Q1 2020 Bulletin: Women in Medicine by SCCMA

Official Magazine of the Santa Clara Medical Association

Vol. 26 | No. 1

First Quarter 2020

This issue:

An Ode to Trailblazing Women in Medicine Suchada Nopachai, MD | Tanya Spirtos, MD | Nirmaljit Dhami, MD | Cindy Russell, MD

The Bulletin | 1

CONTENTS | Vol. 26 | No. 1 | First Quarter 2020

In this issue SCCMA is a professional association representing over 4,500 physicians in all specialties, practice types, and stages of their careers. We support physicians like you through a variety of practice management resources, coding and reimbursement help, training, and up to the minute news that could affect your practice. The Bulletin is our quarterly publication.

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April Becerra, CAE | Chief Executive Officer Thomas M. Dailey, MD | CMA Trustee - District VII Kenneth Blumenfeld, MD | CMA Trustee - District VII

Councilors El Camino Hospital of Los Gatos | Shahram S. Gholami, MD El Camino Hospital | OPEN Good Samaritan Hospital | Kirkor Barsoumian, MD Kaiser Foundation Hospital - San Jose | Priya Rao, MD Kaiser Permanente Hospital | Joshua Markowitz, MD O’Connor Hospital | David Cahn, MD Regional Medical Center | Heather Taher, MD Saint Louise Regional Hospital | Scott Benninghoven, MD Stanford Health Care/Children’s Health | John Brock-Utne, MD Santa Clara Valley Medical Center | Clifford Wang, MD 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: Mike Wamungu, Managing Editor 700 Empey Way San Jose, CA 95128 760/671-2337 Fax: 408/289-1064 mike@sccma.org © Copyright 2020, Santa Clara County Medical Association

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Steven H. Linder MD & Members of The Santa Clara County Opioid Overdose Prevention Project (SCCOOPP)

Departments A Message from the President

Seema Sidhu, MD

Medical Times From the Past

Michael Shea, MD

Classifieds

A Message from the President

by Seema Sidhu, MD

CMO and SCCMA President

Dear Members. Recently, the Bureau of Labor Statistics released its latest job report revealing that the economic shutdown due to COVID -19 caused the unemployment rate to jump to 14.7%. Many anticipate that next month’s number could be even higher. These numbers represent the extreme hardship that many families are facing right now. Hello, my name is Dr. Seema Sidhu and I am the president of the Santa Clara County Medical Association – a professional association representing 4,500 physicians across all specialties, practice types, and stages of their careers who share the collective goal of improving the physician’s ability to deliver the best care possible. I wanted to reach out to you as we all face some of the most challenging time we have seen in our lifetimes which have affected. Most of us have never witnessed such a far-reaching pandemic. As our everyday lives change, we are not only taking care of our patients; a lot of us are also preparing to meet the economic challenge that is following on the heels of this generational public health challenge. Our economy is facing a major disruption and the long-term impacts remain uncertain. But what gives me strength is knowing that SCCMA has a long history of leadership in the face of adversity — 144 years to be exact — and this moment is no different. This is a trying time for our profession, our patients, and our communities. But we can collectively take pride in knowing that our SCCMA medical community is stepping up, across the county, to lead us through this challenge. I want to thank every single one of you for your incredible and inspiring strength and efforts as we fight COVID-19. The measures that have been put in place, both at State and County level—have indeed flattened the curve. We should all be proud of the work we have done to accomplish this together. But our work is not over yet – there are many people in our communities who have been hit harder than others. I ask for your support as the SCCMA teams actively work on helping our physicians and communities through these challenging times. • SCCMA has engaged James Hinsdale, MD (past president of SCCMA & CMA) to serve as the Covid-19 Task Force Lead and to provide clinical leadership and guidance on COVID-19

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response.  The task force is actively working with local medical centers, medical groups and community leaders to continuously monitoring the current situation and tracking the issues/concerns that need to be addressed, share best practices, and coordinate resources. The SCCMA office is serving as a donation drop-off site for essential PPE, medical supplies and handmade cloth masks. Supplies are being donated to our physician members who need them to maintain their active practice, to front line emergency room providers and to our local long-term care facilities such as nursing care homes and homeless shelters. Thus far, we’ve donated over 3,000 face masks, face shields, and gloves. However, since the demand continues to outpace supply, we would love to see more members involved. Please visit our website at SCCMA.org and take an active role in this effort by both donating and sending us your requests for supplies. Last week, we facilitated a Town Hall with executives and physicians from Santa Clara County CEO Dr. Jeffrey Smith, California Medical Association, and SCCMA where we addressed your questions and shared our plans. The town hall can be viewed on demand on the COVID-19 resource page on our website. We will continue sending regular situation updates and new updated public health guidance to members which is always accessible at https://www.sccma.org/news-events/covid-19.aspx

On Re-Opening

Reescalation of medical services needs to be carefully done and we will be guided by our public health officers and our governor. More on this to via our our newsletter. We are all in this together. We will make it through these challenging times. And we have not only accomplished many goals, we will continue this momentum because: We are SCCMA Strong.

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The Santa Clara County Medical Association Santa Clara County Medical Association (SCCMA) was founded in 1876 by a small group of physicians who understood it was their duty to fight for their patients and profession. Confronted with the challenges of rampant quackery, epidemics of contagious disease, and a desperate need to establish standards for the profession, physician leaders of the time called upon their colleagues to help them form the Medical Society of the County of Santa Clara “to develop, in the highest possible degree, the scientific truths embodied in the profession.”

OFFICERS

COUNCILORS

President Seema Sidhu, MD

El Camino Hospital of Los Gatos: Shahram S. Gholami, MD

President-Elect Cindy Russell, MD

El Camino Hospital: OPEN

Past President Kenneth Blumenfeld, MD

Good Samaritan Hospital: Kirkor Barsoumian, MD

VP-Community Health Lewis Osofsky, MD

Kaiser Foundation Hospital - San Jose: Priya Rao, MD

VP-External Affairs Erica McEnery, MD VP-Member Services Randal T. Pham, MD VP-Professional Conduct Gloria, Wu MD Secretary Martin Wong, MD Treasurer Anh T. Nguyen, MD

CHIEF EXECUTIVE OFFICER April Becerra, CAE

Kaiser Permanente Hospital: Joshua Markowitz, MD O’Connor Hospital: David Cahn, MD Regional Medical Center: Heather Taher, MD Saint Louise Regional Hospital: Scott Benninghoven, MD Stanford Health Care/Children's Health: John Brock-Utne, MD Santa Clara Valley Medical Center: Clifford Wang, MD

Printed in U.S.A.

Managing Editor Mike Wamungu

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, or SCCMA. 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 of products or services advertised. The Bulletin and SCCMA reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Mike Wamungu, Managing Editor 700 Empey Way San Jose, CA 95128 760/671-2337 Fax: 408/289-1064 mike@sccma.org

CMA TRUSTEES - DISTRICT VII Thomas M. Dailey, MD Kenneth Blumenfeld, MD 4 | The Bulletin

An Ode to Trailblazing Women in Medicine Earlier this year, SCCMA requested that our community nominate trailblazing women who’ve demonstrated fearless creativity and innovation in healthcare leadership, research, education, medical practice, and community service. We were floored by your submissions. Below are your SCCMA Woman Trailblazers, in the words of their nominees.

Suchada Nopachai, MD Physician | Kaiser Permanente

Nominated by: Colleague, Sharon Ngo Tran | Community Engagement Manager | Kaiser Permanente

The Trailblazing Woman I’m Nominating is a: Ruckus-maker, Change-maker, Altruist What strikes you most about this person? I first met Dr. Suchada Nopachai when she volunteered to teach a group of at-risk high school youth from the Eastside Union High School District hands only CPR. She’s a humble physician with a sparkle in her eyes as she taught this interactive class. It was inspiring to learn how she turned her almost personal tragedy and into a monumental calling. I am putting forth Dr. Suchada Nopachai as my nominee for the TRAILBLAZING WOMEN IN MEDICINE award because of all the work she’s done in just 5 years with the California Medical Association, local schools, fire departments, the American Heart Association, and other entities around education of the life saving hands only CPR training. She is a ruckus maker and catalyzed change in putting forth a law to ensure that teachers and staff of K-12 and high school students all over California are CPR trained. She is an altruist in empowering all, even our youth, with the tools to save lives. She has made a huge impact to our community and society and continues to drive that message every day in her passion.

Tell us a story about something extraordinary this woman has done. Dr. Suchada Nopachai, a gynecologic surgeon at the Kaiser Permanente San Jose Medical Center, took an almost personal tragedy and turned it into a greater calling. In 2014, her then 4 year old son suddenly collapsed into cardiac arrest while playing in a park. She administered CPR and immediately rushed him to Kaiser Permanente San Jose, where he would fully recover. Following this event, Dr. Nopachai wrote to the California Medical Association (CMA) advocating that all teachers and staff of K-12 and high school students be CPR trained. This resolution was passed and she helped push it forward to becoming California law. Because of her efforts, bill AB 1719 mandates that all public and charter high schools require a course in health education for graduation to include instruction in performing hands-only CPR. This work has become her passion and not only has she helped implement CPR recertification training for physicians, piloted a program with the American Heart Association that provides infant CPR kids and training to new moms with premature or health-compromised babies, but can be found training students all across the bay area. She saw an opportunity for positive change and her impactful work may double or triple a person’s chance of surviving a cardiac arrest.

Tanya Spirtos, MD

OBGYN| Stanford’s Women’s Care Medical Group Nominated by: Colleague, Cindy Russell, MD | Palo Alto Medical Foundation

The Trailblazing Woman I’m Nominating is a: Altruist What strikes you most about this person? Her persistent calm stability and fairness in the face of conflict or chaos. Tell us a story about something extraordinary this The Bulletin | 5

woman has done. Altruism is a traditional virtue whereby an individual directs their attention to the happiness and well-being of others, with no expectation of reciprocal benefit. Dr. Spirtos exhibits this quality in all aspects of her life. She has been a rising star in the House of Medicine since she started practice in the San Francisco Bay Area in the 1990’s. She began her career as a Board-certified obstetrician-gynecologist and early on co-authored a series of groundbreaking articles on laparoscopy in the American Journal of Obstetrics and Gynecology. She became president of the Santa Clara County Medical Association (SCCMA) in 2005 and was elected to the CMA Board of Trustees in 2009. She was vice speaker of the CMA HOD in 2018-2019 and is currently the Speaker of the House for the CMA. Despite all of her accomplishments she never sought the limelight to push her own agenda, but only worked to further high-quality patient care, ethics in medicine as well as to support physicians in their increasingly difficult quest to practice good medicine. She is a sincere altruist, giving her time and energy to the House of Medicine. I most fondly remember her in her role as our local delegation chair for the CMA House of Delegates, giving sage advice to us novices. She was not critical of our resolutions, nor our lack of experience. With grace, kindness and wisdom she shepherded us through the complex process of passing resolutions which led to valuable policies for the CMA. It is an intimidating process made much easier with her gentle encouragement. She listens, quickly understands and finds a way to skillfully navigate the boat through rough waters. She is honest and trustworthy, and one who is depended upon for counsel in many areas of medicine and beyond. It is no exaggeration to say that when Dr. Spirtos speaks others listen. I enthusiastically nominate Dr. Tanya Spirtos for The Trailblazing Woman Award as an Altruist.

Nirmaljit Dhami, MD Perinatal Psychiatrist |Bay Area maternal mental health and el Camino health Nominated by: Colleague, Zahida ayyib Zahida Tayyib, MD | Psychiatrist | Mountain View TMS

The Trailblazing Woman I’m Nominating is a: Ruckus-maker, Change-maker, Altruist What strikes you most about this person? Dr. Dhami Has unrelenting kindness, empathy and passion towards our patients and has developed the field of perinatal psychiatry here in the bay area after identifying it as an unmet community need. She’s now recognized as a national and international expert in the field of perinatal psychiatry

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Tell us a story about something extraordinary this woman has done. About 11 years ago Dr. Dhami helped start an outpatient program for pregnant and postpartum women who are suffering with serious mental health issues. The program has now grown to encompass a partial hospitalization day treatment program, intensive outpatient program as well as a one of a kind inpatient psychiatry unit to treat women with perinatal mental health issues. Under her leadership, the El Camino program continues to grow and thrive serving women with serious mental health issues and stabilizing them. She has also brought an attachment and bonding work and emphasized in wall made of infants has the mom recovers from serious mental health issues

Cindy Russell, MD

Physician | Palo Alto Medical Foundation Nominated by: Friend, Steve Physician

Jackson, MD | Retired

The Trailblazing Woman I’m Nominating is a: Change-maker What strikes you most about this person? Dr. Russell’s knowledge, enthusiasm, expertise, and unflagging determination to bring environmental health issues and concerns to the attention of both physicians and the public. Her selfless dedication to educate and advocate for promoting the environmental health of our County, state and nation, and overcoming the multitude of forces and obstacles she inevitably encounters. Tell us a story about something extraordinary this woman has done. Dr. Russell, largely single handedly, has raised awareness about the adverse effects of wireless technology on the health of both children and adults. In addition to her articles and talks on this subject, she has organized two extraordinary and successful educational conferences for the public on the potentially harmful effects of wireless technology. She has battled the giant wireless corporate-industrial complex by bringing the truth - the scientific facts - to her audiences. She is a “voice in the wilderness” in terms of highlighting the impact of wireless technology on the physical, psychological, cognitive and social well being of our society.

COVID-19 FINANCIAL TOOLKIT FOR MEDICAL PRACTICES

For more information, visit cmadocs.org/covid-�� The Bulletin | 7

UPDATED: MAY 12, 2020

CMA COVID-19 FINANCIAL TOOLKIT FOR PHYSICIAN PRACTICES Table of Contents GETTING ORGANIZED--------------------------------------------------------------------------------------------------------------- 2 DIRECT PAYMENTS ------------------------------------------------------------------------------------------------------------------ 2 Telehealth ............................................................................................................................................................................................ 3 $175 Billion HHS Provider Relief Fund ........................................................................................................................................ 3 Phase Two Funding Details ---------------------------------------------------------------------------------------------------------- 4 Phase One Funding Details ---------------------------------------------------------------------------------------------------------- 7 Terms and Conditions ----------------------------------------------------------------------------------------------------------------- 7 What to Do if You Have Not Received a Direct Deposit -------------------------------------------------------------------- 10 Medicare Accelerated and Advance Physician Payments................................................................................................. 10

1. Below is a snippet of CMA's

FINANCIAL ASSISTANCE PROGRAMS ---------------------------------------------------------------------------------------11 COVID-19 Financial Toolkit. Please visit cmadocs.org/covLoan and Grant Programs ..............................................................................................................................................................11 id-19 for the full version.

Small Business Administration ----------------------------------------------------------------------------------------------------- 11 Debt Relief for Existing and New SBA Borrowers ---------------------------------------------------------------------------- 14 Small Business Finance Center ---------------------------------------------------------------------------------------------------- 14 California Capital Access Program for Small Businesses ------------------------------------------------------------------ 14 New Federal Main Street Business Lending Program and Treasury Department Stabilization Fund-------- 15 $200 Million in Financial Support from Blue Shield of California .....................................................................................16 Deferred Mortgage Payments .....................................................................................................................................................16 No Negative Credit Impacts Resulting from Relief ...............................................................................................................17 Student Loans and Continuing Medical Education ..............................................................................................................17 Professional Liability .......................................................................................................................................................................18

UNEMPLOYMENT, PAID SICK AND MEDICAL LEAVE, CHILD CARE ------------------------------------------------- 18 Deferred Employee Health Insurance Premiums for Small Businesses.........................................................................18

FEDERAL AND STATE TAX RELIEF --------------------------------------------------------------------------------------------- 19 Tax Credits ..........................................................................................................................................................................................19 Tax Credits for Sick and Medical Leave ----------------------------------------------------------------------------------------- 19 Employer Retention Tax Credit ---------------------------------------------------------------------------------------------------- 19 Delay of Payment of Employer Payroll Taxes --------------------------------------------------------------------------------- 20 Modification for Employer Net Operating Losses ---------------------------------------------------------------------------- 20 Increased Interest Expense Deductions ---------------------------------------------------------------------------------------- 20 Retirement Plan Early Withdrawals ---------------------------------------------------------------------------------------------- 20

HOTEL ROOMS FOR HEALTH CARE WORKERS ---------------------------------------------------------------------------- 20 CMA RESOURCES -------------------------------------------------------------------------------------------------------------------- 21 CMA’s Health Law Library .............................................................................................................................................................. 21 Consult a Professional .................................................................................................................................................................... 21

WHAT’S NEXT ------------------------------------------------------------------------------------------------------------------------22

Below is a snippet of CMA’s COVID-19 Financial Toolkit. Please visit cmadocs.org/covid-19 for the full version. cmadocs.org

(800) 786-4262 memberservice@cmadocs.org

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During the COVID-19 pandemic, physician practices are confronting operational and business challenges as they continue to deliver high quality care to their patients. This toolkit provides an overview of financial assistance available to medical practices during and after this difficult time so physicians have the information they need to make the right decisions for their businesses and families. NOTE: Substantive changes made over the past week will be highlighted in orange .

Getting Organized The American Medical Association (AMA) has developed a checklist for physician practices that provides high level guidance for practice owners and administrators so they can gain a comprehensive view of the financial status and resiliency of their practices. The checklist includes: 1. Implement a process for rapid decision-making and planning. 2. Understand your insurance coverage. 3. Evaluate ongoing financial obligations. 4. Make a financial contingency plan. 5. Assess current and future supply needs. 6. Understand how to continue business operations. 7. Consolidate administrative resources, including coding tools. 8. Manage workflow. 9. Use digital health tools. 10. Communicate guidelines to employees.

Direct Payments The federal economic relief package, signed into law on March 27, 2020, includes: +

$175 billion in direct assistance to physicians, hospitals and other health care workers for unreimbursed expenses and lost revenues due to reductions in other services as a result of the COVID-19 outbreak. The U.S. Department of Health and Human Services (HHS) distributed the first $30 billion from this fund on April 10-17, 2020. HHS began releasing a second wave of $20 billon for physicians and hospitals and another $20 billion for hospitals in hot zones and rural areas starting on April 25, 2020. HHS also released $10 billion for treatment provided to uninsured COVID-19 diagnosed patients. See “CARES Public Health and Emergency Fund” below.

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CMA COVID-19 FINANCIAL TOOLKIT

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to repay the entire balance due to CMS. Physicians will receive a 30 day final notice of any balance due. Once the 210 days are reached, any balance remaining will carry a 10.25% interest rate CMA and AMA are working to waive the 10.25% interest rate and extend the repayment timeline in reverse in Congress’ next COVID-19 response legislation. For more information, see the CMS fact sheet on the application process. UPDATE: On April 26, 2020, CMS suspended the Advance Payment Program for all Medicare providers. The agency said it is reevaluating the program in light of the $175 billion in direct payments being made available through U.S. Department of Health and Human Services (HHS) Provider Relief Fund that was authorized by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. CMS had expanded this temporary loan program to increase cash flow to providers and suppliers impacted by the COVID-19 pandemic. Since March 28, CMS has advanced $40 billion to physicians, non-physician providers, and durable medical equipment suppliers; and $60 billion to hospitals and nursing facilities. Funding will continue to be available to physicians and hospitals on the front lines of the coronavirus response primarily from the Provider Relief Fund. Payments from this fund do not need to be repaid. The Provider Relief Fund has already released $30 billion to providers, and is in the process of releasing an additional $20 billion, with more funding anticipated to be released soon. This funding will be used to support health care-related expenses or lost revenue attributable to the COVID-19 pandemic and to cover treatment costs for uninsured patients with a COVID-19 diagnosis. Click here for an updated CMS fact sheet on the Accelerated and Advance Payment Programs.

Financial Assistance Programs State and federal policymakers have developed legislation focused on economic relief for small businesses. The following is a list of funding programs that could assist physicians in maintaining financial viability. Please note that the federal economic relief legislation was signed into law on March 27, 2020. Federal regulators are now charged with providing detailed guidance on how to apply for the new funding. CMA will post the new rules as soon as they are released.

Loan and Grant Programs Small Business Administration NEW PAYCHECK PROTECTION PROGRAM Forgivable Loans from Private Lenders UPDATE: On April 24, 2020, Congress appropriated an additional $310 billion to the program so physicians should contact their lenders immediately to ensure you are in line to receive a loan. See additional information below.

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CMA COVID-19 FINANCIAL TOOLKIT

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The Coronavirus Aid, Relief and Economic Security Act (CARES Act) provides $360 billion in funding for new Small Business Administration (SBA) loan and grant programs. One of those programs is the Paycheck Protection Program (PPP), which will provide small businesses with less than 500 employees with forgivable, zero-fee loans of up to $10 million or 2.5 times their average monthly payroll costs. Part of these loans may be forgiven and not counted as income if 75% of the loan is spent during the first eight weeks of the loan origination on payroll. Other allowable expenses for the loan include, group health care benefits, lease payments, mortgage interest, and utilities. These PPP loans are available from participating private financial institutions. Physicians can apply through participating SBA 7(a) lenders or through any participating federally-insured depository institution, federally insured credit union and Farm Credit System institution. You should consult with your local lender as to whether it is participating in the program. Here is the SBA find a lender near you tool: sba.gov/paycheckprotection/find . Principal and interest will be deferred for at least six months and all borrower fees are waived. No collateral or personal guarantees are required. This loan has a maturity of two years and an interest rate of .5%. Forgiveness is based on the employer maintaining or quickly rehiring employees and maintaining salary levels. Forgiveness will be reduced if full-time headcount declines, or if salaries and wages decrease. Seventy five percent of the loan must be dedicated to payroll costs during the first eight weeks of the loan. More specifically, to receive forgiveness, businesses must maintain the same average number of employees for the first eight-week period beginning on the origination date of the loan as you did from February 15, 2019 - June 30, 2019, or from January 1, 2020, until February 15, 2020. If a business does not meet this standard, the amount of the loan that will be forgiven will be reduced. If businesses reduce compensation for employees who make under $100,000 by more than 25%, as compared to the most recent quarter, even less of the loan will be forgiven. There’s one overall exception. Businesses won’t be penalized for a reduction in employment or wages during the period from February 15, 2020, to April 26, 2020, if you rehire employees that you previously laid off or restore any decreases in wages or salaries by June 30, 2020. (The US Chamber of Commerce offers a step-by-step checklist and payroll calculation). However, if you have laid-off or furloughed staff, you probably won’t be able to wait until June 30 to rehire them if your new loan originates much sooner than June 30, because 75% of the loan must be dedicated to payroll during the first consecutive eight weeks from the loan origination date. Therefore, if you want loan forgiveness, you would need to rehire employees when the loan originates to be sure to expend 75% of the loan on payroll. Employers can obtain forgiveness for salary amounts up to $100,000 per employee. For purposes of calculating “average monthly payroll,” most applicants will use the average monthly payroll for 2019, excluding costs over $100,000 on an annualized basis for each employee. CMA recommends that interested physicians apply for the program immediately because the demand for these loans will be high. You can download the application to see the information that will be requested from you.

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Two critical documents related to the implementation of the Paycheck Protection Program were updated and released. See below. +

Paycheck Protection Program Loans: Frequently Asked Questions (Updated 4/14/2020)

Interim Final Rule – Additional Eligibility Criteria and Requirements for Certain Pledges of Loans (Released 4/14/2020)

This temporary emergency assistance can be used in coordination with other COVID financing assistance established in the bill or any other existing SBA loan program. UPDATE: Because of the high demand for these forgivable loans, the Paycheck Protection Program exhausted all funding within two weeks of its start date. In response, on April 24, 2020, Congress appropriated an additional $310 billion for the program. Interested physicians should contact their lenders immediately to be sure they are in line for funding. Sixty billion of the $310 billion was set aside for smaller lending institutions and community banks to make loans.

EXISTING ECONOMIC INJURY DISASTER LOAN PROGRAM UPDATE: On April 24, Congress approved an additional $50 billion for the EIDL program. SBA will work directly with state governors and private financial institutions to provide targeted, low-interest loans to small businesses and non-profits that have been severely impacted by the Coronavirus (COVID-19). The SBA’s Economic Injury Disaster Loan (EIDL) program provides small businesses with working capital loans that can provide vital economic support to small businesses to help overcome the temporary loss of revenue they are experiencing. EIDLs are loans of up to $2 million that carry interest rates up to 3.75% for companies and up to 2.75% for nonprofits, as well as principal and interest deferment for up to 4 years. The loans may be used to pay for expenses that could have been met had the disaster not occurred, including payroll and other operating expenses. A business that receives an EIDL between January 31, 2020, and June 30, 2020, as a result of a COVID-19 disaster declaration is eligible to apply for a PPP loan or the business may refinance their EIDL into a PPP loan. In either case, the emergency EIDL grant award of up to $10,000 would be subtracted from the amount forgiven in the payroll protection plan.

NEW ECONOMIC INJURY DISASTER LOAN PROGRAM GRANTS UPDATE: On April 24, Congress appropriated an additional $10 billion for the EIDL Advance Grants. The federal economic relief law includes $10 billion in grant funding to provide an advance of $10,000 to small businesses and nonprofits that apply for an SBA economic injury disaster loan (EIDL) within three days of applying for the loan. The new $10,000 EIDL grant does not need to be repaid, even if the grantee is subsequently denied an EIDL, and may be used to provide paid sick leave to employees, maintaining payroll, meet increased production costs due to supply chain disruptions, or pay business obligations, including debts, rent and mortgage payments. Eligible grant recipients must have been in operation on January 31, 2020. The grant is available to small businesses, private nonprofits, sole proprietors and

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independent contractors, tribal businesses, as well as cooperatives and employee-owned businesses. The SBA will issue additional details and guidance on the new program shortly.

EXPRESS BRIDGE LOANS Express Bridge Loan Pilot Program allows small businesses who currently have a business relationship with an SBA Express Lender to access up to $25,000 with less paperwork. These loans can provide vital economic support to help small businesses overcome the temporary loss of revenue and can be term loans or used to bridge the gap while applying for a direct SBA Economic Injury Disaster loan. If a small business has an urgent need for cash while waiting for decision and disbursement on Economic Injury Disaster Loan, they may qualify for an SBA Express Disaster Bridge Loan.

Debt Relief for Existing and New SBA Borrowers The federal economic relief law includes $17 billion in funding to provide immediate relief to small businesses with standard SBA 7(a), 504, or microloans. Under this provision, SBA will cover all loan payments for existing SBA borrowers, including principal, interest, and fees, for six months. This relief will also be available to new borrowers who take out an SBA loan within six months after the President signs the bill. The measure also encourages banks to provide further relief to small business borrowers by allowing them to extend the duration of existing loans beyond existing limits; and enables small business lenders to assist more new and existing borrowers by providing a temporary extension on certain reporting requirements. While SBA borrowers are receiving the six months debt relief, they may apply for a PPP loan that provides capital to keep their employees on the job. The six months of SBA payment relief may not be applied to payments on PPP loans. The stimulus also includes a permanent fix that allows SBA to waive fees for veterans and their spouses in the 7(a) Express Loan Program, regardless of the President’s budget. Under current law, SBA may only waive fees on 7(a) Express loans to veterans when the President’s budget does not project a cost above zero for the overall 7(a) loan program.

Small Business Finance Center On April 2, 2020, Governor Newsom announced that the State of California is allocating $50 million to the Small Business Finance Center at California’s IBank to mitigate barriers to capital for small businesses (1-750 employees) that may not qualify for federal funds (including businesses in low-wealth and immigrant communities). The $50 million allocation will be used to recapitalize the IBank Small Business Loan Guarantee Program. Disaster Relief Loan Guarantee Program: This disaster program provides guarantees for loans of up to $50,000 for small business borrowers in declared disaster areas. Contact IBank for more information. California IBank has a Small Business Loan Guarantee Program for guarantees up to $1 million and a micro lending program for loans up to $10,000 with accommodations for disasters. The program is run through local mission-based lenders, the Financial Development Corporations.

California Capital Access Program for Small Businesses

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The California Capital (CalCAP) Access Program for Small Business encourages banks and other financial institutions to make loans to small businesses that have difficulty obtaining financing. If you own a small business and need a loan for start-up, expansion or working capital, you may receive more favorable loan terms from a lender if your loan is enrolled in the CalCAP Loan Loss Reserve Program. This program helps communities by providing financing to businesses that create jobs and improve the economy. CalCAP is a loan loss reserve program which may provide up to 100% coverage on losses as a result of certain loan defaults. With CalCAP portfolio support, a lender may be more comfortable underwriting small business loans. Check to see if your commercial lender or financial institution participates in CalCAP or find a participating lender. If your financial institution does not currently participate, it is easy for lenders to sign up. Please have your institution complete the Financial Institution Application and send to CalCAP to get started.

New Federal Main Street Business Lending Program and Treasury Department Stabilization Fund Recently, the Federal Reserve announced a new Main Street Business Lending Program to support small and medium size businesses, including physician practices, but specific details are not expected until late April. The Federal Reserve said that the program would provide financing to banks and other lenders to make low interest loans capped at 2% (CARES Act) with no principal or interest due during the first six months of the loan. Loans are targeted for eligible businesses with less than 10,000 employees and cannot be forgiven. Available funds could total nearly $1 trillion. Application forms are not yet available but banks and lenders may produce their own applications. This program may be offered in coordination with the new CARES Act $454 billion Stabilization Fund created in the Treasury Department for employers with 500-10,000 employees. Details on the Stabilization Fund are forthcoming. Eligible Main Street Lending Program borrowers are required to make certifications, including but not limited to the following: +

Economic uncertainty makes the loan necessary to support ongoing operations;

Loans will be used to retain at least 90% of the employerâ&#x20AC;&#x2122;s workforce, at full compensation and benefits, until at least September 30, 2020.

The recipient intends to restore not less than 90% of the workforce that existed as of February 1, 2020 and to restore full compensation and benefits to those employees not later than four months after termination of the public health emergency;

Recipient is not a debtor in a bankruptcy proceeding;

Recipient will not abrogate any existing collective bargaining agreement for the term of the loan plus two years and will remain neutral in any union organizing effort for the term of the loan.

Recipient employers would also be subject to restrictions on compensation for highly compensated employees or officers for the period of the loan plus an additional year.

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For employees or officers with total compensation over $425,000 in 2019, those individuals would be capped at their 2019 total compensation for any consecutive 12-month period and could not receive any severance or termination payment great than two times their 2019 total compensation; and

For employees or officers with total compensation over $3 million in 2019, those individuals would effectively have their total compensation reduced by 50% of their 2019 compensation excess over $3 million for any consecutive 12-month period.

CMA will provide additional information as it becomes available. CMA urges interested physicians and physician groups to immediately contact their banks or local lenders to start preparing an application so that when more details are available, physician applications will be further along and more likely to receive funding.

$200 Million in Financial Support from Blue Shield of California Blue Shield of California is providing $200 million in direct support to physician practices and other health care providers. +

Loans: Blue Shield is providing up to $100 million in in provider loans. Loan amounts must not exceed $2 million. .

Advance Payments: Blue Shield is providing up to $100 million in advance payments for contracted Blue Shield providers. There is a grace period of six months and must be repaid in full by 12 months either directly or through offset of future claims.

Value-Based/Risk Sharing Contracts: Physicians can convert their contracts to value-based contracts (where available) or risk sharing contracts, which provide a monthly base revenue stream.

Providers can also opt to receive the patient cost-sharing portion of the bill at the time the claim is paid, eliminating the time and expense of collecting patient out-of-pocket costs. CMA is encouraging interested physicians to apply as soon as possible, as the available funding is limited. For more information and to apply for the programs, email financecommunication@blueshieldca.com.

Deferred Mortgage Payments On March 25, 2020, Governor Newsom announced that financial institutions would offer, consistent with applicable guidelines, mortgage payment forbearances of up to 90 days to borrowers economically impacted by COVID-19. In addition, those institutions must: +

Provide borrowers a streamlined process to request a forbearance for COVID-19-related reasons, supported with available documentation;

Confirm approval of and terms of forbearance program; and

Provide borrowers the opportunity to request additional relief, as practicable, upon continued showing of hardship due to COVID-19.

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In addition, under federal law, borrowers will receive 180 days of forbearance for federally backed mortgage loans (Fannie Mae, Freddie Mac, HUD, VA, USDA). The law also prohibits foreclosures on all federally-backed mortgage loans for a 60-day period beginning on March 18, 2020. This benefit terminates at the end of the national emergency or December 31, 2020.

No Negative Credit Impacts Resulting from Relief Under the new federal law, financial institutions may not report derogatory tradelines (e.g., late payments) to credit reporting agencies, consistent with applicable guidelines, for borrowers taking advantage of COVID-19-related relief. On April 23, 2020, Governor Newsom signed an executive order to stop debt collectors from garnishing COVID-19-related financial assistance. The order exempts garnishment for any individuals receiving federal, state or local government financial assistance in response to the COVID-19 pandemic. This includes recovery rebates under the CARES Act. Funds may still be garnished for child support, family support, spousal support or criminal restitution for victims.

Student Loans and Continuing Medical Education The federal economic relief law: +

Defers student loan payments, principals, and interests through September 30, 2020. Additionally, during this time, involuntary collection related to student loans will be suspended.

Allows students who withdraw from school as a result of COVID-19 to not return Pell grants, other grant assistance, or loans. Additionally, for students who withdraw from school as a result of COVID 19, the current academic term would be excluded from counting toward lifetime subsidized loan or Pell grant eligibility.

Allows schools to use Supplemental Educational Opportunity Grants as emergency financial aid grants to assist graduate students with unexpected expenses and unmet financial needs that arise as the result of COVID-19.

Allows institutions to transfer unused work-study funds to be used for supplemental grants. Additionally, it would give institutions the ability to issue work-study payments to student who are unable to work due to work-place closures, as a result of COVID-19, as a lump sum or in payments similar to paychecks.

Supports foreign education institutions, including graduate medical programs, as they offer distance learning to U.S. students receiving Title IV funds for the duration of the COVID-19 pandemic.

Governor Newsom issued an Executive Order on March 30, 2020 that extends physician Continuing Medical Education (CME) requirements for 60 days.

On April 23, 2020, Governor Newsom announced that most private student loan servicers have agreed to provide payment and other relief to borrowers, including more than 1.1 million Californians with privately held student loans. Under the new initiative by California and other states, students with commercially owned Federal Family Education Loan or privately held student loans who are struggling

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to make payments due to the COVID-19 pandemic may also be eligible for expanded relief. Relief options include providing a minimum of 90 days forbearance, waiving late payment fees, ensuring that no borrower is subject to negative credit reporting, and helping eligible borrowers enroll in other assistance programs.

Professional Liability The new federal law provides professional liability protections with exceptions under the Good Samaritan laws for physicians providing volunteer medical services during the COVID-19 public health emergency.

Unemployment, Paid Sick and Medical Leave, Child Care The economic relief law includes: +

Child Care Block Grant: $3.5 billion to allow child care programs to remain open and meet priority emergency staffing needs for health care workers and first responders.

Expands unemployment benefits for employees who remain unemployed after state unemployment benefits are no longer available. (Earlier legislation enacted by Congress increased funding for state unemployment insurance funds.)

An earlier Congressional bill provided the following expanded Paid Sick and Paid Family and Medical Leave for those impacted by the COVID-19 outbreak: +

Up to two weeks of paid sick leave for workers who work for the government or employers with 500 employees or less.

12 weeks of job-protected paid family and medical leave for government employees and employees who work for employers with less than 500 employees. The paid family and medical leave begins after the first 14 days of sick leave and is not less than two-thirds of the employee's regular payment rate. It will be provided to employees adhering to requirements or recommendations for quarantine; to care for a family member required or recommended for quarantine; or to care for a child whose school or child care is closed.

Tax credits to employers to offset the costs of emergency sick and medical leave.

For additional information on direct employment related issues, see the CMA COVID-19 FAQ and the CMA webinar on COVID-19 Employment Issues.

Deferred Employee Health Insurance Premiums for Small Businesses On April 30, 2020, Covered California for Small Business announced a new program aimed at helping hundreds of small businesses continue to provide insurance to their employees during the current COVID19 pandemic. The program will allow employers, who provide coverage to their employees and were unable to pay their premiums for the month of April, an extra 30 days to make their payments for the months of April and May and a way to spread the costs of those premiums over the balance of the year. The Premium Deferral Program is currently being offered to employers who have not yet paid their premiums for April or May. The program will allow affected businesses the flexibility to pay just 25 Page 18 of 22

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COVID-19 TELEHEALTH TOOLKIT FOR MEDICAL PRACTICES

For more information, visit cmadocs.org/covid-�� 18 | The Bulletin

UPDATED: APRIL 30, 2020

CMA COVID-19 TELEHEALTH TOOLKIT FOR PHYSICIAN PRACTICES Telehealth allows physicians to stay connected and provide care to patients without an in-person visit through the utilization of telecommunications. As physicians around the state are ramping up telehealth services so care can continue to be provided to those who need it during the COVID-19 public health emergency, CMA is compiling telehealth information from CMS and the major payors in the state. This toolkit includes payor guidance for billing and coding telehealth services, privacy and security concerns and flexibilities, and key considerations when implementing telehealth into your practice.

Table of Contents BILLING AND CODING -------------------------------------------------------------------------------------------------------- 1 Has there been any CPT guidance released related to telehealth? ---------------------------------------------------------- 1 What services will CMS allow for telehealth for Medicare patients? -------------------------------------------------------- 1 When billing for telehealth during the COVID-19 emergency, do I still have to document the patient history and/or physical exam in the medical record? ------------------------------------------------------------------------------------- 2 I am due for Medicare revalidation soon. Do I have to respond to the request? ---------------------------------------- 2 Has there been an extension to the MIPS reporting deadline? -------------------------------------------------------------- 3 How should I bill for telehealth services under Medi-Cal fee-for-service? ------------------------------------------------ 3 Are Medi-Cal managed care plans covering telehealth services? ----------------------------------------------------------- 3 Are commercial plans in California reimbursing for telehealth services? ------------------------------------------------ 4 Are PPOs and other plans regulated by CDI reimbursing for telehealth? ------------------------------------------------ 5 How are self-funded ERISA plans handling telehealth? ------------------------------------------------------------------------ 5 Are workers compensation carriers in California reimbursing for telehealth services? ------------------------------ 5 Can I bill telehealth services for new patients? ----------------------------------------------------------------------------------- 6 Is there a resource that lists telehealth guidance by payor? ----------------------------------------------------------------- 6 What should I do if a payor denied my claim for telehealth services? ----------------------------------------------------- 6

PRIVACY AND SECURITY ----------------------------------------------------------------------------------------------------- 7 Did the federal government waive its enforcement of HIPAA for telehealth services? ------------------------------ 7 Does the federal HIPAA waiver apply to all health care services or only to COVID-19 related services? -------- 7 Have California privacy laws been waived? ---------------------------------------------------------------------------------------- 7 What are the relevant California privacy laws? ----------------------------------------------------------------------------------- 8 Are patients required to consent to telehealth services under California law? ----------------------------------------- 8 What do I have to do if I discover a breach or suspected breach of patient data?------------------------------------- 8

IMPLEMENTING TELEHEALTH --------------------------------------------------------------------------------------------- 9 What are the key requirements for implementing telehealth into my practice? -------------------------------------- 9 What should my practice consider when selecting a telehealth solution? ---------------------------------------------- 9 What are my practice’s telehealth platform options? ------------------------------------------------------------------------- 10 Does CMA have any recommended telehealth options? ---------------------------------------------------------------------- 11

cmadocs.org

NOTE: Materials, legal citations and all other information contained in this document are solely intended to be used for informational purposes only. Nothing herein is intended to be, and should not be interpreted as, legal advice. Furthermore, nothing herein is intended to create, and does not form, an attorney-client relationship between or among any parties. To the extent you need specific advice, you may wish to personally consult a qualified attorney. NOTE: Substantive changes from our last update will be highlighted in orange .

Billing and Coding

Has there been any CPT guidance released related to telehealth? New guidance from the American Medical Association (AMA) provides special coding advice during the COVID-19 public health emergency. One resource outlines coding scenarios designed to help health care professionals apply best coding practices. The scenarios include telehealth services, including telephonic visits, for all patients . Examples specifically related to COVID-19 testing include coding for when a patient: comes to the office for E/M visit and is tested for COVID-19 during the visit; receives a telehealth visit re: COVID-19 and is directed to come to physician office or physician’s group practice site for testing; receives a virtual check-in/online visit re: COVID-19 (not related to E/M visit), and is directed to come to physician office for testing; receives a telephone visit, and more. There is also a quick-reference flowchart that outlines CPT reporting for COVID-19 testing. AMA has also published a quick guide to support physicians and practices in expediting the implementation of telemedicine, so care can continue to be provided to those who need it most. VIEW CMA’S ARTICLE ON THE AMA QUICK GUIDE. AMA has also posted guidance to assist physicians on telehealth workflow and patient care. Documentation and Follow Up: Whichever modality of telehealth that your practice is using, it’s important to ensure the documentation matches the requirements of the CPT code you are billing. Also, be aware that, without a face-to-face encounter, it can be more difficult to track patients for follow up care. Physicians should consider adjusting practice workflows ahead of time to ensure that patients fill prescriptions, schedule follow up visits, etc. can occur.

What services will CMS allow for telehealth for Medicare patients? The Centers for Medicare and Medicaid Services (CMS) has issued several temporary waivers and new rules to allow healthcare providers maximum flexibilities to respond to the COVID-19 crisis. On March 31, 2020, CMS authorized additional telehealth flexibilities stating it will pay for more than 80 additional services when furnished via telehealth and advised that CPT codes 99441-99443 (telephone services) are permitted. At this time, the guidance from CMS is if the visit is done with audio-only (no video

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component), it must be billed as a telephone visit code (99441-99443) or as a virtual check in (G2012). Reimbursement rates for telephone services (CPT 99441-99443) by locality can be found on the Noridian website. The expansion of telehealth services is effective as of March 1, 2020. The U.S Health and Human Service Office for Civil Rights announced it will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. VIEW CMA’S ARTICLE ON THE FEDERAL ANNOUNCEMENT. Governor Gavin Newsom on April 3, 2020, issued an executive order that relaxes certain state privacy and security laws for health care providers, so they can provide telehealth services without the risk of being penalized. This action is similar to the waiver issued on March 17, 2020, by the U.S. Department of Health and Human Services regarding federal privacy and security laws. IMPORTANT UPDATE ON BILLING FOR PROFESSIONAL SERVICES: According to Noridian, when billing professional claims for non-traditional telehealth services with dates of services on or after March 1, 2020, and for the duration of the public health emergency, you should bill with the place of service (POS) equal to what it would have been in the absence of a public health emergency, along with a modifier 95, indicating that the service rendered was actually performed via telehealth. This is different than previous guidance to bill with a POS of 02. Claims billed with a POS of 02 will be paid at the facility rate. VIEW CMA’S ARTICLE ON THIS UPDATE.

When billing for telehealth during the COVID-19 emergency, do I still have to document the patient history and/or physical exam in the medical record? No. CMS will permit physicians to select the level of office/outpatient E/M visit (CPT codes 99201-99215) furnished via Medicare telehealth based on time or medical decision making. CMS has removed any requirements regarding documentation of history and/or physical exam in the medical record for such visits. For this purpose, “time” is defined as all the time associated with the E/M on the day of the encounter. The current typical times associated with office/outpatient E/M codes in CPT are what should be met for the purposes of level selection. CMS is maintaining the current definition of MDM. FOR MORE INFORMATION, SEE CMS INTERIM FINAL RULE (PAGE 136).

I am due for Medicare revalidation soon. Do I have to respond to the request? The Centers for Medicare and Medicaid Services (CMS) has temporarily suspended revalidations. Until further notice, no provider will be deactivated or have their payments pended for not responding to a previously sent revalidation request. Additionally, no new requests will be mailed to physicians who are due to revalidate. VIEW CMA’S ARTICLE ON THIS ANNOUNCEMENT. CMS has also established toll-free hotlines for physiciansand non-physician practitioners to enroll and receive temporary Medicare billing privileges. For more details see the FAQ on provider enrollment.

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Has there been an extension to the MIPS reporting deadline? On March 22, 2020, the Centers for Medicare and Medicaid Services (CMS) announced the 2019 MIPS reporting deadline was extended from March 31, 2020 to April 30, 2020. Reporting for 2019 measures will be optional for all MIPS eligible clinicians. MIPS eligible clinicians who have not submitted any MIPS data by April 30, 2020, will qualify for the automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year. Physicians do not need to take any additional action to qualify for the automatic extreme and uncontrollable circumstances policy. However, if a MIPS eligible clinician submits data on two or more MIPS performance categories, they will be scored and receive a 2021 MIPS payment adjustment based on their 2019 MIPS final score. Additionally, no data reflecting services provided January 1, 2020 through June 30, 2020, will be used in CMS’s calculations for the Medicare quality reporting and value-based purchasing programs. VIEW CMA’S ARTICLE ON THE MIPS EXTENSION.

How should I bill for telehealth services under Medi-Cal fee-for-service? Medi-Cal’s telehealth policy allows providers to bill DHCS as clinically appropriate for any covered MediCal benefits or services using the appropriate procedure codes, either CPT or HCPCS. The codes must be billed using place of service, 02, telehealth, and the appropriate telehealth modifier must also be used: +

Synchronous, interactive audio and telecommunication systems – modifier 95

Asynchronous store and forward telecommunications system – modifier GQ

DHCS defines synchronous telehealth as “two-way interactive audio-visual communication.” CMA has confirmed with DHCS that telephonic visits qualify as synchronous telehealth under this policy. This guidance does not apply to FQHCs. See Medi-Cal’s telehealth policy for information on telephonic visits with FQHCs, RHCs, and Tribal 638 clinics.

Are Medi-Cal managed care plans covering telehealth services? On March 19, 2020, the Department of Health Care Services (DHCS) issued a supplement to an All Plan Letter (APL) that mirrors the DMHC’s APL. It requires Medi-Cal managed care plans to immediately begin reimbursing for telehealth services, including telephonic visits, at the same rate as those provided inperson, when medically appropriate. In essence, if the service is one that would otherwise have been provided in-person but is now being provided via telehealth the plans should reimburse as though it was provided in-person. This order applies to Medi-Cal managed care plans that have a Knox Keene license. The Medi-Cal managed care plans are responsible for ensuring their delegated groups comply. County Organized Health Systems are also required to comply. VIEW CMA’S ARTICLE ON THIS APL SUPPLEMENT.

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Are commercial plans in California reimbursing for telehealth services? On March 18, 2020, the Department of Managed Health Care (DMHC) issued an All Plan Letter (APL 20009) requiring plans to immediately begin reimbursing for telehealth services, including telephonic visits, at the same rate as those provided in-person, when medically appropriate. In essence, if the service is one that would otherwise have been provided in-person but is now being provided via telehealth the plans should reimburse as though it was provided in-person. This order applies to all health plans regulated by the DMHC, which includes all HMOs and most of the Blue Cross and Blue Shield PPO products and DMHC has confirmed the plans are required to ensure their delegated entities comply. The letter requires plans to comply immediately and is effective as of March 18, 2020. DMHC has since clarified that plans should not be limiting use of telehealth to a plan’s contracted third party vendor. The intent of the APL is to allow patients to continue to see their own physicians via telehealth, when medically appropriate. Health plans were also instructed that they may not subject enrollees to cost-sharing greater than the same cost-sharing if the service were provided in person. It’s important to note that practices must ensure that their documentation matches the requirements of the CPT code they are billing and appropriate use of the place of service code, 02, telehealth. VIEW CMA’S ARTICLE ON THE DMHC APL. Additionally, on April 7, 2020, DMHC issued a follow-up APL (20-013) and an FAQ that provides specific billing guidance on billing for telehealth services. The guidance advises that practices should document the visit as if it had occurred in person and select the most appropriate CPT code, bill with place of service 02, telehealth, and use modifier 95 for synchronous telemedicine or GQ for asynchronous. The APL and FAQ also clarify the following: +

Health plans may not exclude coverage for certain types of services or categories of services simply because the services are rendered via telehealth, if the provider, in his/her professional judgment, determines the services can be effectively delivered via telehealth.

Plans are prohibited from placing limits on covered services simply because the services are provided via telehealth, if such limits would not apply if the services were provided in-person.

During the COVID-19 emergency, plans cannot require enrollees of DMHC regulated plans to use the plan’s third-party telehealth vendor.

Plans cannot require the provider to be approved/credentialed specifically for telehealth if the plan would have otherwise covered the services if provided in person. However, this does not authorize out-of-network telehealth services.

Plans are prohibited from requiring providers to use particular platforms or modalities of telehealth as a condition of reimbursement.

VIEW CMA’S ARTICLE ON DMHC APL 20-013.

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Are PPOs and other plans regulated by CDI reimbursing for telehealth? On March 30, 2020, the California Department of Insurance (CDI) instructed CDI-regulated health insurance companies to take immediate steps to provide increased telehealth access during the COVID-19 emergency. Insurance carriers will be required to reimburse providers at the same rate for telehealth services as they would for services provided in person. If the service is one that would otherwise have been provided in-person but is now being provided via telehealth, insurers should reimburse for that service as if it were provided in person, when clinically appropriate. Insurers must also reimburse a service provided telephonically at the same rate as services provided via video. The announcement requires insurers to comply immediately and is effective throughout the declared COVID-19 state of emergency. Additionally, insurance companies were instructed that they may not subject enrollees to cost-sharing greater than it would be if the service were provided in person. The CDI notice also clarifies that insurers should not be limiting use of telehealth to an insurer’s third party vendor. The notice states that insurers should allow all network providers to use all available and appropriate modes of telehealth delivery. SEE CMA’S ARTICLE ON THE CDI ANNOUNCEMENT.

How are self-funded ERISA plans handling telehealth? The telehealth requirements issued by the state and federal governments do not currently apply to selffunded ERISA plans. CMA is advocating for parity at the federal level to require self-funded ERISA plans to recognize and reimburse telehealth services, including telephonic visits, at the same rate as they would for in-person visits. CMA has also learned that some self-funded plans are only covering telehealth if it is provided through the plan’s third-party telehealth vendor. The cost sharing waivers also do not apply to ERISA plans. It is currently up to individual employers to decide whether they will waive cost sharing. CMA continues to advocate for telehealth parity at the federal level with self-funded ERISA plans.

Are workers compensation carriers in California reimbursing for telehealth services? On April 13, 2020, the California Division of Workers’ Compensation (DWC) announced that it would be covering telehealth services for injured workers. DWC will be covering the same telehealth services as those being allowed by the Centers for Medicare and Medicaid Services. The order is effective for

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services provided on or after April 15, 2020, and will remain in place throughout the public health emergency. According to the DWC order, providers will reimbursed at same rate for telehealth services provided to injured worker as they would for the same services provided in person. When billing for these services, providers should list the same Place of Service that would have been used had the service been provided in person, along with modifier 95 to indicate that the service was provided via telehealth. SEE CMA’S ARTICLE ON THE DWC ANNOUNCEMENT.

Can I bill telehealth services for new patients? Yes. CMS has clarified in its guidance that physicians can provide the expanded list of telehealth services during the emergency to new or established Medicare patients. Additionally, regulatory guidance from the DMHC, DHCS and CDI collectively indicates that during the state of emergency plans must reimburse providers at the same rate, whether a service is provided inperson or through telehealth, if the service is medically appropriate and is the same regardless of the modality of delivery. CMA believes this would include new patient visits. DWC has adopted Medicare’s telehealth policy during the emergency, which includes new patient visits.

Is there a resource that lists telehealth guidance by payor? As physicians around the state are ramping up telehealth services so care can continue to be provided to those who need it most, CMA is compiling telehealth information from the major payors in the state. Physicians should be aware that each payor's rules on what they will pay may differ. CMA has published a chart of all the guidance that has been released by payors. This chart will be updated regularly as new guidance is released.

What should I do if a payor denied my claim for telehealth services? While regulators issued guidance requiring plans and insurers to comply with the telehealth requirements beginning as early as mid-March, depending on the regulator, it may have taken payors some time to implement those changes in their systems. CMA is inquiring with the large managed care payors to understand when their systems were updated and to ask that the plans conduct a claims sweep to identify any claims that were denied in error and automatically reprocess those claims. Physicians may also appeal in writing. If your practice is experiencing issues with a particular payor, CMA members can contact CMA’s Center for Economic Services for assistance at (888) 401-5911 or economicservices@cmadocs.org.

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Privacy and Security

Did the federal government waive its enforcement of HIPAA for telehealth services? Yes, the HHS Office for Civil Rights (OCR) announced it will waive HIPAA penalties for good faith use of audio or video communication technology to provide telehealth to patients during the COVID-19 public health emergency. The intent of this approach is to allow health care providers to use popular applications that allow for remote communication that might not be secure, including Apple FaceTime, Zoom, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide health care services without risk of penalty for noncompliance. Physicians are encouraged to notify patients that these third-party applications potentially introduce privacy risks and record in the medical record the patient's consent to use these technologies. Physicians should enable all available encryption and privacy modes when using such applications. Under this waiver, however, Facebook Live, Twitch, TikTok, and similar video communication applications that are public facing should not be used in the provision of telehealth. (For more information regarding the HIPAA waiver, click here.)

Does the federal HIPAA waiver apply to all health care services or only to COVID -19 related services? The waiver applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19. For example, physicians in the exercise of their professional judgement may request to examine a patient exhibiting COVID- 19 symptoms, using a video chat application connecting the provider’s or patient’s phone or desktop computer to assess a greater number of patients while limiting the risk of infection of other persons who would be exposed from an in-person consultation. Likewise, a physicians may provide similar telehealth services in the exercise of their professional judgment to assess or treat any other medical condition, even if not related to COVID-19, such as a sprained ankle, specialty consultation or psychological evaluation, or other conditions.

Have California privacy laws been waived? Penalties pursuant to many California laws have been suspended to accommodate greater use of telehealth consistent with the HIPAA waivers, though the laws themselves remain in place. The California Department of Public Health waived nearly all licensing requirements under Division 2, Chapter 2 of the Health and Safety Code (which includes sections 1280.15 and 1280.18) until June 30, 2020, which may be extended as needed. Subsequently, in an Executive Order on April 3, 2020, the Governor suspended: administrative fines, civil penalties, and private rights of action under the California Medical Information Act (CMIA) contained in Civil Code sections 56.35 and 56.36 for disclosures made during the good faith provisions of telehealth services; civil penalties contained in Civil

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Code sections 1798.29 and 1798.82 and related causes of action related to the timely notification to patients of security breaches that occur during the good faith provision of telehealth services; administrative penalties contained in Health and Safety Code sections 1280.15 and 1280.17 and related causes of action related to the unauthorized access or disclosures that occur during the good faith provision of telehealth services; and criminal penalties contained in Welfare and Institutions Code section 14100.2(h) and related causes of action related to the release of information regarding Medi-Cal beneficiaries during the good faith provision of telehealth services.

What are the relevant California privacy laws? The California Medical Information Act (CMIA), Health & Safety code section 1280.15, 1280.18, and Civil Code 1798.82 each obligate health care providers to prevent unlawful or unauthorized access to and disclosure of patients' medical information and safeguard patients' medical information – penalties for failure to do so during the good faith provision of telehealth services were suspended in the Governor's April 3, 2020, Executive Order. However, providers must still comply with notification requirements in Health and Safety Code section 1280.18, but the time period for such notifications was extended from 15 days to 60 days. Penalties have not been suspended for the provision of any services that are not telehealth.

Are patients required to consent to telehealth services under California law? In his April 3 Executive Order, the Governor suspended the requirement to obtain and document a patient's verbal or written consent to telehealth services. (Business and Professions Code 2290.5)

What do I have to do if I discover a breach or suspected br each of patient data? In his April 3 Executive Order, the Governor suspended penalties and causes of action contained in Civil Code 1798.82 with regard to inadvertent, unauthorized access or disclosure that occurs during the good faith provision of telehealth services and extended deadlines for notifications pursuant to Health and Safety Code section 1280.15, which now must be made within 60 days (extended from 15 days). No suspensions have been issued with regard to breaches or suspected breaches of patient data not related to the good faith provision of telehealth services. For detailed information regarding data breaches and notification requirements. See CMA’s health law library document #4006, "Security Breach of Health Information."

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Implementing Telehealth

What are the key requirements for implementing telehealth into my practice? Telehealth is a mode of remote care delivery using electronic information and communication technologies. There are various requirements any practice should keep in mind when electing to conduct telehealth. +

STATE REQUIREMENTS – Each state has their own unique requirements. In California, physicians using telehealth must be licensed to practice medicne in California. More information can be found on the Medical Board of California’s website. In the face of COVID-19, expedited authorizations of out-ofstate medical personnel are being conducted. More information can be found on EMSA’s site.

PATIENT CONSENT AND DOCUMENTATION – California law requires that a physician initiating the use of telehealth inform the beneficiary, obtain consent to the telehealth encounter, and maintain documentation. If a physician or their practice has a general consent protocol that references telehealth as a modality of practice, this would satisfy the consent requirement. However, in his April 3, 2020, executive order, Gov. Newsom suspended the requirements contained in Business and Professions Code section 2290.5 to obtain and document a patient's verbal or written consent to telehealth services.

REIMBURSEMENT – In the past, reimbursement for telehealth was tricky. In the face of COVID-19, however, the laws and commercial payor policies are quickly being amended, waived, or not enforced on both the federal- and state-level to make reimbursement easier and on parity with face-to-face visits. However, practices must still ensure that the documentation matches the code in which they are billing.

PRIVACY AND SECURITY COMPLIANCE – Due to COVID-19, the federal government is offering temporarily relief from federal regulations around HIPAA compliance. California has also relaxed certain state privacy and security laws for health care providers, so they can provide telehealth services without the risk of being penalized.

What should my practice consider when selecting a telehealth solu tion? When selecting a telehealth solution that makes sense for you and your practice, you may want to consider the following criteria. 1. PHYSICIAN AND OFFICE STAFF EXPERIENCE – Consider the barriers to physician and staff use. A solution that ties into or permits continued use of your EHR, has a scheduling option and a waiting room, offers consent and intake forms, allows for billing at the time of service, includes training modules, and offers patient engagement materials (such as flyers and email templates), are all

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CMA COVID-19 TELEHEALTH TOOLKIT

(Rev. 04/30/20)

important considerations. Additionally, consider whether the platform allows for staff to have access, so they can assist with scheduling, responding to messages, and billing. 2. PATIENT EXPERIENCE - Consider the barriers to patient use. The more platforms a telehealth solutions operates on – mobile, desktop browsers, etc. – the more options your patients will have. Additionally, a solution that offers a simple link via email or text might be easier for some patients than one requiring app downloads. 3. TECH REQUIREMENTS – Getting a telehealth solution up-and-running can be time consuming. In the midst of COVID-19, selecting a solution that can be implemented quickly and securely, understood easily, and utilized for your own patients and with your current payer contracts is important. Consider the equipment required to operate the platform, upload/download speeds needed, whether the platform offers technical support, and what practice modalities the platform offers (such as chat, secure email, and videoconferencing over web and mobile) 4. COMPLIANCE – As mentioned above, during COVID-19 the federal and state privacy and security and consent rules have been temporarily waived. However, the best long-standing solution should be HIPAA compliant and, if possible, include a workflow to obtain consent. 5. COST – If telehealth is new to your practice, cost will be an important consideration. Most solutions have month-to-month commitments, allowing you flexibility based on your needs.

What are my practice’s telehealth platform options? There are a few different ways a practice can incorporate a telehealth solution into its daily workflow. The following are the twi main telehealth solution options: 1. EHR-INTEGRATED SOLUTIONS. Your existing electronic health record (EHR) platform may support one or more third-party telehealth applications, allowing remote visits that integrate directly with your EHR platform. 2. STANDALONE SOLUTIONS. Standalone solutions strictly facilitate remote patient communications, allowing you to use your existing EHR system for scheduling, documentation and billing. Standalone solutions can provide the telehealth technologies directly to physicians to see their own patients or provide the telehealth technologies through a medical group to help manage overflow. During the COVID-19 outbreak, the non-enforcement of federal and state privacy standards allows for the temporary use of non-public facing remote connections, such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, and Skype.

Page 10 of 12

CMA COVID-19 TELEHEALTH TOOLKIT

(Rev. 04/30/20)

The Bulletin | 29

Does CMA have any recommended telehealth options? CMA encourages physicians to utilize a telehealth solution that makes the most sense for them and their practice in both the short and long-term. In the midst of COVID-19, however, CMA recognizes that time is of the essence. Physicians and their practices need to be able to see their patients and finding a telehealth solution that can be implemented quickly, easily, and securely is of the utmost importance. For this reason, CMA Physician Services has partnered with Amwell, the nation’s leading telehealth solution, to give all California physicians discounted access to its turnkey telehealth solution. More information on the partnership and Amwell offerings can be found at cmadocs.org/telehealth.

Page 11 of 12

30 | The Bulletin

CMA COVID-19 TELEHEALTH TOOLKIT

(Rev. 04/30/20)

Struggling to make sense of the current pandemic? Keep up with the latest COVID-19 news, research, and developments with by visiting our COVID-19 resource page: sccma.org/covid-19

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The Bulletin | 31

California Readies Army of Coronavirus Detectives BY RACHEL BECKER | Cal Matters

32 | The Bulletin

“ ”

California gears up to train thousands of state workers to trace the spread of the virus amid plans to re-open the state.

The Newsom administration has teamed with two universities to train more than 3,000 employees per week to become coronavirus detectives tracing the spread of the disease throughout California. Starting Wednesday, the University of California, Los Angeles and the University of California, San Francisco will provide 20 hours of online and in-person training to state employees selected for the program. The new “training academy,” as Gov. Gavin Newsom called it, is part of an effort to build an army of 20,000 people to test, trace and isolate people who may have been infected. In addition, a new statewide database will help local health departments trace infected people and their contacts as they travel through the state. “I’m very excited about that innovation,” said Madera County public health director Sara Bosse. “It is something that we have needed for a decade in California, because we often have cases in which contacts cross counties for any disease.” The process of tracking the virus as it spreads from person to person is called contact tracing. And experts agree that it is critical to quashing new outbreaks of the novel coronavirus before they start — particularly as efforts to reopen the state provide more opportunities for infection. “As people move more, we increase the risk for people to get sick,” Sonia Angell, California Department of Public Health director and State Health Officer, said in a live stream. “If people get sick, we want to identify those individuals very early, and then make sure that all of their contacts are also identified.” Right now, 23 of California’s 61 local health departments are actively tracking exposed contacts as the coronavirus spreads from person to person, according to Newsom. Nearly 3,000 investigators interview people who test positive, identify the people they’ve interacted with and notify them that they need to isolate or quarantine. But the National Association of County and City Health Officials estimate that the nation will need 30 contact tracers for every 100,000 Americans to handle the pandemic. Which means that California’s 2,845 contact tracers fall far short of the 12,000 needed to track the virus through California’s population of nearly 40 million. To that end, Newsom announced plans to redeploy state em-

ployees with “the right kind of background cultural sensitivity, cultural competency, different language skills, a health mindset.” Madera County’s Bosse said she hasn’t yet seen the training modules. But she said that training resources have been a real need across the state, although her county has adjusted. “Our contact-tracing resources, as you know, on a regular day, are quite small,” Bosse said — which means few people are generally available to help with training. “At this point, we now have a collection of folks that have significant skills and could easily do shadowing and on-the-job training.” The new online training program could help standardize contact-tracing state-wide, she said. “It’s comforting to know that people would at least have a similar approach.” Newsom and Angell did not say how they would provide in-person instruction, given public health recommendations for physical distancing. They also did not say when the new contact tracers would be deployed. But when they are, local health authorities can request staffing help from the state, according to Angell. The new contact-tracing platform the state announced today will sync up with California’s existing digital disease surveillance platform, and contact tracers can use it to check in on people’s symptoms through texts, chat, emails, and phone automation, according to Angell. Angell emphasized that the database will focus on health information and will be kept confidential. Bosse hopes the new digital database will help streamline contact-tracing for cases and contacts that cross county borders. Still, there’s one major caveat to the state’s efforts to bolster contact-tracing, she said: people must be willing to cooperate, particularly if cooperating means missing work and wages — and potentially putting friends, family, and coworkers out of work for two weeks, too. “With so many people who are unemployed or underemployed at this point, once they have the ability to be employed, are they going to be willing to be tested?” Bosse asks. “Wage replacement, so ability to be paid sick leave, is going to be super important — or people are not going to agree to be tested, and then our contact tracing efforts will be really limited.” The Bulletin | 33

5 Things to Know as California Starts Screening Children for Toxic Stress BY BARBARA FEDER OSTROV | California Healthline

tarting this year, routine pediatric visits for millions of California children could involve questions about touchy family topics, such as divorce, unstable housing or a parent who struggles with

alcoholism. California now will pay doctors to screen patients for traumatic events known as adverse childhood experiences, or ACEs, if the patient is covered by Medi-Cal — the state’s version of Medicaid for low-income families. The screening program is rooted in decades of research that suggests children who endure sustained stress in their dayto-day lives undergo biochemical changes to their brains and bodies that can dramatically increase their risk of developing serious health problems, including heart disease, asthma, depression and cancer. Health and welfare advocates hope that widespread screening of children for ACEs, accompanied by early intervention, will help reduce the ongoing stresses and skirt the onset of physical illness, or at least ensure an illness is treated. The higher the number of such adverse events — and so, the higher a child’s ACEs “score” — the higher the risk of chronic illness and premature death. About 63% of Californians have experienced at least one adverse childhood event, and nearly 18% have faced four or more, according to state health officials. California is the first state to create a formal reimbursement strategy for ACEs screening, and the program will be open to both children and adults enrolled in Medi-Cal. The initiative is part of a larger ACEs awareness campaign championed by the state’s first surgeon general, Dr. Nadine Burke Harris, who is a national leader in the ACEs movement. The public health impact could be significant as Medi-Cal covers 5.3 million kids — roughly 40% of all California children — and 6.3 million adults. “It is a profound shift that’s going to change the type of pre34 | The Bulletin

vention and management we do with families,” said Dr. Dayna Long, a pediatrician who is director of the Center for Child and Community Health at UCSF Benioff Children’s Hospital Oakland and helped develop the state-approved screening tool for children and teens. “We’re not going to make all the hard things go away, but we can help families build resilience and reduce stress.” Here are five key things to know about ACEs and California’s new screening program: 1. How it works.

At a typical well-child visit, parents or caregivers will be asked to fill out a state-approved questionnaire about potentially stressful experiences in their children’s lives. For children under age 12, caregivers fill out the survey. Young people ages 12-19 will complete their own questionnaire in addition to their caregivers’ questionnaire. The questions will touch on 10 categories of adversity spanning the first 18 years of life: physical, emotional or sexual abuse; physical or emotional neglect; and experiences that could indicate household dysfunction, such as a parent who has a serious mental illness or addiction, having parents who are incarcerated or living in a home with domestic violence. The screening will measure for experiences that could regularly trigger fear and anxiety, including homelessness, not having enough food or the right kinds of food, and growing up in a neighborhood marred by drugs and violence. Long acknowledged some caregivers and children might be reluctant or unwilling to disclose sensitive information, particularly if they fear shame or repercussions. “We acknowledge it takes time to build trust,” she said. “But we want to encourage families to have hard conversations with their doctors and to understand how stressful events over the life of the child are impacting that child’s health.”

Physicians will review the responses and discuss them with caregivers during the visit. Doctors will have access to free online training on how to communicate with families and connect them to community resources. Physicians will be eligible for a $29 reimbursement for each Medi-Cal patient screened. The responses are considered confidential patient information and won’t be shared with state officials. But researchers hope that aggregated information will be studied to improve care for patients with high ACEs scores. 2. The screenings are voluntary.

Doctors do not need to offer them, and patients and their caregivers do not have to participate. Doctors will need to complete online training before they can be paid for screening patients. The state will cover the costs of screening once a year for children and once in a lifetime for adults. But children are the main focus of the screening campaign.

screening and intervention, and we could get it wrong with pretty disastrous consequences.” “Mostly, we don’t know what to do with somebody who has a high ACE score,” he said. “There are already long waits to get into family counseling or child mental health programs.” For example, a doctor might be legally required to report previous abuse to authorities, upending a family even if the child no longer is exposed to the abuser, Finkelhor said. “These are tough questions,” Long of UCSF acknowledged. Still, she said, screening is important, because it encourages physicians to engage in difficult conversations they might not otherwise have and pushes clinics to create links to supportive services and resources. “That is the next phase, and that is important,” Long said. “We’re doing this because we care about your child and want them to grow into healthy adults.”

3. What happens after the screening is less clear.

Community clinics often have social workers or “navigators” available to connect families to aid like food stamps or counseling. Doctors in private practice, however, are less likely to have those resources, said Dr. Eric Ball, an Orange County pediatrician who served on a committee advising the surgeon general on the ACEs campaign. Ball said local chapters of the American Academy of Pediatrics will work to educate doctors on how to help children who register high ACEs scores, because social services vary so much by county. Doctors “are not going to get rich doing ACEs screenings, that’s not the point,” Ball said. “If we can pick up kids at higher risk for these issues down the road and mitigate it, that’s really exciting to me.” 4. Researchers aren’t yet sure which interventions will best help kids with high ACEs scores.

Long and her UCSF Benioff colleagues are continuing to study how well the ACEs screening works and what interventions might be most effective. It’s one thing to help hungry families sign up for food stamps and free school lunches. It’s less clear how to help a child whose parent is in prison. Researchers have identified protective factors that can help children better resist the effects of toxic stress, including nurturing relationships with trusted adults, such as grandparents or teachers. “The fact of screening is also an intervention,” Long said. “Being able to sit in a room with a pediatrician is not going to make those hard experiences go away, but it creates a freedom to talk about some things that are solvable. That’s therapeutic in and of itself.” 5. Not everyone agrees that widespread ACEs screening is a good idea.

Sociologist David Finkelhor, director of the Crimes against Children Research Center at the University of New Hampshire, is among those who caution that universal screening for ACEs is premature, given there is little consensus about the potential negative effects of screening or the best interventions. “The good news is that we are focusing on these adversities that are clearly the source of so many downstream health and mental health problems,” Finkelhor said. “But the bad news is we’re moving way too fast, before we know how to best conduct this kind of The Bulletin | 35

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What Providers Can Do to Limit the Vaping Epidemic BY ANNA AISTRICH, MPH County of Santa Clara Public Health Department, Tobacco-Free Communities Current trends in e-cigarette use

E-cigarettes are a rapidly evolving group of products, known also as e-cigs, Juuls, vaporizers, vape pens, e-hookahs, tanks and mods. These are more broadly referred to as electronic nicotine delivery systems (ENDS). Some resemble traditional cigarettes, cigars or pipes, and some look like pens, USB flash drives or other ordinary objects. ENDS entered the US market around 2007 but demand really grew after 2014, especially among youth. Following the introduction of Juul – now the most popular e-cigarette brand – and other cartridge-based devices, ENDS use surged among middle and high school students across the nation between 2017-2018 (48% and 78% increase, respectively). National use among youth is at a record high, going from 1 in 100 (in 2011) to 1 in 5 (in 2018)1 – reversing previous declines in tobacco use. In Santa Clara County, cigarette smoking is at an all-time low (1.4%) among youth, according to recently released data from the California Student Tobacco Survey.2 However, overall tobacco use among youth is still high (13.9%), which is mainly driven by the high use rate of ENDS. E-cigarettes are the most commonly used tobacco product among high school students in Santa Clara County (13.2%).2 These trends are no accident. With declining rates of cigarette smoking all across the US, tobacco manufacturers are attempting to expand their customer base with ENDS. By touting the benefits of these “safer” products, the tobacco industry hopes to lure in users who were too concerned about the health impacts of combustible cigarettes to smoke previously. As of 2018, all major tobacco manufacturers now have entered the ENDS market.3 Lack of regulation of these products has enabled manufacturers to make false claims about their safety. Perpetuation of these myths (see dialog box) have motivated youth – who never would have taken up cigarettes – to initiate tobacco use. The meteoric rise in ENDS use among youth is now deemed “epidemic” by health officials. Health and Human Services Secretary Alex Azar reported that, “In the data sets we use, we have never seen use of any substance by America’s young people rise as rapidly as e-cigarette use is rising. Combustible cigarettes remain the leading cause of preventable death in the United States, and providing an effec40 | The Bulletin

The rising popularity of vaping exposes Santa Clara County residents, especially youth, to new health harms. By being informed about the trends and the products behind them, health providers can help dispel myths and support strategies to curb the vaping epidemic. tive off-ramp for adults who want to quit using them is a public health priority. But we cannot allow e-cigarettes to become an on-ramp to nicotine addiction for younger Americans.”4 Cigarettes vs. ENDS: What’s the difference?

As health concerns around cigarette smoking increased in the mid-1900s, manufacturers attempted make cigarettes appear “safer,” “cleaner,” and “less harmful,” by introducing filtered, light and low-tar cigarettes. Each modification was accompanied by unsubstantiated claims that mislead the public on the health risks of smoking. The introduction of ENDS is no different. ENDS were designed to reduce the health harms from the combustion process of a traditional cigarette. These devices instead use battery-power to heat liquids (e-liquid), wax, or other substances to their boiling temperature to transform them into aerosol. The process of inhaling the aerosol is referred to as “vaping.” Although ENDS users do not inhale tar and other toxic byproducts of combustible cigarettes, the aerosol produced by ENDS is far from harmless.5 Most ENDS products contain nicotine, which can harm the developing adolescent brain; impact learning, memory, and attention; and even increase the risk of future addiction to other drugs.5,6 ENDS can also be used to deliver other drugs, including marijuana.5 In 2016, one-third of U.S. middle and high school students who ever used e-cigarettes had used marijuana in e-cigarettes.7 Many of the cartridge or pod-based devices have especially high levels of nicotine. One popular brand, JUUL, uses cartridges, or “pods,” containing about as much nicotine as TWO packs of conventional cigarettes; newer devices have even more. Using nicotine salts, these devices enable users to inhale higher levels of nicotine (25-50mg) more quickly and with less irritation than via the first types of e-cigarettes (3mg).8 This format makes it easier for youth to initiate nicotine use and more likely to progress to regular use and nicotine dependence. In addition to nicotine, ENDS also contain other chemicals that help create the aerosol and flavorings like diacetyl, a chemical linked to serious lung dis-

ease. The aerosol can expose users and bystanders to other harmful substances, including heavy metals, volatile organic compounds, and ultrafine particles that can be inhaled deeply into the lungs. The potential for lung damage was highlighted in August 2019, with the identification of several cases of severe lung illness in patients who were generally healthy. The Centers for Disease Control coined this “E-cigarette, or Vaping, product use-Associated Lung Injury” (EVALI). “As of Feb. 18, 2020, 2,807 cases of hospitalized EVALI or deaths were reported by all 50 states, the District of Columbia, and 2 U.S. territories (Puerto Rico, and the U.S. Virgin Islands),” and “68 deaths have been confirmed in 29 states and the District of Columbia.” Although the majority of cases were among people who vaped marijuana, there were some patients who reported vaping exclusively nicotine products. In either case, use of e-cigarette devices has the potential to cause serious harm. Furthermore, as ENDS products have been largely unregulated, there is limited data on the longer-term effects of their use. Hundreds of e-liquid formulations and new ENDS products continue to enter the market, which makes researching a given product’s health impacts nearly impossible. Flavor Frenzy

Historically, tobacco manufacturers have added menthol and other flavorings to their products to make them easier to inhale – by softening the harshness of tobacco – as well as increasing the speed at which nicotine reaches the brain. Using flavors to make tobacco more palatable clearly succeeds in attracting youth as customers. Over 80% of youth who ever tried tobacco started with a flavored product. ENDS manufacturers are capitalizing on this tactic by developing a wide range of flavored products aimed at youth, young adults, and other vulnerable populations. E-liquids are now available in over 7,500 flavors. The 2016 Surgeon General report recognized this trend, stating that, “E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and apThe Bulletin | 41

VAPING MYTHS AND REALITIES Myth: E-cigarettes produce a harmless water vapor.

Myth: E-cigarettes are safe and do not contain toxins.

Reality: E-cigarettes produce an aerosol that has nicotine, harmful chemicals, and toxins known to cause cancer (and other health issues). These chemicals and toxins include formaldehyde, lead and nickel, among others.

Reality: E-cigarettes are not risk-free. They still deliver nicotine (sometimes at high levels) and low levels of toxins and chemicals, many of which are present in tobacco products.

Myth: E-cigarettes can help people quit tobacco.

Reality: Nicotine is a highly addictive drug and is one of the main ingredients in e-cigarettes and tobacco products.

Reality: E-cigarettes are NOT approved by the US FDA to help people quit tobacco. Many people switch to e-cigarettes from traditional cigarettes, but switching is not quitting. Scientific studies are mixed about whether e-cigarettes help people quit using tobacco and nicotine.

proaches that have been used in the past for marketing conventional tobacco products to youth and young adults.” Not only does the marketing of flavors get youth started in using tobacco products, those who use flavored tobacco have greater odds of using multiple tobacco products. Furthermore, recent studies show that youth who start using e-cigarettes are more likely to move on to using conventional cigarettes and other combustible forms of tobacco. In January 2020, the U.S. Food and Drug Administration issued an enforcement policy on certain unauthorized flavored e-cigarette products that appeal to youth. However, this policy exempts menthol-, tobacco-, and non-flavored ENDS products and includes only prefilled, cartridge-based products. Disposable or refillable flavored e-cigarettes, plus the 15,000+ existing flavored e-liquids, remain on the market. This resulted in a boom in the market for disposable products, such as Puff Bar, which are priced more affordably for youth than Juul. Since we cannot rely on effective regulation of these products, preventing initiation and promoting cessation of their use is a critical step in protecting youth from addiction and future health effects. Providers can play a key role in addressing this public health epidemic. What can my practice do to help reduce youth vaping?

There are proven strategies that work to protect youth from tobacco product use, which can be applied to ENDS as well. Providers can help support both individual and population level solutions towards curbing vaping. When working with patients, Ask, Advise and Refer: Ask patients about their ENDS product use, including discreet devices such as JUUL and Suorin, when screening patients for the use of any tobacco products. Advise patients about the harms of ENDS products, especially to the developing adolescent brain, and help dispel myths and the misleading advertising that portrays these products as “safer.” Some free materials are available here: nobutts-catalog. org/collections/vape. Refer for cessation services, such as those offered by the California Smokers’ Helpline (1-844-8-NO-VAPE) or by the free, youth-centered, quit-vaping mobile program called This is Quitting (thetruth.com/articles/hot-topic/quit-vaping) and encourage patients to quit. 42 | The Bulletin

Myth: E-cigarettes are not addictive.

Myth: Big Tobacco is not involved in making e-cigarettes. Reality: By 2021, Big Tobacco will sell the majority of e-cigarettes in the US, and sales will overtake traditional tobacco revenue.

Providers also can help advocate for the implementation of evidence-based, population-level strategies, such as including ENDS in smoke-free indoor air policies and restricting youth access to ENDS in retail settings, through retail licensing and enforcement programs. Participation by health providers in policy initiatives brings credibility that ENDS products are harmful for health, especially among adolescents. While there are regulatory and market-driven barriers to reducing youth vaping, a coordinated effort between health providers, educators, parents and communities can make a significant impact on the local level. References

1. Tobacco Product Use Among Middle and High School Students — United States, 2011-2018. Morbidity and Mortality Weekly Report (MMWR), February 2019. 2. Zhu S-H, Lee J, Zhuang YL, Braden K, Cole A, Wolfson T, Gamst A (2019). Tobacco use among high school students in Santa Clara County: Findings from the 2017-2018 California Student Tobacco Survey. San Diego, California: Center for Research and Intervention in Tobacco Control (CRITC), University of California, San Diego. 3. Craver R. Analyst projection: E-cigs will overtake traditional tobacco revenue at Reynolds in 2021. Winston-Salem Journal, 2013. 4. https://www.hhs.gov/about/news/2018/12/18/surgeon-general-releases-advisory-e-cigarette-epidemic-among-youth. html 5. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Increase in use of electronic cigarettes and any tobacco product among middle and high school students — United States, 2011–2018. MMWR Morbid Mortal Wkly Rep. 2018;67(45). 6. U.S. Department of Health and Human Services. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Atlanta, GA, 2016. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html#one 7. Willett JG, Bennett M, Hair EC, et al. Recognition, use and perception of JUUL among youth and young adults. [published ahead of print April 18, 2018]. Tob Control.

Medical Times From the Past THE LONG AND WINDING ROAD

By Michael Shea, MD

Leon P. Fox Medical History Committee

For information about the Leon P. Fox Medical History Committee or any of SCCMA’s other committees, please visit sccma.org/About-Us/ Committees

In ancient times disease was believed to be a curse of the Gods. If they favored you, you were healthy. If you were sick, you had done something to displease them. In 460 B.C., a man named Hippocrates was born. He had different ideas on the cause and treatment of diseases. He believed that disease might be transported by something in the air or in the water. He suspected that epidemics to occur due to contaminated winds coming in contact with large masses of people. He proposed dietetics, exercise, cleanliness, and nutrition as the basis for prevention of illness. He also believed in the Four Humor Theory to explain and treat some illnesses. This theory proposes that the body functions on the proper proportion of these humors or liquids. They are blood, phlegm, yellow bile, and black bile. The correct balance between them was necessary to maintain good health. This led to the use of bloodletting and purgatives to treat the majority of illnesses. This medical model was also favored by another famous Greek physician, Aelius Galenus, born in 130 A.D. The Four Humor Theory lasted well into the nineteenth century. Benjamin Rush was born on January 4, 1746 in Byberry Township, Pennsylvania. Perhaps no other physician in American history has influenced U.S. medical practice as this man did. He was the surgeon general of his time. Dr. Rush championed the use of bloodletting and purgatives to treat most acute illnesses.He is most remembered for treating the yellow fever epidemic in 1793 with bloodletting and calamel. There was growing opposition to this approach, and by the mid to late 1800’s, bloodletting was on the wane. It must be remembered that bacteria were unknown to doctors until 1856, when Louis Pasteur, a french biologist, discovered them while investigating the spoilage of wine. This led to the Germ Theory and ultimately the discovery of penicillin. Pasteur’s discovery caught the attention of Joseph Lister, a Scottish surgeon who, in 1865, used an antiseptic solution(carbolic acid) to prevent infection in wounds and surgical cases. This, plus the discovery of anesthesia, changed surgery from a “game of chance” to a safer scientific field. Also noticing Pasteur’s work was a Hungarian born physician, Ignaz Semmelweis. He changed

the maternal mortality rate of childbirth from eleven to fifteen percent to near one percent. He did this by insisting on frequent hand washing with a chlorinated solution. Like Lister, his findings were, at first, rejected by his colleagues, and it was twenty years later(1899) before these antiseptic measures were widely used. There were many other discoveries along the way that brought more science into the medical world. The compound microscope was invented in Holland circa 1590 by two spectacle makers, Hans Jannsen, and his son, Zacharias. The stethoscope was created by a French physician, Rene Laennec, in 1816. A funnel shaped otoscope was created by Austrian physician, Ignaz Gruber in 1838. The opthalmascope was made in 1851 by a German physicist, Hermann Von Helmhaltz. This led to the Welch and Allen version in 1915. The first sphygmomanometer was invented by Samuel Von Bosch in 1881. The syringe and needle came into existence in 1853, and discovery of diagnostic x ray was credited to William Roentgen, a german professor of physics, in 1895. One of the blockbuster discoveries of the past was penicillin. It was discovered in 1928 by a Scottish physician, Alexander Fleming. It would save thousands of military lives during WWII, and even more in the civilian population. Diabetes was first described by Egyptian physicians about 3500 years ago. It was a devastating disease, killing children and adults in just a few years after onset. The scene changed dramatically when insulin was discovered in the 1920’s by two Canadian researchers, Frederich Banting M.D. and Charles Best M.D. The Nobel prize for medicine was awarded to Dr. Banting, who shared it with Dr. Best. In the early twentieth century, polio was one of the most feared diseases in the United States. It affected mainly children under the age of five, with one out of two hundred suffering permanent paralysis. In 1952, there were 58,000 cases in the United States with 3145 dying, and 21,269 left with mild to disabling paralysis. A dedicated scientist, Jonas Salk M.D., developed the polio vaccine in 1952, and it was successfully used nationwide in 1955. An oral vaccine was developed by Albert Sabin in the 1950’s. It was also an effective vaccine. The dark ages were definitely over.Surgical ad-

Continues on page 46 >> The Bulletin | 43

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Naloxone Conversion to Over The Counter Status May Create a Financial Strain for Some Groups Steven H. Linder MD & Members of The Santa Clara County Opioid Overdose Prevention Project (SCCOOPP)

https://www.sccgov.org/sites/bhd/info/opioid/ pages/home.aspx https://w w w.drugabuse.gov/news-events/ news-releases/2019/03/opioid-overdose-reversal-news-fda-approved-naloxone-devices-produce-substantially-higher-blood Naloxone is an opioid antagonist used to reverse otherwise lethal opioid induced respiratory depression. It can be rapidly administered through either intramuscular/intravenous injection or nasal spray. Naloxone is currently available as a prescription drug, but it is not a controlled substance. Take-home naloxone (THN) can be provided directly to members of the community who encounter opioid overdoses. As a prescription medication, THN costs are covered by most health insurance plans, Medi-Cal, and Medicare Part D. Prices for out of pocket expenses vary widely by THN formulation. The California Department of Health Care Services has a program to distribute THN to reduce

morbidity and mortality associated with opioid overdose. California pharmacist may dispense naloxone without a prescription from another health care provider. Many recipients use the statewide standing order from the California Department of Public Health. https://www.pharmacy.ca.gov/licensees/naloxone_info.shtml https://www.cdph.ca.gov/Programs/CCDPHP/ DCDIC/SACB/Pages/Naloxone-Standing-Order. aspx California pharmacists furnished naloxone is covered by most health insurance plans, Medi-Cal, and Medicare Part D. Yearly Medi-Cal THN costs currently approximate six million dollars. One potential way to improve access to naloxone is to make it available for over-the-counter (OTC) sales. The Food and Drug Administration (FDA)is helping to encourage development of over the counter OTC naloxone products https://www.fda.gov/news-events/press-announcements/statement-continued-efforts-inThe Bulletin | 45

Medi-Cal FFS Naloxone Utilization SFY 2018-19 Drug Naloxone Injection Naloxone Nasal Total

# of Claims

Amount Reimbursed ($)

597

$30,963

47,312

$6,075,504

47,909

$6,106,468

Figure Courtesy of California Department of Health Care Services. Time frame is fiscal year 18/19 from July 1, 2018 through June 30, 2019 crease-availability-all-forms-naloxone-help-reduce-opioid-overdose?utm_campaign=092019_Statement_FDA’s%20efforts%20 to%20increase%20availability%20of%20all%20forms%20of%20 naloxone&utm_medium=email&utm_source=Eloqua Concerns exist that moving naloxone OTC will reduce insurance coverage for the medication and create a financial hardship in some cases. (Davis et al 2020). Currently THN is a covered pharmacy benefit for all Medi-Cal beneficiaries. This could continue to be the case if naloxone became an OTC drug. However, a prescription would have to generated for the OTC product in order to have the drug paid for by the state. Covered California is a health insurance exchange enables eligible individuals to purchase health insurance coverage at federally subsidized rates. Over the counter medications may or may not be covered by Covered California Health Insurance exchange or other health insurance plans. Medicare drug plans aren’t required to cover over-the-counter drugs. https://www.medicare.gov/Pubs/pdf/11109-Your-Guide-toMedicare-Prescrip-Drug-Cov.pdf Plan coverage may vary with naloxone formulation and may be limited to generic naloxone. Currently there is no generic naloxone nasal spray formulation marketed in the United States. An argument could be made for health care coverage plan to cover the purchase of naloxone OTC in order to reduce health care costs involving opioid overdose. Otherwise legislation changing regulations could be considered. It is uncertain how much time needed to change regulations and how health in-

surance plans will react. There is no guarantee that insurance will cover costs of naloxone OTC to avoid taking away from a vulnerable population the access to THN that the current system provides. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/ PrescriptionDrugCovContra/Downloads/QACY2007OTCsandUM_051206.pdf Some naloxone formulation could retain legend status and remain covered by insurance. It is unclear what would be the determination of which THN formulation would be available OTC. States and localities could subsidize the cost of naloxone with grant programs. However insurance benefits that cover naloxone are less volatile than grant dependent Overdose Education and Naloxone Distribution (OEND) programs. A recent modeling study found naloxone conversion to overthe-counter status is could lead to increased pharmacy sales. (Murphy et al., 2019). This could lead to a decrease in naloxone pricing but not with certainty. Physicians and other health care providers may still need to furnish a THN prescription for patients seeking a naloxone OTC formulation which is a requirement for third party reimbursement. The degree to which a conversion of naloxone to OTC would affect public health will depend on how the change affects those persons most likely to encounter an overdose. Changing THN to OTC could reduce insurance coverage for naloxone resulting in greater out of pocket cost for people relying on Covered California Health Insurance exchange/Medicare programs. Low-income individuals who are more challenged by price increases may not have insurance that covers a THN OTC formulation. This could result in reduced naloxone access to those in need. References:

• C. S. Davis, D. Carr. Over the counter naloxone needed to save lives in the United States. Preventive Medicine, Volume 130,2020, 105932, SSN 0091-7435. https://www.ncbi. nlm.nih.gov/pubmed/31770540 • S.M. Murphy, J.R. Morgan, P.J. Jeng, B.R. Schackman Will converting naloxone to over-the-counter status increase pharmacy sales? Health Serv. Res., 54 (4) (2019), pp. 764772 https://onlinelibrary.wiley.com/doi/pdf/10.1111/14756773.13125

Medical Times From the Past, From Page 43 vances were surging. Coronary bypass, arterial stents and heart transplants all brought new life to thousands of patients. New drugs to lower cholesterol,maintain regular rhythm, maintain normal blood pressure, and dissolve clots, all contributed to the breakthroughs in maintaining health in cardio vascular and cerebral vascular disorders. Breakthroughs in radiation techniques and new chemotherapeutic drugs are extending the five year survival in cancer patients. Medical progress has not always been consistent. It has fal46 | The Bulletin

tered along the way, and during the Middle Ages must have seemed hopeless. Scientific breakthroughs came in clusters. They came from all over the world, but in the nineteenth and twentieth centuries, they were largely from Europe and the United States. Is the end in sight? The answer is sadly no. Alzheimers and cancer are just two examples of mountains still to climb, but they will be climbed. Medical research is relentless and will continue to uncover the secrets to a healthy life. That long and winding road is getting shorter!

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Q1 2020 Bulletin: Women in Medicine

Articles inside

Classifieds

Medical Times From the Past

Naloxone Conversion to Over The Counter Status May Create a Financial Strain for Some Groups

Children for Toxic Stress

COVID-19: Financial Toolkit for Medical Practices

What Providers Can Do to Limit the Vaping Epidemic

Things to Know As California Starts Screening