider Portal, please go to: https://www.cdph.ca.gov/Programs/CID/DCDC/ CDPH%20Document%20Library/Provider-Portal-Flyer.pdf

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The Bulletin January / February 2019

For additional sexual health history-taking resources and training, information on Confidential Communications Request, or other sexual health resources for your patients, please contact the Santa Clara County Health Department at HIVPrevention@ phd.sccgov.org or call 408-792-3739.

REFERENCES ■■ Workowski, K. A., & Bolan, G. A. (2015). Sexually

Transmitted Diseases Treatment Guidelines, 2015 (3rd ed., Vol. 64, MMWR, p. 45, Rep.). Atlanta, GA: Center for Disease Control and Prevention.

1. Name was changed to protect confidentiality.

2. Confidential Communications Requests can be submitted here: https://www.myhealthmyinfo.org/sites/ default/files/Confidential-Communications-Request. pdf 3. Framework adapted from CDC “A Guide to Taking a Sexual History” https://www.cdc.gov/std/treatment/ sexualhistory.pdf 4. Dx/RX Test Your Knowledge Answers: 1.-c., 2.-c., 3.-f., 4.c.&e., 5.-b., 6.-a., 7.-d., 8.-g.

Secured the Proposition 56 supplemental budget bill, which appropriates over $1 billion in funding for improved access to care.

Achieved record-setting 6.24 percent increase in membership with a 92 percent retention rate.

Drafted and filed a 2020 Sugar-Sweetened Beverages tax ballot initiative.

Stopped predatory practices by health insurance companies, including attempts to substantially limit same-day services (modifier -25 payments).

Launched a mobile app, as well as updated brands and websites for CMA, PHC, CALPAC and 20+ component medical societies.

Defended the medical profession and patients from dangerous legislation, including AB 3087 (Kalra).

Helped the Tulare Regional Medical Center medical staff restore independence and self-governance against the hospital.

Recouped nearly $11 million from payors on behalf of CMAâ&#x20AC;&#x2122;s physician members â&#x20AC;&#x201C; a record year!

Secured $30 million commitment from Blue Shield of California to support the launch of a Physician Services Organization.

Secured $200 million to establish a loan repayment program and $40 million for the University of California to support, retain and expand physicians trained in California.

Visit cmadocs.org for more information.

Challenging Times, continued from page 6 business practices and unconscionable medical loss ratios need to stop. Enough said.

4. A rational and balanced approach needs to be taken in controlling the costs of pharmaceuticals and medical devices. Although handsome profit needs to be the carrot of innovation, the carrots have gotten too big and real innovation as opposed to incremental advances often comes from underfunded academic research and not industry. Lastly, I challenge anyone to explain how pharmacy benefit managers have improved

health care.

5. How much health care we provide has to be better managed in an evidence-based fashion. This is a scary and difficult concept. Its initial implementation will involve choosing not to provide futile or unproven care but is an admittedly slippery slope that will need to be navigated much as it has been in the U.K. and elsewhere.

6. Since this is the U.S., our system will need to be multi-tiered. In simple terms, those who can afford to pay for more comprehensive health care should be allowed to do so. I know this is distasteful for some, but it is a reality. There should also

be basic, essential and affordable health care coverage offerings for low-income families.

We are in for contentious debate. I am hopeful that organized medicine, including our SCCMA, CMA and the American Medical Association (AMA) can have a unified voice. It is also a call to action for our members. This is not the time to put our heads in the sand. Rather, I would ask that our members be vocal and engaged. Join a committee or council, be a delegate, meet with your legislators and Members of Congress, and give to our PACs. I like to think of challenging times as providing opportunity, and I strongly believe that California and our nation need our help and collective wisdom.

January / February 2019â&#x20AC;&#x192; The Bulletin

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The Bulletin January / February 2019

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January / February 2019â&#x20AC;&#x192; The Bulletin

23

Health Care Dream Team

CMA’s economic advocates recoup $29 million on behalf of physician members

BY TINA TEDESCO

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The Bulletin January / February 2019

C

alifornia physicians have a powerful ally when it comes to dealing with problematic payors—the California Medical Association (CMA) Center for Economic Services (CES). Staffed by practice management experts with a combined experience of more than 125 years in medical practice operations, the CES team has recovered $29 million on behalf of its physician members over the past 10 years.

Each member of the CES team brings something unique to the table, allowing them to bounce ideas off each other when trying to help practices.

“We are the dream team of health care,” said Mark Lane, CES Director of Publications and Resources. “There are few issues presented that we do not have experience dealing with in some capacity. We can also draw upon our vast network of contacts to find a resource or point person to help address almost any issue. No other organization, that I am aware of, can assist physicians or their practices on this level,” said Lane.

Lane began his career as a claims processor for plans such as Blue Shield of California and Health Net. Before long, he had moved up to a position in provider relations, allowing him to get a unique vantage point on the relationship between physicians and payors.

EMPOWERING PHYSICIAN PRACTICES

that upon renewal, the medical board showed no lapse in the permit. As a result, Anthem agreed not only to not pursue the recoupment, but also to release approximately $600,000 in pending claims for payment.

Another success story was getting Medicare to agree to reinstate billing privileges and release almost $1 million in pending payments to another practice that had its billing privileges revoked when Medicare discovered an undisclosed criminal offense by a practice employee.

CMA, the American Medical Association and Noridian, California’s Medicare Administrative Contractor, worked together to get the practice’s appeal reviewed within three days, rather than the normal 90 days as allowed by law, to help get the practice’s billing privileges reinstated and avoid overpayments dating back nine years.

“This is money that would have likely gone unrecouped if we didn’t step in,” said Black, who has been with CMA for 14 years, building relationships with both physicians and payors on behalf of CMA. Prior to joining CMA, she spent 15 years working with a group of emergency physicians, a field she entered while still in college. She changed her major to health care administration because she believed in the cause so much.

CES is constantly developing resources and tools to assist practices with new laws, including its monthly CMA Practice Resources newsletter, webinars, seminars and phone conversations. These services are free to all members.

“It feels great to help our doctors, so they can get back

CES also provides one-on-one practice management assistance to physician members and their staff on reimbursement, practice operations and contract-related issues. The center’s goal is to empower physician practices by providing Continued on page 26 resources and guidance to improve practice success. Assistance ranges WHEN DO I CALL CMA? from coaching and education to diCMA members can call on CMA’s practice management experts for free one-onrect intervention with payors or regone help with contracting, billing and payment problems. If you answer “yes” to any of ulators. the following questions, it might be time to call for help: “The ultimate goal is to empower ■■ Are your claims not being paid in a timely manner or according to your practices to be able to advocate succontract? cessfully for themselves,” said CES ■■ Do you need assistance regarding the new law on payment and billing for outVice President Jodi Black. “Someof-network services (AB 72)? times processes fail and that’s when ■■ Are you receiving untimely requests for refunds or is a payor recouping money we intervene on their behalf.” without first notifying you in writing of a refund request?

In the first three quarters of 2018, ■■ Do you need assistance creating a business case as to why a payor should CES recovered more than $9 million consider contracting/re-contracting with your practice? on behalf of physician members, up ■■ Do you need help with Medicare-related issues? from $3 million in all of 2017. One of ■■ Are your claims being denied after obtaining prior authorization?

■■ Are you receiving unreasonable requests for medical records? the biggest successes this year was ■■ Do you need help identifying common practice mistakes costing you money? getting Anthem Blue Cross to agree ■■ Have you been presented with a managed care contract and you’re not sure if not to pursue a $4.2 million recoupthe terms are consistent with California law? ment from a member practice.

■ ■ Have you done everything you can to resolve an issue with a payor, including Anthem had notified the pracappealing, and have been unsuccessful? tice it was planning to recoup more Call CMA’s reimbursement helpline today at (888) 401-5911 and they will arm you than $4 million due to problems with with the knowledge you need to identify and fight unfair payment practices. Learn the renewal of a fictitious name permore about how CMA’s practice management experts can help you at cmadocs.org/ mit. CMA escalated the issue to Ances. them’s medical director, highlighting

January / February 2019 The Bulletin

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to work helping their patients,” said Juli Reavis, CES Associate Director, who focuses largely on helping physicians with California’s new out-of-network billing and payment law (AB 72). The law, which went into effect July 1, 2017, placed limits on what physicians can bill patients for using an out-of-network physician at in-network facility. CES has created more than 10 new resources to help practices succeed and comply with these new requirements.

YOU ARE NOT ALONE

In just the first eight months of 2018, CES assisted physicians and their office staff with nearly 900 calls from 555 different practices within 30 different component medical societies. Seventeen percent of those calls were from first-time callers.

Often, the only way CES finds out about an issue is by members contacting the call center. Typically, if an issue is affecting one practice, it’s impacting others. Small errors, sometimes on the part of the payor, sometimes on the part of the physician, can have a snowball effect.

“Our goal is to take the noise out of the system so doctors can get back to treating patients,” said Black.

“I always felt a need to help others and prevent pain and suffering wherever I could,” said Lane. “The role I serve at CMA, assisting physicians and their practice staff, has given me the opportunity to fulfill my mission. It’s the most rewarding role I have ever had in my 25 years of health care.”

Tina Tedesco is a freelance writer in Sacramento.

CMA HELPS YOU GET PAID CMA’s reimbursement experts have recouped more than $29 million from payors on behalf of CMA physicians in the past 10 years. This represents actual monies that would have likely gone unpaid if not for CMA’s intervention.

Access to CMA’s practice management experts is free, members-only benefit. To reach CMA’s reimbursement helpline: (888) 401-5911 or economicservices@cmadocs.org.

$30M

$29 Million

$28M $26M $24M $22M $20M $18M $16M $14M $12M $10M $8M $6M $4M $2M

TOTAL ANNUAL

$1.3M $4.0M $6.8M $8.0M $8.8M $9.8M

$12M

$15M

$18M

$29M

$1.3M

$2.2M

$3.0M $3.0M

$11M

2009

$2.7M $2.8M $1.2M $0.8M $1.0M 2010

2011

2012

2013

2014

2015

2016

2017

2018

Meet Your Advocates JODI BLACK, VICE PRESIDENT Jodi is the Vice President of CMA’s Center for Economic Services. She has spent the past 14 years working through practice operational issues and advocating on behalf of members of CMA and its county medical societies. Prior to her time at CMA, Jodi spent 15 years working with a group of emergency physicians. “Our team not only provides one-on-one assistance when needed, but we also work hard to educate and empower practices to be able to advocate successfully for themselves.”

CHERYL BRADLEY, PHYSICIAN ADVOCATE Cheryl specializes in Medicare issues. Before joining CMA, Cheryl served as a provider outreach and education specialist for Noridian Healthcare Solutions, California’s Medicare contractor. She came to CMA with over seven years of Medicare experience. “Our goal is to empower CMA member physicians and their staffs to use tools and resources that increase their understanding of the health care topics at hand – and their bottom lines.”

MARK LANE, DIRECTOR OF PUBLICATIONS AND RESOURCES For more than a decade and a half before joining the CMA team in 2010, Mark had a career as a claims processor for plans such as Blue Shield and Health Net. Before long, he had moved up to a position in provider relations, giving him a unique vantage point on the relationship between physicians and payors.

“Communication really is the answer to a lot of payor issues. CMA has the contacts and the relationships to cut through the red tape and get things done.”

KRIS MARCK, PHYSICIAN ADVOCATE Before joining CMA in 2011, Kris spent 23 years working on the payor side of the health care industry. This previous experience makes her a very effective and approachable advocate for physicians in need of reimbursement and contracting assistance. “Working with payors is challenging and the reimbursement process is complex. Don’t hesitate to call us. It’s easy to give the easy answer, but it’s difficult to go and find the right answer. We’ll get you the right answer.”

JULI REAVIS, PHYSICIAN ADVOCATE Juli primarily focuses on helping members navigate the new AB 72 billing restrictions for out-of-network services at in-network facilities. “We are fighting to ensure that payors do not game the system to set artificially low physician payment rates. If you’re being negatively impacted by AB 72’s new billing and payment restrictions, call me. I can help.” Learn more at cmadocs.org/ab-72.

JENNIFER WILLIAMS, EXECUTIVE ASSISTANT Jennifer, who has spent the last 12 years with CMA, is often the first point of contact for practices in need of reimbursement assistance or practice management advice. “A lot of practices think we’re too busy to answer questions or don’t want to ‘bother’ us with what they think is a ‘silly’ question. Please don’t wait to call us. We’re here to help our members; it’s our job.”

MITZI YOUNG, PHYSICIAN ADVOCATE Mitzi has spent more than 20 years in health care settings, including county organized health programs, surgery centers and specialty health care practices, and brings a variety of skills suited to help CMA members tackle their practice management questions. “With over 125 years of practice management experience on the CES team, we can help medical practices work smarter, not harder.”

The CES team can be reached at (888) 401-5911 or economicservices@ cmadocs.org.

Visit cmadocs.org for more information.

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The Bulletin January / February 2019

Physician Wellness

CMA Announces New Statewide Effort to Promote Physician Wellness

A

s the delivery of health care undergoes fundamental shifts and the rate of burnout among physicians continues to rise, physician wellness and professional fulfillment have become hot topics throughout the health care community – and for good reason.

In a recent Medscape survey, nearly two-thirds of U.S. doctors said they felt burned out, depressed or both. More troubling still, one-third of respondents said such feelings affected their relationships with patients.

Burnout can erode the quality of patient care and decrease patient satisfaction. It can also limit patient access to care, as physicians experiencing burnout often cope by reducing the number of patients they see, reducing their clinical time or leaving the profession entirely.

To help physicians succeed in their life’s work of caring for patients, the California Medical Association (CMA) has made physician wellness and the prevention of burnout a core priority. By advancing initiatives that enhance efficiency, professional satisfaction and the delivery of care, CMA is striving to help physicians navigate and succeed in a continually evolving health care environment.

To that end, CMA is working with nationally recognized leaders on physician wellness who bring unparalleled academic expertise and hands-on experience to build an organizational initiative to improve physician fulfillment and well-being.

The new initiative is a statewide collaborative effort with physician wellness experts from the Stanford Medicine WellMD Center: Tait Shanafelt, M.D., associate dean, chief wellness officer and professor of hematology; and Mickey Trockel, M.D., project

By Katherine Boroski co-leader and clinical associate professor of psychiatry and behavioral sciences.

Under the leadership of CEO Kathleen Creason, CMA’s Physician Wellness Services will be the most comprehensive effort in the country to increase physician wellness as a vehicle to improve the quality of care they provide patients.

“CMA is extremely proud to work with Dr. Shanafelt and his team to better combat physician burnout, which occurs from medical school through active practice,” said CMA President David H. Aizuss, M.D. “This program’s scope, innovative approach and resources are unmatched in the nation, and it will substantially improve physician wellness while supporting patient access to quality care.”

The program will utilize a population health framework to address systemic contributors to physician burnout, along with providing tailored support for physicians at increased risk or experiencing specific challenges. In addition to creating tools to support changes that the health care system can make to increase physician well-being, the program will assist those already expressing signs of burnout.

“This collaboration will implement a comprehensive approach to promote the wellness of California’s physicians,” said Dr. Shanafelt. “Given the strong links between physician distress and the care they provide patients, we believe improving physician wellness benefits not only physicians, but the patients and communities they serve.”

The program will also include offerings that range from local physician commensality groups (to help physicians reconnect with their peers and to find meaning in their work) to tools that help physicians

calibrate their well-being, while also linking those physicians who have markers of burnout to additional resources. Training will be made available to empower physician leaders to build practice environments that support professional fulfillment. The program will also include an annual comprehensive, longitudinal assessment of the experiences of California physicians to identify new opportunities and measure progress.

“This project aims to promote wellness for all physicians, deliver specific interventions to those most at risk for burnout, and provide timely interventions to those already in distress,” said Dr. Trockel. “Along with broad focus on promoting well-being, this tiered approach also sets the ambitious goal of preventing physician suicide in California.”

National studies led by Dr. Shanafelt indicate that burnout is more common among physicians than U.S. workers in other fields. Physician burnout has also been associated with risk for suicide among physicians.

“The well-being of the nation’s physicians is a critical factor in maintaining access to care and the quality of our health care system,” said Creason. “The program will help physicians conquer these issues, so they can do what they do best – care for patients.”

For more information on CMA’s Physician Wellness Services Program, contact Kathleen Creason at kcreason@cmadocs. org or (916) 551-2031.

Katherine Boroski is Senior Director of Communications for the California Medical Association. She can be reached via email at kboroski@cmadocs.org.

January / February 2019 The Bulletin

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Significant New California Laws of Interest to Physicians for 2019 TheThe California hadanan active year, passing new laws affecting CaliforniaLegislature Legislature had active year, passing many many new laws affecting health health care.

In particular, there was a strong focus on health care coverage, drug care. In particular, there was a strong focus on health care coverage, drug prescribing, public mental health issues.

Onfollowing the following pages prescribing, publichealth, health, and and mental health issues.

On the pages you will you willfind findhighlights highlights of the most significant health laws of interest to physicians. of the most significant health laws of interest to physicians. gonadotropin (hCG) as a Schedule III conALLIED HEALTH ALLIED HEALTH PROFESSIONALS trolled substance under the California PROFESSIONALS

injured as a result of intimate partner violence, as defined, to consent to medical Uniform Controlled Substances Act. This care related to the diagnosis or treatment bill exempts hCG from being subject tolaboratory of the injurytechnicians and the collection of medical AB 2281 –(Irwin) licensed medical AB 2281 (Irwin) Clinical– Clinical laboratories: the reagent regulations of the Controlled evidence with regard to the alleged intilaboratories: licensed medical CMA Position: Support Substances Act when possessed by, sold mate partner violence. laboratory technicians Exempts blood smear reviews other than manual leukocyte differentials, to, purchased by, transferred to, or admin- microscopic urinalysis, and CMA Position: Support istered by a licensed veterinarian, a li- and blood typing of moderate complexity such as automated ABO/Rh or testing antibody screen testing DEATH AND ORGAN Exempts blood smear reviews other censed veterinarian’s designated agent, from the prohibition of licensed medical laboratory technicians from performing microscopic analysis or DONATION than manual leukocyte differentials, miexclusively for veterinary use. immunohematology procedures. croscopic urinalysis, and blood typing of AB 2096 (Frazier) – Personal moderate complexity such as automatSB 762 (Hernandez) – income taxes: voluntary ed ABO/Rh antibody– screen AB testing 2423 and (Holden) Physical therapists: direct access Optometry: administration of to services contributions: Organ and Tissue testing from the prohibition of licensed immunizations CMA Position: Neutral Donor Registry Voluntary Tax medical laboratory technicians from perRequires training programs for cerProvides physical therapists with an exemption from the provision in the Physical Therapy Practice Contribution Fund Act forming microscopic analysis or immu- tification of optometrists to administer Allows a taxpayer to designate an that prohibits the physical therapist from continuing treatment beyond 45 calendar days or 12 visits, nohematology procedures. immunizations to be endorsed by the Acamount in excess of personal income tax whichever occurs first, without receiving specified doctor approvalEducaof the physical therapist’s plan of care creditation Council for Pharmacy liability to be transferred into the Organ AB 2423 (Holden) – Physical in addition to theoffederal Centers forthe federal Individuals with to enable them to provide servicestion within their scope practice under and Tissue Donor Registry Voluntary Tax therapists: direct access to Disease Control Individualized and Prevention.Education Program (IEP) or an Disabilities Act (IDEA) under a school-developed Contribution Fund, which the bill creates. services Individualized Family Service Plan (IFSP).

CMA Position: Neutral SB 1003 (Roth) – Respiratory

SB 1163 (Galgiani) – Postmortem

therapy Provides physical therapists with examination or autopsy AB 2589 substances: human chorionic gonadotropin an exemption from (Bigelow) the provision –inControlled the CMA Position: Neutral Makes various changes to provisions lists human chorionic gonadotropin (hCG) as agency, a Schedule III controlled substance under the Physical Current Therapylaw Practice Act that proProhibits any state as deregarding postmortem examination or hibits the physical therapist from conCalifornia Uniform Controlled Substances Act. This hCGCare from being subject to the reagent fined, except for bill theexempts Respiratory autopsies of unidentified bodies or retinuing treatment beyond 45 calendar Board of California, from defining or intermains, including to provisions regulations of the Controlled Substances Act when possessed by, sold to, purchased by, transferred to, orregarding days or 12 visits, whichever occurs first, preting respiratory care for those licensed dental examinations, tomography scans, by a licensed or a licensed veterinarian’s designated agent, exclusively for without administered receiving specified doctor veterinarian, ap- under the Respiratory Care Practice Act, and retention of tissue and bone samples. use.therapist’s plan of proval ofveterinary the physical or from developing standardized proceAuthorizes an agency tasked with the excare to enable them to provide services dures or protocols, unless authorized by humation of a body or skeletal remains within their of practice under– the SB scope 762 (Hernandez) Optometry: administration immunizations these provisions or specificallyof required of a deceased person that has suffered federal Individuals with Disabilities Act by state or federal statute. significant deterioration or decomposiRequires training programs for certification of optometrists to administer immunizations to be endorsed (IDEA) under a school-developed Indition, where the circumstances surroundbyEducation the Accreditation for Pharmacy Education in addition to the federal Centers for Disease vidualized Program Council (IEP) or an ing the death afford a reasonable basis to CONSENT Control and Service Prevention.

Individualized Family Plan (IFSP). suspect that the death was caused by or related to the criminal act of another, to AB 3189 (Cooper) – Consent by AB 2589 – Controlled SB(Bigelow) 1003 (Roth) – Respiratory therapy minors to treatment for intimate perform the exhumation in consultation substances: human chorionic with a board-certified forensic patholopartner violence CMA Position: Neutral gonadotropin gist.

Authorizes a board-certified forenAuthorizes a minor who is 12 years of Current law lists human chorionic sic pathologist to suggest to the agency age or older and who states he or she is

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The Bulletin January / February 2019

tasked with an exhumation to consider retaining the services of an anthropologist, as specified.

DRUG PRESCRIBING AND DISPENSING AB 315 (Wood) Pharmacy benefit management CMA Position: Sponsor Requires a pharmacy to inform a customer at the point of sale for a covered prescription drug whether the retail price is lower than the applicable cost-sharing amount for the prescription drug unless the pharmacy automatically charges the customer the lower price. If the customer pays the retail price, the bill requires the pharmacy to submit the claim to the plan or insurer in the same manner as if the customer had purchased the prescription drug by paying the cost-sharing amount when submitted by the network pharmacy.

AB 1751 (Low) – CURES database: Interstate data sharing CMA Position: Oppose Unless Amended Requires the Department of Justice, no later than July 1, 2020, to adopt regulations regarding the access and use of the information within CURES by consulting with stakeholders, and addressing certain processes, purposes, and conditions in the regulations. Authorizes the department, once final regulations have been issued, to enter into an agreement with any entity operating an interstate data sharing hub, or any agency operating a prescription drug monitoring program in another state, for purposes of interstate data sharing of prescription drug monitoring program information, as specified.

information to the department for all prescription forms delivered.

AB 2037 (Bonta) – Pharmacy: automated patient dispensing systems Provides an alternative program to authorize a pharmacy located in the state to provide pharmacy services to the patients of covered entities, as defined, that are eligible for discount drug programs under federal law, as specified, through the use of an automated patient dispensing system, as defined. Provides that the responsibility of the operation, maintenance, and security of the automated patient dispensing system would be the responsibility of the pharmacy and requires that the drugs dispensed from the system be labeled in accordance to existing law. Requires the pharmacy to complete an annual self-assessment.

AB 2086 (Gallagher) – Controlled substances: CURES database CMA Position: Support Allows prescribers to access the Controlled Substance Utilization Review and Evaluation System (CURES) database for a list of patients for whom that prescriber is listed as a prescriber in the CURES database.

and dying patients.

AB 2760 (Wood) – Prescription drugs: prescribers: naloxone hydrochloride and other FDAapproved drugs CMA Position: Neutral Requires a prescriber, as defined, to offer a prescription for naloxone hydrochloride or another drug approved by the United States Food and Drug Administration for the complete or partial reversal of opioid depression to a patient when certain conditions are present and to provide education on overdose prevention and the use of naloxone hydrochloride or another drug to the patient and specified others, except as specified. Subjects a prescriber to referral to the licensing board charged with regulating his or her license for the imposition of administrative sanctions, as that board deems appropriate, for violations of these provisions.

AB 2783 (O’Donnell) – Controlled substances: hydrocodone combination products Reclassifies specified hydrocodone combination products as Schedule II controlled substances under the California Uniform Controlled Substances Act.

AB 2256 (Santiago) – Law enforcement agencies: opioid antagonist

AB 2789 (Wood) – Prescriptions: electronic data transmission

CMA Position: Support

Requires, on and after January 1, 2022, health care practitioners authorized to issue prescriptions to have the capability to transmit electronic data transmission prescriptions and would require pharmacies to have the capability to receive those transmissions. Mandates electronic prescribing, unless specified exceptions are met.

Authorizes a pharmacy, wholesaler, or manufacturer to furnish naloxone hydrochloride or other opioid antagonists to a law enforcement agency, as provided.

AB 1753 (Low) – Controlled substances: Security form

AB 2487 (McCarty) – Physicians and surgeons: continuing education: opiate-dependent patient treatment and management

CMA Position: Neutral

CMA Positing: Neutral

Authorizes the Department of Justice to reduce or limit the number of approved security printers for controlled substance prescription forms to 3, as specified and requires prescription forms for controlled substance prescriptions to have a uniquely serialized number, in a manner prescribed by the department, and requires a printer to submit specified

Authorizes a physician and surgeon to complete a one-time continuing education course of 12 credit hours on opiate-dependent patient treatment and management, including eight hours of training in buprenorphine treatment as an alternative to the mandatory continuing education course on pain management and the treatment of terminally ill

CMA Position: Oppose

SB 212 (Jackson) – Solid waste: pharmaceutical and sharps waste stewardship CMA Position: Support Establishes a stewardship program, under which a manufacturer or distributor of covered drugs or sharps, or other entity defined to be covered by the bill, is required to establish and implement, either on its own or as part of a group of covered entities through membership

January / February 2019 The Bulletin

29

in a stewardship organization, a stewardship program for covered drugs or for sharps, as applicable. Imposes various requirements on a covered entity or stewardship organization that operates a stewardship program, including submitting a proposed stewardship plan, an initial stewardship program budget, an annual budget, annual report, and other specified information to CalRecycle.

in a single course of treatment for a controlled substance containing an opioid.

Requires youth sports organizations to distribute specified Opioid Factsheet for Patients to each athlete and requires each athlete and their parent to sign a document acknowledging receipt.

SB 1021 (Wiener) – Prescription drugs

CMA Position: Neutral

Extends existing provisions related to formularies for outpatient prescription drugs by health care service plans or health insurers and cost-sharing for covered outpatient prescription drugs until January 1, 2024. Prohibits, until January 1, 2024, a drug formulary maintained by a health care service plan or health insurer from containing more than 4 tiers, as specified. Requires a prescription drug benefit to provide that an enrollee or an insured is not required to pay more than the retail price for a prescription drug if a pharmacy’s retail price is less than the applicable copayment or coinsurance amount, and the payment rendered by an enrollee or insured would constitute the applicable cost-sharing. Extends until January 1, 2023, coverage requirement to antiretroviral drug treatments that are medically necessary for the prevention of AIDS/HIV.

SB 1109 (Bates) – Controlled substances: Schedule II drugs: opioids CMA Position: Support Requires training and continuing education under the Medical Practice Act, Nursing Practice Act, Physician Assistant Practice Act, Dental Practice Act, Osteopathic Act, and the Optometry Practice Act to include risks of addiction associated with the use of Schedule II drugs. Requires pharmacy or practitioner dispensing an opioid to a patient for outpatient use to display a notice on the label or container that warns of the risk of overdose and addiction as specified.

Requires a prescriber to discuss specified information with the minor, the minor’s parent or guardian or other adult authorized to consent to the minor’s medical treatment before directly dispensing or issuing for a minor the first prescription

30

SB 1254 (Stone) – Hospital pharmacies: medication profiles or lists for high-risk patients Requires a pharmacist at a hospital pharmacy to obtain an accurate medication profile or list for each high-risk patient upon admission of the patient under specified circumstances. Authorizes an intern pharmacist or a pharmacy technician to perform the task of obtaining an accurate medication profile or list for a high-risk patient if certain conditions are satisfied. Requires the hospital to establish criteria regarding who is a high-risk patient for purposes of the bill’s provisions and determine a timeframe for completion of the medication profile or list, based on the populations served by the hospital.

EMERGENCY SERVICES AB 2576 (Aguiar-Curry) – Emergencies: health care CMA Position: Support if Amended Authorizes a pharmacist or a community clinic to furnish a dangerous drug or device in reasonable quantities without a prescription during a declared emergency. Requires the Pharmacy Board to allow for the use of a mobile pharmacy or clinic during an emergency if certain conditions are met. Authorizes the Governor, during a state of emergency, to direct all state agencies to utilize, employ, and direct state personnel, equipment, and facilities for the performance of any and all activities that are designed to allow community clinics and health centers to provide and receive reimbursement for services provided during or immediately following the emergency, including directing DHCS to seek federal approvals to allow community clinics and health centers to provide and be reimbursed for Medi-Cal or other services that are provided either telephonically, or to patients at a shelter or other location within the geo-

The Bulletin January / February 2019

graphical boundaries of the emergency as stated in the proclamation declaring the state of emergency.

END-OF-LIFE AB 282 (Jones-Sawyer D) – Aiding, advising or encouraging suicide: exemption from prosecution Prohibits a person whose actions are compliant with the End of Life Option Act from being prosecuted for deliberately aiding, advising, or encouraging suicide.

AB 3211 (Kalra) – Advance health care directives Revises the language of the form for written advance health care directives created under the Health Care Decisions Law to allow a person to authorize an agent to consent to any temporary medical procedures necessary to maintain organs, tissues, and/or parts for the purpose of donation.

HEALTH CARE COVERAGE AB 595 (Wood) – Health care service plans: mergers and acquisitions CMA Position: Support if Amended Requires a health care service plan that intends to merge or consolidate with, or enter in an agreement resulting in its purchase, acquisition, or control by, any entity, as defined, including another health care service plan or a licensed health insurer, to give notice to, and secure prior approval from, the Director of the Department of Managed Health Care.

Requires a health care service plan subject to these provisions to meet specified requirements and to provide information necessary for the director to make the determination to approve, conditionally approve, or disprove the transaction or agreement, as specified. Requires health care services plans subject to these provisions to pay specified fees and to reimburse the director for specified costs related to making a decision on whether to approve, conditionally approve, or disapprove the transaction.

AB 1860 (Limón) – Health care coverage: cancer treatment CMA Position: Support Existing law prohibits, until January 1, 2019, an individual or group health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2015, that provides coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells from requiring an enrollee or insured to pay, notwithstanding any deductible, a total amount of copayments and coinsurance that exceeds $200 for an individual prescription of up to a 30-day supply of a prescribed orally administered anticancer medication, as specified. Existing law authorizes health care service plans to adjust that $200 limit on January 1 of each year, to the extent that adjustment does not exceed the percentage increase in the Consumer Price Index for that year.

Raises the limit on copayments and coinsurance to $250 for an individual prescription of up to a 30-day supply of a prescribed orally administered anticancer medication, eliminates provisions authorizing health plans and insurers to adjust this limit, and extends the period the limit remains in effect to January 1, 2024.

AB 2119 (Gloria) – Foster care: gender affirming health care and mental health care CMA Position: Support if Amended Makes specified findings and declarations regarding transgender and gender nonconforming children in foster care.

Specifies that the rights of minors and nonminors in foster care to be involved in the development of case plan and plan for placement includes the development of case plan elements related to gender affirming health care, with consideration of their gender identity. Provides that the rights of minors and nonminors in foster care to receive medical, dental, vision, and mental health services includes covered gender affirming health care and gender affirming mental health care, as defined, subject to existing consent laws. Requires the Department of Social Services, in consultation with the Department of Health Care Services and other stakeholders, to develop, as specified, guidance and best practices to identify, coordinate, and sup-

port foster youth seeking access to gender affirming health care services and gender affirming mental health services.

AB 2499 (Arambula) – Health care coverage: medical loss ratios CMA Position: Support Existing law requires a health care service plan or health insurer to provide an annual rebate to each enrollee or insured under that coverage, on a pro rata basis, if the medical loss ratio, calculated as specified, is less than a certain percentage. Existing law excludes all specialized health care service plan contracts and specialized health insurance policies from these requirements. Limits the exemption from annual rebate requirements to specialized health care service plan contracts and specialized health insurance policies that provide only dental or vision services.

AB 2674 (Aguiar-Curry) – Health care service plans: disciplinary actions CMA Position: Sponsor Under the Knox-Keene Health Care Service Plan Act of 1975, a health care service plan is prohibited from engaging in an unfair payment pattern, as defined, and allows providers to report instances in which a plan is engaging in an unfair payment pattern to the department.

Requires the Department of Managed Health Care to review complaints of unfair payment patterns on or before July 1, 2019, and at least annually thereafter and permits the department to conduct an audit or enforcement action pursuant to existing authority if the review of the complaint data indicates a possible unfair payment pattern.

AB 2863 (Nazarian) – Health care coverage: prescriptions Requires a pharmacy to inform a customer at the point of sale for a covered prescription drug whether the retail price is lower than the cost-sharing amount for the drug unless the lower price is charged automatically. Limits the amount a health care service plan or health insurer may require an enrollee or insured to pay at the point of sale for a covered prescription to the lesser of the applicable cost-sharing

Did you know CMA’s online health law library is free to members?

The California Medical Association (CMA) online health law library contains nearly 5,000 pages of up-to-date legal information on a variety of subjects of everyday importance to practicing physicians.

One of CMA's most valuable member benefits, the searchable online library contains all the information available in the California Physician's Legal Handbook (CPLH), an annual publication from CMA's Center for Legal Affairs.

CMA members can access the library documents free at cmadocs. org/health-law-library.

Nonmembers can purchase documents for $2 per page. CPLH, the complete health law library, is also available for purchase in a multi-volume print set or annual online subscription service. To order a copy, visit cplh.org or call (800) 882-1262. amount or the retail price. Prohibits a health care service plan or health insurer from requiring a pharmacist or pharmacy to charge or collect a cost-sharing amount from an enrollee or insured that exceeds the total retail price for the prescription drug. Provides that the payment rendered by an enrollee or insured constitutes the applicable cost sharing and shall apply to any deductible as well as to the maximum out-of-pocket limit, as specified.

AB 2941 (Berman) – Health care coverage: state of emergency Requires a health care service plan or health insurer to provide its enrollees or insureds who have been displaced by a state of emergency, as defined, access to medically necessary health care services. Requires a health care service plan or health insurer, within 48 hours of a declaration of emergency by the Governor that displaces or has the immediate potential to displace enrollees or insureds, to file a notification with the regulator containing specified information regarding how the

January / February 2019 The Bulletin

31

plan or insurer is communicating with and addressing the needs of its enrollees or insureds during the state of emergency.

SB 997 (Monning) – Health care service plans: physician to enrollee ratios Deletes the repeal date of existing law that would have sunset on January 1, 2019 and requires a health care service plan to ensure that there is at least one full-time equivalent primary care physician for every 2,000 enrollees and authorizes the assignment of up to an additional 1,000 enrollees, as specified, to a primary care physician for each full-time equivalent non-physician medical practitioner, as defined, supervised by that physician.

These provisions will operate indefinitely.

SB 1034 (Mitchell) – Health care: mammograms CMA Position: Neutral Extends, until January 1, 2025, the operation of existing law that requires a health facility at which a mammography examination is performed to include a prescribed notice on breast density in the summary of the written report that is sent to a patient, if specified circumstances apply. Makes technical and conforming changes.

HEALTH CARE FACILITIES AND FINANCING AB 1953 (Wood) – Skilled nursing facilities: disclosure of interests in business providing services Requires an organization that operates, conducts, owns, or maintains a skilled nursing facility to additionally report to the office whether the licensee, or a general partner, director, or officer of the licensee, has an ownership or control interest of 5% or more in a related party, as defined, that provides any service to the skilled nursing facility. If goods, fees, and services collectively worth ten thousand dollars ($10,000) or more per year are delivered to the skilled nursing facility, the disclosure shall include the related party’s profit and loss statement, and the Payroll-Based Journal public use data of the previous quarter for the skilled nursing facility’s direct caregivers.

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AB 2428 (Gonzalez-Fletcher) – Federally qualified health centers: rural health clinics Exempts from Medi-Cal provider enrollment a primary care clinic with an additional physical plant added to its consolidated primary care clinic license from the requirement to separately enroll the additional physical plant as a separate provider and from the requirement to submit a complete application package, if the primary care clinic has notified the department of its additional physical plant. Allows an FQHC or RHC adding a new licensed location to its primary care license to elect to have the reimbursement rate for the new location established in accordance with the standard PPS methodology, or to have one PPS rate for all its locations.

AB 2983 (Arambula) – Health care facilities: voluntary psychiatric care CMA Position: Support Prohibits a general acute care hospital or an acute psychiatric hospital from requiring a person who voluntarily seeks care to be in custody as a danger to himself or herself or others or gravely disabled as a condition of accepting a transfer of that person after his or her written consent for treatment and transfer is documented or in the absence of evidence of probable cause for detention.

SB 1152 (Hernandez) – Hospital patient discharge process: homeless patients CMA Position: Oppose Unless Amended Requires each hospital to include a written homeless patient discharge planning policy and process within the hospital discharge policy. Among other requirements, the policy shall require a hospital to inquire about a patient’s housing status; to connect the patient with available community resources and supportive services; and to identify a post discharge destination for the patient. Requires a hospital to document specified information before discharging a homeless patient, including that the patient has been offered a meal and weather-appropriate clothing. Requires, commencing on July 1, 2019, a hospital to develop a

The Bulletin January / February 2019

written plan for coordinating services and referrals for homeless patients with the county behavioral health agency, health care and social service agencies in the region, health care providers, and nonprofit social service providers, as available, to assist with ensuring appropriate homeless patient discharge.

SB 1397 (Hill) – Automated external defibrillators: requirement: modifications to existing buildings CMA Position: Support Applies the automated external defibrillator (AED) requirements to certain structures that are constructed prior to January 1, 2017, and subject to subsequent modifications, renovations, or tenant improvements, as specified.

INSURANCE SB 910 (Hernandez) – Shortterm limited duration health insurance Prohibits a health insurer from issuing, selling, renewing, or offering a shortterm limited duration health insurance policy, as defined, for health care coverage in California. Makes conforming changes.

SB 1008 (Skinner) – Health insurance: dental services: reporting and disclosures CMA Position: Support Requires a health care service plan or a health insurer that issues, sells, renews, or offers a health care service plan contract or insurance policy that covers dental services in California to utilize a uniform, specified benefits and coverage disclosure matrix. Requires the Department of Managed Health Care and the Department of Insurance to develop the uniform benefits and disclosure matrix in consultation with stakeholders and to implement the bill’s provisions relating to the benefits and coverage disclosure matrix through emergency regulations, as specified.

SB 1375 (Hernandez) – Health insurance: small employer groups Amends the definition of “eligible

employee” for the purpose of determining whether a business is a “small employer” eligible to purchase group coverage by excluding sole proprietors, partners of a partnership, and the spouses of sole proprietors and partners. Prohibits employer group health care service plans and employer group health benefit plans from being issued, marketed, or sold to sole proprietorship or partnership without employees through any arrangement, and requires that only individual health care service plans and individual health benefit plans be sold to any entity without employees.

MEDI-CAL AB 1785 (Nazarian) – Medi-Cal eligibility: assets Excludes the principal and interest of a 529 savings plan, as defined, from consideration for purposes of any asset or resources test to determine eligibility for certain Medi-Cal benefits, as specified.

Excludes qualified distributions from a 529 savings account from consideration for purposes of any income test to determine eligibility for certain Medi-Cal benefits.

AB 2861 (Salas) – Medi-Cal: telehealth: alcohol and drug use treatment CMA Position: Support Requires, to the extent federal financial participation is available and any necessary federal approvals have been obtained, that a Drug Medi-Cal certified provider receive reimbursement for individual counseling services provided through telehealth by a licensed practitioner of the healing arts or a registered or certified alcohol or other drug counselor, when medically necessary and in accordance with the Medicaid state plan.

SB 849 (Committee on Budget and Fiscal Review) – Medi-Cal Establishes, until January 1, 2026, the Proposition 56 Medi-Cal Physicians and Dentists Loan Repayment Act Program, to be developed by the State Department of Health Care Services to provide loan assistance payments to qualifying, recent graduate physicians and dentists that serve beneficiaries of Medi-Cal and

other specified health care programs as specified. Allows the department to authorize a dental integration pilot program in San Mateo County as a component of the Medi-Cal 2020 demonstration project.

SB 1287 (Hernandez) – Medi-Cal: medically necessary services Revises the Medi-Cal definition of “medically necessary” for purposes of an individual under 21 years of age to incorporate federal standards related to Early and Periodic Screening Diagnostic, and Treatment (EPSDT) services and requires the department and its contractors to update any specified materials to ensure the new medical necessity standard for coverage for individuals under 21 years of age is accurately reflected in all materials.

SB 1423 (Hernandez) – Medi-Cal: oral interpretation services Modifies the minimum qualifications that an interpreter is required to possess to provide oral interpretation services to limited English-proficient (LEP) Medi-Cal beneficiaries enrolled in either a managed care plan or a mental health plan.

MEDICAL CANNABIS AB 710 (Wood) – Cannabidiol Provides that, if specified changes in federal law regarding the controlled substance cannabidiol occurs, a physician, pharmacist, or other authorized healing arts licensee who prescribes, furnishes, or dispenses a product composed of cannabidiol, in accordance with federal law, is deemed to be in compliance with state law governing those acts. Excludes from the Medicinal and Adult-Use Cannabis Regulation and Safety Act (MAUCRSA), any medicinal product composed of cannabidiol approved by the federal Food and Drugs Administration and either classified as a Schedule II-V controlled substance or exempted by MAUCRSA.

AB 1996 (Lackey) – The California Cannabis Research Program Conforms the name of the Cannabis Research Program as the California Marijuana Research Program hosted by the Center for Medicinal Cannabis Research, throughout the code. Authorizes the program to cultivate cannabis for its use in

research, as specified and expands the program to include the study of naturally occurring constituents of cannabis and synthetic compounds that have effects similar to naturally occurring cannabinoids. Authorizes controlled clinical trials on testing methods for detecting harmful contaminants in cannabis, including mold and bacteria.

MEDICAL RECORDS AB 2088 (Santiago) – Patient records: addenda Requires a health care provider to allow a patient, regardless of their age, who inspects their patient records to provide to the health care provider a written addendum with respect to any item or statement in their records that the patient believes to be incomplete or incorrect.

MENTAL HEALTH AB 1968 (Low) – Mental health: firearms CMA Position: Neutral Prohibits a person who has been taken into custody, assessed, and admitted to a designated facility because he or she is a danger to himself, herself, or others, as a result of a mental health disorder and who was previously taken into custody, assessed, and admitted one or more times within a period of one year preceding the most recent admittance from owning a firearm for the remainder of his or her life, subject to existing notice and hearing procedures.

AB 2099 (Gloria) – Mental health: detention and evaluation CMA Position: Support Requires that a facility accepting a person taken into custody and placed in a designated facility for up to 72 hours for evaluation and treatment pursuant to existing law, treat a copy of the application stating the circumstances surrounding the event the same as the original.

AB 2193 (Maienschein) – Maternal mental health CMA Position: Neutral Requires, by July 1, 2019, health care service plans and health insurers to devel-

January / February 2019 The Bulletin

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op a maternal mental health program, as specified. Requires a licensed health care practitioner who provides prenatal or postpartum care for a patient to offer to screen or to appropriately screen a mother for maternal mental health conditions, subject to specified exceptions.

AB 2315 (Quirk-Silva) – Pupil health: mental and behavioral health services: telehealth technology: guidelines CMA Position: Support if Amended Requires the State Department of Education, in consultation with the State Department of Health Care Services and stakeholders, to, on or before July 1, 2020, develop and post guidelines, as specified, for the use of telehealth technology in public schools, to provide mental health and behavioral health services to pupils on school campuses.

AB 2325 (Irwin) – County mental health services: veterans CMA Position: Support Prevents a county from denying an eligible veteran county mental or behavioral health services while the veteran is waiting for a determination of eligibility for, and availability of, mental or behavioral health services provided by the United States Department of Veterans Affairs.

Makes specific findings and declarations about the county’s duty to provide mental and behavioral health services to veterans.

AB 2639 (Berman) – Pupil suicide prevention policies: reviews: updates CMA Position: Support Requires the governing board or body of a local educational agency that serves pupils in grades 7 to 12 to review, at minimum every 5th year, its policy on pupil suicide prevention and, if necessary, update its policy.

AB 3032 (Frazier) – Maternal mental health conditions Requires a general acute care hospital or special hospital that has a perinatal unit to develop and implement, a program as specified, relating to maternal mental health conditions including, but not limited to, postpartum depression.

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SB 1004 (Wiener) – Mental Health Services Act: prevention and early intervention CMA Position: Support Requires the Mental Health Services Oversight and Accountability Commission to establish priorities for the use of prevention and early intervention funds and to develop a statewide strategy for monitoring implementation of prevention and early intervention services, as specified. Requires the commission to establish a strategy for technical assistance, support, and evaluation to support the successful implementation of the objectives, metrics, data collection, and reporting strategy. Amends the Mental Health Services Act by requiring a portion of funds in the county plan relating to prevention and early intervention focus on the priorities established by the commission. Permits a county to include other priorities, as determined through a stakeholder process.

SB 1113 (Monning) – Mental health in the workplace: voluntary standards CMA Position: Support Authorizes the Mental Health Services Oversight and Accountability Commission, in consultation with the Labor and Workforce Development Agency, to establish a framework and voluntary standard for mental health in the workplace that serves to reduce mental health stigma, increase public, employee, and employer awareness of the recovery goals of the Mental Health Services Act, and to provide guidance to California’s employer community to put in place strategies and programs, to support the mental health and wellness of employees.

PROFESSIONAL LICENSING AND DISCIPLINE AB 505 (Caballero) – Medical Board of California: adjudication: expert testimony CMA Position: Sponsor Authorizes the administrative law judge to extend the time for the exchange of specified expert witness testimony information with counsel for the other party to be completed, upon a motion based

The Bulletin January / February 2019

on a showing of good cause, for a period not to exceed 100 calendar days from the current requirement that the exchange of the information to be completed 30 calendar days prior to the commencement date of the hearing or as specified.

SB 1448 (Hill) – Healing arts licensees: probation status: disclosure CMA Position: Oppose Requires, on or after July 2, 2019, the licensing boards for podiatrists, naturopathic doctors, chiropractors, acupuncturists, physicians and surgeons, and osteopaths to provide, before the patient’s first visit, a specified disclosure to a patient or the patient’s representative if the licensee is on probation pursuant to a probationary order made on and after July 1, 2019. Also requires the licensing boards to post specified information related to licensees on probation on their website.

PUBLIC HEALTH AB 2370 (Holden) – Lead exposure: child day care facilities: family day care homes CMA Position: Support Makes various changes to the California Child Day Care Facilities Act including, but not limited to, requiring, as a condition of licensure, health and safety training in the prevention of lead exposure as a part of the preventive health practices course or courses component and requiring child day care facilities to provide the parent or guardian with written information on the risks and effects of lead exposure, blood lead testing recommendations and requirements, and options for obtaining blood lead testing, as specified.

Requires specified child day care centers to have its drinking water tested for lead contamination levels.

AB 2507 (Jones-Sawyer) – County jails: infant and toddler breast milk feeding policy CMA Position: Support Requires, on or before January 1, 2020, a county sheriff or the administrator of a county jail to develop and implement an infant and toddler breast milk feeding policy for lactating inmates detained in or

sentenced to a county jail that is based on currently accepted best practices.

REPRODUCTIVE HEALTH AB 2289 (Weber) – Pupil rights: pregnant and parenting pupils CMA Position: Support Codifies federal and state regulations that prohibit an educational institution from applying any rule concerning a pupil’s actual or potential parental, family, or marital status that treats pupils differently on the basis of sex. Establishes accommodations for pregnant and parenting pupils including eight weeks of parental leave.

WORKFORCE & OFFICE SAFETY ISSUES AB 1791 (Waldron) – Physicians and surgeons: continuing education Requires the Medical Board of California, in determining continuing education requirements, to consider including a course in integrating HIV/AIDS preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) medication maintenance and counseling in primary care settings, especially as it pertains to HIV testing, access to care, counseling, high-risk communities, patient concerns, exposure to HIV/AIDS, and the appropriate care and treatment referrals.

AB 1976 (Limón) – Employment: lactation accommodation CMA Position: Sponsor Requires an employer to make reasonable efforts to provide an employee with use of a room or other location, other than a bathroom, for an employee to express breast milk in private. An employer shall be deemed in compliance if: (1) the employer is unable to provide a permanent lactation location because of operational, financial, or space limitations; (2) the temporary lactation location is private and free from intrusion while an employee expresses milk; (3) the temporary lactation location is used only for lactation purposes while an employee expresses milk.; and (4) the temporary lactation location otherwise meets the requirements of state law concerning lac-

tation accommodation.

AB 2009 (Maienschein) – Interscholastic athletic programs: automated external defibrillator CMA Position: Support If a school district or charter school elects to offer any interscholastic athletic program, require the school district or charter school to: (1) ensure that there is a written emergency action plan in place, and posted as specified, that describes the location and procedures to be followed in the event of sudden cardiac arrest or other medical emergencies related to the athletic program’s activities or events; (2) acquire, commencing July 1, 2019 at least one AED for each school within the school district or the charter school to be available on campus; (3) encourage that the AED or AEDs are available for the purpose of rendering emergency care or treatment, as specified; (4) ensure that the AED or AEDs are available to athletic trainers and coaches and authorized persons at the athletic program’s on campus activities or events; and 5) ensure that the AED or AEDs are maintained and regularly tested, as specified.

AB 2202 (Gray) – U C School of Medicine: San Joaquin Valley Regional Medical Education Endowment Fund CMA Position: Support Creates the University of California San Francisco San Joaquin Valley Regional Medical Education Endowment Fund for the purpose of supporting the annual operating costs for the development, operation, and maintenance of a branch campus of the University of California, San Francisco, School of Medicine in the San Joaquin Valley.

AB 2311 (Arambula) – Medicine: trainees: international medical graduates CMA Position: Support Eliminates the reference to the specific courses in clinical instruction authorized to be offered to the international medical graduate participants in the preresidency training program at the David Geffen School of Medicine of the University of California, Los Angeles.

SB 1348 (Pan) – Postsecondary education: allied health professional clinical programs: reporting CMA Position: Support As part of the Strong Workforce Program, requires, beginning in 2019 and in each year thereafter, the Office of the California Community Colleges must report, for each community college program that offers a certificate or degree related to allied health professionals, specified information, including the number of students participating in the clinical training and the license number or employer identification number of each clinical training site, delineated by program and occupation, with multiyear implementation for the reporting.

These are just a sampling of the new laws impacting health care in 2019 and beyond. For a comprehensive list, see “Significant New California Laws of Interest to Physicians for 2019,” at cmadocs. org/new-laws-2019.

Did you know CMA’s online health law library is free to members?

The California Medical Association (CMA) online health law library contains nearly 5,000 pages of up-to-date legal information on a variety of subjects of everyday importance to practicing physicians.

One of CMA's most valuable member benefits, the searchable online library contains all the information available in the California Physician's Legal Handbook (CPLH), an annual publication from CMA's Center for Legal Affairs.

CMA members can access the library documents free at cmadocs. org/health-law-library.

Nonmembers can purchase documents for $2 per page. CPLH, the complete health law library, is also available for purchase in a multi-volume print set or annual online subscription service. To order a copy, visit cplh.org or call (800) 882-1262.

January / February 2019 The Bulletin

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Medical Times From the Past 36

The Infancy of Anesthesia

By Michael Shea, MD

Leon P. Fox Medical History Committee

I

n the pre-anesthetic era, surgery was infrequent, of short duration, and limited to the surface of the body, repair of hernias, and amputation of diseased limbs and breasts. At the Massachusetts General Hospital only 184 operations were undertaken during the five years preceding the introduction of anesthesia, an average of three per month. Efforts to mitigate pain during surgery included alcohol, opium, and brute force.

Three compounds ushered in the anesthetic era: nitrous oxide, ether, and chloroform.

Nitrous oxide was discovered by Joseph Priestly in 1776. It was not recognized as an anesthetic until Humphrey Davy announced in 1799 that nitrous oxide could alleviate pain. He had inhaled it to relieve the pain of an erupting wisdom tooth.

Although inhaled and safe when combined with oxygen, nitrous oxide was not strong enough for major surgery. It did find some use in dental offices, labor and delivery suites.

Ether was first produced by Valerius Cordus, a German physician, in 1540. Using ether as an anesthetic is credited to Crawford Long of Jefferson, Georgia, who had a friend inhale the gas while he removed a small tumor in his neck. The date was 1842.

Prior to that event, others, including Michael Faraday, had noticed the depressant effects of ether but had not applied it to surgical use. Of interest here are the recorded ether and nitrous “jag” parties. These were social events put on by medical students, in which inhalation of these gases produced an alcoholic effect.

Ether has positive properties for anesthesia. It is inhaled in open drop form, not hepato or cardiotoxic, and caused only one death per 2,000 cases of surgery.

The big breakthrough for ether came in 1846 when William Morton, a second year medical student at Harvard, used ether on himself to extract a tooth.

Soon after he engaged J. C. Warren, MD, professor of surgery at Mass General, to allow him to prepare a patient with ether for a surgical operation. The day was set on October 16, 1846, at Massachusetts General Hospital. The operation was a success. The patient sailed through the removal of a tumor from his jaw without pain and without movement. From that day forward that operating room was known as the “Ether

The Bulletin January / February 2019

The Ether Dome Dome” and surgery was on its way.

Morton obtained a patent on November 12, 1846, calling his anesthetic “Letheon.” This term was soon abandoned when it was discovered that Letheon was ether.

As a result of this ether dome operation, physician Oliver Wendell Holmes suggested to Morton the word anesthesia be used to describe the process of making a patient unconscious in order to free him of surgical pain.

Following ether came chloroform. It was first prepared by Dr. Samuel Guthrie, an American chemist in 1831. He was attempting to produce a cheap pesticide.

In 1847, a Scottish physician, Sir James Young Simpson, first used the sweet smelling colorless, nonflammable liquid as an anesthetic. Chloroform was three times more potent than ether and more skill was needed in using it to avoid serious side effects. These include depression of the myocardium resulting in a drop-in blood pressure and cardiac output with risk of ventricular fibrillation during the induction. It was also found to be very hepatotoxic. Mortality risk has been reported as high as five per two thousand surgical cases.

Due to increasing skill of the administrator of the gas, the use of chloroform continued. It became even more popular after being administered to Queen Victoria during the birth of her eighth child, Prince Leopold. It became the most utilized anesthetic during the civil war due to its fast-acting nature and a large number of positive reports in the Crimean War of the 1850’s.

The use of all three agents later declined as safer, more effective anesthetic products were developed.

However, they were the pioneers and allowed the field of surgery to make significant progress in life saving and life altering operations.

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Classifieds OFFICE SPACE FOR RENT/LEASE MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/228-0454.

MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.

BEAUTIFUL MENLO PARK OFFICE TO SHARE New office, upscale and modern – to share with existing pain management practice. Ideal for psychologist or psychiatrist. Contact Dr. Maia Chakerian at 408/832-3930.

OFFICE SPACE FOR LEASE AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building. Please call 408/926-2182 or 408/315-4680.

MEDICAL OFFICE SPACE TO SHARE • CAMPBELL Specialist wanted to share a private office with family practitioner in Campbell. Hamilton/Winchester area. Contact Mary Phan at (408) 364-7600.

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MEDICAL OFFICE TO SHARE • LOS GATOS Extra exam room to share, across from El Camino Hospital Los Gatos, for professional. $1,000/mo. Call 408/8666776.

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.

WANTED FAMILY PHYSICIAN Family medicine physician needed to share a growing outpatient practice.

Start at 16 hours/week and share patient load. Practice caters to 75% PPO, rest Medicare and HMO. Contact ntnbhat@yahoo.com / 408/839-6564.

The Bulletin January / February 2019

FOR SALE OFFICE SPACE FOR LEASE AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building. Please call 408/926-2182 or 408/315-4680.

PRIVATE PRACTICE AND BUILDING FOR SALE Family Practice for sale, including inventory, equipment and Real Estate (can also be leased). Great downtown San Jose location. Financing may be available. Minor Laser Surgery performed as well. Call 415/308-3064.

MEDICAL OFFICE FOR SALE • SAN JOSE Beautiful Pediatric medical office.

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January / February 2019 The Bulletin

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BULLETIN THE

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

700 Empey Way, San Jose, CA 95128-4705

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1 An applicant must have, or open prior to closing, a checking or savings account with Bank of America. Applicants with

an existing account with Merrill Edge®, Merrill Lynch® or U.S. Trust prior to application also satisfy this requirement.

Eligible medical professionals include: (1) medical doctors who are actively practicing, (MD, DDS, DMD, OD, DPM, DO), (2) medical fellows and residents who are currently employed, in residency/fellowship, or (3) applicants who are medical students or doctors and are about to begin their new employment/residency or fellowship within 90 days of closing. Must be actively practicing in their field of expertise. Those employed in research or as professors are not eligible. For qualified borrowers with excellent credit. PITIA (Principal, Interest, Taxes, Insurance, Assessments) reserves of 4–6 months are required, depending on loan amount.

2 Minimum down payment requirements vary by property type and location; ask for details.

3 If applicant’s employment does not commence until after closing, in addition to the minimum cash reserves required, sufficient reserves to handle all debt obligations between closing and employment start date up to an additional 90 days must be verified.

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Credit and collateral are subject to approval. Terms and conditions apply. This is not a commitment to lend.

Programs, rates, terms and conditions are subject to change without notice. Bank of America, N.A., Member FDIC. Equal Housing Lender. ©2018 Bank of America Corporation. ARY89JD7 HL-112-AD 02/2018 Protect your personal information before recycling this document.

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