2016 November/December

NOVEMBER / DECEMBER 2016

ALSO INSIDE: • House of Delegates • Legislative Wrap Up • MACRA Does Not Create New Reporting Burdens • Telemedicine

VOLUME 22 | NUMBER 6

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BULLETIN THE

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

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

MEMBER BENEFITS

Feature Articles

Billing/Collections

5 MACRA Does Not Create New Reporting Burdens

CME Tracking

8 What’s the Diagnosis, Doctor?

Discounted Insurance

12 Telemedicine for Everyone

Financial Services

14 2016 House of Delegates

Health Information Technology Resources

22 2016 Legislative Wrap Up

House of Delegates Representation

Departments

Human Resources Services Legal Services/On-Call Library

6 Message From the SCCMA President

Legislative Advocacy/MICRA

7 Message From the MCMS President

Membership Directory APP for

26 SCCMA Award Nominations

the iPhone Physicians’ Confidential Line Practice Management Resources and Education Professional Development Publications Referral Services With Membership Directory/Website

28 Medical Times From the Past 30 Partner Spotlight: CapAlt Advantages 31 Classified Ads 32 MCMS Member Spotlight: Alfred M. Sadler, Jr., MD 34 MEDICO News 38 SCCMA Alliance Foundation Grant Application

Reimbursement Advocacy/ Coding Services Verizon Discount NOVEMBER / DECEMBER 2016 | THE BULLETIN | 3

THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS

CHIEF EXECUTIVE OFFICER

COUNCILORS

William C. Parrish, Jr.

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

President Scott Benninghoven, MD President-Elect Seham El-Diwany, MD Past President Eleanor Martinez, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Ryan Basham, MD VP-Professional Conduct Vanila Singh, MD Secretary Seema Sidhu, MD Treasurer Anh Nguyen, MD

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

BULLETIN THE

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

THE MONTEREY COUNTY MEDICAL SOCIETY

Printed in U.S.A.

OFFICERS

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising.

Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2016 by the Santa Clara County Medical Association.

4 | THE BULLETIN | NOVEMBER / DECEMBER 2016

President Craig Walls, MD PhD President-Elect Maximiliano Cuevas, MD Past-President James Hlavacek, MD Secretary Alfred Sadler, MD Treasurer Steven Harrison, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Valerie Barnes, MD David Holley, MD John Jameson, MD William Khieu, MD Eliot Light, MD

Phillip Miller, MD David Ramos, MD James Ramseur, MD Marc Tunzi, MD Raymond Villalobos, MD

MACRA Does Not Create New Reporting Burdens Is Significant Improvement Over Existing Law On October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) issued the final rule to implement the Medicare Access and CHIP Reauthorization Act of 2015, known as MACRA. The final regulation represents a significant improvement over the existing Medicare payment system and quality reporting programs.

The California Medical Association (CMA), the American Medical Association (AMA) and 788 other physician organizations supported the MACRA legislation because it reduces the administrative burdens in the Medicare fee-for-service quality and electronic health record (EHR) reporting programs. The MACRA legislation and the implementing regulations revised the existing reporting programs and will significantly reduce the administrative burdens on physicians. Contrary to popular myth, MACRA does not create new reporting burdens.

Legislative intent • Repeal the Medicare sustainable growth rate (SGR) formula, which threatened payment cuts and stagnated physician payments for over a decade.

• Allow physicians to develop innovative physician-led alternative payment models.

• Provide stable annual updates in the Medicare fee-for-service program.

• Consolidate, streamline, and reduce the administrative burdens in the Medicare quality and EHR meaningful use reporting programs.

Penalties lower, bonuses higher Before MACRA, physicians were facing double-digit SGR payment cuts and 11 to 13 percent or more in payment penalties for not meeting the all-ornothing requirements in the three Medicare reporting programs (Physician Quality Reporting System, EHR Incentive Program and Value-Based Payment Modifier).

Under MACRA, physicians will be exempt from penalties in 2019 if they report on just one quality measure in 2017. In 2020, the maximum penalty is 5 percent, eventually going up to a maximum of 9 percent in 2022, but physicians would have faced much higher penalties under the pre-MACRA payment rules. Before MACRA, the Medicare bonus payments had all expired.

MACRA restores bonus payments of up to 9 percent, plus an additional bonus for exceptional performance.

To see a chart that compares current law payments, bonuses and penalties to MACRA, see this story at http://www.cmanet.org/news.

Improvements over current law Though not perfect, the final MACRA rule, which takes effect January 1, 2017, is clear improvement over current law. While CMA is still reviewing the final rule, below are key improvements that CMA and AMA fought to achieve: • Restores the 0.5 percent payment update for 2017.

• Exempts one-third of all Medicare physicians from MACRA’s MeritBased Incentive Payment System (MIPS) reporting program.

• Eliminates all of the meaningful use and value modifier quality measures.

• Reduces by half the remaining number of measures that physicians must report, from 30 to 15. Small and rural practices must report on

even fewer measures.

• Eliminates the EHR Clinical Decision Support and Computerized Physician Order Entry measures.

• Eliminates penalties in 2019 (for the 2017 performance period) for physicians who report for one patient on one quality measure, one improvement activity OR the four EHR measures.

• Only requires physicians to report for 90 days in 2017 to receive a bonus in 2019.

• Only requires physicians to report on 50 percent of their patients in 2017 for the quality category.

• Mostly eliminates the pass/fail system and provides proportional credit for the measures that are met.

• Providers will not be scored on “resource use” (physician cost) in 2017 • Expands the types of alternative payment models (APM) that can participate in MACRA, most notably Track 1 accountable care organizations. The final rule also reduces the financial risk requirements for APMs. CMA will continue to fight for improvements to the MACRA regulations and the law to reduce the administrative burdens and open up more opportunities for fair payment.

For a summary of the final MACRA rule, visit https://qpp.cms.gov. Physicians can also visit CMA’s MACRA resource center at www.cmanet.org/ macra to access information and resources to help with the transition. The center is a one-stop-shop with tools, checklists and information from CMA, CMS, AMA and national specialty society clinical data registries. CMA will add an updated summary and materials, including additional webinars, to the resource center in the coming weeks.

MACRA Compared to Current Law: Bonuses, Penalties and Payment Updates

BONUS PENALTIES (excludes Exceptional Bonus) Current 2015

0

MACRA MIPS+ QAPMs N/A N/A

2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 +

0 0 0 0 0 0 0 0 0 0 0

N/A N/A N/A +4% +5% +7% +9% +9% +9% +9% +9%

Year

N/A N/A N/A +5% +5% +5% +5% +5% +5% +5% 0%

Current

-6% -9% -10% -11% -11% -11% -11% -11% -11% -11% -11%

-4.5%

or more or more or more or more or more or more or more or more

FEE SCHEDULE INCREASES (regardless of performance) MACRA Current MIPS+ QAPMs N/A N/A -21% under SGR N/A N/A 0% 0% 0% 0% 0% 0% 0% 0%* 0%* 0% -5% 0% 0% -7% 0% 0% -9% 0% 0% -9% 0% 0% -9% 0% 0% -9% 0% 0% -9% 0% 0%

MACRA MIPS APMs N/A N/A +0.5% +0.5% +0.5% +0.5% 0% 0% 0% 0% 0% 0% +0.25%

+0.5% +0.5% +0.5% +0.5% 0% 0% 0% 0% 0% 0% +5.75%

* CMS will not impose penalties for the 2017 performance reporting period for physicians who report for one

patient on one quality measure, one improvement activity, or the four required EHR Advancing Care Information measures. However, physicians who choose not to report any performance data will be subject to a 4% penalty.

+ Bonuses and penalties in MIPS, not including exceptional performance bonuses, must be budget neutral.

APMs shall receive 5% bonus payments.

NOVEMBER / DECEMBER 2016 | THE BULLETIN | 5

Physician Burnout

President, Santa Clara County Medical Association

SCOTT BENNINGHOVEN, MD

MESSAGE FROM THE

SCCMA PRESIDENT

T

Scott Benninghoven, MD is the 2016-2017 president of the Santa Clara County Medical Association. He has a general surgery practice in the South County and practices at Saint Louise Regional Hospital, Regional Medical Center of San Jose, as well as O’Connor and Good Samaritan Hospitals.

his year is the first House of Delegates (HOD) Meeting since the governance changes made over the past three years.

The new format at the HOD is to discuss six major issues concerning California physicians. This year the topics were ACA rule 1332, MACRA, Maintenance of Certification, Opioids, 5-year Public Health Plan and Physician Burnout. Each of the topic discussions began with an educational presentation by one or two experts on the topic. This followed delegate discussion from which CMA policy, concerning that topic, was created.

As I listened to each of the issues discussed, having worked an 80-90 hour week before leaving for a “work weekend” at the HOD, PHYSICIAN BURNOUT seemed to hit home for me and my practice. The following week was the American College of Surgeons meeting in Washington, DC. Though I didn’t attend, I read through the lecture titles and summaries. The Martin Memorial lecture, this year, was given by Dr. Cosgrove titled “Doctors in Distress: The Burnout Crisis.”

In my opinion, Physician Burnout is the single biggest issue to face the medical profession since the invention of Medicare. According to studies sited by Dr. Cosgrove, burnout among the general population is 28 percent, but among physicians that rate is now 54 percent and increasing. Today, more than a third of physicians say they would not choose medicine again if they had the choice, and 6 percent reported having suicidal thoughts.

“Burnout is an imbalance between job demands (cognitive, emotional, situational) and the resources” according to Dr. Karen Miotto, speaking at the HOD. She reports that medicine is changing, leading to evermore stress in the physician work environment. A number of factors have contributed to the ever-increasing stress for physicians; therefore, resulting in increasing burnout among physicians.

Physicians have less autonomy, more regulation, increasing productivity requirements, charting in electronic medical records, and time demands to keep up with the explosion in medical knowledge. If we continue to try to do more without the resources of energy and time, it is understandable that something or someone will break.

Fortunately, many physician organizations

6 | THE BULLETIN | NOVEMBER / DECEMBER 2016

and large corporations that employ physicians have been aware of this problem and are trying to combat the issue. The AMA and CMA are working hard to educate physicians to be aware of personal and professional stress. The AMA has a developed “Steps forward” modules that help physicians determine their burnout potential and to manage the stress and distress in their lives.

The AMA program found online at www.stepsforward.org consists of 43 modules that address specific topics surrounding physician lives and practice.

The modules are grouped into categories of Patient care, Workflow and Process, Leading Change, Professional Well-Being, and Technology and Finance.

The modules about physician well-being are simple to complete, easy to understand, and very valuable.

These modules help oneself identify stress in the work environment. The modules teach about resiliency techniques to combat the effects of stress and help to try to protect against physician burnout.

Whether you are a resident, newly in practice or nearing retirement, I encourage all of you to take the first steps in identifying the sources of stress and distress in your personal and professional lives. We can all use techniques to improve our resiliency to allow each of us to live better more fulfilled lives.

President, Monterey County Medical Society

CRAIG A. WALLS, MD PhD

and symptoms. The boy had developed numbness in both feet while walking home. His mother, at first dismissing the complaint, became worried when the boy developed difficulty walking. When he lost all motor control of both legs she began to panic and left the house to find a doctor. The family carried him all over their region to doctors, practitioners, and clinics, but none of these could offer any help or diagnosis. They all told her, “Go to Zanmi Lasante.”

Finally he was brought to Zanmi Lasante. He was seen by an attending emergency physician who recognized Guillain-Barré Syndrome. The boy was having increasing respiratory difficulties. Fearing an ascending paralysis that might reach the diaphragms and kill the boy, the ED doc intubated the child and sent him to the ICU. As an ED doc myself, I might not have been completely blown away by this story had it occurred in Monterey County. This is what we do. For it to happen where it did is another story.

Farmer was excited about several elements of his story. If PIH and its supporters and contributors had not made the huge investment and commitment to melioration, surely this child would have died. To have an American level of training and education in emergency medicine present in Haiti – Zanmi Lasante trains Haitian emergency medicine residents to American Board of Emergency Medicine standards – is revolutionary.

To have residents there learning about Guillain-Barré Syndrome and airway protection and mechanical ventilation is amazing. To have a fully staffed and equipped intensive care unit operating and training intensivists in Haiti is inspiring.

Several days later, Farmer was asked to see the boy and provide an infectious disease consult. The local and visiting docs were most interested to know if this could have been a manifestation of our latest emerging disease – Zika Virus. It could be, he believed. It could also be 82 other things instead, and for this young boy, it did not matter! What mattered to the boy and to Farmer was that a modern, trained, and equipped teaching hospital stood ready to accept the boy.

Several days later the boy was extubated, and he eventually left the hospital fully recovered.

At 57, Paul Farmer is just getting into the swing of his career, if you ask me. His energy and ideas are rich and flowing. He inspires those around him and is the model of a leader in medicine. I can only imagine what he will accomplish in the years ahead. As members of the Monterey County Medical Society, we should aspire to be leaders in the vein of Farmer. By embracing the mission of caring for the underserved, supporting and extending medical education, and working for social justice, we can change the world, one child at a time.

MESSAGE FROM THE

T

hey say you should never meet your heroes. You will always be disappointed, they say. When I was 14, John Denver painfully stepped on my foot and then gave me a dirty look – how dare I put my foot beneath his – and I was disappointed.

This week I met Dr. Paul Farmer, the physician who has famously been called “a man who would cure the world.” I was not disappointed – I was inspired. My foot remained uninjured.

Paul Farmer is an infectious disease doc and medical anthropologist who earned his M.D. and Ph.D. at Harvard. He trained at Brigham and Women’s Hospital in Boston, Massachusetts. He accomplished these all while directing the organization he founded in 1987 – Partners in Health (PIH), which builds healthcare for marginalized populations around the world. This he had established in the wake of several projects he worked on to help the poor. While an undergraduate at Duke he worked to improve the living conditions of migrant workers in North Carolina. Providing medical care for migrant agricultural workers is something any physician in the Monterey County Medical Society will be familiar with.

Before medical school Dr. Farmer traveled in Haiti, working in public health clinics where he saw the poorest of the poor being cared for by providers who were starved for modern medical resources. After medical school, in addition to growing PIH, he worked on issues of HIV and TB in the inner city of Boston.

Along the way, Dr. Farmer has been awarded a MacArthur Foundation “genius grant” and has written several books. He is a Professor of Medical Anthropology in the Department of Social Medicine at Harvard Medical School and is an attending physician and Chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston, Massachusetts. Not a disappointing career so far!

Dr. Farmer was in the area this week for an alumni meeting that was also an opportunity for him to speak to an illustrious group of philanthropists and global health players. He is friendly and gracious and completely engaging. I could see how he had been elected senior class president of his high school. I was super proud to have II+ (“indigenous interpreting plus”), Monterey County’s own momentously groundbreaking, curriculum-writing team of indigenous language interpreters, was a focus of conversation at the event.

Paul Farmer told the story of a recent clinical encounter he had in Haiti. While visiting the impoverished country still devastated from the 2010 earthquake, he visited Zanmi Lasante, the teaching hospital PIH built on Haiti’s Central Plateau. Treating physicians asked him to see a boy with a strange set of signs

MCMS PRESIDENT

Paul Farmer, MD, PhD

Craig A. Walls, MD PhD, is the 2016-2017 president of the Monterey County Medical Society. He is an Emergency Medicine doctor with the California Emergency Physicians Medical Group and is currently practicing with Natividad Medical Center in Monterey.

NOVEMBER / DECEMBER 2016 | THE BULLETIN | 7

Dr. Scott Eberle has been medical director of Hospice of Petaluma in Petaluma, California for 24 years. He specializes in end-of-life care and also co-founded “The Practice of Living and Dying,� an innovative wilderness curriculum for which he is also a guide. This article is reprinted from Sonoma Medicine, Fall 2014, by permission of the Sonoma County Medical Association.

8 | THE BULLETIN | NOVEMBER / DECEMBER 2016

CASE STUDY A 56-year-old high-functioning professional man presents with a recent decline in mental capacity, coupled with daily headaches and insomnia. He has a history of chronic carbon monoxide (CO) poisoning in 2010, manifesting as rapid mental decline and severe headaches, which improved dramatically hours after identifying and removing the CO source, a faulty gas heater. He had a slow, incomplete recovery over the next year, as measured by an improved capacity to do focused mental work.

After a second year of relative stability, he began getting worse during the third year out, 2013. Mental resilience is again declining and appears noticeably worse after he spends time in the office building where he has worked for 15 years. Nonfocal headaches and insomnia are also frequent. He has no significant physical symptoms from the neck down. He exercises almost daily and has noticed no significant decline in strength or endurance.

THE PATIENT’S STORY “What’s the diagnosis, doctor?”

For weeks on end, I asked myself that question several times a day. You see, that previously high-functioning professional was me, and by early 2013 I was not functioning well at all.

I did lots of research and consulted several specialists. Ideas and tests were pursued, but nothing definitive was discovered. Could it simply be that, after two years of improvement and stability, the CO poisoning was now entering a second stage of decline? Or was something new developing, in particular something that worsened whenever I went to Hospice of Petaluma, my workplace of many years?

An important shift in my thinking occurred when I developed severe confusion and headache during monthly meetings held at our sister program, Memorial Hospice, which had just moved into a newly remodeled building. I wondered: Is it the carpet degassing that others have complained about? Or is it the wireless broadcaster on the ceiling of the meeting room?

The latter got me thinking about the wireless system at our Petaluma office, which had been installed nine months earlier — around the time I had begun getting worse.

My suspicions aroused, I decided to do a “scientific trial.” At home I had a router with both wireless and wired options. For 30 minutes I sat with eyes closed a few feet from the router and, at an unknown time, a friend turned on the silent wireless function. About 10 minutes into the trial, I started having a piercing headache:

sharp and pointy going up the middle of my brain just left of midline. My friend confirmed that he had turned the router on less than a minute before I had become symptomatic. Might this be the answer?

A few hours of Internet research produced a diagnosis —electromagnetic hypersensitivity (EHS) — along with information about what to do, most of which focused on avoiding and/or shielding myself from radiowave exposure. But clearing the environment of electromagnetic fields is no easy task. With a newly-bought radiowave meter in hand, I began mapping out my world and soon discovered how ubiquitous this technology is: wireless routers and computers; cellphones and cell towers; cordless phones and

POSSIBLE SYMPTOMS OF EHS • • • • •

Auditory: earaches, tinnitus Cardiovascular: dysrhythmias Dermatologic: rashes, facial flushing Musculoskeletal: weakness, spasms Neurological: headaches, poor concentration, sleep problems, fatigue • Ophthalmologic: dry or itching eyes, impaired vision • Psychological: irritability, anxiety, depression, panic attacks • Respiratory: cough, throat irritation

POSSIBLE PRECURSORS OF EHS • Physical trauma to brain or spinal cord • Electro-trauma: electric shock, lightning strike, acute or chronic electrical exposures • Chemical trauma: CO poisoning, exposure to toxic chemicals, metal implants • Biological sensitivities or allergies • Impaired immune function: people with autoimmune diseases, the elderly, infants

microwave ovens; smart meters and smart keys.

I recently heard a physician speaker estimate that the current density of radiowaves, per cubic inch of air, is now several million times greater than it was 10 years ago.

For months after the self-diagnosis, I worked closely with an experienced consultant, meticulously testing my environment, keeping a detailed journal about exposures and symptoms, and completing an array of shielding and rewiring projects. As I write now, a year has passed and, as a result of all that I’ve learned and done, I feel great most of the time — the best I have felt since before the CO poisoning.

That said, I remain vulnerable to any surprise electromagnetic exposure. I call it “getting zapped.” When that happens, an all-too-familiar pattern unfolds. Within an hour, my brain feels unnaturally activated, like a shot of mental caffeine. An hour or two later, a headache starts and mental function slows, followed by a night of poor sleep. The next day I awaken feeling mentally washed out. It takes me 24 hours to feel okay and 48-72 hours to return to normal. According to a leading theory about EHS, my CO poisoning may have caused blood-brain barrier damage, meaning that voltage-gated ion channels are now triggered by radiowaves, prompting unwanted chemical leakage into the brain.

With 60-80 exposures in the last year, I have, in effect, repeated my original experiment over and over. Cause and effect are beyond question to me now, as it would be if a person with a suspected drug allergy took that drug many times and repeatedly developed the same rash.

Using a radiowave meter to closely monitor peak exposures, I have learned that my threshold for risk with an exposure is at or above 0.001 microwatts per square centimeter (μW/cm2). Current American standards, however, claim we are safe at radiowave levels up to 100 μW/cm2 — 100,000 times higher than my danger threshold.

Seems I’m a classic canary in a coalmine.

That’s why I write.

HISTORY OF EHS “Radiowave sickness” was first named and described in 1932, with most of the early cases being discovered in military personnel. The advent of the personal computer in the 1980s led to a growing number of cases, mostly due to low-frequency electromagnetic fields. The subsequent increase in cellphones and other wireless technologies was followed by a rise in radiowave-related cases. In 2005 the World Health Organization (WHO) coined the term “electromagnetic hypersensitivity” to encompass symptoms caused by any electromagnetic field (EMF), independent of frequency.

Not coincidentally, WHO recognition of the syndrome came three years after their director general, Dr. Gro Harlem Bruntland — a physician and former prime minister of Norway — revealed that she had severe EHS. Her disclosure likely enhanced Europe’s role as a world leader in both EHS research and public policy.

While debate about the validity of an EHS diagnosis still exists in Europe, various organizations there have taken forward-thinking steps to address a rising concern. In 2007, the European Environmental Agency called for a reduc-

NOVEMBER / DECEMBER 2016 | THE BULLETIN | 9

tion in acceptable levels of radiowave exposure, with several countries adopting the revised limits. In 2009, the European Union parliament voted to recognize EHS as a disability, again with some countries following this lead. In 2011, the WHO’s International Agency for Research on Cancer classified radiofrequency EMFs as possibly carcinogenic for humans. And in 2011, the Parliamentary Assembly of the Council of Europe adopted a report on EMF dangers recommending that “all reasonable measures” be taken to reduce EMF exposures, especially cellphone use by young people, given their vulnerability to getting brain tumors.

In parallel with the above public policy measures, a unified medical response has also developed in several European countries; two examples are worth highlighting. In 2008, Swiss Doctors for the Environment (www.aefu. ch) created a physician working group, “Electromagnetic Fields and Health,” which serves as the coordinating and consulting center for a nationwide network of physicians caring for people with EMF health issues. Then in 2012, the Austrian Medical Association published detailed guidelines for diagnosing and treating EMF-related health problems.[1] The United States has lagged far behind Europe in addressing EMF exposure, both in general understanding and in public health response. Current American guidelines for safe exposure are decades old and are based on studies measuring the intensity of radiowave radiation needed to heat body tissue, analogous to using a microwave to cook food. Many studies have since demonstrated that nonthermal effects from EMF exposure can occur at much lower levels. Leading researchers have advocated that American public health guidelines be based on nonthermal effects, describing the recent evolution in understanding EMF exposure as a shift in scientific paradigm.

In 2013, the American Academy of Environmental Medicine sent a letter to the Federal Communications Commission urging a marked

reduction in EMF exposure limits, more in line with some countries in Europe.[2] Here’s an excerpt from that letter: It became clear to AAEM physicians that by the mid-1990s patients were experiencing adverse health reactions and disease as a result of exposure to electromagnetic fields. In the last five years, with the advent of wireless devices, there has been an exponential increase in the number of patients with radiofrequency-induced disease and hypersensitivity.

Numerous peer-reviewed, published studies correlate EMF exposure with a wide range of health conditions and diseases. These include neurological and neurodegenerative diseases — such as Parkinson’s Disease, ALS, paresthesias, dizziness, headaches and sleep disruption — as well as cardiac, gastrointestinal and immune disease, cancer, developmental and reproductive disorders, and electromagnetic sensitivity.

Doubt and indifference still exist about the growing body of literature concerning EMF health effects. Are the peer-reviewed studies mentioned above of sufficient quality to give us a definitive answer about the dangers? An international panel of experts authored the BioInitiative 2012 Report, a 1,479-page review of over 1,800 studies, and concluded that sufficient quality research already exists and that new safeguards should be implemented.[3] In contrast, the American approach is to insist that more research be done.

Our current public health policy runs contrary to “the precautionary principle,” which states that if an action or policy has a suspected risk of causing harm to the public or the environment, and no clear scientific consensus exists, then the burden of proof falls on anyone initiatiating a potentially risk action or policy to demonstrate that harm is not being done. Laws of the European Union make the application of this principle a statutory requirement (though

it’s not always followed), while in the United States no equivalent limitation exists.

Several factors serve as obstacles to the U.S. taking this precautionary approach with radiowave technology: the potentially offensive agent is silent, invisible, and odorless; the technologies offered are ubiquitous and addictive; and the telecommunications industry is wealthy and powerful. Definitive future research will likely confirm or deny suspected dangers. In the meantime, we are conducting a large-scale, uncontrolled public health experiment that may have dire consequences for many people.

GUIDELINES FOR PHYSICIANS According to the American Academy of Environmental Medicine, the number of EHS cases is on the rise. As a physician, how might you help patients who come to you with EHS symptoms?

I turn again to Europe for information and guidance. I have been in regular contact with two members of the aforementioned Swiss Doctors for the Environment, both to receive consultation about my own health situation and to garner general advice for physicians caring for patients with EHS. The following recommendations combine advice received from these experts, a review of the Austrian Medical Association guidelines, and my own experience.

Take the patient’s symptoms seriously.

Some people with suspected EHS will have a confirmable diagnosis; some will have other environmental issues; some will have a psychiatric or psychosomatic illness; and some will have a combination of the above. Regardless of which category a patient falls into, a physician’s support is vitally important.

Take a full history and physical. Diagnose and treat other disorders where possible, while also taking a detailed environmental history that explores not only electromagnetic issues, but also chemical sensitivities, carbon monoxide, air pollution and mold. See the Austrian Medical Association guidelines for an outline of

Websites With Information About EHS • bioiniative.org: The full 1479-page report summarizing research into the health effects of EMF. • electromagneticman.co.uk: UK site includes videos of people with EHS. • electrosense.com: European site with information about making homes and offices safe.

• emfcenter.com: Website of a Sonoma County electromagnetic field consultant.

10 | THE BULLETIN | NOVEMBER / DECEMBER 2016

• emfsafetynetwork.org: Sonoma County advocacy group with links to other sites.

• lessemf.com: Online store for meters, shielding material and related products.

• magdahavas.com: Dr. Havas is a leading researcher in the health effects of electromagnetic fields.

• weepinitiative.org: Canadian website with pamphlet “Living with electro-hypersensitivity: a survival guide.”

a full workup.[1] Have the patient keep a detailed symptom diary. Learning about one’s environment, including testing the effects of any interventions made, can be a long and convoluted process.

Consider the patient’s journal to be a foundational record for this journey of discovery. A few lines can be written each day under the headings of Date, Possible Exposures, Daytime Symptoms, Sleep, and Morning Symptoms.

Help the patient design exposure experiments to confirm or deny a suspected cause.

Blinded exposure to a wireless router turned on and off by another person, for example, can help define sensitivity to radiowave technology.

Advise the patient to take simple steps toward reducing EMF exposure. These may include using a landline phone whenever possible; using the speakerphone feature of a cell phone if it must be used; turning the cellphone off when not in use; changing Internet connectivity from wireless to wired; shielding smart meters, or having PG&E turn them off. Various patient websites offer detailed suggestions for reducing EMF exposure (see sidebar).

If indicated, encourage the patient to have EMF levels evaluated at home and/or work.

Different people with EHS will have varying degrees of sensitivity to different kinds of electromagnetic fields. Testing should include meters suitable for measuring low-frequency electric fields and magnetic fields, high-frequency radiowaves, and medium-frequency “dirty electricity” (distortions of the usual sinusoidal AC electric current). Ideally, testing should be performed by a knowledgeable, well-equipped electrical consultant. As an alternative, meters costing $100-$200 can help begin the evaluation process. Some people with severe EHS are reactive to the meters themselves and are unable to use them.

Recommend a diagnostic camping trip.

Careful journaling about symptoms before, during and after the trip may help clarify if an environmental sensitivity is present. The task of identifying the source — be it at home or work — will still remain.

Encourage a healthy lifestyle. This includes quality food and water, regular exercise, good sleep hygiene and spending time in nature on a near-daily basis.

Consider aerobic exercise with heavy sweating soon after a strong EMF exposure.

Exercise can help mitigate symptoms from an exposure, though caution is advised if exercise is contraindicated for any reason (e.g., coronary artery disease, electrolyte disorders, neuromus-

Scott Eberle, MD cular diseases).

Encourage cultivation of the relaxation response. Excess brain stimulation — with attendant anxiety, agitation and insomnia — can be a major problem for EHS patients. Cultivating deep relaxation with meditation, yoga, massage, hot baths or other modalities can be healing.

Encourage avoiding excess blue light (e.g., from computers and televisions) during the two hours before sleep. If blue light is unavoidable, recommend blue-filter glasses. The blue portion of the light spectrum has been shown to delay the onset of sleep more than other parts of visible light. Quality sleep is essential for healing any EMF-related brain injury.

Support the patient’s exploration of complementary therapies. Functional medicine treatment and bodywork can be beneficial. In addition, therapies that resonate with a patient’s own ideas about healing may play a role.

Refer for counseling as indicated. The experience of having one’s environment feel unsafe can

induce profound secondary psychological effects, even in people without previous mental health problems. Manifestations may include fear, panic, anxiety, shame, avoidance, helplessness, depression and insomnia — to name just a few. Do not dismiss the possibility of physical disease by over-interpreting these secondary psychological symptoms as mere paranoia, hypochondriasis or mental illness.

I close on a personal note. The crescendo of physical symptoms I experienced a year ago was overwhelming, but almost as bad was the fear and shame I felt when speculating that other people might think I was crazy. The understanding and support I received from friends and colleagues, especially fellow physicians, was hugely important in surviving this dark and difficult time. If patients come to you suspecting they might have EHS, I offer this simple encouragement: Believe what they say. That alone will help immensely.

Email: seberle@sbcglobal.net

REFERENCES 1. EMF Working Group, “Guideline of the Austrian Medical Association for the diagnosis and treatment of EMFrelated health problems and illnesses,” Austrian Medical Association (2012).

(Article available from author.)

2. American Academy of Environmental Medicine, “Letter to the FCC regarding radiofrequency exposure limits,” www. aaemonline.org (2013).

3. BioInitiative Working Group, “BioInitiative 2012,” www.bioinitiative. org (2012).

NOVEMBER / DECEMBER 2016 | THE BULLETIN | 11

Telemedicine for Everyone

By Christopher P. Schmidt, MD As a dermatologist, the possibilities of telemedicine were evident early in my career. You did not need a patient to make a diagnosis. You just needed a good picture.

Telemedicine was initially promoted as a benefit to patients. It would increase their access to specialty care and surmount geographic barriers. Unfortunately, the only reimbursed format at the time was live interactive video, which was too impractical for widespread use. Patients also had limited access to the technology. Telemedicine languished.

During this dark time, I was involved with a few unsuccessful startup telemedicine platforms that focused on direct patient access to specialists. There was a lot learned from the experience but there were no compelling reasons for physicians to adopt the practice.

That changed, in 2012, when California’s own telehealth law (AB 415) went into effect. Now physicians of all specialties would be the primary beneficiaries of telemedicine. The new law authorized physicians to collect for all forms of electronic interaction. This means you could now be reimbursed for all the free care that you normally give out via the phone or email by using store-and-forward telemedicine.

The largest benefit, however, is the savings that will occur when physicians no longer have to shoulder the burden of rent, staff, and other expenses when providing care that can be done outside the boundaries of an office. As a result, physicians should explore what aspects of patient care can be responsibly provided online and then try to move patients in that direction. Any progress that physicians make in moving portions of their practice online will be protected by the parity clause in this law. It requires that online visits be reimbursed at the same full level as an office visit.

Telemedicine is now very practical.

Physicians should be wary of many of the telemedicine sites that are out there. Most of the ones you read about in the headlines do not meet the California Medical Association’s (CMA) Principles of Telemedicine.

These are the anonymous doctor banks, prescription mills, and sites that use physicians in foreign countries.

Fortunately, there are telemedicine sites that closely adhere to the CMA’s telemedicine standards. Store-andforward platforms like HealthLens (Author is a founder), Azova, and SkyMD enable physicians to practice online in a medically sound and ethical manner.

The primary standard is allowing patients to receive online care from their established physician. This enables follow up with that particular physician and a physical location if an office visit is necessary. The CMA adherent platforms also provide secure messaging between patient and physician so the visits can be interactive. Some sites even facilitate the use of the patient’s medical insurance to cover the visit.

12 | THE BULLETIN | NOVEMBER / DECEMBER 2016

Most commercial insurance companies including Blue Cross, Blue Shield, Cigna, UnitedHealthcare, and Aetna cover store-and-forward telemedicine. Medicare only covers it in Alaska and Hawaii, but there is legislation in progress to expand to all 50 states. To get reimbursed for store-and-forward telemedicine visits, just attach the GQ modifier to your CPT code; e.g. 99203 GQ. In my practice, I see about 60 patients online per month. Acne, eczema, and seborrheic keratoses make up the majority of the conditions I diagnose online. Time sensitive conditions, like shingles, are not uncommon online diagnoses and it is much easier to get patients on antivirals within that 72-hour window of opportunity when they don’t have to wait for an office visit.

I even see new patients on the internet. According to the Medical Board of California, you can evaluate a new patient online and establish a physician-patient relationship as long as the photo(s) submitted by the patient allows the physician to perform an adequate physical examination to reasonably make a diagnosis. Established patients, who make up the majority of my online visits, can be evaluated and treated without a photograph. This works out well for prescription renewals.

Medical research will also benefit from the shift to online care because of the data that telemedicine provides. In the short time HealthLens has been in operation, we have amassed a large library of clinical images, corresponding diagnoses, treatments and, most importantly, outcomes.

The granularity of the data will allow for unprecedented levels of analysis.

Veering from long practiced norms is a troubling process for the medical community. However, the opportunity to eliminate so much of the expense involved in patient care cannot be ignored. Physicians should be leading the charge in shifting patient care online. We will be the primary beneficiaries.

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2016 House of Delegates

M

ore than 500 California physicians convened in Sacramento for the 145th Annual Session of the California Medical Association (CMA) House of Delegates, October 15-16, 2016, at the Sacramento Convention Center. This meeting marks the end of the first year of CMA’s new governance reforms and the first time the delegates have reconvened since they approved the reforms at last year’s House of Delegates (HOD).

Under the new system of governance, proposed policies are considered on a quarterly basis, with online testimony throughout the year. The HOD still meets annually, but the delegates now establish broad policy on current major issues affecting members, the association and the practice of medicine.

The major issues discussed this year were: MACRA: As the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is implemented over the next several years, the CMA will be working hard to ensure it is workable for practicing physicians and improves patient care. The CMA House of Delegates discussed various recommendations to guide CMA’s policy on this issue.

Maintenance of Certification: CMA supports the highest standards for licensure that are based on education, training, experience and ethical criteria. In a sometimes heated debate, delegates discussed various mod14 | THE BULLETIN | NOVEMBER / DECEMBER 2016

els and proposals regarding maintenance and recertification of specialty board certification, including alternative approaches.

Opioids: The issue of opioid-related misuse, abuse and overdose continues to be a major policy issue at the federal, state and regional levels. The delegates discussed various strategies and policies to promote prescribing controlled substances safely and effectively to relieve pain, while simultaneously reducing the risk of prescription medication misuse, addiction and overdose.

Physician Burnout: Recognizing that it is the responsibility of the medical community to identify risk factors for and appropriately respond to signs of physician burnout, the CMA House of Delegates explored strategies to preserve the physical and mental well-being of physicians.

ACA Changes: Beginning in 2017, states can request a five-year renewable exemption on key coverage provisions within the Affordable Care Act, including those related to benefits and subsidies, the exchanges, and the individual and employer mandates. The CMA House of Delegates discussed various recommendations related to a possible Section 1332 waiver for California.

Five-Year Public Health Plan: For many decades, CMA has taken an active role in championing notable and successful public health policy campaigns that promote healthy practices and behaviors. Continuing its

California Medical Association delegates discuss major issues and elect officers at annual meeting

commitment to public health, the CMA House of Delegates strategies to prevent and treat chronic disease and supports healthy and safe communities, focusing on the following areas: adult and childhood obesity, tobacco use, pain, behavior health disorders, violence and infectious disease.

Before debating the issues, the delegates heard from experts in each major issue area, and for the first time continuing medical education (CME) credit was offered for these educational sessions. Final reports detailing the actions taken by the delegates are posted at www.cmanet.org/ hod.

AWARDS AND ELECTIONS NEW PRESIDENT OF CMA PROMISES TO RESTORE VALUE TO THE PROFESSION Ruth Haskins, MD was installed as CMA’s 149th president. In her address to the delegates,

Tanya Spirtos, MD – Newly elected CMA Vice Speaker of the House, poses with new CMA President Ruth Haskins, MD at the House of Delegates.

she promised that in the face of the big changes taking place in health care and the overarching administrative burdens that have been placed on physicians, she would bring back value to the profession of medicine during her year as president.

“For most of us, being physicians is not something we ’do’, it is something we ‘are,’ she said. “ We need to be valued for the sacrifices we have made to earn our professional titles. We dedicated years of our lives for our education and training – giving up social events, missing holidays.”

“We need to be valued for what we give up every day as we try our best to remain passionate about our work,” she said. “The responsibility of life and death decisions, compounded by administrative burdens often feels overwhelming.

“The public needs to know how much we’d rather be touching our patients than stroking our electronic medical record keyboards; how much we’d rather be enjoying family time or exercis-

NOVEMBER / DECEMBER 2016 | THE BULLETIN | 15

ing than completing charts at home every evening. We need to be valued for the hours of time we spend agonizing over details about our patients’ health and the business of our practice: time we will never be compensated for.”

Dr. Haskins, an ob-gyn practicing in Folsom, has been a member of CMA and the Sierra Sacramento Valley Medical Association for 23 years.

She served on the CMA Board of Trustees from 2013-15 and as chair of the CMA Council on Legislation from 2010-13.

Dr. Haskins is a U.S. Air Force veteran who began active duty while enrolled in the University of Pittsburgh School of Medicine. She completed her residency in Obstetrics and Gynecology at the David Grant USAF Medical Center at Travis Air Force Base before transferring to the Illinoisbased Scott Air Force Base Medical Center, where she later became chair of the department of obstetrics and gynecology.

Dr. Haskins progressed to the rank of major in the military and was involved in the readiness campaign for Operation Desert Storm and Desert Shield in the early 1990s. The strength of her loyalty to her country is only matched by her passion for her hometown heroes, the Pittsburgh Steelers. Her fervor for sports and appreciation of great teamwork feeds into her enthusiasm for restoring the joy and value of the practice of medicine.

“California’s physicians are fortunate to have a champion for health care on their side,” said outgoing CMA President Steve Larson, MD, MPH. “Dr. Haskins brings energy and enthusiasm into everything she does, and I know she’ll provide the leadership needed to help tackle the health care challenges facing California.”

2016-2017 EXECUTIVE COMMITTEE Joining Dr. Haskins on the Executive Committee are: President-Elect: Theodore M. Mazer, MD, was elected presidentelect and will serve in this capacity for one year, taking office as president during next October’s annual meeting. Dr. Mazer is a board-certified otolaryngologist who has been working in a small, solo practice in San Diego for more than 25 years. A CMA member since 1988, Dr. Mazer served on the association’s Board of Trustees from 2002 to 2010, speaker of the house from 2013 to 2016, and has chaired various committees, including those focusing on medical services and access to specialty care.

Speaker of the House: Lee T. Snook, Jr., MD, a Sacramento pain management specialist, was elected Speaker of the House. A CMA member since 1985, Dr. Snook has served as chair of the CMA Worker’s Compensation Technical Advisory Committee and as a member of CMA’s Board of Trustees. Dr. Snook has served as vice speaker of the CMA House of Delegates since 2011.

Vice Speaker of the House: Tanya Spiritos, MD, a Redwood City obgyn was named Vice Speaker. Dr. Spiritos has been a member of CMA since 1985, serving on the CMA Board of Trustees since 2009 and on the CMA delegation to the American Medical Association.

Chair of the Board: David H. Aizuss, MD, an ophthalmic surgeon from Los Angeles, will be returning as chair of the CMA Board of Trustees, a position he has held since 2014. Dr. Aizuss, a CMA member since 1981, previously served as vice chair of the board from 2011-2014, and is a former president of the Los Angeles County Medical Association and the California Academy of Eye Physicians and Surgeons.

Vice Chair of the Board: Robert E. Wailes, MD, a pain specialist and board-certified anesthesiologist from Encinitas, will be returning as vice chair of the Board of Trustees, a position he has held since 2014.

Dr. Wailes, a CMA member since 1982, has served as president of the San Diego County Medical Society and represents the American Academy of Pain Medicine at the American Medical Association.

16 | THE BULLETIN | NOVEMBER / DECEMBER 2016

Immediate Past President: Steven E. Larson, MD, a board certified internist and infectious disease specialist from Riverside, will serve one last year on the Executive Committee as immediate past president. Dr. Larson, a CMA member since 1980, is the current CEO and chairman of the board of Riverside Medical Clinic and is also a delegate to the American Medical Association, serving as vice chair of the Pacific Rim Delegation.

Full bios for the Executive Committee members are available at www. cmanet.org/about/cma-governance.

ANNUAL AWARDS GALA RAISES MORE THAN $70,000 FOR PUBLIC HEALTH PROGRAMS The California Medical Association (CMA) Foundation raised more than $70,000 for public health programs during the 20th Annual President’s Reception and Awards Gala at the iconic Sacramento Memorial Auditorium. The event, held annually during the CMA House of Delegates, raises money for important public health programs from the CMA Foundation, including projects that focus on increasing adult immunization rates, reducing health care disparities and educating providers about the impact of climate change on health. This year’s Gala was extra special, as we are celebrating a big milestone in the history of CMA – 160 years. The Memorial Auditorium was transformed for the black tie affair with stunning décor and lighting that mimicked the night sky.

The program included CMA 160th anniversary video messages from Governor Jerry Brown, Lieutenant Governor Gavin Newsom and U.S. Senator Dianne Feinstein, among others. Guests danced to “America’s Best Dance Band” — Hip Service, whose music has wowed the likes of Arnold Schwarzenegger, Condoleezza Rice and Huey Lewis and the News.

During the exciting live auction, featuring Northern California’s most dynamic benefit auctioneer David Sobon, big ticket items auctioned off including a “Wine Collector’s Dream” that included cabernets from Napa stalwart Caymus Vineyards and a 1989 bottle of Dom Perignon; a custom-tailored suit from R. Douglas Custom Clothier; and the ever popular and perennial auction item of dinner with CMA CEO Dustin Corcoran. One of the most popular items was a stay in a 4,000-square-foot 18th century Italian farmhouse in a medieval Italian village.

CMA DELEGATES CONTRIBUTE $150K TO SUPPORT PHYSICIAN FRIENDLY CANDIDATES FOR PUBLIC OFFICE The CMA Political Action Committee (CALPAC) raised an impressive $155,000 during CMA’s annual House of Delegates meeting. The donations collected over the weekend, as well as all contributions made to CALPAC, are used to support candidates who share medicine’s agenda and priorities, and will work to affect policies beneficial to the house of medicine.

JOIN CALPAC TODAY! Please join your colleagues in supporting CALPAC and help strengthen our political voice. To become a member of CALPAC, fill out the online application form or download the application form, to be submitted by mail or fax. You can now also choose to have your contribution deducted monthly from your bank account.

To mail a check, please make payable to CALPAC and send to: 1201 J Street, Ste 275, Sacramento, CA 95814-9813.

SCCMA’s Pride is Showing:

By William C. Parrish, Jr. Chief Executive Officer One of our own, Tanya Spirtos, MD was elected, Vice Speaker of the House, by acclamation, at the recent CMA House of Delegates. I know I speak for our entire leadership and membership by stating how proud we are and how happy we are for Tanya!

She has not only proven herself as a wonderful practitioner, but has also demonstrated excellent leadership skills at the local, state, and national levels. The Delegates to the House certainly got it right when they elected Tanya. Her speaking abilities, parliamentary prowess, consensus building, and positive speaking skills make this decision a home run!

On behalf of SCCMA and District VII, we congratulate Tanya Spirtos, MD on achieving such a significant position, and thank you for the work and dedication you have committed to for the improvement of the profession and the betterment of the patients served.

Congratulations Tanya and God speed!

In addition…Tenured SCCMA member, Past President and leader Philipp Lippe, MD was aptly recognized when presented with the Lifetime Achievement Award to a standing ovation of the entire HOD. The citation on the award reads: “Presented to Philipp Lippe, MD For your many years of selfless dedication to Medicine, Neurosurgery, Pain Medicine, Industrial Medicine, The Specialty Delegation and The California Medical Association.”

Congratulations Phil for your many years of dedication, leadership, and stewardship. Well done and well deserved!

Also, Ken Blumenfeld, MD, currently SCCMA’s Vice President of External Affairs, was elected to CMA’s Board of Directors as District VII Trustee. Congratulations Ken, we look forward to many years of your leadership!

Dr. Philipp Lippe receives the Lifetime Achievement Award

Dr. Tanya Spirtos and her husband Elias at HOD.

Dr. Kenneth Blumenfeld at HOD NOVEMBER / DECEMBER 2016 | THE BULLETIN | 17

Photos From the House of Delegates

Newly elected CMA District VII Trustee –Dr. Kenneth Blumenfeld (also SCCMA’s VP of External Affairs).

MCMS/CMA Delegate Dr. Valerie Barnes gives her comments at the House of Delegates annual session.

SCCMA/CMA Delegate and VPCommunity Health Dr. Cindy Russell poses with CMA Past President Dr. Luther Cobb.

18 | THE BULLETIN | NOVEMBER / DECEMBER 2016

Newly elected Vice Speaker of the House and CMA District VII Trustee and Delegate Dr. Tanya Spirtos gives her comments at HOD.

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, n i a g A t e Y e s i R e W o

by Janus L. N

rman

The California Medical Association’s 2016 Legislative Wrap-Up

The delivery of health care,

and its costs, continue to be at the forefront of California politics. Dramatic changes, such as the implementation of the Affordable Care Act, escalating health care premiums, consolidation of health plans, rising drug costs and the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), continue to create uncertainty in the marketplace, causing a relatively new state Legislature to question nearly every aspect of health care delivery in California. The result has been a record number of significant legislative challenges to the core policy 22 | THE BULLETIN | NOVEMBER / DECEMBER 2016

beliefs of the California Medical Association (CMA).

“Transition” was the consistent variable in 2016. The year began with a transition of power in the Assembly as then-Speaker Toni Atkins (D - San Diego) handed over her leadership position to current Speaker Anthony Rendon (D - Lakewood). Chairs of policy committees during Speaker Atkins’s tenure worked quickly to conclude unresolved legislation from 2015, while policy chairs appointed by Speaker Rendon rushed to learn the full breadth of their policy committees’ jurisdictions. During all this time, the special legislative sessions on health care and transportation continued to convene.

Great Opportunities Legislative transition is synonymous with opportunity — and these opportunities are both good and bad.

The continuation of the special session on health care gave CMA and the Save Lives Coalition the opportunity to beat Big Tobacco by passing the most expansive package of tobacco reform legislation in the history of the Golden State. We closed loopholes in workplace and school campus smoking laws, brought e-cigarettes under the umbrella of tobacco products, increased licensing fees, and raised the legal purchasing age to 21. But our war against tobacco is not over yet, as we take on the industry again at the ballot box in November to increase the state tax on all tobacco products in order to help fund Medi-Cal. Our public health focus did not end with tobacco.

After the tragic loss of two San Diego medical students to a drunk driver in 2015, CMA pushed for mandatory responsible beverage training for managers, servers and bartenders in establishments that serve alcohol.

We took advantage of the shift in Senate chairmanships to reestablish CMA’s position at the bargaining table on reforms to the workers’ compensation system. Last year, partnering with Senator Richard Pan, M.D., CMA sponsored SB 563 to ensure the utilization review program was not providing incentives for denying medically appropriate care. This effort, combined with our continual effort to push for improvements to the system, resulted in our sponsored bill being incorporated into a larger workers’ compensation reform bill, which decreased the usage of prospective utilization review – solidifying the physician’s place in that discussion.

We also turned our eye inward to the health and

the future of the profession. Working closely with our colleagues at the California Academy of Family Physicians, the California Primary Care Association and other organizations, we secured a badly-needed investment in our state’s primary care workforce: a $100 million appropriation in the 2016-17 state budget. This appropriation will provide $33 million each year for three years to increase funding for the Song-Brown Program, a competitive grant program that supports primary care residency programs in medically underserved areas.

The budget will set aside some portion of this money exclusively for residency programs at clinic-based Teaching Health Centers, including support for the six existing sites as well as for clinics interested in starting new training programs. We believe this augmentation represents one of the biggest investments in the primary care physician workforce the state has ever undertaken.

Then, with the California American College of Emergency Physicians, we co-sponsored legislation to extend the program that donates certain traffic fines to the Maddy Emergency Medical Services Fund, which provides reimbursement to physicians who treat uninsured patients. Finally, CMA ensured that physicians suffering from substance abuse had a credible, viable health and wellness program to ensure that their patients continue to receive the very best care from those impacted physicians.

Great Threats Our opponents also have the ability to recognize and take advantage of opportunities, resulting in threats that must either be defeated or neutralized depending on the political realities surrounding the particular issue.

Threats to the profession during this legislative

Our war against tobacco is not over yet, as we take on the industry again at the ballot box in November to increase the state tax on all tobacco products in order to help fund Medi-Cal. NOVEMBER / DECEMBER 2016 | THE BULLETIN | 23

Contact: Janus Norman, CMA Senior Vice President, (916) 444-5532 or jnorman@cmanet.org

(Rev. 10/05/16)

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session came in the shape of SB 932 (Hernandez) and SB 1033 (Hill). SB 932 sought to put limitations on what may be included in contracts between health care insurers/plans and providers, as well as to implement a new process for approving mergers and acquisitions of health plans and risk-based organizations. Meanwhile, SB 1033 would have required doctors under probation with the Medical Board of California to disclose their probationary status to all patients. Neither measure made it out of their House of Origin.

Once again, we protected patients from undertrained practitioners offering treatment outside of their scope of practice. Nurse practitioners, optometrists, naturopathic doctors and certified nurse midwives — all had their scope expansion efforts decisively defeated.

Scope bills on nurse practitioners (SB 323 - Hernandez) and optometrists (SB 622 - Hernandez) were not even brought up for a vote in the Legislature this year due to overwhelming pressure and negative perception of the proposals in the Capitol. Naturopathic doctors (SB 538 - Hueso) and certified nurse midwives (AB 1306 - Burke) were longer fights, with both lasting up until the last hours of the legislative session. Ultimately, however, both bills were defeated by wide margins.

Great Compromises Amid all of these defeats, this year was also a year of great compromises. The majority of the bills we opposed at the start of the year were neutralized through amendments and negotiations during the course of the legislative session.

This year saw the completion of the CURES database negotiations that were begun in 2015. SB 482 (Lara) is a great achievement in mitigating the inevitable tightening of requirements for CURES database use. More work on this issue remains to be done, but much has been achieved through this bill and through building a foundation of cooperation with the Legislature and other stakeholders.

The most contentious negotiation this session was that of AB 72 (Bonta, et. al.), the out-of-network

bill signed into law by the Governor. AB 72 is a direct result of our defeat last session of AB 533 (Bonta), which essentially would have extended Medicare rates to all non-participating physicians. CMA defeated AB 533 last year on the last night of session. However, Assemblymember Bonta requested reconsideration, a procedural maneuver that granted him an opportunity to bring up the bill at any point in 2016 for a second vote.

To neutralize the threat of a revote on AB 533, our allies forced Bonta to restart negotiation on out-of-network billing, not only with CMA but also with the legislators as well. Their intervention precipitated the development of the jointly-authored AB 72. The joint authorship of Assemblymembers Wood, Santiago, Maienschein, Gonzalez, Dahle and Bonilla was far more favorable for our association than the prior year’s stakeholder process, which was solely directed by Assemblymember Bonta’s office. The end result is a law that puts to rest the issue of so-called “surprise billing” in a way that preserves the ability of a physician to continue collecting their usual rate (as long as they obtain the consent of the patient), implements a statutory payment structure that borrows significantly from CMA policy and ensures that the statutory payment structure only applies in a narrow set of circumstances.

While the enactment of AB 72 can never be describe as favorable, it did present CMA with the opportunity to rise above the negative political constructs and portrayals of physicians conjured up by the health insurer lobby. Through our good faith participation in the AB 72 stakeholder process, CMA once again represented the true nature of physicians delivering care in a complex system. We were able to convey that physicians desperately do not want patients to be financially injured by the profit-driven decisions of health insurers to narrow physician networks so that patients are barred from having a substantive opportunity to utilize their in-network benefits.

Yet again, CMA rose to the occasion, transforming

24 | THE BULLETIN | NOVEMBER / DECEMBER 2016

Contact: Janus Norman, CMA Senior Vice President, (916) 444-5532 or jnorman@cmanet.org

(Rev. 10/05/16)

Page 3 of 13

Change is happening, and change will continue to happen.

CMA’s charge must be to look into the future and act boldly to shape the world of health care in a way that is most favorable for all physicians and their patients. an absolute debacle into an advocacy gateway leading to enhanced network adequacy standards and allowing physicians a means to continue collecting their normal rate. Our actions also weakened the narrative weaponry available to health insurers. Surprise billing, or balance billing, was the primary “white hat” issue for health insurers. With the introduction of AB 533, they sought to exchange that “white hat” issue for a substantial financial windfall. With the passage of AB 72, the insurers have lost that issue in a manner that could see the overall physician compensation increase over time and stricter oversight of their networks.

Change Is Happening The question is whether CMA will continue this trend of rising above a turbulent political environment and marketplace to lead California from uncertainty to clarity. No longer can organized medicine maintain an overly defensive posture, hoping and working to simply maintain the status quo or to get things back to the way they used to be; such a position is unrealistic and will lead to decisive losses in the near future.

Change is happening, and change will continue to happen. CMA’s charge must be to look into the future and act boldly to shape the world of health care in a way that is most favorable for all physicians and their patients.

CMA’s leadership challenge is not new. The physician leaders and staff that set the course of this organization had the same duty. I submit to you the same call to action as CMA’s former Chief Lobbyist Steve Thompson:

“Crisis… is an opportunity for leadership. It’s an opportunity for the CMA to take the lead in providing solutions to the myriad problems facing health care today. The challenge ahead is to know what solutions to propose. But, if CMA does not lead in problem solving, that role will be filled by others who are far less concerned with what the future holds for physicians and patients.”

As we embrace this challenge, we must recognize that sometimes it is impossible to find complete agreement — what might help one physician might be less favorable to another. But we are organized medicine. We cannot allow rifts to seep outside of our House. We cannot give into the temptation to tear down what has been built.

Our enemies are waiting and counting on division within the House of Medicine to create fractures so they may exploit the harmful opportunities that would result.

We rise today because we were unified yesterday.

We will rise tomorrow, because we reaffirmed our bond today.

In Unity,

Janus L. Norman Senior Vice President of Government Relations

On the following details of that the major For more detailspages of theare major bills CMAbills followed this year,this seeyear. www.cal.md/legwrap2016. that CMA followed NOVEMBER / DECEMBER 2016 | THE BULLETIN | 25

Santa Clara County Medical Association 700 Empey Way • San Jose, CA 95128 • 408/998-8850 • FAX 408/289-1064 November 2016 TO:

All Members, Santa Clara County Medical Association (SCCMA)

FROM:

Seham El-Diwany, MD, Chair, 2016-2017 Awards Committee

At the 2017 Medical Association’s annual banquet, the association will honor several individuals with its perpetual awards. These awards are significant honors which reflect the respect, recognition, and appreciation of our membership. The recipients are selected from among our outstanding members who have distinguished themselves with extraordinary service to medicine in general, to the association, to the community, or to medical education.

Selections are made by the Awards Committee, with the aid of input from the membership at-large.

Your suggestions for recipients for each of the awards, outlined on the next page of this memo, will be appreciated.

Please complete the form below to submit suggestions, keeping in mind the requirements for each award as listed on the opposite page. If you would like to nominate more than one person, or for more than one award, please photocopy this form or send a letter.

Suggestions must be received by February 16, 2017. Thank you for your recommendations.

If you previously suggested a candidate who was not given an award, please feel free to resubmit that name.

I THINK ______________________________________________________ WOULD BE A GOOD CANDIDATE FOR THE _____________________________________________________________________________________ . (Name of Award) PLEASE ATTACH ALL SUPPORTING INFORMATION, INCLUDING ACCOMPLISHMENTS AND CONTRIBUTIONS THAT WILL HELP THE AWARDS COMMITTEE EVALUATE THE CANDIDATE FOR THE AWARD SELECTED. YOU MAY MAIL, FAX, OR EMAIL THE INFORMATION TO PAM JENSEN AT SCCMA. SUBMITTED BY: __________________________________________________________________________________ MD (Please print) MAIL FORM TO: SCCMA

Attn: Pam Jensen

700 Empey Way

San Jose, CA 95128 EMAIL: pjensen@sccma.org FAX: 408/289-1064 DEADLINE: February 16, 2017 26 | THE BULLETIN | NOVEMBER / DECEMBER 2016

Santa Clara County Medical Association

ANNUAL AWARDS

ROBERT D. BURNETT, MD LEGACY AWARD

For a physician member of the Medical Association who has demonstrated extraordinary visionary leadership, tireless effort, selfless long-term commitment, and success in challenging and advancing the health care community, the well-being of patients, and the most exalted goals of the medical profession. The only five recipients of this award are Robert D. Burnett, MD, Philipp Lippe, MD, Robert Pearl, MD, Sharon Levine, MD and Richard J. Slavin, MD.

BENJAMIN J. CORY, MD AWARD

For a physician member of the Medical Association who has displayed forward-looking, pioneering ideas, enterprise, enthusiasm, and prolonged professional stature and ability.

AWARD FOR OUTSTANDING ACHIEVEMENT IN MEDICINE

For a physician member of the Medical Association who, during his/ her medical career, has made unique contributions to the betterment of patient care, for which he/she has achieved widespread recognition.

Consideration shall be given to research and/or the development of procedures, methods of treatment, pharmaceutical agents, or technological advances in the field of medicine.

AWARD FOR OUTSTANDING CONTRIBUTION TO THE MEDICAL ASSOCIATION

For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the Association over and above that expected of the membership at-large.

AWARD FOR OUTSTANDING CONTRIBUTION IN MEDICAL EDUCATION

For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more medical education activities over and above that expected of the membership at-large.

AWARD FOR OUTSTANDING CONTRIBUTION IN COMMUNITY SERVICE

For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the community over and above that expected of the membership at-large.

CITIZEN’S AWARD

For an individual who is not a member of the Medical Association, who has achieved public recognition for a significant contribution in the health field. (This usually will be a non-physician, although physicians are not categorically excluded.)

Benjamin J. Cory, MD Award

Outstanding Outstanding Contribution To The Contribution In Medical Association Medical Education

1994

Robert W. Jamplis

Richard M. O’Neill

John B. Shinn

Thomas J. Fogarty

1995 1996

---

Robert W. Andonian

Ronald L. Kaye

Norman E. Shumway

Christopher C. Chow

David M. Rosenthal

William C. Fowkes

Thomas A. Stamey

1997 1998 1999 2000 2001

Outstanding Achievement In Medicine

Outstanding Contribution In Community Service Arthur A. Basham / Arthur L. Messinger ---

Citizen’s Award Gary W. Steinke, MD / Mrs. Pamela Steinke Mr. Howard W. Pearce

Cindy Lee Russell / Minoru Yamate

Florene Poyadue, RN

---

Bernice S. Comfort

Robert J. Frascino

Michael R. Fischetti

Suzanne Jackson, RN

Mansfield F. W. Smith

Stanley D. Harmon

Howard R. Porter

Burton D. Brent

William A. Johnson

Judge Leonard Edwards

Donald J. Prolo

Steven S. Fountain

C. Michael Knauer

Jack S. Remington

M. Ellen Mahoney

Rigo Chacon

Sharon A. Bogerty

Stephen H. Jackson

Theodore Fainstat

Richard P. Jobe

Barbara C. Erny

Janet Childs

Roger P. Kennedy

Bert Johnson

Nelson B. Powell / Robert W. Riley

Robert Michael Gould

Tony & Brandon Silveria

---

2002 2003

Robert M. Pearl

2004

Robert Wuerflein

2005 2006

Harvey J. Cohen

2007 2009 2010 2011 2012 2013 2014 2015 2016

---

Elliot C. Lepler

Allen H. Johnson

Bruce A. Reitz

David Morgan

Tom Campbell / Ted Lempert

Joseph E. Mason, Jr.

Anthony S. Felsovanyi

David A. Stevens

Martin D. Fenstersheib

Michael E. & Mary Ellen Fox

Eugene W. Kansky

Barry Miller

D. Craig Miller

Elizabeth Menkin

Jayne Haberman Cohen, DNSc

Richard L. Miller

Gus M. Garmel

Rodney Perkins

Elouise Joseph

Doris Hawks, Esq.

Arthur A. Basham

Robert W. R. Archibald

G. David Adamson

Harmeet S. Sachdev

Edward A. Hinshaw, Esq.

Stephen H. Jackson

Cindy L. Russell

Catherine L. Albin

John R. Adler, Jr.

Madhur Bhatnagar

Debbi Ricks

Bernadette Loftus

Martin L. Fishman

George P. Kent

Thomas Krummel

Seham El-Diwany

Peggy Fleming-Jenkins

Melvin Britton

James G. Hinsdale

David Levin

Gary Steinberg

Leo Strutner

Judge Lawrence Terry

Tanya Spirtos

Dennis Siegler

Robert Armstrong

Gary Silver

Kathleen King

Steven S. Fountain

Robert Gould

William Jensen

Eleanor Levin

David Quincy

Assemblymember Jim Beall

James G. Hinsdale

Stephen C. Henry

Rosaline Vasquez

Diane E. Craig

Jeffrey D. Urman

Congresswoman Anna Eshoo

Martin L. Fishman

David H. Campen

Jonathan H. Blum

Gary E. Hartman

Keith A. Fabisiak

Gay Crawford

John P. Sherck

J. Ronald Tacker

James D. Wolfe

Stephen L. Wang

Susan E. Kutner

Senator Jerry Hill

Raj Bhandari

Lynn B. Rosenstock

Danny L. Sam

Daniel I. Jacobs

Paul M. Jackson

Janice Bremis & Robin Riddle

---

---

NOVEMBER / DECEMBER 2016 | THE BULLETIN | 27

Arthur Wellsley Saxe, MD Santa Clara Pioneer Physician

By Michael Shea, MD Chairman, Leon P. Fox Medical History Committee Arthur Saxe was of German and Scottish descent. He was born in Plattsburg, New York, 1820, the fourth son of 13 siblings.

His college education was at Weslayan University at Middletown, Connecticut and medical school was Castleton Medical College located at Castleton, Vermont. He graduated in 1843.

In 1844, he was married at Sheldon, Vermont to Mary Elizabeth, daughter of Dr. Fred W. and Lois Judson. They had two living children, Fred J., a dentist at Oakland, and Frank K., a physician and surgeon at San Jose. They lost two children in infancy.

After seven years of practicing medicine in Swanton, Vermont, he traveled to California via the Overland Trail in search of gold. After two years of mining attempts, he located in Santa Clara, ready to practice medicine full time. He was joined there by his wife and two sons.

Santa Clara was a newly incorporated town in 1852 and gained state chartered city status in 1862. Henry Warburton, MD was the city’s first doctor, in 1848, with Arthur Saxe close behind.

Dr Saxe, however, was the first physician to build a medical office from which he practiced his craft. It was customary in those days for doctors to practice out of their homes. His office still stands today at 1075 Benton Street and historic tours of the city include a visit there.

The doctor was also a lover of flowers. He had a beautiful floral and botanical garden, which revealed his horticultural abilities. Among his hundreds of varieties of flowers, he had 250 varieties of roses.

28 | THE BULLETIN | NOVEMBER / DECEMBER 2016

Arthur Wellsley Saxe, MD

He also excelled as an amateur artist, with his paintings shown throughout his home and office. He painted himself and his wife in separate poses, which are on display today in the Santa Clara City Library.

Both Doctor Saxe and his wife were members of the Santa Clara Methodist Episcopal Church. The charitable works they performed during their lifetime left a lasting mark in the hearts of Santa Clarans.

Dr. Saxe was also interested in politics. In 1880, he was elected President of the California Medical Society. During the same year, he went to the Hawaiian Islands to study the history, cause, and cure of leprosy. He presented his findings to the Society the following year. In 1884, he was elected to represent his district in the California State Senate. He served both positions with honor and integrity.

Dr. Arthur Saxe passed away at Paraiso Springs in Monterey County in 1891. He was 71 years old.

Sadly, his son Frank died one year later of pulmonary tuberculosis at age 35.

A special thank you to Mary Hanel, retired history librarian from the Santa Clara City Library, for furnishing much of the factual material for this article.

Mary Elizabeth Saxe

Leon P. Fox Medical History Committee The Leon P. Fox Medical History Committee meets bi-monthly, the first Monday at noon (lunch provided). The purpose of the committee is to identify, collect, and preserve archival material, memorabilia, and artifacts representing the medical history of Santa Clara County. A guest speaker gives a historical presentation at each of the meetings, which is then transcribed for SCCMA’s Medical History archives.

If you are interested in joining this committee, please contact Pam Jensen at SCCMA at (408) 998-8850 or pjensen@sccma.org.

There will be 23 educational sessions and five optional workshops. The workshops include pre- and postconference Knowledge Self-Assessments (KSAs, formerly known as SAMs) for your family medicine Maintenance of Certification (MOC), as well as in-depth workshops on palliative care and long-lasting reversible contraceptives (LARC).

There will also be two keynote presentations. Rishi Manchanda, MD, MPH, physician public health innovator, who will discuss upstreaming, which looks for the root cause of illness rather than just treating its symptoms. Don Abrams, MD, cancer and integrative medicine specialist at UCSF, will discuss the latest issues around

medical marijuana.

There will also be breakfast table talks, an exhibit hall, an all-attendee welcome reception and silent auction to benefit the CAFP-Foundation, and much more.

Up to 28 hours of prescribed credit.

Registration is open now. All prices increase by $100 on December 10, 2016. California Academy of Family Physicians (CAFP) Family Medicine Clinical Forum, April 8-9, 2017, San Francisco Hilton, Union Square.

Learn more and register at familydocs.org/17forum or contact CAFP at (415) 345-8667 or cafp@familydocs. org.

NOVEMBER / DECEMBER 2016 | THE BULLETIN | 29

PARTNER SPOTLIGHT

CapAlt Advantages WHAT DOES AN INSURANCE CAPTIVE HAVE TO DO WITH MY BUSINESS? Basil Hantash, MD, PhD, MBA, from Turlock, Calif., realized the greatest threat to his dermatology practice wasn’t medical malpractice.

What kept him and so many other doctors up at night were worries over things like loss of license or hospital privilege, a cyber attack, staffing issues, losing a patient referral source or needing to pay out for legal defense. These are problems that could prove catastrophic to any practice. Dr. Hantash did his research and found a solution. Enter CapAlt, a captive insurance company administrator, specializing in protected captives.

Working with CapAlt, Dr. Hantash was able to protect his practice in a way that was not only tailored for his specific needs, but would increase his bottom line. It may sound too good to be true, but here’s how it works.

A large commercial insurance company takes your premiums and invests those funds, growing the company’s assets. Through CapAlt, business owners (including physicians) can set up their own captive insurance company and not only protect their business, but make money in the process. Allstate Insurance actually started as a captive. So the idea of a captive isn’t a new insurance model; CapAlt is a new partner for SCCMA and MCMS members.

We want you to know that CapAlt went through an extensive vetting process by CMA, the CMA Insurance Committee and SCCMAMCMS. The result is that, in addition to all the advantages of owning a captive, CapAlt is now offering free SCCMA and MCMS membership to any physician who adopts a captive.

The representatives at CapAlt will take you through a fairly painless process with a risk assessment questionnaire to help determine your exposure and budget. From there, you’ll determine where to invest your premiums and they’ll do the heavy lifting. You don’t have to become an insurance specialist. You may not have heard of insurance captives or been offered this kind of opportunity because captives don’t work for everyone. Physicians and small physician groups can qualify and really benefit from captives.

The premium you pay to your captive is tax-deductible and over time this investment acts almost like a 401(k). Captives usually cover claims that have a high payout but a low occurrence rate. This means that your captive keeps you from paying out of pocket and keeps you protected from high-risk situations such as someone hacking into your computer system or if you’re facing the need to defend your reputation.

CapAlt recognizes that physicians have specific risks they are working to mitigate. In coming on as a partner with CMA and SCCMA-MCMS, they have developed a comprehensive program for 30 | THE BULLETIN | NOVEMBER / DECEMBER 2016

physicians, addressing issues such as HIPAA compliance and licensing. Mark Sims is VP of Business Development for CapAlt. He’s been active in talking to physicians and organizations like CMA. If you’d like to find out more about managing risk and assets through captive insurance, Sims is happy to answer questions and help you determine if setting up a captive is right for you. You can reach him at msims@ captivealternatives.com or 404/823-6200.

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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.

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FOR SALE MEDICAL WEIGHT LOSS PRACTICE / RETIREMENT SALE Proven, highly recognized, and profitable established weight loss practice in beautiful Marin County. Current six figures, room for expansion. Work-life balance, time freedom, financial security, relationship-driven practice. I am 100% committed in assisting the new owner with all the support necessary to ensure a smooth transition. Please contact me for more information or to schedule a visit.

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Convenient location. 5+ exam rooms NOVEMBER / DECEMBER 2016 | THE BULLETIN | 31

MCMS MEMBER SPOTLIGHT Alfred M. Sadler, Jr., MD Dr. Sadler has been a member of the Monterey County Medical Society for 12 years and is the current MCMS Secretary for the Board of Directors.

Ketchum University to grant honorary degree of Doctor of Science (DSc) to Alfred M. Sadler, Jr., MD Marshall B. Ketchum University will be granting an honorary degree of Doctor of Science (DSc) to Alfred M. Sadler, Jr., MD at MBKU’s School of Physician Assistant Studies inaugural graduation on November 11, 2016. Dr. Sadler, who will be the keynote speaker at the commencement ceremony, is being honored for the significant contributions he has made to the PA and the medical professions, over the past 50 years.

“It is both fitting and inspirational for one of the PA profession’s instrumental leaders to deliver the keynote address and be awarded the honorary degree of Doctor of Science at the graduation of MBKU’s first class of PA students. As we send our newest PAs to become leaders in health care, they will be motivated by one of the field’s most accomplished providers,” said MBKU President Kevin Alexander, OD, PhD. Dr. Sadler, a resident of Carmel, CA, is a graduate of Amherst College, Amherst, MA in 1962 and Drexel University College of Medicine, Philadelphia, PA. In 1967, after completing a surgical internship at the Hospital of the University of Pennsylvania, he joined the U.S. Public Health Service at the National Institutes of Health. There, with his identical twin brother Blair, a lawyer, he was instrumental in drafting the Uniform Anatomical Gift Act, the model law governing organ donation. Drafted in 1968, it was adopted in all states by 1971 and has served as the legal underpinning for the nationwide transplantation system ever since.

In 1969, the Sadler brothers conducted a review of each state’s licensing laws governing allied health personnel and each state’s medical practice act. This was at the request of DHEW’s Assistant Secretary of Health, Roger O. Egeberg, MD. They concluded that amending each state’s medical practice act to enable PAs to practice under physician supervision was the best legal choice at that time.

In 1970, Dr. Sadler cofounded the Physician Assistant Program at the Yale University School of Medicine and served as its first Director. Dr. Sadler became the first President of the Association of Physician Assistant Programs (APAP) in 1972 and during his tenure, worked with the American Medical Association and the Association of American Medical Colleges to develop accreditation standards for PA programs. Over the 32 | THE BULLETIN | NOVEMBER / DECEMBER 2016

following two years, Dr. Sadler led the development of important professional programs for PAs, including: the first national conference for PAs, the first National Certifying Examination administered by the National Board of Medical Examiners, the founding of the National Commission on Certification of PAs, and establishing the joint national executive office for APAP and the Academy of PAs (AAPA) in Washington, D.C. In 1972, with his brother, Dr. Sadler coauthored “The Physician’s Assistant: Today and Tomorrow,” the first book on PAs, which addressed important policy issues and emphasized the importance of interdependence among health professionals.

While at Yale, he led a major study on the Emergency Medical Services System in Connecticut which established a new system of EMS in the State and served as the template of the Robert Wood Johnson Foundation’s program in 44 regions throughout the country.

He left Yale in 1973 to assume the role of Senior Officer at the newly formed Robert Wood Johnson Foundation where he advocated for PAs and helped start the Stanford and UC Davis PA programs the following

$1.1 billion in Zika funding approved

by Congress year.

In 1976, he completed an internship, residency and fellowship in primary care internal medicine at the Massachusetts General Hospital and Harvard Medical School.

From 1981 until last year, he has practiced primary care and urgent care in Monterey and Salinas in association with PAs. Since 2010, Dr. Sadler served on the PA History Society Board as a trustee, historian, president-elect and president. In 2013, he co-authored “The Physician’s Assistant: An Illustrated History,” the most comprehensive review of the history of the profession and received the Distinguished Service Award from the PA Education Association that year.

Additional honors include: Fellow and recipient of the Lifetime Achievement Award from the American College of Physicians; one of 40 “Luminaries” selected by the Robert Wood Johnson Foundation at its 40th anniversary in 2012; and the Lifetime Achievement Award from Drexel College of Medicine earlier this year.

“Dr. Sadler clearly has had a distinguished career as a physician and advocate for the PA profession,” said MBKU’s Dean, College of Health Sciences and Director, School of PA Studies Judy Ortiz, PhD, PA-C. “It will be a great honor to award him the Doctor of Science Honorary Degree from Marshall Ketchum University and an even greater honor for our students to hear him address their class during the commencement ceremony,” she continued.

“I am excited and humbled to receive this honorary degree and speak at the inaugural commencement of Marshall B. Ketchum University’s School of PA Studies,” said Dr. Sadler. “The remarkable growth of this profession over the past 50 years requires the best preparation, and MBKU is at the forefront of excellence in teaching, patient care, research and public service,” he continued.

MBKU’s School of PA Studies was established in 2012, and offers a 27-month, post-baccalaureate program leading to the degree, Master of Medical Science (MMS). The PA program is nine quarters in duration. 27 students will receive their degrees at the commencement ceremony on November 11, 2016 at 11 a.m. at the Ketchum University campus in Fullerton, CA.

Funding for public health efforts against the Zika virus was finally approved by Congress with the passage of a stopgap measure to avoid a federal government shutdown. The spending measure includes $1.1 billion to fight the virus, capping a fierce months-long debate over the money that dismayed public health experts.

The White House first requested $1.9 billion in funds to fight Zika in the spring. But Republicans initially resisted the request, before finally putting forward their own $1.1 billion Zika funding bill in July. The Republicans’ bill failed to pass this summer due to a rider that would have prevented funding of Planned Parenthood.

With more than 3,358 Zika cases in the U.S. (mostly from people who acquired the virus abroad) and another 19,777 cases in U.S. territories, the money will go towards areas like vaccine research and mosquito control.

“It has been clear over the past several months that the U.S. has needed additional resources to combat the Zika virus,” said Andrew W. Gurman, MD, president of the American Medical Association (AMA). The American Medical Association is pleased that Congress has taken action to provide the resources necessary to help contain the virus and limit any further impact on Americans.”

Although most people infected with Zika have no symptoms, Zika infection during pregnancy can cause microcephaly and other severe defects in the developing fetus.

The Aedes mosquitoes that carry the disease are not native to California, however they have been detected in 12 California counties in recent years. To date there has been no local mosquito-borne transmission of Zika virus in California.

A team of experts across several disciplines at the California Department of Public Health (CDPH) is working closely with local public health departments, vector control agencies and the medical community to ensure that California is responding aggressively and appropriately to the emerging threat of Zika virus.

As of September 23, CDPH has confirmed 302 travel-associated Zika virus infections in 29 California counties. A total of 36 infections have been confirmed in pregnant women. CDPH has also confirmed that two infants with Zika-related microcephaly have been born in California to women who had Zika virus infections during pregnancy after spending time in a country where the virus is endemic.

For more information on the Zika virus in California, visit www. cdph.ca.gov.

CMA Alert, October 3, 2016 issue NOVEMBER / DECEMBER 2016 | THE BULLETIN | 33

CMA Alert, October 3, 2016 issue

Physician morale continues to decline, with 80% of physicians feeling overextended U.S. physicians continue to struggle to maintain professional satisfaction levels as they are forced to adapt to changing delivery and payment models, according to a Physicians Foundation survey of 17,000 U.S. physicians.

The 2016 Survey of America’s Physicians: Practice Patterns and Perspectives found that 80 percent of physicians report being overextended or at capacity, with no time to see additional patients. Not surprisingly, 54 percent of physicians surveyed rate their morale as somewhat or very negative, with 49 percent saying they are either often or always feeling burnt out.

Physicians identified regulatory and paperwork burdens and loss of clinical autonomy as their primary sources of dissatisfaction. Respondents indicated that they spend 21 percent of their time on non-clinical paperwork duties, while 72 percent said third-party intrusions detract from the quality of care they can provide.

Forty-eight percent of surveyed physicians plan to cut back on hours, retire, take a non-clinical job, switch to “concierge” medicine or take other steps that would further limit patient access to care. These patterns are likely to reduce the physician workforce by tens of thousands of full-time equivalents at the time that a growing, aging and more widely insured population is increasing overall demand for physicians.

“Many physicians are dissatisfied with the current state of medical practice and are starting to opt out of traditional patient care roles,” said Walker Ray, MD, president of the Physicians Foundation and chair of its research committee. “By retiring, taking nonclinical roles or cutting back in various other ways, physicians are essentially voting with their feet and leaving the clinical workforce. This trend is to the detriment of patient access. It is imperative that all health care stakeholders recognize and begin to address these issues more proactively, to support physicians and enhance the medical practice environment.”

This survey, conducted biennially since 2008, 34 | THE BULLETIN | NOVEMBER / DECEMBER 2016

has consistently demonstrated that the professional morale of physicians is declining. Physicians have also consistently indicated that their primary source of professional satisfaction is the patient-physician relationship. In the 2016 survey, 73.8 percent of respondents list this as the most satisfying aspect of their jobs, followed by “intellectual stimulation” at 58.7 percent.

Physicians note that issues such as a lack of clinical autonomy, liability concerns, struggle for reimbursement and decreased patient face-time can all negatively impact the patient-physician relationship – thereby undermining physician satisfaction.

Recognizing that it is the responsibility of the medical community to identify risk factors for and appropriately respond to signs of physician burnout, the California Medical Association has identified the topic as one of six major issues to be discussed at this year’s annual House of Delegates, which convenes in Sacramento October 15-16. The delegates will explore strategies and develop policies aimed at preserving the physical and mental well-being of physicians.

CMA Alert, October 18, 2016 issue

CMA publishes FAQ on controversial new law to end “surprise billing” In September 2016, Governor Jerry Brown signed into law a controversial bill (AB 72) that will change the billing practices of non-participating physicians providing non-emergency care at in-network hospitals, ambulatory surgery centers and laboratories.

While the enactment of AB 72 can never be described as favorable, the end result is a law that puts to rest the issue of so-called “surprise billing” in a way that preserves the ability of physicians to continue collecting their usual rate (as long as they obtain the consent of the patient), implements a statutory payment structure that borrows significantly from California Medical Association (CMA) policy and ensures that the statutory payment structure only applies in a narrow set of circumstances.

“Through our good faith participation in the AB 72 stakeholder process, CMA once again represented the true nature of physicians deliver-

ing care in a complex system,” said CMA Senior Vice President of Government Relations Janus Norman, in his annual legislative wrap up. “We were able to convey that physicians desperately do not want patients to be financially injured by the profit-driven decisions of health insurers to narrow physician networks so that patients are barred from having a substantive opportunity to utilize their in-network benefits.”

To help clarify the new law and to address physicians’ concerns and questions, CMA has published, “A Physician’s Guide to AB 72: Questions and Answers.” The FAQ is available to members only in CMA’s online resource library at http://www.cmanet.org/resource-library.

CMA Alert, October 31, 2016 issue

Cloud computing providers need to sign business associate agreements, says OCR The U.S. Department of Health and Human Services Office of Civil Rights (OCR) recently released updated guidance on the use of cloud computing for the storage or transmission of electronic personal health information (ePHI). The new guidance clarifies that cloud service providers are considered “business associates” under HIPAA, even if the provider only stores encrypted data and doesn’t have a decryption key to view the data.

This means that if a covered entity (or business associate) uses a cloud service provider to maintain ePHI without entering into a business associate agreement, the covered entity (or business associate) is in violation of HIPAA. “As a business associate, a cloud service provider providing no-view services is not exempt from any otherwise applicable requirements of the HIPAA Rules,” OCR said. “However, the requirements of the rules are flexible and scalable to take into account the no-view nature of the services

provided by the [cloud service provider].” Cloud service providers generally offer online access to shared computing resources with varying levels of functionality ranging from data storage to complete software solutions (e.g., an electronic health record system), platforms to simplify the ability of application developers to create new products, and entire computing infrastructure for software programmers to deploy and test programs.

The guidance also includes answers to several other common questions related to cloud computing and HIPAA. To read the guidance in its entirety, go to http://www.hhs.gov/hipaa/for-professionals/special-topics/ cloud-computing/index.html.

For more information, see CMA On-Call document #3301 “Physician Use of Mobile Devices and Cloud Computing.” CMA On-Call documents are available free to members in CMA’s online health law library at www. cmanet.org/cma-on-call.

NOVEMBER / DECEMBER 2016 | THE BULLETIN | 35

CMA Alert, October 3, 2016 issue

Podcast series: Inside Medicare’s new payment system Changes to the Medicare payment system are on the horizon, and physicians around the country are wondering how the new Medicare Access and CHIP Reauthorization Act (MACRA) will impact their practices. The American Medical Association (AMA) and ReachMD have produced a podcast series to provide physicians with an inside look at what’s to come and what they can do now to prepare for the transition to MACRA. Hear from industry experts and physician leaders about their experiences with new payment models, quality reporting and more.

Available episodes include: • Implementing MACRA: The AMA’s

Keys to Advancing Opportunities, Avoiding Pitfalls • APMs in Cancer Care: The PatientCentered Oncology Payment Model • The Rise of Specialist-Driven Alternative Payment Models in American Medicine • Thoughts on Physician Advocacy and Payment Reform with AMA President Andrew Gurman, MD. • The Future of Medicare Payment Reform: Perspectives on MACRA with CMS’s Andy Slavitt To listen to the podcasts, visit www.reachmd.com.

More MACRA resources To help physicians understand MACRA payment reforms, and what they can do now to start preparing for the transition, the California Medical Association CMA) has published a MACRA resource center.

There you will find an overview of MACRA, and a comprehensive list of tools, resources and information from CMA, AMA and the Centers for Medicare and Medicaid Services.

View the resource center at www.cmanet. org/macra.

CMA Alert, October 3, 2016 issue

When was your last HIPAA risk assessment?

The U.S. Department of Health and Human Services (HHS) has updated the Security Risk Assessment (SRA) tool, which is designed to help health care providers in small to medium sized practices conduct information security risk analyses of their organizations, as required under the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. New features of the tool include Windows 10 compatibility and improved reporting features.

The tool, available at www.HealthIT.gov, is the result of a collaborative effort by the HHS Office of the National Coordinator for Health Information Technology (ONC) and Office for Civil Rights (OCR). It is designed to help practices conduct and document an assessment of potential security risks in a thorough, organized fashion. The tool also produces a report that can be used in case of a HIPAA audit or investigation.

HIPAA requires organizations that handle protected health information to regularly review the administrative, physical and technical safeguards they have in place to protect the security of the information. By conducting the risk analysis, health care providers can uncover potential weaknesses in their security policies, processes and systems. It also addresses vulnerabilities, potentially preventing health data breaches or other adverse security events.

Conducting a security risk analysis is a key requirement of the HIPAA Security Rule and a core requirement for providers seeking payment through the Medicare and Medicaid EHR Incentive Program, commonly known as the Meaningful Use Program.

Despite the name, it is important to note that this tool is a risk analy36 | THE BULLETIN | NOVEMBER / DECEMBER 2016

sis tool, rather than a tool to assist physicians in conducting a “risk assessment” in order to determine whether certain breach notification requirements have been triggered following a breach of security. It is also important to note that this tool is provided for informational purposes only and does not guarantee compliance with federal, state, or local laws.

The tool is available for both Windows operating systems and iPad. The iPad version is available from the iTunes App Store (search “HHS SRA tool”).

For more information on the risk analysis requirements under HIPAA, see CMA On-Call document #4102, “HIPAA Security Rule.” OnCall documents are available free to members in CMA’s online health law library at www.cmanet.org/cma-on-call.

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Santa Clara County Medical Association Alliance FOUNDATION Grant Application Form Program: The Santa Clara County Medical Association Alliance Foundation provides funds for distribution to partners that provide needed community services. Categories for which funds may be granted include but are not limited to health fairs, hospital special needs, supplemental patient services, and health related information.

Eligibility: All community partners with a nonprofit status are invited to submit a proposal. Due to limited funding, applicants may submit only one proposal.

Deadline: Grants are evaluated individually. However, the earlier the grant application is received, the more likely funds will be available to allocate. Applications will not be accepted after Feb. 15.

Budget: Proposals may call for expenditures of up to $2500.00. Since SCCMAA FOUNDATION obtains funding through donations and membership, the number of grants available each year may vary.

Criteria: • Directness of a health connection to community needs • Number of community members served • A follow up letter to the SCCMAA will be required when the project is completed Proposal Format: Proposals must be typed and limited to two pages. Please include the following information: 1. Description of how and when funds will be used.

2. Health benefits to community members.

3. Description and estimated cost of materials and/or services.

4. Signature of applicant and date of application Questions: Please refer your questions to Kathleen Miller by email at kmmlg1027@aol.com. The SCCMA Alliance office is located at 700 Empey Way, San Jose, CA 95128. To learn more about the SCCMA Alliance Foundation, please visit us on Facebook.

Revised October 26, 2016

38 | THE BULLETIN | NOVEMBER / DECEMBER 2016

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