MAY / JUNE 2017
VOLUME 23 | NUMBER 3
BULLETIN THE
Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
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6 Message From the SCCMA President
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THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS 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
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
CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Kenneth Blumenfeld, 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 2017 by the Santa Clara County Medical Association.
4 | THE BULLETIN | MAY / JUNE 2017
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 William Khieu, MD Eliot Light, MD
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End of Life Option Act – A Real Experience
President, Santa Clara County Medical Association
SCOTT BENNINGHOVEN, MD
MESSAGE FROM THE
SCCMA PRESIDENT
M
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.
y first President’s column was going to be on the End of Life Option Act because I felt it was the most important legislation passed in 2015. During the passage of ABX2-15 in special session, there was much passionate discussion pro and con about the bill and how it would affect physicians, patients and whether it was in the Doctors Oath to “do no harm.” This discussion was both within CMA and in the medical community. Each side had very compelling arguments and spoke with compassion and conviction right up to Governor Brown’s signing the bill into law on October 5, 2015. In June 2016, the Act had just become law and I really had nothing new to write about. That was until two months ago. By chance I had the rare opportunity to see the effect of all that legislative discussion and work affect the family of a friend and colleague. I have known and worked with my friend “Lynne” for 25 years. She is the most caring, thoughtful and compassionate nurse, one I am proud to be associated with. In fact, she provided the best patient experience in the operating room before there was a “patient experience.” Knowing Lynne as I do, I know she would accept nothing but the best care for her mother. Lynne had been off work for an extended leave of 8 weeks. When she returned, I casually inquired as a friend if she was “OK” not knowing the nature of her time off. She replied that she had been through a most difficult and wonderful experience. She related, after several minutes, that she had taken the time off to help her mother through the process of the “end of life.” Lynne’s mother, much like my own mother, is a very proud and private lady. When she was diagnosed with Metastatic Lung Carcinoma 15 months ago she immediately knew how she didn’t want to die. She tried Radiation Therapy, which had little effect on the tumor, and she weighed the risk and benefits of Chemotherapy and declined it as not right for her. Her husband had passed from Alzheimer’s four years earlier and, therefore, length of time was not as important as quality time. Fortunately, the End of Life Option Act was passed to allow people like her to control the quality of their lives. As her mother became weaker and less able to care for herself, Lynne took time off work to both care for and spend time with her mother and help her through the final weeks of her life. Her mother
6 | THE BULLETIN | MAY / JUNE 2017
had approached her oncologist to find out about the End of Life Option Act. She faced a dead-end, receiving neither help nor referral to someone who could help. Likewise, when Lynne contacted her mother’s physicians, Hospice and local hospitals, no one had any contacts for a physician to evaluate and assist these very ill patients through the most difficult decision and time of their lives. Fortunately a friend of a friend had read an article in the newspaper about the End of Life Option Act. Mentioned in the article was a physician who was taking up the challenge to provide this service. Dr. Katherine Shade spent a lot of time both with Lynne’s mother, alone and with the whole family, to determine if her mother met the requirement of the Act and I think more importantly whether it was the right decision for her. As within many families there are dissenters and one of Lynne’s siblings was sure that their mother was making the wrong decision, but it is the patient who makes the final decision. The legal requirements were met, prescriptions written and medication obtained. Lynne’s mother gained control of her life, which is all she cared about in the first place. Lynne related that as the disease progressed, her mother became weaker due to difficulty breathing and effects of the pain medication. Significantly reducing her pain medication use, and accepting the pain, allowed her mother to become mentally clearer, which made the last weeks a wonderful experience for her family and friends. I believe the most important benefit of the Act is to give the patient the power to control their medical condition allowing a sense of security over their future. Family and friends were notified and therefore had the chance to personally say good-bye. These meetings took place over two weeks and most were memorialized with photos and video. Lynne will always have the memories of how her mother lived. Those photos and video will remind her of the laughter, jokes and stories, caring and compassion and heartfelt good-byes. Isn’t this better than the alternative. Understanding this experience has shown me that our care must be patient focused. What is right for one person may not be universally right for all. This End of Life Option Act gives those who choose to control the manner in which they live and so die that ability.
Thank You
I have two inspiring new chief residents starting in July who came to me entirely unsolicited and announced that they had decided to have a theme for their year and that theme was “gratitude.” I encourage you, reader, to thank someone today. You are a doctor not by your efforts alone. You do not perform surgery alone. You do not resuscitate alone. Your prescriptions do not fill themselves. You did not teach yourself. Perhaps I wrote this alone, but only now that you have read this does it convey anything. Thank you, fellow members of the Monterey County Medical Society for reading and thank you for the privilege of being your President.
President, Monterey County Medical Society
Thank you for channeling Florence Nightingale into this wonderful facility, culture and history that is Natividad Medical Center.”
CRAIG A. WALLS, MD PhD
Florence Nightingale was a social reformer and a massively productive author. She advocated modern healthcare for all classes of British society. She pioneered hunger relief in the third world. She was a champion of the use of sanitary techniques, such as hand washing, in hospitals that reduced infections by up to 90%. She was hugely influential in expanding the acceptable forms of work for women. She was one of the first to write medical literature in simple English that common people could understand. She was a statistician and popularized using graphs to illustrate statistical data. She was elected the first female member of the Royal Statistical Society. She founded the first secular nursing school in the world and in so doing laid the foundation of professional
So, as your chief medical officer and as a doctor: Thank you for loving our patients. Thank you for your therapeutic touch. Thank you for teaching our residents. Thank you for keeping us doctors safe. Thank you for your expertise and your professionalism.
MCMS PRESIDENT
“I want to tell you about a remarkable English woman who was born 197 years ago in Florence, Italy but who stands here today, in our hospital, as these awards are presented.
nursing – the proud tradition of which you are heir to. In fact, she mentored Linda Richards, “America’s first trained nurse,” and enabled her to return to the United States with the training and knowledge to establish high-quality nursing schools. Our nurses can therefore trace their professional heritage directly back to Florence Nightingale.
MESSAGE FROM THE
M
y time as President of your Monterey County Medical Society draws to a close. I will conclude my comments in these pages by giving thanks. As I write this, my hospital, your county hospital, in our beautiful and historic Monterey County is celebrating National Hospital Week. This week we appreciate the people who support the health of our communities through the institutions represented by the American Hospital Association. We presented our Florence Nightingale Nursing Awards in our sunny, open atrium and we shared smiles and a couple of tears. Seven amazing nursing professionals were presented with awards and recognized, but truly we have some 600 nurses who they stood for. I will tell you what I told them:
Craig A. Walls, MD, PhD is the 2016-2017 president of the Monterey County Medical Society. He is currently the Chief Medical Officer at Natividad Medical Center in Monterey.
MAY / JUNE 2017 | THE BULLETIN | 7
MEDICATION-ASSISTED TREATMENT (MAT): WHAT YOU SHOULD KNOW ABOUT BUPRENORPHINE
B
uprenorphine is an opioid drug that has become increasingly more popular for use in medication-assisted treatment (MAT) for opioid addiction and dependence. Buprenorphine is a potent pain reliever with particular advantages for patients with chronic pain or pain complicated by opioid dependence. Although traditional practice has been to discontinue buprenorphine during hospital admissions, new research shows that buprenorphine can be continued when patients are admitted to the hospital, with pain controlled by other opioids used on top of the baseline buprenorphine regiment. Studies of patients on high-dose opioids transitioned to sublingual or buccal buprenorphine have shown improved pain control, improved control of psychiatric symptoms, and much lower risk of overdose death.
One of the most important differences between buprenorphine, and other popular addiction therapy drugs, such as methadone, is that buprenorphine is a partial agonist, while methadone is a full opioid agonist. The full agonist classification of drugs includes the illicit drug heroin, as well as widely prescribed opioid painkillers such as morphine, hydrocodone, and oxycodone. In the case of full opioid agonists, greater opioid effects can be achieved by increasing the drug dosage until the opioid receptor is fully activated. It is in this effect that the critical difference in buprenorphine’s interaction with the brain becomes unique and promising for its use in opioid addiction therapy. The partial agonist characteristic of buprenorphine gives the opioid a “ceiling effect.” This ceiling effect means that at a certain point, a greater
From the California Healthcare Foundation 8 | THE BULLETIN | MAY / JUNE 2017
dose of the drug will not cause an increase in the opioid effect on the body, meaning a reduced euphoria and addictive qualities associated with the full agonist opioids. Along with the reduced euphoria, buprenorphine also has a much more limited depressive effect on the respiratory system, making a lethal overdose on buprenorphine extremely rare. In fact, deaths due to buprenorphine overdoses usually involve multiple medications (e.g., benzodiazepines, alcohol, other opioids or intravenous use). When buprenorphine binds to the opioid receptors in the brain, it is able to activate the receptor, displace full agonists already bound to the receptor, and block other opioids from binding. Buprenorphine also has a slow dissipation rate from the opioid receptor, producing prolonged withdrawal making it a much more convenient option in terms of medication assisted treatment.1
BUPRENORPHINE IN MEDICATION ASSISTED TREATMENT
Treatment with buprenorphine has been proven effective in opioid addiction, decreasing mortality by approximately 50%. Patients treated with buprenorphine show improved social functioning with increased retention in treatment (67% at one year) compared to drug-free treatment (7% to 25% at one year), reduced criminal activity, lower rates of illicit substance abuse, and reduced risk of HIV and hepatitis infection. 2-6 In the context of MAT, buprenorphine is recommended to be delivered as part of a comprehensive treatment approach. Experts emphasize the importance of behavioral health services, such as cognitive-behavioral therapies, counseling, and mindfulness training, combined with medication treatment. They also emphasize that patients should not be refused buprenorphine treatment if they cannot, or will not, access behavioral treatment. Although buprenorphine can be used in short-term detoxification programs, experts increasingly discourage this approach and encourage maintaining MAT over the long term. Studies have shown that patients who stop taking buprenorphine during the first few months of their treatment experience high rates of relapse, even with inten-
sive behavioral support. One frequently cited Swedish study randomized a heroin-using population to buprenorphine or placebo, after a detoxification period; both groups received cognitive-based therapy, individual counseling, and drug screens. Four out of the 20 patients in the placebo group died during the one-year study; none of the patients in the buprenorphine arm died, and 75% of them stayed in treatment. Studies comparing methadone and buprenorphine show that methadone leads to better treatment retention, but do not show a major difference in mortality or illicit drug use. Also, methadone cannot be prescribed for addiction outside of a licensed opioid treatment program, while buprenorphine is available to primary care physicians. Due to the inherent opioid qualities of buprenorphine, risk of abuse in addiction patients still exists, and standards of care for treating opioid abuse should still be employed such as regularly checking CURES and perhaps periodic screenings of urine for undisclosed drug use. The risk of abusing or misusing buprenorphine can be reduced further by utilizing combination products like, Bunavail, Suboxone, and Zubsolv that incorporate naloxone as opposed to solely the generic buprenorphine Subutex. Despite the fact that buprenorphine products that have been FDA approved for treating pain, including Butrans and Belbuca, generally come in relatively low doses, the reduction in misuse potential may not be worth the decline in effectiveness in terms of MAT. Opportunities to become more greatly involved in practices such as MAT and more are becoming more readily available as well. For instance, Addiction Medicine recently became a recognized specialty through the American Board of Medical Specialties (ABMS), and certification of physicians in this specialty will begin in the Fall of 2017, through the first board examination. The Addiction Medicine certification is open to physicians from any primary ABMS specialty. The Addiction Medicine specialty should be able to work in parallel with Addiction Psychiatry, which has been an ABMS specialty since 1993.
PHYSICIAN PERSPECTIVE:
Kelly Pfeifer, MD Kelly Pfeifer, MD, is the Director of High-Value Care at the California Health Care Foundation. She has led the CHCF California Opioid Safety Coalitions Network. Historically, addiction treatment was considered “someone else’s job,” since few clinicians had any training, experience, or knowledge about managing substance use disorders, noted Doctor Kelly Pfeifer, Director of High-Value Care at the California Health Care Foundation. “There are not enough addiction specialists to manage the problem. If not us, who?” Primary care providers can be part of both sides of the solution, she said, by decreasing the quantity of opioids prescribed, thus exposing fewer patients to the risk of addiction, and by ensuring that those with addiction have access to treatment. Pfeifer said she became an advocate of MAT after studying the direct impacts of opioids on the brain. “I learned Neurobiology 101. When you use opioids, dopamine floods the brain; each use produces less of a response, until people need opioids just to feel normal.” Buprenorphine’s value is that it stabilizes the dopamine system; allowing people to escape the cycle of withdrawal and craving that prevent them from making different choices. Buprenorphine has the potential to prevent deaths and to reduce the suffering of addiction — but very few people who need it can find it, she said. Pfeifer noted that many clinicians think buprenorphine induction is difficult, or will take up too much of their time, or they fear being overwhelmed by unmet need in their communities. (For details, read Buprenorphine: Questions and Answers.) Many physicians continue to work under the misunderstanding that buprenorphine is difficult to obtain on Medi-Cal, despite the fact that the TAR (treatment authorization request) requirement for buprenorphine was removed in 2015. One meeting participant had heard a provider say, “I prescribe buprenorphine, but don’t tell anybody,” because of fear of becoming the de facto addiction treatment provider in the community and being overrun by challenging patients. Prescribers also hesitate to provide MAT if there are not enough counseling resources around, said Pfeifer. She added that conditions do not have to be perfect to get started with MAT. Although counseling in coordination with buprenorphine induction is the standard of care, she said, buprenorphine can be initiated even if the counseling component is not yet in place, and the meta-analyses looking at the impact of behavioral health added to buprenorphine.
Continued on page 10 MAY / JUNE 2017 | THE BULLETIN | 9
NEUROBIOLOGY 101: Addiction and the Brain This is an excerpt of a 2015 presentation for CHCF by addiction specialist R. Corey Waller, MD, medical director of the Center for Integrative Medicine at Spectrum Health Medical Group in Michigan. “We need three things to survive [besides oxygen]: food, water, and dopamine– and dopamine is the most important. If you deprive study subjects of water for three days, then put them in functional MRI and place water on their lips, the relative size of the craving is like a baseball. Do the same with food, and it is like a basketball. Then take someone with an addiction to opioids, up to one year after their last use, and talk about OxyContin while they are in a functional MRI, and the relative size of that craving is the size of a baseball field. “Why? Because dopamine is the chemical behind our drive to live and survive. It rewards us with feelings of pleasure, satisfaction, and well being when we pursue things that are good for survival. It punishes us with feelings of desperation, illness, and hopelessness when we pursue things that are bad for survival. Our limbic system is fine-tuned to keep our dopamine levels between 40 ng/dl (a terrible day, when you can’t get out of bed and get anything done) and 100 ng/dl (the best day ever, when you feel invincible). “Long-term opioid use changes the system, sometimes permanently. The first hit of heroin brings dopamine levels up to 1,000. However, our brain is designed to keep us in balance, excess dopamine over time causes our brain to ramp up systems to get back to normal: less dopamine gets released each time, the number of dopamine receptors go down, and the ‘anti-dopamine’ inhibition system ramps up and works in overdrive. Over time, the same dose of heroin or OxyContin causes less and less dopamine release, until the point where the brain can’t get beyond 10 to 20 ng/ dl without help. Daily pills or daily heroin is required just to feel normal. Functional MRI studies have shown that these brain changes take one to two years to recover, and in many people, after long enough use, the brain never recovers. “This is why people are 14 times more likely to die if they don’t use buprenorphine or methadone for treatment. These meds stabilize the dopamine system and bring it back to normal, and since they are long acting, they take people out of the cycle of withdrawal and craving. If our goal is to punish people and make them feel terrible, then we require abstinence, consign them to lives at 10 to 20 ng/dl dopamine levels, and judge them for not being able to get their lives together. If we follow science, data, and math, we will use the treatments that work and save lives.” 10 | THE BULLETIN | MAY / JUNE 2017
WAIVER REQUIREMENT
Any provider licensed by the Drug Enforcement Administration (DEA) (e.g., physician, nurse practitioner, physician assistant) can prescribe buprenorphine for pain. As a Schedule III drug, buprenorphine can be ordered by phone or fax, and refills can be included on the original prescription. In contrast, Schedule II drugs, such as hydrocodone, require tamperproof prescriptions and one-month supply limits with no refills. Currently, there are no additional certifications necessary in order to prescribe buprenorphine for the management of chronic and acute pain. However, per the Drug Addiction Treatment Act of 2000 (DATA 2000), physicians need a waiver to prescribe buprenorphine for addiction; attendance in an eight-hour in-person or online course is required to obtain a waiver. The Comprehensive Addiction and Recovery Act of 2016 allows nurse practitioners and physician assistants to prescribe buprenorphine treatment after 24 hours of certified training. Clinicians are capped at 30 patients the first year and 100 patients per year thereafter. The cap increases to 275 patients for physicians board-certified in addiction, or those in practices that meet certain qualifications: 24-hour call coverage, use of health information technology, provision of care management services, registration with CURES (Controlled Substance Utilization Review and Evaluation System, California’s prescription drug monitoring database), and acceptance of third-party insurance. Patients using buprenorphine for pain relief and not addiction are not included in federal cap requirements. This article is comprised of excerpts from multiple reports published by the California Health Care Foundation: Medication-Assisted Treatment: Recovery Within Reach and Buprenorphine: Everything You Need to Know.
ENDNOTES
1. https://www.naabt.org/education/pharmacoloy_of_buprenorphine.cfm 2. Thomas CP, et al., “Medication-Assisted Treatment with Buprenorphine: Assessing the Evidence,” Psychiatric Services. 2014; 65(2):158-170. doi:10.1176/appi.ps.201300256. 3. Kimber J, et al. “Mortality Risk of Opioid Substitution Therapy with Methadone Versus Buprenorphine: A Retrospective Cohort Study.” Lancet Psychiatry. 2015;2(10):901-908. 4. Degenhardt L, et al. “The Impact of Opioid Substitution Therapy on Mortality Post-Release from Prison: Retrospective Data Linkage Study.” Addiction. 2014;109(8):1306-1317. 5. Pierce M, et al. “Impact of Treatment for Opioid Dependence on Fatal Drug-Related Poisoning: A National Cohort Study in England.” Addiction. 2016;111(2):298-308. 6. Schuckit MA. “Treatment of Opioid-Use Disorders.” New Engl J Med. 2016;375(4):357-368.
GETTING WAIVERED TO PRESCRIBE BUPRENORPHINE FOR MAT
In order to prescribe or dispense buprenorphine, physicians must qualify for a physician waiver, which includes completing eight hours of required training, and applying for a physician waiver. Physicians must notify the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) of their intent to prescribe buprenorphine for medication-assisted treatment (MAT). The notification of intent must be submitted to CSAT before the initial dispensing or prescribing of opioid treatment. Physicians also must fax their training certificate after completing the waiver form to show that they have completed the required training to prescribe and dispense buprenorphine. SAMHSA reviews applications within 45 days of receipt. Once the application process is complete and the application is approved, SAMHSA will email a letter that confirms the waiver and includes the physician’s prescribing identification number. For more information, go to https://www.samhsa.gov/medication-assisted-treatment/buprenorphinewaiver-management.
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MAY / JUNE 2017 | THE BULLETIN | 11
State of California—Health and Human Services Agency
California Department of Public Health KAREN L. SMITH, MD, MPH Director and State Public Health Officer Statewide Prescription Opioid Misuse and Overdose Prevention Workgroup Member Agencies* CA Public Employees’ Retirement System – CalPERS Covered California CA Conference of Local Health Officers CA Department of Corrections and Rehabilitation CA Department of Justice CA Department of Public Health CA Health Care Foundation County Health Executives Association of CA CA Health and Human Services Agency California Society of Addiction Medicine CA State Board of Pharmacy Dental Board of CA Medical Board of CA Department of Health Care Services Department of Industrial Relations Department of Managed Health Care Department of Motor Vehicles Emergency Medical Services Authority Office of Statewide Health Planning and Development - OSHPD Office of Traffic Safety UC Davis Medical Center
EDMUND G. BROWN JR. Governor
March 21, 2017 Dear Health Care Provider/Prescriber, As you are aware, the overuse of prescription opioids has become a national epidemic. In California, there were 1,966 opioid-related overdose deaths in 2015. On behalf of the Statewide Prescription Opioid Misuse and Overdose Prevention Workgroup and partners, I am contacting you to offer resources to assist you in addressing this critical issue with your patients including: • strategies for assisting high-risk patients • medication-assisted treatment certification programs • local addiction recovery services locator • information about CURES (California’s prescription drug monitoring program) • opioid prescribing guidelines • opioid prescriber resource sheet Please see the sections below for brief descriptions on each topic and a link to all resources at the bottom of this letter. Don’t “Fire” Your Patients Who May Be Over-using Opioids We recognize providing safe and effective pain management can be challenging. We understand there are multiple complexities to be considered in pain management when treating patients with acute and chronic pain. One of the most difficult situations for prescribers may be how to respond to patients with difficulty decreasing opioid intake or with other possible addiction symptoms. It is our hope that these resources can help you maintain your clinical relationship with your patients who are using opioid medications and improve their overall well-being. These patients may need your assistance more than ever. Clinician Tools for Assisting Patients on Opioids Patients on high doses of opioids are at increased risk of overdose and diminishing function. Tapering a patient, weaning them from higher opioid doses, can be an important first step to reducing overdose risk and improving function. It is also helpful to maintain ongoing communication with your patient about your concern for their wellbeing and your commitment to safe prescribing. A variety of tools are available on the prescriber resource sheet (link below) including a tapering pocket guide, telephone consultation services, an opioid overdose toolkit, and more.
US Drug Enforcement Administration *Agencies listed for information only
CDPH Safe and Active Communities Branch, MS 7214 P.O. Box 997377 (916) 552-9800 ● (916) 552-9821 FAX Internet Address: www.cdph.ca.gov
12 | THE BULLETIN | MAY / JUNE 2017
Sacramento, CA 95899
Resources Page 2
Medication-Assisted Treatment When addiction is confirmed, the use of medication-assisted treatment (MAT), such as buprenorphine has proven highly effective in lowering overdose risk, decreasing HIV and hepatitis C, and increasing patient retention in treatment. If you are not already certified to prescribe buprenorphine, consider obtaining a certification. There are several online MAT training programs available for prescribers. Referral and Treatment Service Locators If you are unable to provide medication assisted treatment yourself, refer patients to an opioid treatment program or other drug recovery program within your community. Access to more information about local addiction recovery services is readily available. Prescription Drug Monitoring Program - CURES An important tool for identifying patients at risk is the Controlled Substance Utilization Review and Evaluation System (CURES). CURES can be accessed relatively easily, and checking CURES with each new patient, and every four months thereafter, will soon be required by law. In the next few months, the Medical Board of California will send additional information specifically about CURES and how to best utilize it. Prescribing Guidelines for Opioids and Controlled Substance for Pain Both the Medical Board of California (MBC) and the Centers for Disease Control and Prevention (CDC) guidelines provide information about best practices for prescribing opioids, options for nonpharmacological treatment of pain symptoms, along with recommendations for those patients presenting with symptoms of addiction. Abbreviated versions of these guidelines are also available. To access the above mentioned resources and tools – please scan this QRC code below with your mobile device. It will quickly take you to a resource sheet for opioid prescribers with helpful links. Opioid Prescribers Resource Sheet Also available at this URL: https://www.cdph.ca.gov/PrescriberResources
Healthcare prescribers are essential partners in ending this epidemic. Working together, we want to ensure that California prescribers have access to resources and support to help improve patient pain management, while avoiding opioid overdose and addiction. Thank you for providing quality medical care to your patients in need of effective pain management. Sincerely,
Karen L. Smith, MD, MPH Director and State Public Health Officer California Department of Public Health MAY / JUNE 2017 | THE BULLETIN | 13
Physicians Converge in Sacramento for CMA’s 43rd Annual Legislative Advocacy Day BY ELIZABETH ZIMA Staff Writer, CMA Over 500 physicians, medical students and stakeholders gathered in Sacramento on April 18 to bring the voice of medicine to legislators for the 43rd annual California Medical Association (CMA) Legislative Advocacy Day. Wearing white coats, physicians converged on the Capitol to educate
legislators about critical health care issues, including the negative impact Governor Brown’s proposed budget would have on health care in our state. “It’s a day-in and day-out grind to make sure that health care rises to the top in the Capitol,” CMA CEO Dustin Corcoran told attendees before they headed out to meet with their legislators. “But when the legislators see you in your white coat [they] will remember your face and remember the stories you tell about how bills will impact you and your patients.”
MAKING OUR VOICES HEARD AT CMA LEGISLATIVE ADVOCACY DAY
The SCCMA-MCMS Delegation meets with Assemblymember Marc Berman.
Meeting with Senator Bill Monning.
Busy Day – also with Assemblymember Kansen Chu. 14 | THE BULLETIN | MAY / JUNE 2017
And the physicians and medical students who took time out of their busy schedules to be there indeed felt that they made a difference. “I was really impressed by how interested the legislators are in listening to what we have to say, and how much they respect our opinion as practicing physicians,” said Jessica Deas, MD, a pediatric resident at UC San Francisco’s Children’s Hospital. “They’re interested in hearing our stories, and I really felt like in a single day, we had some impact, which is very cool.” California Attorney General Xavier Becerra spoke to attendees and reinforced how much weight the physician voice carries with lawmakers. “You were a force in D.C. and you have always been a force in Sacramento,” said Becerra, encouraging California physicians to remain engaged as the health reform debate continues. “We’ll move forward with health reform; it’s a work in progress,” he said, pointing out that California has served like a lab for the rest of the country, testing and improving the process of providing care to large numbers of people. “We’ll figure out how to make this better,” he said, calling the current proposals on health reform in the nation’s capital “frightening.” Becerra, whose wife is an OB/GYN physician, said he sees firsthand the challenges faced by physicians. “I know you work hard and spend plenty of time in the evening checking boxes,” he said. “I understand what you do, and the closer we get to universal health care for all, the easier it will be for you to practice. I’ve got your back on this.” Attendees also heard from California Health and Human Services Secretary Diana Dooley, who got right to the point. “I know we don’t pay enough,” said Dooley. “I know what it means to be a Medi-Cal provider. There aren’t enough resources. So we work together to stretch what we have as far as it will go. And in California, we’ve stretched it much further than anywhere in the country.” Dooley noted that the quest for universal coverage in California has been going on for close to 40 years. “We’ve been searching for a way to find a level of cost that is manageable,” she said. “We do have very good quality health care in this country. We provide care to a lot of people, but we provide it at a very high cost. We have to be looking at ways we can reduce that
cost, or at least mitigate its growth.” The reason California has been as successful as it has in the implementation of the Affordable Care Act (ACA), according to Dooley, is because we haven’t had the partisan rancor. “I’m very proud of the work that we’ve done to make it work as well as it has,” she said. “It’s a work in progress and there’s more we need to do but at the moment, I’m deeply committed to preserving the gains that we’ve made and doing everything we can to assure that we can move forward in California.” “What we’ve heard over the past six or seven years as we’ve worked to implement the law is what’s wrong with it,” said Dooley. One of the side effects of the challenge to the ACA has been the recognition of what we actually have done right, she said. “What we’ve done in the past three or four months is coalesce around the actual language of the law and what it has done. And I think the political system has actually worked very well.” “There have been a lot of voices about what’s wrong with it, and those voices have been across the spectrum. From consumers who want more. From plans who want more flexibility. From physicians who want higher pay,” said Dooley. “All of the challenges in the health care system have now been given a name: Obamacare. But many of those challenges existed precedent to the law. And, in fact, the law was trying to address some of them.” Dooley believes that California can lead the way as we continue to work to address the challenges of our market-driven health care system. “It’s a patchwork of add-ons that has very much encumbered our ability to function in an efficient way,” she said. “The first order of business for me is to illustrate in every way that I know the gains that we’ve made, the success that we’ve had and the willingness to reach across lines—whether they’re partisan or professional—and find solutions to the real problems that get beyond the rhetoric of the left and the right.”
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A Physician’s Guide to AB 72 Questions and Answers On July 1, 2017, a new law (AB 72) will take effect that will change the billing practices of non-participating physicians providing non-emergent care at in-network facilities including hospitals, ambulatory surgery centers and laboratories. The law, signed in 2016, was designed to reduce unexpected medical bills when patients go to an in-network facility but receive care from an out-of-network doctor. The new law requires an “interim payment” to physicians and place limitations on the ability of physicians who do not contract with a patient’s health plan or insurer to collect their full billed charges for non-emergency services performed at a contracting health facility. CMA has compiled the following questions and answers in order to help clarify the new law and to address the concerns and questions of CMA members. GENERAL APPLICABILITY Q1: In what situations do the provisions of AB 72 apply? AB 72 applies in the circumstance where a physician who is not contracted with his or her patient’s health plan or insurer provides covered non-emergency services to the patient at a facility that is contracted with the patient’s health plan or insurer. (Health & Safety Code §1371.30(g), 1371.31(f), 1371.9(a)(1),(g),(k); Insurance Code §10112.81(f), 10112.82(e),10112.8(a) (1),(g),(i)). Q2: How do I know whether the services I provided to a patient are “emergency services” and thus not subject to AB 72? A: AB 72 specifies that its provisions do not apply to emergency services as defined by Health & Safety Code § 1317.1. (Health & Safety Code §1371.30(g), 1371.31(f), 1371.9(k); Insurance Code §10112.81(f), 10112.82(e),10112.8(i)). California Health & Safety Code § 1317.1 defines emergency services as medical screening, examination, and evaluation by a physician (or to the extent permitted by law, appropriate personnel under the supervision of a physician) to determine if an emergency medical condition or active labor exists and the care, treatment, and surgery, necessary to relieve or eliminate the emergency medical condition. (Health & Safety Code § 1317.1(a)(1)). An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in seriously jeopardizing the patient’s health, serious impairment to the bodily functions, or serious dysfunction of any bodily organ or part. (Health & Safety Code § 1317.1(b)). A patient is considered “stabilized” and no longer receiving “emergency” medical services only when, in the opinion of the treating physician, the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from, or occur during, the release or transfer of the patient. (Health & Safety Code § 1317.1(j)). For a more in-depth discussion of what constitutes “emergency services,” please refer to CMA On Call documents #7504, “Authorization and Payment for Emergency Services” and #5000, “Emergency Transfer Laws.” Q3: Does AB 72 apply to patients regardless of their insurance type? A: No. AB 72 amends the California Health & Safety Code and the California Insurance Code and thus applies only when the patient has an individual or group insurance product that is regulated by Department of Managed Health Care (DMHC) or the Department of Insurance (DOI). (Health & Safety Code §1343; Insurance Code §10112.1). It does not apply to services provided to patients enrolled For more information: CMA’s Member Service Center, (800) 786-4262 or memberservice@cmanet.org. 16 | THE BULLETIN | MAY / JUNE 2017
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in Medicare, Medi-Cal, out-of-state plans, self-insured employer plans or other products regulated by federal law, as these products are either not subject to AB 72 or — in the case of Medi-Cal managed care products — are explicitly excluded from AB 72. (Health & Safety Code §1371.30(3), 1371.31(e), 1371.9(j)). Q4: Does AB 72 apply to care furnished in all settings? A: No. AB 72 applies only if care is furnished in a contracting health facility. (Health & Safety Code § 1371.9(a)(1); Insurance Code §10112.8(a)(1)). For purposes of AB 72 a “contracting health facility” means a health facility that is contracted with the patient’s health plan or insurer to provide services under the patient’s policy. This includes a licensed hospital, laboratory, radiology or imaging center, and an ambulatory surgery or other outpatient setting as described in Health & Safety Code §1248.1(a),(d),(e),(g), or (h). (Health & Safety Code § 1371.9(f)(1)); Insurance Code §10112.8(f)(1)). The outpatient settings described in current law as set forth in Health & Safety Code §1248.1(a),(d),(e),(g), and (h) include ambulatory surgical centers that are certified to participate in the Medicare program; health facilities licensed as general acute care hospitals, primary care clinics licensed under subdivision (a) of Section 1204, also known as “free” and “community clinics,” surgical clinics licensed under subdivision (b) of Section 1204 (which does not include any place or establishment owned or leased and operated as a clinic or office by one or more physicians or dentists in individual or group practice); and outpatient surgery settings accredited by an accreditation agency approved by the Medical Board of California (such as the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the Joint Commission, the Institute for Medical Quality, or the American Osteopathic Association/ Healthcare Facilities Accreditation Program (HFAP)). (Health & Safety Code § 1371.9(f)(1)(B)); Insurance Code §10112.8(f)(1)(B)). Q5: When does AB 72 take effect? A: AB 72 applies to services provided on or after July 1, 2017. (Health & Safety Code § 1371.31(a)(1), 1371.9(a)(1); Insurance Code §10112.82(a)(1), 10112.8(a)(1)).
PAYMENT FROM HEALTH PLANS AND INSURERS Q6: How will I be reimbursed for services by a health plan or insurer under AB 72? A: Health plans and insurers must pay physicians an interim payment that is the greater of the average contracted rate (including only commercial contracts) or 125 percent of the amount that Medicare reimburses on a fee-for-service basis for the same or similar services in the geographic region in which the services were rendered. (Health & Safety Code § 1371.31(a)(1); Insurance Code §10112.82(a)(1)). Geographic regions for AB 72 purposes will be the same regions specified for physician reimbursement in Medicare fee-for-service by the United States Department of Health and Human Services. (Health & Safety Code § 1371.31(a) (6); Insurance Code §10112.82(a)(6)). Q7: Will the interim payment rate be adjusted annually? A: Yes. Until 2019, when DMHC and DOI develop a standardized methodology for plans and insurers to use in determining the average contracted rate, health plans and insurers must adjust their initial average contracted rate each calendar year by the Consumer Price Index for Medical Care Services, published by the Untied States Bureau of Labor Statistics. (Health & Safety Code § 1371.31(a)(2)((B); Insurance Code §10112.82(a)(2)(B)). Q8: How will the “average contracted rate” be determined? A: By January 1, 2019, DMHC and DOI are required to develop a methodology for plans and insurers to use in determining services most frequently subject to payment under AB 72. (Health & Safety Code § 1371.31(a)(3)(A); Insurance Code §10112.82(a) (3)(A)). The methodology will be developed in consultation with stakeholders, including CMA, and will take into account informaFor more information: CMA’s Member Service Center, (800) 786-4262 or memberservice@cmanet.org.
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tion from the independent dispute resolution process (see below), the specialty of the individual physician, the geographic region in which the services are rendered, and the plans’ and insurers’ highest and lowest contracted commercial rates. (Health & Safety Code § 1371.31(a)(3); Insurance Code §10112.82(a)(3)). Until DMHC and DOI develop a standardized methodology, plans and insurers must base average contracted rates on the average of the contracted commercial rates paid and must include in the calculation the highest and lowest contracted rates for calendar year 2015. (Health & Safety Code § 1371.31(a)(1)-(2)(A); Insurance Code §10112.82(a)(1)-(2)(A)). Plans and insurers will also be required to submit to DMHC and DOI a list of average contracted rates for the services most frequently the subject of AB 72, their methodology for determining the average contracted rate, and their policies and procedures for determining average contracted rates for purposes of AB 72. (Health & Safety Code § 1371.31(a)(2)(A); Insurance Code §10112.82(a)(2)(A)). Q9: Will I receive payment directly from the health plan or insurer under AB 72? A: Yes. Health plans and insurers are required to authorize and permit assignment of a patient’s right to any reimbursement for services covered under a plan contract to a noncontracting physician who provides non-emergency treatment to a patient at an in-network facility. Even if a patient has not assigned his or her benefits to the noncontracting physician, payment for covered services will be made directly to the physician. (Health & Safety Code § 1371.31(a)(7); Insurance Code §10112.82(a)(7)).
DISPUTING THE AMOUNT OF PAYMENT Q10: If I don’t agree with the amount I am paid, can I challenge it? A: Yes. (Health & Safety Code §1371.30; Insurance Code §10112.81). By September 1, 2017, DMHC and DOI must establish an independent dispute resolution process (IDRP) for the purpose of processing and resolving claim disputes between a health care service plan or health insurer and a noncontracting individual physician for services subject to AB 72. (Health & Safety Code §1371.30(a)(1); Insurance Code §10112.81(a)(1)). DMHC and DOI must develop uniform procedures for the submission, receipt, processing, and resolution of claim payment disputes but may contract with one or more independent organizations to conduct the proceedings. (Health & Safety Code §1371.30(b)-(c)); Insurance Code §10112.81(b)-(c)). To dispute the interim payment for services they provide between July 1, 2017 (when AB 72 goes into effect), and September 1, 2017 (when the IDRP will be functional), physicians can hold their claims and submit them all at once. Health & Safety Code §1371.30(b)(3)); Insurance Code §10112.81(b)(3)). Q11: How is the interim dispute resolution process different under AB 72 than the processes health plans and insurers currently have in place? A: Currently, DMHC has an IDRP in place for physicians to resolve billing and claims disputes, but a plan can decline to participate, which means the only remedy is to seek resolution through the court. (Health & Safety Code §1367(h); Bell v. Blue Cross of California (2005) 131 Cal.App.4th 211, 217–18; California Physicians’ Service v. Aoki Diabetes Research Institute (2008) 163 Cal.App.4th 1506, 1518). AB 72 requires both parties to participate in IDRP. If either elects to use it but before initiating IDRP, the parties must complete the plan's or insurer’s internal process for resolving billing and claims disputes. (Health & Safety Code §1371.30(a)(2)-(3); Insurance Code §10112.81(a)(2)-(3)). The costs of the IDRP will be established by DMHC and DOI and will be paid by both parties. (Health & Safety Code §1371.30(b)(2); Insurance Code §10112.81(b)(2)). Q12: Can an IPA, a medical group, or another person or entity file a dispute on my behalf? A: Yes. A physician group, independent practice association, or other entity authorized to act on behalf of a noncontracting physician may initiate and participate in IDRP. (Health & Safety Code §1371.30(b)(4); Insurance Code §10112.81(b)(4)). For more information: CMA’s Member Service Center, (800) 786-4262 or memberservice@cmanet.org. 18 | THE BULLETIN | MAY / JUNE 2017
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Q13: Do I have to dispute each claim individually? A: No. Bundled claims are permitted if they are submitted to the same plan or same delegated entity for the same or similar services by the same noncontracting physician. (Health & Safety Code §1371.30(b)(3); Insurance Code §10112.81(b)(3)). Q14: What can I do if I disagree with the decision I receive through IDRP? A: While the decision of the IDRP is binding on both parties (which means the plans must pay the physicians), either party may still pursue any remedy, right, or penalty available under applicable law, including legal remedies following the decision. (Health & Safety Code §1371.30(d); Insurance Code §10112.81(d)).
BILLING PATIENTS Q15: Are there limits on what patients are responsible for paying noncontracted physicians under AB 72? A: Yes. As a general rule under AB 72, a patient who receives covered non-emergency services at an in-network facility is only responsible for paying his or her in-network cost-sharing amount. ((Health & Safety Code § 1371.9(a)(1); Insurance Code §10112.8(a)(1)). When it issues payment to the physician, the patient’s health plan or insurer will notify the patient and the noncontracting physician of the amount of in-network cost-sharing the patient is responsible for paying. ((Health & Safety Code § 1371.9(a)(2); Insurance Code §10112.8(a)(2)). AB 72 prohibits a physician from billing a patient until after the plan or insurer informs both the patient and physician of the amount of the patient’s in-network cost sharing. ((Health & Safety Code § 1371.9(a) (3); Insurance Code §10112.8(a)(3)). Aside from the patient’s cost-sharing, the amount paid by a plan or insurer to a noncontracting physician who provides care subject to AB 72 is considered payment in full, with the caveat that the physician may challenge the amount of reimbursement via IDRP. (Health & Safety Code § 1371.31(d); Insurance Code §10112.82(d)). Q16: What happens if a patient pays me more than the amount he or she is responsible for? A: AB 72 requires that if a noncontracting physician receives more than the in-network cost-sharing amount from a patient, he or she must refund the overpayment within 30 calendar days after receiving the excess payment. If the physician does not refund the patient within 30 days of the date he or she is informed of the patient’s cost-sharing amount, interest will accrue at a rate of 15 percent from the date of receipt of the patient’s payment. Refunds of overpayments to patients, in this case, must include any accrued interest along with the amount of the overpayment. (Health & Safety Code § 1371.9(a)(4); Insurance Code §10112.8(a)(4)). Q17: What if I am a noncontracting physician but my patient wants to use his or her out-of-network benefits to obtain care from me? A: AB 72 is aimed at ensuring that patients who schedule care at an in-network facility and unknowingly receive care from a physician who does not contract with their plan or insurer are not subject to bills for out-of-network care they thought would be covered. However, patients whose health plans or insurers offer an “out-of-network” benefit (which generally requires them to pay higher cost sharing) may utilize that benefit by consenting in writing to do so. (Health & Safety Code § 1371.9(c); Insurance Code §10112.8(c)). A noncontracting physician must get written consent for the use of out-of-network benefits at least 24 hours in advance of scheduled care. (Health & Safety Code § 1371.9(c)(1); Insurance Code §10112.8(c)(1)). Consent must be obtained through a document that is separate from any document used to effect consent for any other part of care. (Health & Safety Code § 1371.9(c)(2); Insurance Code §10112.8(c)(2)). It cannot be obtained by the facility or any of its representatives nor can it be obtained at the time of admission or while the patient is being prepared to undergo any procedure. (Ibid). At the time consent for the use of out-of-network benefits is obtained from a patient, a noncontracting physician must provide the patient with a written estimate of the patient’s total out-of-pocket For more information: CMA’s Member Service Center, (800) 786-4262 or memberservice@cmanet.org.
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cost of care based on the physician’s billed charges for the service and must indicate that these costs are in addition to any in-network cost-sharing and that they may not count toward the patient’s deductible or out-of-pocket maximum. (Health & Safety Code § 1371.9(c)(3)&(6); Insurance Code §10112.8(c)(3)&(6)). Consent and estimates must be provided in the patient’s spoken language (if it is a Medi-Cal threshold language) and the consent must also inform the patient that he or she can seek care from a contracted physician or contact his or her health plan or insurer to arrange for care from a contracted physician for lower out-of-pocket costs. (Health & Safety Code § 1371.9(c)(4)-(5); Insurance Code §10112.8(c)(4)-(5). Q18: Do any special rules apply to my efforts to collect payment from a patient under AB 72? A: Yes. Noncontracting physicians may only send to collections the in-network cost-sharing amount or, in cases where the patient elected to use his or her out-of-network benefits, the out-of-network cost-sharing amount. (Health & Safety Code § 1371.9(e) (1); Insurance Code §10112.8(e)(1)). Physicians have to wait a minimum of 150 days from the date they issue the initial bill to the patient before reporting the debt to consumer credit reporting agency or filing a civil action to collect the debt and may not garnish a patient’s wages or place a lien on a patient’s primary residence to collect an unpaid bill for AB 72 services. (Health & Safety Code § 1371.9(e)(2)&(3); Insurance Code §10112.8(e)(2)&(3).
HEALTH PLAN AND INSURER OBLIGATIONS Q19: If a health plan or insurer delegates claims processing and payment functions to a contracted entity like a medical group or IPA, is the responsibility for complying with AB 72 also delegated? A: Yes. (Health & Safety Code §1371.30(f)). 1371.31(c), 1371.9(i); Insurance Code §10112.81(e), 10112.82(c); 10112.8(h)). Q20: Are health plans still bound by the continuity of care law that allows me to negotiate with a managed care plan to continue to treat an existing patient even if I am no longer contracted with the patient’s plan? A: Yes. AB 72 specifies that the continuity of care provisions in existing law remain in effect, which means that under certain conditions a patient may still have a right to get covered services from a physician whose contract with a health plan was terminated. (Health & Safety Code §1371.9(h); 1373.96). A patient who has an acute health condition, a serious chronic condition, a terminal illness, or who is pregnant, is a newborn up to 36 months, or who has a documented recommendation for a surgery or procedure within six months of the end of the contract can still request that his or her plan pay for covered services provided by his or her treating physician, even if the physician is now “noncontracting.” (Health & Safety Code §1371.9(h); 1373.96(c)). Physicians providing care to patients under existing continuity of care provisions will not be subject to the interim payment provisions of AB 72 and can negotiate a rate with the plan. (Health & Safety Code §1371.9(h); 1373.96(d)). Q21: Does AB 72 do anything to ensure that health plans and insurers maintain adequate physician networks? A: Yes. AB 72 will allow the state health insurance regulators to better determine whether plans’ and insures’ networks are adequate and to take action if they find they are not. The law requires health plans and insurers to submit to DMHC and DOI, respectively, the number of payments they make to noncontracting physicians for covered non-emergency services at a contracting facility along with data that will allow the regulators to determine the proportion of noncontracting physicians to contracting physicians at contracting health facilities. (Health & Safety Code §1371.31(a)(4); Insurance Code §10112.82(a)(4)). The regulators must then make findings regarding the impact of AB 72 on health plan and insurer contracting and network adequacy and report on these findings to the Legislature and the Governor. (Ibid). AB 72 also gives DMHC and DOI the authority to issue new network adequacy regulations to ensure access to hospital services and specialist physician services. (Health & Safety Code §1371.31(a) (5); Insurance Code §10112.82(a)(5)).
For more information: CMA’s Member Service Center, (800) 786-4262 or memberservice@cmanet.org. 20 | THE BULLETIN | MAY / JUNE 2017
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Physicians face many obstacles in private practice. It is difficult to be all things to all people. Very often, the day to day business aspect of a physician’s practice is delegated to an office manager or in larger groups to a CFO. After insurance has paid its portion, the rest of the unpaid portion becomes revenue recovery. Obviously, the best outcome is an appreciative patient who pays his/her patient responsibility portion without much prompting. However, sometimes, for whatever reason, the patient doesn’t pay their portion to your office or group and the balance becomes outstanding or bad debt. In an attempt to alleviate the costs and time associated with bad debt recovery, some physicians/groups have turned to practices requiring either payment upfront via electronic funds transfers (EFT) or utilization of preauthorized agreements to bill the outstanding balance against an on file credit card at a later date.
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BY MARK CHRISTIANSEN, ESQ. Manager, Bureau of Medical Economics
THE IMPORTANT QUESTION IS: ARE YOU GRABBING LOW LYING OR FORBIDDEN FRUIT? THE PROS:
• You require EFT (Electronic Funds Transfer) from your clients at the point of sale, your office. The check is never “in the mail.” Maybe you even require a deposit for services (money up front). • You utilize authorization agreements to retain credit card information requiring post billing patient balances to be debited from the patient’s on file credit card. No need to pursue contact with the patient to obtain authorization for payment. The benefits seem obvious. One must ask, “If the solution is so simple, and it would save costs and headaches down the road, why isn’t everyone doing it?” Well? After all, if it is legitimate, it would seem to make good business sense. If it isn’t an appropriate business practice, what are the possible repercussions for violations and do I want to be subject to possible fallout?
SOME OF THE CONS:
• Compulsory use of EFT is prohibited in California. Your office may not demand EFT payment. The decision to authorize payment of money by electronic means belongs to the consumer. There must be non-electronic option provided. • A “preauthorized transfer” cannot be made unless the patient has given advance authorization in writing, and a copy of the written preauthorization has been given to the patient by your office. • If the amount of the transfer is not known at the time of the preauthorization, the patient must be given at least ten days written notice in advance of the transfer. • A patient/consumer may stop any future preauthorized transfer at any time by notifying the financial institution/or physician’s office at least three business days before the scheduled transfer that patient wishes to stop the transfer. Failure to comply with the stop request is a violation of law. • A request to stop the transfer must be honored regardless of any written contract to the contrary. This is a basic right at law of the consumer/patient which cannot be waived by contract. • You may require the patient provide written confirmation of the stop payment instruction within 14 days of the verbal notification; however, only if you inform the patient of that requirement, and give the patient the address to send the written notification, and these requirements are provided to the patient at the time of the verbal stop notification by the patient.
PROBLEMS INHERENT TO THE EFT:
• Failing to advise the patient of alternative methods of payment or stating only EFT payments will be accepted appear to violate California and federal laws regarding EFT. • Has the patient been advised of the nature of the transfer pursuant to federal Regulation E, i.e. the funds will be immediately debited from the patient’s bank account. Another potential area for liability. • Various entities/individuals who may be interested in your lack of compliance: the California Department of Consumer Affairs, the Federal Trade Commission, the Consumer Financial Protection Bureau, and consumer law attorneys looking for various wrongs including violations of the Consumers Legal Remedies Act, and California Business & Professions Code, among others.
PROBLEMS INHERENT WITH PREAUTHORIZED TRANSFERS:
• Are you and your system PCI (payment card industry security standard) compliant? You upload information to a PCI protected cloud environment only to have your employees inadvertently keeping copies of debit/credit cards in patient files in your office? • If your office doesn’t accept a timely given oral or written notice to stop payment, or your office conditions the stop notice on payment of the debt, you are in violation of both state and federal law. • If the amount of the transfer is unknown at the time of the preauthorization agreement, it is required that you send the patient written notice of the amount and date of the transfer at least 10 days before the transfer. What if the patient is on vacation or in the hospital? Do you send out these notifications or does a separate entity? Who keeps track? • Debit cards with a Mastercard or Visa logo. An unplanned debit to patient’s bank account resulting in an overdraft and insufficient funds on a mortgage or car payment and the additional problems associated with a negative credit report entry. • If your office debits a credit card/bank card based on erroneous billing or denial by insurance. Both EFTs and preauthorized transfers appear tempting, with their apparent ease of execution and definitive results. Sometimes the easiest path doesn’t yield the desired result. Are you requiring your patients to do something you wouldn’t in your search of increased revenue and cost savings? How many of us would give our creditor a signed blank check with the trustful understanding that, once the total owed is calculated, the creditor could fill in the amount and cash it. These practices amount to the same thing. There may be issues of professional conduct. In certain instances a patient may not be billed prior to service. Are these practices in violation of your contracts with insurance carriers? Are these practices creating a loss of your good will with the patient community? There are many things to consider. In Conclusion, you should know whether your revenue recovery process is appropriate or forbidden. It’s tough out there. When all factors are weighed, are these methods worth the risk posed to save time and effort? In the very least, you owe it to your practice to run your billing and in-house revenue recovery practices by qualified counsel. There are other risk alternatives available. If you would rather your revenue recovery issues be handled by a qualified staff under qualified legal supervision (BME has been around for 70 years and has seen many alluring offers and shortcuts), please take advantage of the Bureau of Medical Economics (BME) as a SCCMA/MCMS member benefit. BME is a not-for-profit organization, created by physicians for physicians, where all profits go back to the medical community. We hope you will give us the opportunity to become part of your revenue recovery efforts. For further information, please contact BME’S client relations director, KAREN JORGENSON, at (408) 286-6219. NOTICE: This article is published to be informative and is not intended as a definitive statement of the law, and is not intended as a substitute for review by qualified counsel. Questions about application of the law to your particular situation should be directed to a qualified attorney. MAY / JUNE 2017 | THE BULLETIN | 23
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44,649 SF FOR SALE
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393 Blossom Hill Rd, San Jose
1635 Meridian Ave, San Jose
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Rare owner/user building in prime Willow Glen corner. Exceptional visibility & signage. Zoned CO Commercial Office.
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1360 N. Winchster Blvd, San Jose
1835 Park Ave, San Jose
Multi-tenant, owner/user building. Ideal for dentist or doctor. Close to O’Connor Hospital. Good central San Jose-Santa Clara location.
Rare single-story medical/dental building in Rose Garden area. One mile from O’Connor Hospital. Easy access to Hwys 280, 880 & 87.
2080 S. Bascom Ave, Campbell Freestanding, single-story retail building. Rare owner/user opportunity. Exceptional visibility & signage. Across the street from Pruneyard Shopping Center. 17 parking spaces on-site.
Do you have an office EMERGENCY? Call us at (408) 217-6000 24 | THE BULLETIN | MAY / JUNE 2017
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Park-like setting with mixed used tenants including retail, office, medical & dental. High traffic area with easy access to Hwys 280 & 85.
Single-story medical building directly across from O’Connor Hospital. Flexible floor plans and sizes. TI dollars available.
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690 Saratoga Ave | Suite 200 | San Jose, CA 95129 408-217-6000 T | 408- 457-8803 F www.HealthMedRealty.com Lic. 01902032
MAY / JUNE 2017 | THE BULLETIN | 25
Tip of the Month:
Take Advantage of Your Group-Buying Discounts
Members can offset the price of their annual dues when using CMA membership services and discounts. Thanks to CMA’s group buying power, members receive deep discounts on everything from magazines to office supplies to insurance products including, group medical, workers’ comp, homeowners, auto & more… For details, visit www.cmanet.org/benefits or www.sccma-mcms.org/membership/benefitsservices.
Medical School Debt Management
Bureau of Medical Economics and Collections
Mercedes Benz and BMW repair
- INFORMATION
CMA Health Law Library Updated with 2017 Content CMA On-Call, the California Medical Association (CMA)
online health law library, has been updated with 2017 content. One of CMA's most valuable member benefits, On-Call contains nearly 5,000 pages of up-to-date legal information on a variety of subjects of everyday importance to practicing physicians. The searchable online library contains all the information available in the California Physician's Legal Handbook (CPLH), an annual publication from CMA's Center for Legal Affairs. New documents for 2017 include: • • •
Promoting Quality of Life for Older Patients (#3504) MACRA Overview (#7210) California's Prescription Drug Monitoring Program: The Controlled Substance Utilization Review and Evaluation System (#3212)
Other recently updated documents of particularly timely interest include: • • •
The California End of Life Option Act (#3459) Non-Contracting Physicians (#7508): With updates on California's new out-of-network billing and payment law (AB 72) Practice Promotion through Third-Party Coupons (#0104): With updates on new state law relating to referrals (AB 2744)
CMA members can access On-Call documents free at www.cmanet.org/cma-on-call. CPLH, the complete health law library, is also available for purchase in a multi-volume print set or annual online subscription service. To order a copy, visit the CMA resource library or call (800) 882-1262.
To join, call Leslie at 408.998.8850/831.455.1008 or email leslie@sccma.org.
26 | THE BULLETIN | MAY / JUNE 2017
700 Empey Way, San Jose, CA 95128 (408) 998-‐8850 FAX (408) 289-‐1064
2017-2018 SCCMA COMMITTEE RESPONSE FORM
Listed below are the current SCCMA committees—all meet at the Medical Association building. Omitted are those where membership is by election (e.g., Council and Executive Committee), bylaw consideration, and/or existing protocol (e.g., Awards, Membership, Physicians’ Well-Being, and Professional Standards/Conduct). SCCMA committees help recommend policies for the Association, standards for practice in Santa Clara County, and aid in the development of important relationships with governmental and public service organizations. Committee service commences on July 1, 2017. The majority of the committees will not meet during July and August, however. In accordance with SCCMA bylaws, committee appointments are made each year by the President and state that, “The terms of office of the chairs and members of all committees shall be at the discretion of the President, and, in any event, shall end with the term of office of the President by whom they were appointed…” Therefore, the terms of fiscal 16-17 committee members and chairs, having been appointed by Scott Benninghoven, MD, will officially end with his term of office — June 30, 2017. Name:
(Please Print)
Specialty:
Phone:
Fax:
Members interested in serving on any of the following Committees are asked to return this form.
❏
Bioethics (Bi-monthly, dinner) To educate its
❏ ❏
members regarding bioethical decision making, discuss bioethical issues and develop guidelines, and advise government and industry leaders regarding the ethical aspects of health care policy.
Leon P. Fox Medical History (Bi-monthly, first Monday, lunch) To identify, collect, and preserve archival material, memorabilia, and artifacts representing the medical history of Santa Clara County.
❏
Environmental Health (Bi-monthly, dinner) To study and address environmental and occupational health concerns.
❏
High School Outreach Program (Yearly) To speak about your specialty before local high school students at the annual program, which is designed to pique the students’ interest in becoming a physician in our community.
Medical Student Mentor Program (Yearly) To volunteer as a mentor to a Stanford medical student. Students can “shadow” practicing physicians to learn about their specialties and modes of practice.
FAX form to 408/289-1064 or mail to SCCMA by 7/28/17. MAY / JUNE 2017 | THE06/12 BULLETIN | 27
Expanded Lucile Packard Children’s Hospital Stanford Set to Open in December More than doubling its current size, the expanded Lucile Packard Children’s Hospital Stanford, slated to open in December, will aim to transform the patient experience through family-centered design and technological innovation, while setting new standards for sustainability in hospital design. The Packard Children’s expansion will more than double the size of the existing campus by linking the original hospital with a new main building, bringing the total hospital space to measure 844,000 square feet. “This will be the nation’s most technologically advanced, environmentally sustainable and family-friendly hospital for children and expectant mothers,” said Christopher Dawes, chief executive officer. The topranked children’s hospital in Northern California is at the center of the Stanford Children’s Health enterprise, which is the largest healthcare system in the Bay Area exclusively dedicated to pediatric and obstetric care. According to Stanford News Center, the new facility will include: • A new, 521,000-square-foot addition to the hospital • An additional 149 patient beds • Six state-of-the-art operating suites, with a design that allows room to grow as demand increases. • A neuro-hybrid surgery suite — the only one of its kind in a California children’s hospital — featuring a state-of-theart diagnostic MRI, direct access to angiography imaging equipment and a full operating room. The suite will enable surgeons to view updated images during surgery and reimage patients before closure of the surgical incision. For a patient having a tumor removed, their surgical team will be better assured of the procedure’s success. Ultimately, this will reduce the number of procedures, which in turn will impact overall cost and the amount of time a young patient will spend under anesthesia. • A dedicated isotope radiation therapy room for cancer patients • One of the nation’s only stand-alone combined PET/MRI scanners dedicated to pediatric patients. The hybrid scanner combines the two modalities, positron emission tomography imaging and magnetic resonance imaging, into a single scan, allowing physicians to see how diseases are behaving in the body, monitor the effects of treatment and craft informed treatment plans to cater to the patient’s case. • More spacious private patient rooms with sleeping accommodations for two family members and amenities like laundry facilities and family kitchens on every floor. • Special features that help make the space unique and kid-friendly include a large digital, interactive wall as well as a dedicated broadcast studio where children can create, record and edit
28 | THE BULLETIN | MAY / JUNE 2017
video content that can be shared in patient rooms throughout the hospital. • 3.5 acres of healing green space and gardens with overlook areas with views of the landscape and a planter box in the window of every patient’s room to provide a connection to nature for everyone. With 13 surgical suites, the new Packard Children’s will have more operating rooms than any children’s hospital in Northern California, reducing scheduling delays and long waits when surgeries take longer than planned. Planning for emerging technology was integral to the design for the new hospital. “When planning and design began many years ago, we knew we had to leave room for ever-evolving technology,” said Dennis Lund, MD, chief medical officer. “So, we’ll have the most advanced capabilities available when we open later this year, with the ability to implement emerging technologies in the future.”
TRANSFORMING THE ORIGINAL BUILDING According to Stanford News, the new building will allow for a transformative renovation of much of the existing hospital’s space, including the Johnson Center for Pregnancy and Newborn Services, into mostly private obstetrics rooms. Some major programs will grow and transition into the new, main building, including the Bass Center for Childhood Cancer and Blood Diseases, the Pediatric Transplant Center and the Betty Irene Moore Children’s Heart Center. Additionally, services previously shared with Stanford Hospital will now have a dedicated presence inside the children’s hospital, including nuclear medicine, catheterization labs, interventional radiology and patient food services. Packard Children’s growth is connected with the advancement of adult care through the new Stanford Hospital, which is expected to open in 2018. “An integral part of Stanford Medicine, the expanded Lucile Packard Children’s Hospital will help us continue to provide the best possible care for children and pregnant women,” said Lloyd Minor, MD, dean of the Stanford School of Medicine. “The new hospital’s innovative technology, family-centered design and advanced sustainability features will further advance our academic mission and vision for precision health — enabling us to offer the highest levels of predictive, preventive and personalized care to all of our patients.” “We are all working with focused dedication and excited anticipation as we move toward the opening of our new campus,” said Dawes. “Together, we are advancing a vision to heal humanity through science and compassion, one child and family at a time.
Kaiser Strategy to Deal with Overprescribing Opioids Shows Promise In 2009, when eight Kaiser Permanente doctors met to review the HMO’s most prescribed drugs, they came to an unsettling realization. A recent California Healthline story set the scene and describes what followed. “We were doing so much work treating people with hypertension and diabetes, we thought those drugs would be on the list,” said Joel Hyatt, MD, then Kaiser’s quality management director in Southern California. Instead, hydrocodone, a generic opioid painkiller, led the list. OxyContin was near the top, even though the HMO didn’t subsidize it and patients had to pay for it themselves. At the time, few if any physicians were talking about an “opioid epidemic.” But to the doctors in the room, the slides told a bleak story: Narcotics were being dispensed in numbers and doses higher than any of them had ever seen. The potential for addiction and overdoses among patients was frightening, something doctors around the country would later realize. The meeting resulted in an effort by a task force at Kaiser Permanente-Southern California to change how their colleagues practiced, and thought about, pain management. Steps taken by the task force included: • Tapering the number of patients on high doses of narcotic painkillers. • Reprogramming computer software for doctors. • Developing new urine tests for patients and empowering pharmacists to question potentially excessive prescriptions. • Pushing colleagues to expand the use of non-drug options for chronic pain sufferers: physical therapy, acupuncture, cognitive behavioral therapy, healthier diets and increased exercise. Studying Kaiser’s centralized patient data system and finding statistics indicating doctors were regularly boosting the dosage for hundreds of patients by about 30% every six months and that they were prescribing a high number of branded opioids — Vicodin and Percocet, especially — instead of generic hydrocodone or oxycodone. Brand-name pills are more popular on the street and more likely to end up on the black market; Talking to colleagues at the health plan’s 14 medical centers in the region, citing studies that connected overprescribing to overdoses. They used “the same type of strategy that Pharma used” to promote opioid prescribing years ago — offering free seminar lunches, handing out pens and other knickknacks to reinforce essential messages — to reduce prescriptions rather than boost them; and Asking Kaiser’s tech people to reprogram the computer records system to guide doctors’ decisions in the clinic for “physicians [having] a hard
time saying no while face-to-face with insistent patients.” The reprogramming provided doctors with the choices “we want them to prefer at the top: Tylenol, Motrin, physical therapy, meditation, exercise. Down at the very bottom are opioids.” Five years into its initiative, Kaiser’s Southern California operation reports prescriptions of opioids have plunged, according to the article: Today, a Kaiser physician about to prescribe OxyContin will receive an alert that the drug has a high risk of abuse. A doctor about to prescribe a benzodiazepine to a patient already receiving an opiate painkiller — a dangerous combination — gets a large yellow alert on the computer screen, along with scientific articles describing the hazards of prescribing the two classes of drugs. The physician has to override the alert to go ahead with the prescription. Kaiser developed broader urine tests for opioids allowing doctors to establish verifiable agreements with patients about how much opiate medication they would take. Prescriptions of opioid pills such as Vicodin and Percocet in amounts greater than 200 tablets dropped from 2,500 a month to almost zero, according to the HMO. Kaiser patients coming out of routine surgery no longer receive 60 Vicodin, a month’s worth of pills for what are usually a few days of pain, Dr. Hyatt said. Now “you would probably be given no more than 18” pills of generic hydrocodone. Kaiser is deploying these strategies across the organization, and the prescription of opioids has fallen by a third since March 2015, officials at Kaiser’s Oakland headquarters said. Ramana Naidu, MD, an assistant professor of anesthesiology and pain specialist at University of California, San Francisco, agrees with the Kaiser approach overall but cautioned that weaning patients off of opioids should be done in a “slow and gradual manner” to avoid the risk of rebound pain and a withdrawal syndrome. He said that while it’s important to discern whether patients are seeking prescriptions to abuse or sell opioids, pill counting and urine drug screens may introduce distrust into the patient-doctor relationship. Kaiser’s Dr. Hyatt said the Kaiser approach is founded on building that trust. The biggest problem he sees is patients’ headlong rush for relief. “Patients in America are impatient. They want a quick fix,” said Dr. Hyatt. “But I think we’ve made real progress. The more we can arm physicians and pharmacists with the right information and scripting, the more likely the right thing is going to happen.”
MAY / JUNE 2017 | THE BULLETIN | 29
New CEO to Lead O’Connor and St. Louise Regional Jordan R. Herget, FACHE, will become the new president and chief executive officer of the 358-bed O’Connor Hospital in San Jose and the 93-bed acute care hospital St. Louise Regional in Gilroy, effective Nov. 14. Both hospitals are part of Verity Health System. According to the announcement, Herget is a highly respected healthcare leader with 16 years of hospital executive experience and comes to Verity Health from HCA’s (Hospital Corporation of America’s) 474-bed Good Samaritan Hospital in San Jose, serving as its chief operating officer since 2012. His responsibilities there included overseeing physician contracts, service line development and market growth strategy, including developing important affiliations with the University of California, San Francisco, and Stanford Medicine. Beginning his healthcare career as a senior consultant with Ernst & Young, Herget joined HCA in 1999 as an associate in the chief financial officer/controller development program with St. Mark’s Hospital in Salt Lake City. Acquiring a broad foundation in finance and managed care, he soon moved into hospital operations, becoming the COO of Alaska Regional Hospital and later, the COO of Eastern Idaho Regional Medical Center. From there, he became CEO of Oklahoma University Medical Center-Edmond for two years before assuming his current position with Good Samaritan Hospital. Herget holds a bachelor’s degree from Brigham Young University and a master’s in health finance and management from Johns Hopkins Bloomberg School of Public Health. He also holds Advanced Lean Training Certification from the Virginia Mason Institute and is a Fellow of the American College of Healthcare Executives.
Good Samaritan Hospital Earns Elite Three-Star Rating for Heart Bypass Surgery from The Society of Thoracic Surgeons San Jose’s Good Samaritan Hospital has earned a distinguished threestar rating from The Society of Thoracic Surgeons (STS) for its patient care and outcomes in isolated coronary artery bypass grafting (CABG) procedures. The three-star rating, which denotes the highest category of quality, places Good Samaritan Hospital among the elite for heart bypass surgery in the United States and Canada. The STS star rating system is one of the most sophisticated and highly regarded overall measures of quality in healthcare, rating the benchmarked outcomes of cardiothoracic surgery programs across the United States and Canada. The star rating is calculated using a combination of quality measures for specific procedures performed by an STS Adult Cardiac Surgery Database participant. 30 | THE BULLETIN | MAY / JUNE 2017
$50 Million Gift to Packard Children’s Lucile Packard Children’s Hospital Stanford has received a gift of $50 million from Gordon and Betty Moore to deliver exceptional patient care and advance research that improves the health of children with heart disease. The Moores’ donation is the largest private gift to Lucile Packard Children’s Hospital Stanford since the hospital’s founding donation from David and Lucile Packard. In honor of the new gift, Packard Children’s Heart Center will be named the Betty Irene Moore Children’s Heart Center. The gift provides funding for clinical and research facilities, an endowment for the center’s highest strategic priorities and endowed positions for faculty to lead specialized care and research. Gordon Moore is co-founder of Intel Corp. He and his wife, Betty, are also founders of the Gordon and Betty Moore Foundation, which works to create positive outcomes for future generations. They are longtime supporters of Packard Children’s and previously made gifts to enable the hospital’s 521,000-square-foot expansion, which is now nearing completion. The Moores were motivated to make their latest gift after a child in their family benefited from the care of the Children’s Heart Center. “Our grandchild had lifesaving surgery at the hospital, and we would like to help make sure the capability is there for others,” Gordon Moore said.
O’Connor Hospital Receives Get With The Guidelines-Stroke Gold Plus Quality Achievement Award O’Connor Hospital in San Jose has received the American Heart Association/American Stroke Association’s Get With The Guidelines-Stroke Gold Plus Achievement Award with Target: StrokeSM Honor Roll Elite Plus. This award recognizes the commitment to providing the most appropriate stroke treatment according to nationally recognized guidelines, based on the latest scientific evidence. O’Connor earned the award by meeting specific quality achievement measures for the diagnosis and treatment of stroke patients at a set level for a designated period. Hospitals must achieve 85% or higher compliance to all Get With The Guidelines-Stroke achievement indicators for two or more consecutive 12-month periods and achieve 75% or higher compliance with Get With The Guidelines-Stroke Quality measures to receive the Gold Plus Quality Achievement Award.
Population Health Sciences Awards $275,000 in Pilot Grants to 11 Projects The Stanford Center for Population Sciences has funded 11 additional pilot projects in 2017, bringing the year’s total to 16. These grants support investigators whose work aims to improve the health of populations through healthcare system-based or community-based studies. The grant-receiving projects and their principal investigators are:
POPULATION HEALTH SCIENCES
health research and policy. • “Telomere length changes as a marker of chronic disease risk among children participating in lifestyle behavior change” — Thomas Robinson, MD, MPH, professor of pediatrics and of medicine.
COMMUNITY ENGAGEMENT
• “Design and development of a personal environmental exposure monitoring device” — Michael Snyder, PhD, professor of genetics. • “Assessment of statins in understudied races and ethnicities” — Latha Palaniappan, MD, clinical professor of medicine. • “Living laboratories in institutional food settings: Building a research model to help develop strategies for improving healthy food choices” — Christopher Gardner, PhD, professor of medicine. • “Improving personalized medicine through n-of-1 causal inference and predictive modeling” — Eric Daza, DrPH, postdoctoral scholar in heart disease prevention. • “GapMap: A mobile surveillance system to map autism and gaps in autism services globally” — Dennis Wall, PhD, associate professor of pediatrics. • “Quantifying individual genetic risk in diverse populations” — Laramie Duncan, PhD, instructor of psychiatry and behavioral sciences. • “Assay development for the study of skin flora and allergy in infants” — Julie Parsonnet, MD, professor of medicine and of
• “Pediatrics and education: A transdisciplinary approach to improve school readiness” — Lisa Chamberlain, MD, MPH, associate professor of pediatrics. • “Improving food insecurity screening and referral to healthy food resources in a community clinic population in San Mateo County” — Michelle Hauser, MD, postdoctoral scholar, and Christopher Gardner, PhD, professor of medicine. • “Developing and evaluating a K-drama precision mental health curriculum among Asian Americans and Pacific Islanders” — Van Ta Park, PhD, MPH, associate professor of health science and recreation at San Jose State University, and Mildred Cho, PhD, professor of pediatrics. These pilot grants are administered by Spectrum (the Stanford Center for Clinical and Translational Research and Education) and the Stanford Center for Population Health Sciences. Primary funding comes from Spectrum’s $45.3 million Clinical and Translational Science Award (grant UL1TR001085) from the National Institutes of Health. The proposal deadline for next year’s Spectrum pilot grants will be late in 2017. For more information, visit https://spectrum.stanford.edu/ pilot-grants--3.
Roots Community Health Center Santa Clara County Opens First AfricanCentered Community Health Clinic | Roots Community Health Center, South Bay, recently celebrated the grand opening of their new health center. Roots Community Health Center was founded in East Oakland in 2008 to address the growing need for accessible, culturally appropriate, community-responsive, comprehensive healthcare for Oakland residents. The African Ancestry Community in Santa Clara County has suffered from higher incidences of HIV/AIDS and hepatitis C infections, as well as increased rates of diabetes, hypertension, cancer and other morbidities. Roots Community Health Center seeks to address the disparities that exist by serving as a medical home, offering primary care, community outreach and education, and wraparound services. Roots will co-locate and partner with Ujima Adult and Family Services, a mental health outpatient
clinic, to offer complete holistic care. Start-up funding for the culturally responsive clinic was provided by the Santa Clara Board of Supervisors by a unanimous vote in August 2016. The funds helped to secure and build out existing office space adjacent to Ujima Adult & Family Services located at 1898 The Alameda in San Jose. The 2,500-square-foot facility boasts a welcoming reception area, three exam rooms and a multi-purpose room designed for community programs. “We look forward to opening our clinic doors and making an impact in Santa Clara County,” said Roots Community Health Center Area Director Alma Burrell. “The work we do will change lives and improve health outcomes.”
Monterey County Health Department Wins Arnold X. Perkins Award The California Endowment and the Health Equity Award Planning Committee named the Monterey County Health Department (MCHD) as the winner of the Arnold X. Perkins Award for Outstanding Health Equity Practice. MCHD received the award primarily for its use of the Health in All Policies (HiAP) framework and its robust community leadership program, which is a collaborative approach to improve a community’s health by incorporating health considerations into decision making in all sectors and policy areas. MAY / JUNE 2017 | THE BULLETIN | 31
Keeley Institute By Gerald E. Trobough, MD Leon P. Fox Medical History Committee One of the first hospitals established in Los Gatos was the Keeley Institute. It was built on East Main Street in 1891 by building contractor, Herman Sund. The hospital was owned by Dr. Leslie Keeley, who was a graduate of Rush Medical College and a retired Civil War physician. Dr. Keeley became interested in treating alcoholism during that war and established over 200 clinics across the nation and Europe. Dr. Keeley’s first clinic was established in Dwight, Illinois in 1880. The mission of the clinics was to treat alcohol, tobacco, and opiate addiction. He pioneered medical studies and a treatment for alcoholism. His treatment for addiction was called the “gold cure” because he used oral bichloride of gold. However, a chemical analysis of the oral tonic revealed 27.55% alcohol, ammonium chloride, aloin, and tincture of cinchoa, but no gold. The injections contained strychnine, atropine and boracic acid, and no gold. The magic cure, however, was probably Group Therapy, which he introduced to medicine. He told patients that gold chloride and alcohol didn’t mix and the combination of the two could be harmful to their health. His clinics were recognized as some of the most advanced rehabilitation centers in the country. Keeley published numerous articles and pamphlets about his clinics and reported his successes. 32 | THE BULLETIN | MAY / JUNE 2017
He also wrote several books on alcohol and drug addiction. “The Morphine Eater” was published in 1881 and the “Non-Heredity of Inebriates” in 1896. The Los Gatos facility remained open for four years and closed in 1895. During that brief period of time over 1,000 patients were treated, many who came from long distances. Documents suggest that 50 of these patients were from the Los Gatos area. The treatments lasted six weeks and the cost was $25 to $50 a week. The treatments were the same in all the clinics. The whisky ration was quickly reduced. Eight ounces was allowed on the first day, six ounces on the second day, four ounces Dr. Leslie Keeley on the third day, and none after that. InjecCalifornia were built in Auburn and Riverside. tions were given four times a day and the oral Dr Keeley died in the Los Angeles area in 1900 “gold tonic” was given every two hours. After the facility closed, Sund donated the at the age of 63. At the time of his death, his esuse of the building to the town of Los Gatos for tate was estimated to be greater than one million its new Town Hall. Other Keeley Institutes in dollars.
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.
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Growing Medical Group seeking Full Time BC / BE Family Medicine Physicians Palo Alto Medical Foundation (PAMF) has openings in the Bay Area for Family Medicine Physicians. Come join an organization which has received the highest possible rating for patient experience from the California Office of the Patient Advocate, and ‘elite’ status by the California Association of Physician groups. SCCMA
• Physician-led and collegial environment 09-03-15 • Schedule flexibility and sabbaticals for work-life balance • Relocation allowance • Malpractice tail coverage
Palo Alto Medical Foundation Physician Resources Recruitment Dpt 650-934-3582 | MDCareers@pamf.org MAY / JUNE 2017 | THE BULLETIN | 33
Classifieds OFFICE SPACE FOR RENT/LEASE MEDICAL OFFICE SPACE TO SUBLET • MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/228-0454.
MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.
LOS GATOS OFFICE TO SHARE Newly-remodeled office next to ECHLG, including private office, four exam rooms, lab, reception, and waiting areas. Can share staff. Contact Dr. Maia Chakerian at 408/832-3930.
MEDICAL OFFICE SPACE TO SHARE • CAMPBELL Convenient location. 5+ exam rooms M-F. In-office digital x-ray. Two large private offices, shared waiting room and front office. Total office size 3,000 sq. ft. Available now. Call 408/376-3305 or marlene@svspine.com.
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MTN VIEW
Mountain View Medical Office space to sublet. 1,100 sq. ft. Available three days a week. In large medical complex, behind El Camino Hospital. Basement storage, utilities included. Large treatment rooms, small lab space, bathroom, private office, etc. Call Dr. Klein. Cell 650/269-1030.
OFFICE SPACE FOR LEASE Office space, located at 999 Saratoga Avenue, San Jose, is suitable for medical/ dental office; 2,100 sq. ft. – 2,700 sq. ft. Contact 650/796-1887.
EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or e-mail riflovin@ allianceoccmed.com for additional information.
INTERNAL MEDICINE PHYSICIAN NEEDED We are looking for an internal medicine physician for our multi-specialty group. Please email your CV to kaajhealthcare@ gmail.com. Continued on page 44
Full Time/Part-Time/ Per-Diem Adult and Pediatric Urgent Care Physician Opportunities Palo Alto Medical Foundation (PAMF) has multiple Urgent Care openings in the San Francisco Bay Area for BE/BC Internal Medicine, Family Medicine, Pediatrics, or Emergency Medicine Physicians. Come join an organization which has received the highest possible rating for patient experience from the California Office of the Patient Advocate, and ‘elite’ status by the California Association of Physician groups. • Competitive salary guarantee plus incentive for full time and part time opportunities • Competitive Hourly Rate for perdiem opportunities • Generous benefit package • Shareholder track position leading toward full shareholdership following 24 months of employment • Physician-led and collegial environment • Malpractice tail coverage included Contact: Palo Alto Medical Foundation Physician Resources Recruitment Dpt 650-934-3582 MDCareers@pamf.org www.pamfmdjobs.org
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Course can be offered in a group training using a single log-in. Contact Leslie Iacopi at (415) 882-5167 for more details. Register NOW at: http://www.imq.org/education/caprrc.aspx MAY / JUNE 2017 | THE BULLETIN | 35
Local Medi-Cal Patients Having Trouble Finding Primary Care Physicians Adults who qualify for Medi-Cal in Santa Clara County may have trouble finding a primary care physician to provide primary and preventive care. When access is difficult or denied, according to a report issued by the County Civil Grand Jury, individuals defer care, turn to free clinics or utilize a hospital emergency room for conditions that could be treated in a doctor’s office. Santa Clara has an above-average number of primary care physicians and specialists, reports the California Health Care Foundation. But only 50% of Bay Area primary care physicians were taking Medi-Cal patients in 2015, according to a report from University of California, San Francisco (UCSF). The grand jury investigated whether Medi-Cal enrollees using the Santa Clara Family Health Plan, which was created to manage Medi-Cal coverage for low-income residents, are able to access medical care. The Health Plan contracts with Valley Health Plan (a county-run health maintenance organization), Physicians Medical Group, Kaiser, Premier Care, Palo Alto Medical Foundation, and with independent physicians and nonprofit primary care clinics. Medi-Cal enrollees come through different routes, according to the report. Some are signed up by Santa Clara County Social Services or by nonprofits that specialize in providing access to healthcare. Others go on the Covered California website, enter their income and discover they are eligible for Medi-Cal. They are given a choice of Santa Clara Family Health Plan or Anthem Blue Cross: 78% enrolled with the Health Plan. Physicians may refuse to accept MediCal patients or accept a limited number. A physician who stops taking people on Medi-Cal – known as closing the panel – is supposed to inform the Health Plan. The investigation found: • California had a shortage of primary care physicians willing to treat people on Medi-Cal before expanding eligibility in 2013, which increased the Bay Area Medi-Cal population by 60%. • Statewide, 80% of Medi-Cal enrollees are in managed-care 36 | THE BULLETIN | MAY / JUNE 2017
plans, which require they have a primary care physician. • Health Plan members are asked to select a primary care physician from directories that are confusing and sometimes inaccurate. • Health Plan members’ complaints to the nurse advice line about access to care may not be referred directly to member services staffers. The report references a February 7, 2015, Mercury News story that indicated new Medi-Cal enrollees in the Bay Area were having trouble finding a physician or waiting months for an appointment.
“California did a good job of getting people signed up, but they basically stuck their heads in the sand and assumed that California physicians would just jump right on board and want to take more Medi-Cal patients,” said Del Morris, MD, president of the California Academy of Family Physicians. In the first three quarters of 2016, Medi-Cal enrollees in the county were more than twice as likely as the privately insured to visit hospital emergency rooms for outpatient care, according to data provided to the grand jury by the Office of Statewide Health Planning and Development. The report surmises that physicians and their networks have little financial in-
centive to treat Medi-Cal, citing: • California ranked 48th in physician reimbursement for Medicaid/Medi-Cal services and in the percentage of primary care physicians taking new Medicaid/Medi-Cal patients, a 2012 University of California San Francisco (UCSF) study found. • In 2014, California had the secondlowest rate (49.2%) of office-based physicians taking new Medicaid/ Medi-Cal patients in the nation, the National Center for Health Statistics reported. The national average was 70.4% for office-based physicians. • A UCSF survey in 2016 found that only 55% of primary care physicians statewide were taking new Medi-Cal patients: 78% of doctors surveyed cited low payments; 72% cited payment delays; and 72% complained of “administrative hassles.” • In addition, 40% of physicians cited Medi-Cal patients’ greater health needs as a reason to close their panels. Under the risk-based managed-care funding model, physicians receive the same pre-set amount for each patient: They lose money if their panel includes too many medically needy patients. Adults enrolled in Medi-Cal were three times more likely than the privately insured to have fair or poor health, the Department of Health Care Services reported in 2014. The report concluded with recommendations that include suggesting the Health Plan provide more frequent provider directory updates, make it clear when doctors aren’t taking new patients and improve its “find a doctor” tool. In addition, the grand jury recommends that the Santa Clara County Board of Supervisors advocate for improved physician reimbursements to raise the likelihood that sufficient numbers of medical providers in the county will accept Medi-Cal patients. The report was written in early 2017 and did not address the future of the Affordable Care Act or the implications of the American Health Care Act.
Analysis Finds State Single-Payer Health System to Cost $400B Annually Analysis of a proposed single-payer health system that would provide care for all 39 million people in California found it would cost approximately $400 billion annually. The bill, SB 562, cleared a hurdle this month, passing the Appropriations Committee in a 5-2 party-line vote and is advancing to a vote in the full Senate. The cost findings, published April 17 in a report by the state Senate Appropriations Committee, indicated federal, state and local taxpayer funding of about $200 billion a year for existing programs could be available to offset the overall tab of $400 billion for universal coverage. However, additional tax revenue would be needed to foot the other half of the cost, according to the report, which raised the possibility of a 15% payroll tax on earned income. The proposed state-run system would supplant existing employer health insurance and public programs such as Medicaid and Medicare. It is important to note, the report states, that the overall cost of those new tax revenues would be offset to a large degree by reduced spending on healthcare coverage by employers and employees. Although precise estimates of total spending for employer-sponsored health insurance are not available, the best available information indicates that existing spending is between $100 billion and $150 billion per year. Therefore, total new spending required under the bill would be between $50 billion and $100 billion per year. A chief sponsor of the legislation, State Sen. Ricardo Lara (D-Bell Gardens) is receiving support from the Santa Clara and Marin counties’ board of supervisors as well as the city of Los Angeles, and Insurance Commissioner Dave Jones, a candidate for state attorney general. Lara said the present system is unsustainable with health spending continuing to grow faster than the overall economy, making coverage unaffordable for too many people. Besides the matter of how to pay for it, a Sacramento Bee editorial points out that the bill fails to say how the state, which would be entrusted with managing the brave new healthcare system, would curb healthcare costs. As drafted, it would permit patients to gain access to medical services in ways that would be “largely unconstrained.” Key provisions of the bill would include the following: • Require collection of certain information from hospitals (but not other providers); • Prohibit any cost sharing for enrollees such as premiums, copayments or deductibles; • Require coverage for “all medical care determined to be medically appropriate by the member’s healthcare provider”; • Require coverage for all healthcare services covered by Medi-Cal, Medicare, health plans regulated under the Knox-Keene Act, and the essential health benefits mandated in the Affordable Care Act; • Authorize any licensed healthcare provider to provide services to a member; • Authorize members to receive healthcare services from any willing provider, without needing a referral from a primary care provider or a care coordinator; • Require care coordination services to be provided to members; • Prohibit care coordination administrative tracking and record keeping from requiring the utilization of electronic health records by providers; • Require payments to providers to be made on a fee-for-service basis unless other payment methodologies are developed by the Board; • Require all payments to be reasonable and reasonably related to the cost of providing healthcare services and to ensure an adequate supply of services; • Require the Program to negotiate payment rates with providers’ representatives; • Authorize providers to collectively negotiate payment rates with the Board.
According to the report: • The current California healthcare system is primarily based upon an employer-sponsored health insurance model (about 45% of the population), with a significant number of people covered by Medi-Cal (26%), Medicare (10%), the individual market (9%), and other federal coverage (2%). Currently, about 8% of the state’s population is uninsured. • In the United States, healthcare spending represents about 19% of gross domestic product. This is roughly twice the average level of spending in other developed countries. Of the total spending on healthcare, 32% is for hospital care, 27% is for physician and other professional services, 13% is for prescription drugs, 7% is for health insurance administration, and 5% is for capital investment. It is important to note, however, that a significant portion of the nation’s spending on prescription drugs (particularly highcost drugs) takes place in hospitals or physicians’ offices, and is therefore not counted in the estimated 13% of spending that goes for prescription drugs.
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CBO Scores GOP Healthcare Plan The Republican overhaul of the federal health law passed by the House this month would result in slightly lower premiums and slightly fewer uninsured Americans than an earlier proposal. But it would leave as many as one-sixth of Americans living in states where older and sicker people might have to pay much more for their healthcare or be unable to purchase insurance at all, the Congressional Budget Office (CBO) said. In some states, said the report, “less healthy people would face extremely high premiums, despite the additional funding that would be available” in the bill to help offset those increases. The report incorporates the changes to the bill made just before it narrowly passed the House on May 4. Those changes included an amendment offered by Rep. Tom MacArthur (R-N.J.) that would let states waive some key provisions of the health law, including requirements to cover “essential health benefits” and to offer insurance to people with preexisting conditions at no extra cost. CBO said the current version would result in savings of $119 billion over 10 years and 23 million more uninsured people than would be expected under the current law. According to the estimate, premiums would be slightly lower than under the Affordable Care Act but mostly because “the insurance, on average, would pay for a smaller proportion of healthcare costs.” Prior to the changes, the CBO estimated that the bill would result in savings of $150 billion over the next decade and grow the number of uninsured Americans by 24 million. That dollar figure was a considerable change from the original version of the bill that CBO said would have saved $337 billion, but lawmakers decided to spend back some of those savings on help for those likely to be cut off from insurance. The two earliest versions of the bill could not muster enough support for the House leadership to bring them to a vote on the floor. Later, MacArthur and leaders of the conservative Freedom Caucus negotiated changes that they said should help bring down premium costs for consumers. That is the bill approved and now evaluated by CBO. The CBO also estimated that in states deciding to take the option to waive requirements related to charging sicker people more, “the nongroup market would start to become unstable.” In particular, said the report, “people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all.” And in states that chose to waive the requirements for essential benefits, even people with insurance “would experience substantial 38 | THE BULLETIN | MAY / JUNE 2017
increases in what they would spend on healthcare,” because their policies might no longer cover expensive treatments like those for maternity care or mental health and substance abuse. Despite repeated claims from President Donald Trump and congressional Republicans that the Affordable Care Act is collapsing, the CBO specifically said that the market would continue “to be stable in most areas” under current law. It predicted the same for the original version of the House bill. In fact, the only place the CBO specifically said the individual insurance market might become unstable is in states that decide to waive the ACA’s coverage requirements. It did not guess which states might do that, but the report says that one-sixth of the population could be subject to that instability. “What is clear is that these waivers make life much, much worse for people with preexisting conditions, for older people, for sicker people,” said Aviva Aron-Dine, a senior fellow at the Center on Budget and Policy Priorities and former Obama administration health staffer. The savings in the bill are mostly the result of capping federal funding to states for the Medicaid program for those with low incomes and scaling back the tax credits that help some people with low and modest incomes pay for private insurance. An estimated 14 million of the 23 million people who would no longer have insurance would otherwise have obtained it through Medicaid. The bill would also repeal nearly all the taxes imposed in the ACA to pay for the new benefits, including taxes on wealthy individuals and much of the health industry. Reaction to the new estimate fell mostly along predictable party lines. “CBO continues to find that through our patient-focused bill, premiums will go down and that our reforms will help stabilize the market,” said a statement from House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) and its health subcommittee chairman, Michael Burgess (R-Texas). By contrast, Rep. Steny Hoyer (D-Md.) said the new estimate shows “TrumpCare will kick millions of Americans off their insurance coverage and force consumers to pay more for less.” But the reaction was not completely partisan. Sen. Bill Cassidy (R-La.), a key swing vote in the Senate, said that “Congress’s focus must be to lower premiums with coverage which passes the Jimmy Kimmel test,” referring to the late-night host’s tearful monologue about the health problems of his newborn son. The Housepassed bill, he said, “does not. I am working with Senate colleagues to do so.” SOURCE: By Julie Rovner | Kaiser Health News
Proposed State Bill Would Limit Pharmaceutical Gifts to Healthcare Providers A new California bill aims to reduce the pharmaceutical industry’s influence in medical decision-making by restricting payments and gifts from drug companies to doctors and other medical providers. State Sen. Mike McGuire (D-Healdsburg), who authored the bill, said that when drug-makers woo physicians with meals and other enticements they generate brand loyalty, which can raise healthcare costs and even compromise patient safety. McGuire’s bill would limit drug company payments to healthcare providers — including cash and gifts of food, travel or entertainment — mostly to educational and scientific purposes, such as seminars. “Financial incentives change minds,” said McGuire, who cited a news media report showing that doctors who accepted money or meals from the pharmaceutical industry were two to three times more likely to prescribe high-priced brand-name drugs than those who did not accept such benefits. Brand-name drugs tend to be pricier than generic drugs, even though research shows they are not necessarily more effective. The proposed measure would allow pharmaceutical companies to continue paying healthcare professionals for their work on clinical trials and other scientific research. And the industry could continue to sponsor educational events, as long as they were not for the purpose of promoting specific products. Doctors would still be allowed to accept free drug samples and take up to $250-ayear’s worth of food paid for by companies. But drugmakers could be slapped with a $10,000 state fine if they pay a physician, or cover the cost of a flight, hotel room or entertainment for purely promotional purpose. Doctors can receive hundreds of thousands of dollars from drug companies, according to a ProPublica investigation. One New Hampshire nephrologist received more than a half-million dollars in speaking and consulting fees, and a Brooklyn-based psychiatrist prescribed much higher rates of brand-name drugs while receiving $53,400 from drug companies, according to ProPublica. The Pharmaceutical Research and Manufacturers of America (PhRMA), the drug industry’s primary trade association, opposes McGuire’s measure, arguing that the legislation could compromise communication with companies that help doctors stay up-to-date on medication safety and effectiveness. Information provided by drugmakers “may inform a physician’s prescribing decisions as they weigh the best options for their patients,” said
Holly Campbell, a PhRMA senior director for public affairs, in an emailed statement. “Collaboration between biopharmaceutical companies and physicians not only helps advance patient care, but is essential in the development of new treatments and diagnostics.” Advocacy groups, including Consumers Union and Health Access, support the bill, saying it could lower drug costs by reducing incentives for doctors to prescribe higher-cost brand-name drugs when cheaper generic drugs are available. A 2016 survey of more than 107,000 healthcare consumers showed that about $73 billion from 2010 to 2012 was spent unnecessarily on brandname drugs in cases where generic medications were available. The advocates also say cutting pharmaceutical industry ties with doctors will make patients safer because providers will be more likely to prescribe based on medical evidence. A new study published in JAMA found that doctors at academic medical centers that have restricted financial ties to the pharmaceutical industry prescribed fewer medications promoted by drug companies. Several states and the District of Columbia already restrict pharmaceutical gifts to healthcare providers, according to Sen. McGuire and medical education researchers. California healthcare providers received more money from pharmaceutical companies in 201415 — about $1.4 billion — than their counterparts in any other state, according to ProPublica. But some health providers in California already ban company payments and gifts to their staff. Kaiser Permanente, which covers more than 8 million Californians, does not allow employees involved in drug-buying decisions to accept gifts from the industry, and some physicians are restricted from accepting anything of value from the industry. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.) The hospitals and clinics of the University of California-San Francisco does not allow faculty, staff or students to receive gifts from the industry. “UCSF wishes to minimize such conflicts and to ensure to the best of its ability that all decisions regarding clinical care, research activities and educational content are unbiased and independent of outside influence,” according to its written policy. SOURCE: By Pauline Bartolone | California Healthline MAY / JUNE 2017 | THE BULLETIN | 39
Future Health Index Shows Value of Connected Care, Not Wearable Devices Results were recently announced of an international study that examines the views of both the general population and healthcare professionals on healthcare access and the use of connected care technologies. The second annual Future Health Index (FHI) from Royal Philips found that, despite Americans’ love of wearable devices, both the general population and their healthcare professionals see the real value of connected care technology in diagnosis and treatment. According to the report: • 45% of Americans are open to using these technologies if recommended by a healthcare professional. • Despite the potential positive impact of an integrated healthcare system on the quality of healthcare, both Americans and healthcare professionals perceive cost remains as an issue. • 84% of the general population rate their health positively; however, only 53% of healthcare professionals would rate the overall health of the American population positively. • Both the U.S. general population and healthcare professionals believe connected technology plays a role in healthcare, but only 21% feel connected care technology will be the most beneficial for preventive care. • 78% of the general population and healthcare professionals see connected care technology as important for improving treatment of medical issues; 75% to 76% see connected care’s importance for diagnosis of medical conditions, and 71% to 74% think it’s important for home care services. • 64% of Americans and 59% of healthcare professionals believe that healthcare professionals should focus the majority of their time and resources overall on preventive care. • 65% of Americans are taking preventive actions such as making healthy eating selections, with 61% seeing a doctor on a regular basis to maintain their health; only 56% of those surveyed claim to exercise routinely. • 16% of Americans indicate the use of wearable devices; 12% list health-related smartphone apps among their efforts. According to the announcement, 60% of Americans do not currently use connected care technology to monitor health indicators, and those who do feel it has helped them take better control of their health. The study also finds that both Americans and healthcare professionals are aligned on which artificial intelligence (AI) tools would have the most impact on improving the current state of healthcare. • 40% of Americans currently report using some sort of connected care technology to track health indicators. • Of those who use connected care technology, 87% believe that wearable devices, specifically, have helped them take better control of their health. • 96% of healthcare professionals whose patients use connected care technology see health monitoring devices, including blood pressure monitors and medical alert systems, as the most helpful devices, while mobile health apps (90%) and wearables (88%) follow closely. 40 | THE BULLETIN | MAY / JUNE 2017
• 77% of the population could be more likely to use connected care technology; 45% of Americans would be more likely to use the technology if a healthcare professional recommended its use or an insurance company paid for the technology (43%). • 23% of Americans regard an AI health tracker wearable on their smartphone as the tool that would have the most impact on improving healthcare, while 20% believe AI-enabled healthcare tools that offer guidance using historical medical data would have the most impact. Healthcare professionals are aligned with the general population on which tools they believe will have the most benefit. When it comes to technology increasing the flow of information between healthcare professionals and patients, there’s tremendous opportunity for change. • Both healthcare professionals (86%) and the general population (61%) think an integrated healthcare system would improve the quality of healthcare in the U.S. • Nearly half of the general population feels that integration will make the cost of healthcare more expensive to themselves (46%) and overall (47%). • More healthcare professionals (86%) than the American general population (61%) believe integration will improve the quality of healthcare, and assume it will make healthcare more expensive to both patients (49%) and overall (54%). • Just 1 in 10 healthcare professionals (13%) and a quarter of Americans (24%) consider the current healthcare system in the United States to be integrated. “The driving force behind building a healthier tomorrow starts with preventive care today. Much of the acceleration we’ve seen in healthcare costs come from diseases associated with lifestyle choices. We need to tackle the problem from all angles, including looking for ways technology can play a role,” said Brian Donley, MD, chief of staff at Cleveland Clinic. “As a medical community, from expanding access to care to enabling innovative treatments, we’ve been successfully integrating technology into treatment and care. However, with chronic conditions affecting so many globally, we also need to explore ways to use technology to harness data for prevention in ways that are meaningful to doctors and impactful for patients.”
State Assembly, Senate Budget Committees Reject Using Tobacco Tax Revenues for General Fund The state Assembly and Senate budget committees voted to reject the governor’s budget proposal, which would have taken $1.3 billion in tobacco tax revenues to cover general fund responsibilities in the Medi-Cal program. Instead of using that money to improve access to care for the 13.7 million Californians served by Medi-Cal — as intended by the voters of California — the governor had proposed using tobacco tax funds to backfill a cut to the state’s general fund contribution to the program. The California Medical Association (CMA) is asking physicians to contact their legislators and urge them to support the Assembly proposal, which allocates the majority of funding to physician and dental services. Last year, CMA co-sponsored the Proposition 56 tobacco tax increase “with the intent of saving lives put at risk by tobacco products and improving the access and quality of medical services for all Californians – especially our
most vulnerable communities who rely on Medi-Cal for healthcare. The language of Prop. 56 was clear – the people voted overwhelmingly in support of improving payments to providers to ensure that patients can see a doctor when and where they need one.” “With the budget committee actions, it is clear your voices were heard. However, we’re not out of the woods yet,” said a statement on the CMA website. “The Assembly and Senate have introduced very different tobacco tax spending proposals that will need to be reconciled in the Legislative Budget Conference Committee.” CMA claims that California cannot afford to continue starving this program by diverting tobacco tax revenues to cover the state’s general fund obligations and concludes: “The stakes are high – urge the Legislature to adopt a budget that reinstates tobacco tax revenues for MediCal patient access to care.”
Report: Covered California Continues to Attract Healthy Mix of Enrollees, Keeping It Stable, Strong A new analysis shows that Covered California continues to attract a healthy mix of enrollees, and the overall health of its enrollees improved from 2016 to 2017. According to the report, this data is key to Covered California’s stability and will be used to help shape and inform rate negotiations with its 11 qualified health plans for 2018, according to the announcement from Covered California. “We continue to attract a healthy mix of enrollees, and this is further evidence that the individual market in California is stable and strong,” said Peter V. Lee, executive director of Covered California. “A healthy pool of consumers means lower premiums, resulting in lower costs to those who do not receive financial help and receive less federal spending.” The study, titled “Amid ACA Uncertainty, Covered California’s Risk Profile Remains Stable,” was posted last month on Health Affairs. Covered California released an expanded description of the results of the analysis, “Covered California Continues to Attract Sufficient Enrollment and a Good Risk Mix Necessary for Marketplace Sustainability.” According to the data, California’s risk score dropped from 1.11 in 2016 to 1.09 in 2017, indicating that the current population is healthier with respect to chronic conditions than it was a year ago. In addition, new enrollees in 2017 have an approximately 16% lower mean risk score than renewing enrollees, which is an improvement of 4% between 2016 and 2017. This suggests that Covered California is successfully attracting healthy enrollees to stabilize the risk pool.
Lee pointed to four key reasons why California has been successful in attracting a healthy mix of consumers: • The expansion of coverage linked to providing financial help through federal tax credits is bringing a healthy mix of consumers into the individual market and keeping them there. • Covered California continues to invest significantly in marketing and outreach, recognizing that there is high turnover in the individual market. • Unlike many other states, California converted all health coverage in the individual market into “compliant” plans and created one common risk pool as of 2014. • Health plans through Covered California offer patient-centered benefit designs, which allow consumers to access a wide variety of care that is not subject to a deductible, meaning consumers get more value from their coverage. “Doing early analysis of California’s risk mix is important because we can share this information with health insurance carriers during rate negotiations to get the best value for California’s consumers,” Lee said. Last month Covered California released an analysis that showed health plan premiums could rise up to 49%, and up to 340,000 Californians would drop from coverage, if cost-sharing reduction reimbursements were no longer directly made to carriers, and the individual shared responsibility payment were not enforced.
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Physician Salaries, Satisfaction on the Rise On average, physicians’ salaries have increased 42% since 2011, according to the latest nationwide salary survey from healthcare publisher Medscape. More than 19,200 physicians in more than 27 specialties responded to the Medscape Physician Compensation Report 2017, which showed average compensation climbed by $88,000 — from $206,000 in 2011 to $294,00 this year. According to the report: • Specialists earn $316,000 a year, and primary care physicians (PCPs) earn $217,000. That’s a pay gap just shy of $100,000, with specialists making 45.6% more than what PCPs make, a gap consistent with previous reports. • Seven specialties have seen double-digit growth over last year: plastic surgery (24%), allergy & immunology (15%), otolaryngology (13%), ophthalmology (12%), pulmonology (11%), orthopedics (10%) and pathology (10%). • Overall, self-employed physicians earn 28% more than employed physicians: $343,000 versus $269,000 for employed physicians. That 28% gap was the same among specialists: $368,000 for self-employed specialists versus $287,000 for their employed counterparts. • The gender gap for PCPs has narrowed somewhat. It was 18.9% in 2012 and is 16% this year, with male doctors earning $229,000 and females $197,000. • White/Caucasian physicians earn the most ($303,000), followed by those who are Asian ($283,000), Hispanic ($271,000), and black/ African-American ($262,000). The gap can be partly explained by participation in primary care, which pays less. Of the four groups, black/African-American doctors are most likely (30%) and white doctors least likely (20%) to be PCPs. • Participation in concierge increased from 1% to 3% from 2012 to 2014, but it has been stuck at that 3% since then. Similarly, participation in direct pay rose from 3% to 6% in that same period, but it has also not budged any more. • Participation in accountable care organizations (ACOs) mushroomed from 3% to 24% from 2012 to 2014, but the rate of growth since then has been about three or four percentage points a year, leading to the 2017 participation level of 36%. • Substantially more physicians say they would choose medicine again. That percentage rose from 64% in 2016 to 77% in 2017. • When asked about the most challenging part of the job, most respondents chose too many rules and regulations (28%), followed by working longer hours for less money
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(18%), dealing with difficult patients (15%), having to work with EHR systems (12%), dealing with difficulties of fair reimbursement (11%), and worrying about getting sued (8%). In other encouraging news for the medical profession, the American Medical Association (AMA) announced the results of a February 2017 survey that explored the experiences, perceptions and challenges facing physicians in the rapidly changing healthcare environment. The survey of 1,200 physicians, residents and medical students asked when respondents knew they would become physicians, who encouraged them down that path, what challenges they face professionally, and whether they are satisfied with their career choice. According to the survey, nine in 10 physicians are satisfied with their career choice, despite challenges common to each career stage. Three-quarters of medical students, residents and physicians said that helping people is a top motivator for pursuing their career, and 61% of all respondents said they would encourage others to enter the field of medicine. Personal experiences as a patient, volunteer and with family members played a role — across career stages — in realizing one’s calling to practice medicine. Additionally, 73% of respondents knew before they reached the age of 20 that they wanted to be physicians, and nearly a third knew before becoming a teenager. “Physicians may be discouraged at times, but almost every single one of us remains confident in our decision to enter medicine and continues to be driven by our desire to help our patients,” said Andrew W. Gurman, MD, AMA president. The AMA survey found administrative burden, stress and lack of time were among the top three challenges of respondents; however, among residents, a larger proportion indicated long hours and on-call schedule among their top challenges.
THE HIGHEST PAYING JOBS IN THE U.S. FOR HEALTHCARE, FINANCE AND TECHNOLOGY BASED ON LINKEDIN SALARY DATA 1. Orthopedic Surgeon - $400,000 [110+ jobs] 2. Surgeon - $400,000 [140+ jobs] 3. Cardiologist - $400,000 [100+ jobs] 4. Radiologist - $373,000 [60+ jobs] 5. Anesthesiologist - $368,000 [80+ jobs] 6. Medical Director - $260,000 [800+ jobs] 7. Pathologist - $258,000 [20+ jobs] 8. Vice President Of Quality - $245,000 [20+ jobs] 9. Physician - $235,000 – [3,000+ jobs] 10. Hospitalist – $233,000 [760+ jobs]
The $100 Billion Cost of Diabetes Heightened awareness of healthcare costs in recent years has put diabetes — and its prevention — in the spotlight. Recent studies have found, among other things, that out of U.S. spending on 155 medical conditions diabetes is far and away the top expense, reaching $101.4 billion in 2015; that nearly four times the number of U.S. adults may die of diabetes than is documented on death certificates, which would move the disease up from the seventh-leading cause of death to No. 3; and that preventing diabetes is more than a vital public health solution — it’s an effective financial strategy as preventing the onset of type 2 diabetes can reduce annual healthcare costs by thousands of dollars per patient and generate large positive returns on investment (ROI) for health systems, insurers and employers; and a California-focused study found 13 million adults (46% of all adults in the state) are estimated to have prediabetes or undiagnosed diabetes. According to the JAMA report “U.S. Spending on Personal Health Care and Public Health, 1996-2013,” all the chronic diseases on the list of the 20 costliest conditions “have an underlying health burden nearly exclusively attributable to modifiable risk factors. For example, diabetes was 100% attributed to behavioral or metabolic risk factors that included diet, obesity, high fasting plasma glucose, tobacco use and low physical activity.” “While some 29 million Americans have diabetes, another 86 million have prediabetes, including half of those 65 and older, according to the Centers for Disease Control and Prevention (CDC). But nine in 10 who have prediabetes don’t know it, suggesting there is a great opportunity for physicians and health systems to identify patients at risk for diabetes and help them get evidence-based prevention,” said AMA Wire staff writer Timothy M. Smith in a recent article. Another recent study focused on prediabetes and medical expenditures and confirmed that preventing the onset of type 2 diabetes could reduce annual healthcare costs by thousands of dollars per patient and generate large positive returns on investment (ROI) for health systems, insurers and employers. Researchers in the study, published in Population Health Management, used individual-level claims data from more than 8,000 commercially insured adults to estimate medical expenditures among individuals with prediabetes. Data on expenditures were combined with findings from previous studies to estimate net savings and ROI if they were to participate in a Centers for Disease Control and Prevention (CDC)-recognized diabetes prevention program (DPP). Based on an analysis of the data, researchers found that: • Expenditures during the one-to-three-year period following HbA1c screening are one-third higher for those who develop diabetes. That amounts to an annual average of $2,671 per patient. • Because the annual cost differential for patients who develop diabetes is significant, “the three-year ROI for a National DPP is estimated to be as high as 42 percent,” wrote the study’s authors, Tamkeen Khan, PhD, Stavros Tsipas, and Gregory Wozniak, PhD, all of the American Medical Association (AMA). • Diabetes prevention programs are still one of the best solutions for improving health outcomes and reducing burdensome
medical expenditures. In fact, patient participation in a CDCrecognized DPP in a community-based or primary care setting costs between $400 and $500 per person — far less than the average annual medical care expenditure savings. Not to mention previous research confirms that the impact of these programs extends beyond dollar signs: People who complete DPPs are one-third less likely to develop type 2 diabetes after 10 years. Using results from this analysis and findings in previous studies, the study authors estimated just 14% of patients who complete a DPP will be diagnosed with diabetes within three years, compared with 29% of those who do not participate. “The diabetes epidemic is out of control and getting worse. In California, diabetes rates have increased by 35 percent since 2001,” says California Medical Association President Ruth Haskins, MD. “In partnership with AMA, we are working hands-on with California’s physicians to implement meaningful diabetes prevention efforts to improve the health of Californians and ultimately improve the health of people across the country.”
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Classifieds
Continued from page 34 WANTED FAMILY PHYSICIAN
PEDIATRICIAN NEEDED IN LOS GATOS
Family medicine physician needed to share a growing outpatient practice. Start at 16 hours/week and share patient load. Practice caters to 75% PPO, rest Medicare and HMO. Contact ntnbhat@yahoo. com / 408/839-6564.
Four member Pediatric Group looking for a new physician to replace retiring partner. Office is independently owned and operated. Congenial working environment. Partnership track available, or remain as an associate indefinitely. Contact sbezecny@comcast.net.
PRIMARY CARE PHYSICIAN Busy primary care office is looking for board certified Internal or Family Medicine Physician. Contact inna@dryaskin. com or call 650/318-3384.
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FP/GP. Primary Care Practice for sale including inventory, equipment and medical building. 132 Alta Street, Gonzales, CA 93926-3005. If interested, please call Dr. Gines at 831/262-9238.
Santa Clara and Monterey County Medical Associations
2017 Physician Membership Resource Directory CONT
RPHEYFSOICRIAMNS
NAL PROFESSPIOMENT DEVELO
BILLING
HEAL
GEMENT E MANA S PRACRTAICCT NEGOTIATION
IRECTORY D P I H S R E B 2017 MEM TH CARE TE DISPU
CME
K S A E ODINGTH
DS L RECOR MEDICA
G KEEPIN
S M C M A SCCM
C
EC EHR SEML ENTATION & IMPLE TION
S SEMENT EIMBUR PAYOR R
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Available Now!
Directory Includes: • All Member Physicians • Santa Clara County • Monterey County • Specialty Listings • Advanced Practice Clinicians & Practice Locations • Pharmacies with Contact Information • Hospitals with Medical Staff Information and Contact Information • Lawmakers with Contact Information • Executive Board & Committee Members (Must be ordered through member and/or Office Manager to get reduced price)
Email: pjensen@sccma.org or call (408) 998-8850
GOVERNMENT
Final Budget Agreement Provides Over $1 Billion to Improve Medi-Cal Provider Payments June 16, 2017 Last November, the California Medical Association (CMA) took on Big Tobacco to improve access throughout the Medi-Cal program. California voters overwhelmingly approved Proposition 56, which added a $2 tax on tobacco products and stipulated that funds should increase access by improving provider payments. In January, the Governor’s budget redirected all tobacco tax revenues to support the state’s General Fund obligations. In May, he doubled down on his proposal, offering no additional funding to improve provider payments. Restoring Prop 56 funds was CMA’s #1 budget priority, and we engaged the legislature through earned media, digital advertising, grassroots outreach and direct advocacy. The legislature heeded CMA’s leadership and efforts – both houses rejected the Governor’s proposal and laid out a different framework for appropriating tobacco tax revenues into the final budget. And yesterday, the Senate and Assembly approved the state budget, which includes a Prop 56 appropriation bill that provides over $1 billion ($546 million in state funds plus a federal match) for the 2017-2018 fiscal year to improve provider payments. Specifically, the budget and Prop 56 appropriation bill provide: • $650 million for supplemental payments for physicians ($325 million in state funds plus a federal match). The legislative intent is for the rate increase to apply to physicians who participate in Medi-Cal fee-for-service or managed care. • $100 million for women’s health services ($50 million in state funds plus a federal match) and $8 million for HIV/AIDS waiver provider payments ($4 million in state funds plus a federal match). Physicians qualify for these supplemental payments if they provide such services. • $54 million for supplemental payments for Intermediate Care Facilities for the developmentally disabled ($27 million in state funds plus a federal match). • $280 million for supplemental payments for dentists ($140 million in state funds plus a federal match).
• $33 million in graduate medical education funding reallocated to the Song-Brown Program. In addition, the appropriation bill includes a mechanism to increase the supplemental payments for physicians and dentists to $800 million depending on the state’s fiscal condition, which would increase the allocation for physicians from $650 million to over $1 billion ($559.5 million in state funds plus a federal match). While the budget does not appropriate all tobacco tax revenues to improve provider payments as required by Prop 56, it explicitly sets aside millions to improve physician payments. The initiative required the state to improve payments to providers without specifying how to divide the revenues. Questions remain about how the remainder of tobacco tax revenues will be invested – but yesterday’s vote provides certainty that physicians will, at minimum, receive $650 million in the 2017-2018 fiscal year, $108 million for women’s health and AIDS/HIV services, and 70 percent of future supplemental provider payments. Other key details include: • The appropriation bill directs the Department of Health Care Services to develop and post on its website by July 31, 2017, a proposal on the structure for provider payments. • Consistent with federal law, the state will have to seek State Plan Amendments (SPA) to implement the increased payments. The SPA approval process normally takes a minimum of three months; money cannot be disbursed until the SPA is approved. The legislative intent is that physicians will be allowed to retroactively bill eligible claims made after July 1. CMA remains committed to ensuring that the state honors the will of Prop 56 voters, and we will continue to monitor and engage during implementation. The dialogue is ongoing, and additional details will be shared with members as they become verified.. Thanks to our member physicians for your tireless advocacy on behalf of California’s most vulnerable patients!
MAY / JUNE 2017 | THE BULLETIN | 45
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NO STRESS ACLS and BLS Courses Get your American Heart Association ACLS and BLS cards on Sunday August 20, 2017 at the Santa Clara County Medical Association, 700 Empey Way, San Jose, CA. These NO STRESS ACLS and BLS courses will utilize the full AHA curriculum including all the required videos, megacode practice and testing, written exams, and debriefing. Courses will start promptly at 9:00 a.m. You will receive your AHA course completion cards the day of the class, no waiting. To register contact: Randal Pham, MD at (408) 295-1201 or by email randal.pham@ alumni.ucsf.edu.
46 | THE BULLETIN | MAY / JUNE 2017
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