ACCMA March/April 2019 Bulletin

ACCMA BULLETIN Serving East Bay physicians since 1860

March/April 2019

SPECIAL ISSUE: How the Medical Community is Addressing the Opioid Epidemic Progress at Home: How the East Bay is Addressing the Opioid Epidemic (p. 9)

Changing Physicians’ Approach to Chronic Pain Management: Member Spotlight on Ruben Kalra, MD (p. 19)

Updates on Naloxone Laws (p. 17) Proposition 56 Supplemental Payments Update (p. 24)

A L A M E D A

C O U N T Y

Helping People in Our Community Since 1996

www.alamedaalliance.org

71

R AT E D JA N

.

ACCMA Executive Committee Lubna Hasanain, MD, President Katrina Peters, MD, President-Elect Suparna Dutta, MD, Secretary-Treasurer Thomas Sugarman, MD, Immediate Past President Councilors & CMA Delegates Eric Chen, MD Robert Edelman, MD Rollington Ferguson, MD Harshkumar Gohil, MD Russ Granich, MD James Hanson, MD Shakir Hyder, MD Irina Kolomey, MD Terence Lin, MD Lilia Lizano, MD Abbas Mahdavi, MD Joshua Perlroth, MD Jeffrey Poage, MD Stephen Post, MD Thomas Powers, MD Richard Rabens, MD Steven Rosenthal, MD Katrina Saba, MD Suresh Sachdeva, MD Ahmed Sadiq, MD Jonathan Savell, MD Edmon Soliman, MD Judith Stanton, MD Michael Stein, MD CMA & AMA Representatives Patricia L. Austin, MD, AMA Delegate Mark Kogan, MD, CMA Trustee, AMA Alternate-Delegate Suparna Dutta, MD, AMA Alternate Delegate (at Large) Ronald Wyatt, Jr., MD, CMA Trustee Membership & Communications Committee Mark Kogan, MD, Chair Patricia Austin, MD Sharon Drager, MD Robert Edelman, MD James Hanson, MD Jeffrey Klingman, MD Stephen Larmore, MD Terence Lin, MD Irene Lo, MD Lamont Paxton, MD Katrina Peters, MD Frank Staggers, Jr., MD Ronald Wyatt, MD ACCMA Staff Joseph Greaves, Executive Director Mae Lum, Deputy Director Jan Jackovic, Director of Operations Griffin Rogers, Director, Napa & Solano County Medical Societies David Lopez, Assoc. Dir. of Advocacy & Policy Essence Hickman, Operations Coordinator Jennifer Mullins, Education and Events Coordinator Hannah Robbins, Communications Coordinator Aimee Robinson, Physician Engagement Coordinator

ACCMA BULLETIN Vol. LXXV, No. 2

Serving East Bay physicians since 1860

NEWS & COMMENTS

7

PRESIDENT’S PAGE East Bay Safe Rx: Making Progress, Saving Lives

By Lubna Hasanain, MD, ACCMA President 9

East Bay Making Progress on Opioid Epidemic

By Thomas Sugarman, MD, and Kathleen Clanon, MD 10

Coding Corner: How to Report a Consult Service When Your Payor Doesn’t Accept Consult Codes

By the California Medical Association 11

East Bay Safe Prescribing Coalition MAT Waiver Training

14

Best Practices for Chronic Pain Management Poster

16

Latest Federal Legislation on Opioids By the California Health Care Foundation

17

Updates on Naloxone Policies and Distribution

18

Rx Drop Boxes Let Contra Costa Residents Safely Dispose of Unwanted Medicine

19

Member Spotlight: Ruben Kalra, MD

21

California Bridge Program Selects 31 Health Facilities to Expand MAT for Opioid Use Disorder

By the Public Health Institute 24

Reducing Opioid Misuse and Increasing Prop 56 Supplemental Payments

By Scott Coffin, CEO, Alameda Alliance for Health

22

COUNCIL REPORTS

23

NEW MEMBERS

26

CLASSIFIED ADVERTISING

O

R

71

ASSOCIATION

INC

DA–CON TR AME AL

A COS1T8 6 0MEDIC

AL

A

REDUCE – REUSE – RECYCLE Printed in the U.S.A. with soy inks on paper stock certified by the Forest Stewardship Council.

March/April 2019

4

PO

18

PO

18

O

R

ASSOCIATION

INC

DA–CON TR AME AL

A COS1T8 6 0MEDIC

AL

A

R AT E D JA N

.

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION 6230 Claremont Avenue, Oakland, CA 94618 Tel: 510/654-5383 Fax: 510/654-8959 www.accma.org

ACCMA BULLETIN | March/April 2019

3

NEWS & COMMENTS

CDPH Issues Measles Clinical Guidance Following Outbreaks The California Department of Public Health has issued a Measles Clinical Guidance, highlighting symptoms, risk factors, and testing methods for cases of suspected measles. As of March 27, 2019, 16 confirmed measles cases have been reported in California. Physicians should immediately report any suspect case of measles to the Alameda County Public Health Department at 510-267-3250 (or 925-422-7595 after hours) or the Contra Costa Public Health Division at 925-3136740. To view the Measles Clinical Guidance, go to https://bit. ly/2SYnSbE.

Alameda County Issues Hep B Update The Alameda County Public Health Department is asking physicians to test patients for hepatitis B infection, vaccinate those who are susceptible, and provide guideline-driven evaluation, monitoring, and treatment for persons with chronic HBV. It is estimated that there are over 23,000 cases of chronic hepatitis B infection in Alameda County, yet only 8,000 cases are documented in the California Reportable Disease Information Exchange (CalREDIE). To read the county health update, go to https://bit.ly/2HTAFWM.

UnitedHealthcare to Discontinue Payment of Consultation Services In their March 2019 Network Bulletin, UnitedHealthcare announced that it will no longer reimburse consultation services for commercial product lines. Consultation services represented

by CPT codes 99241-99245 and 99251-99255 will now need to be billed using the appropriate evaluation and management (E/M) procedure code, properly describing the office visit, hospital care, nursing facility care, home service or domiciliary/rest home care. UHC will implement this policy change in two parts; for providers on a 2010 and newer fee schedule, CPT codes 99241-99255 will no longer be reimbursed starting June 1, 2019. Beginning October 1, 2019, CPT codes 99241-99255 will no longer be reimbursed for all fee schedules. To read more, go to https://bit.ly/2FGV5Ps.

New CMA Survey Reveals CA Physician Priorities for Health Care A new statewide survey conducted by the California Medical Association (CMA) collected responses from nearly 900 California physicians, providing valuable insight into the future of health care. When asked about the most important challenges facing California’s health care system, participating physicians responded saying that increasing costs and affordability (32 percent), access to quality care (24 percent), and lack of universal coverage (18 percent) were impacting health care the most. Responses indicated that serving low-income, uninsured, and homeless populations, and regulatory interference with the practice of medicine (11 percent each) were also noteworthy issues. To read more, go to https://bit.ly/2YJmmcw.

4

National Health Care Decisions Week April 9 through 16 was National Health Care Decisions Week, during which the ACCMA and the California Medical Association (CMA) encouraged physicians to speak with their patients about the importance of completing an advance care directive to make sure their end-of-life wishes are known in case illness or injury prevents them from speaking for themselves. The ACCMA, through its Community Health Foundation, supports a coalition of individuals and organizations who are passionate about promoting advance care planning in the community—the East Bay Conversation Project (EBCP). The EBCP held several outreach events that week. The EBCP webpage hosts end-oflife health care resources and legally recognized documents, such as Physician Orders for Life-Sustaining Treatment (POLST) and Advance Health Care Directives. Go to the EBCP webpage at eastbayacp.org.

CMA & AMA Urges CMS to Provide PA Guidance The California Medical Association (CMA), in conjunction with numerous other medical societies including the American Medical Association (AMA), have submitted a sign-on letter to the Centers for Medicare and Medicaid Services (CMS), urging the agency to require Medicare Advantage plans to selectively apply prior authorization (PA) requirements and provide examples of criteria to be used in specific situations. The CMA and AMA believe such guidance will help promote safe, timely, and affordable access to care for patients; enhance efficiency; and reduce administrative burden on physician practices. To read the letter, go to https://bit.ly/2I5RSvJ.

J. Elliot Royer Award Accepting Physician Nominations The J. Elliot Royer Award, which recognizes notable practitioners in the field of neurology and psychiatry, will be accepting nominations until 5:00 pm on Wednesday, May 1, 2019. This award, established in 1957 by J. Elliot Royer, MD, recognizes two psychiatrists or neurologists, one academic and one community, located in San Francisco, Alameda, or Contra Costa county, who have made the most significant contribution to the advancement of psychiatry or neurology during the year.

This year, the award will be given to an academic neurologist and a community-based practitioner who have contributed significantly to their fields throughout the year. The award for academic excellence is based on an individual’s record of influential scholarly contributions to the field, their university service, community service, and their prominence within the community.

The award for community excellence is based on an individual’s demonstration of service to the local, state, or national community, their demonstration of teaching excellence, and evidence of unique contributions to the field. For more information or to nominate a colleague for the award, contact Mr. Joseph Greaves, ACCMA Executive Director, at 510-654-5383.

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

NEWS & COMMENTS

Responding to Medicare Revalidation Notices Physicians are reminded to respond to Medicare revalidation notices, or their Medicare billing privileges will be deactivated.

Noridian, the Medicare contractor for California, usually emails revalidation notices with the subject line “URGENT: Medicare Provider Enrollment Revalidation Request” two or three months prior to the revalidation due date. Physicians can also proactively go to https://go.cms.gov/2dvqlD9 to look up their revalidation date. For more information about the Medicare revalidation process, contact Noridian at (855) 609-9960.

UPCOMING EVENTS MBA for MDs and Practice Managers Wednesday, May 1 | 9:00 am – 3:30 pm ACCMA Offices, 6230 Claremont Ave., Oakland Breakfast & lunch will be served! $199 for members, $299 for non-members Register online at ACCMA.org/Events or call the ACCMA at 510-654-5383.

Social Media and Health Care: Benefits, Risks, and Best Practices

ACCMA NOW AN ACCREDITED CME PROVIDER! As part of their membership benefits, ACCMA members will be able to claim CME for FREE for most eligible events. Check the events calendar at accma.org for the most current lineup:

Making Conversations Count: A Workshop on Advance Care Planning Thursday, May 2 | 8:30 am – 12:30 pm 6230 Claremont Ave., Oakland CME FREE FOR MEMBERS To register for events, go to www.accma.org/ events or call the ACCMA at (510) 654-5383.

Tuesday, June 18 | 12:30 - 1:30 pm Online Webinar Free for members, $49 for non-members Register online at ACCMA.org/Events or call the ACCMA at 510-654-5383.

How to Hire Excellent Medical Office Staff Wednesday, June 26 | 12:30 – 1:30 pm Online Webinar Free for members, $49 for non-members Register online at ACCMA.org/Events or call the ACCMA at 510-654-5383.

For the latest news, go to the ACCMA website at www.accma.org/news.

NEW LAW DELAYS IMPLEMENTATION OF NEW SECURITY PRESCRIPTION PADS UNTIL 2021 The ACCMA and the California Medical Association (CMA)’s intense lobbying has ended the confusion caused by the flawed security prescription pad law (AB 1753) that went into effect on January 1, 2019. The new law (AB 149) will allow a transition period of two years until physicians are required to prescribe controlled substances on new security prescription pads that contain a uniquely serialized number.

Under the new law, both the security prescription pads that were used before January 1 and the new security prescription pads will allow patients to fill their

controlled substance prescriptions at pharmacies. The new law requires physicians to obtain new security prescription pads by January 1, 2021.

The previous law had not established a timeline for implementation and many patients were unable to obtain their controlled medications when pharmacies did not honor the older prescription pad forms.

If you have any questions or want more information, please contact David Lopez, ACCMA Associate Director of Advocacy and Policy at dlopez@accma. org or (510) 654-5383.

ACCMA BULLETIN | March/April 2019

5

“I thought First Republic’s student loan refinancing was too good to be true, but it was right on.”

P U YA H O S S E I N I , M . D.

Anesthesiologist and Athlete

(855) 886-4824 | Ŕrstrepublic.com | New York Stock Exchange symbol: FRC MEMBER FDIC AND EQUAL HOUSING LENDER

PRESIDENT’S PAGE

East Bay Safe Rx: Making Progress, Saving Lives

By Lubna Hasanain, MD, ACCMA President

Lubna Hasanain, MD

A

CCMA has a long history of bringing East Bay physicians together to collaborate for the betterment of our community and the public health. ACCMA continues in this fine tradition today through several community health projects that are all aimed at improving the health of our community.

One of these projects is the East Bay Safe Prescribing Coalition.

Launched in 2015, the East Bay Safe Prescribing Coalition is a collaborative effort by the East Bay medical community, consumers and community leaders to promote safe and appropriate prescribing practices and reduce prescription drug abuse in our community. The Coalition is co-sponsored by local organizations that represent the medical community: the AlamedaContra Costa Medical Association (ACCMA), the Hospital Council of Northern and Central California, the Alameda County Health Care Services

Agency, Contra Costa Health Services and the Alameda Health Consortium.

These organizations serve as the steering committee for the Coalition.

Some of the Coalition’s latest efforts are highlighted in this issue of the ACCMA Bulletin. Through the East Bay Safe Prescribing Coalition, the ACCMA is taking a hands-on approach to tackling the opioid epidemic by working hard to provide resources, tools, and educational seminars on safe prescribing techniques to health care providers. EBSPC consistently provides clinical education to providers, actively promoting the best practices and principles to implement change on the ground floor, within health care settings. They also conduct regular Medication Assisted Treatment (MAT) waiver trainings for health care professionals to prescribe buprenorphine, which can help treat Opioid Use Disorder (OUD), as well as periodic naloxone trainings in order to help treat opioid overdose. In addition to their educational tools and trainings, EBSPC provides a litany of resources to physicians and health care providers, ranging from toolkits for acute and chronic pain management to online webinars.

The Coalition has numerous ongoing activities and goals set for 2019-2021, including continuing to promote clinical education on safe prescribing, providing access to MAT (Medication Assisted Treatment) and Naloxone training, assisting physicians in implementing practices to reduce opioid misuse, and continuing to engage with our local Bay Area community. The Coalition hopes to

reduce the quantity of opioids prescribed while ensuring pain is treated appropriately, increase physician and patient access to naloxone, and, most importantly, reduce the number of opioid-related deaths.

We have hosted two regional convenings over the past year and continue to hold multiple educational programs, both in person and via webinar. In addition, our webinars are available on our website, so physicians can have continued access on demand to the programs. The coalition has also sponsored two Medication Assisted Treatment (MAT) waiver trainings for health care providers to prescribe buprenorphine for Opioid Use Disorder, as well as a MAT training on the overdose reversal drug naloxone.

Looking through to the end of 2019, ACCMA will continue to offer and expand on these educational programs, emphasizing and educating providers on methods to integrate non-pharmacological alternatives to opioids into their clinical practice. We are beginning to see steady declines in opioid prescriptions, MMEs, co-prescriptions with benzodiazepines, and increases in buprenorphine prescriptions in both Alameda and Contra Costa counties.

ACCMA strives to continue being an active contributor in the fight against the opioid epidemic. ACCMA members can be proud to know that you are part of an organization working hard to address the opioid epidemic and many other community health priorities. For more information on the coalition, visit www.

EastBaySafeRx.org.

ACCMA BULLETIN | March/April 2019

7

Practice Management: Tip of the Month

+1 +*Ć?0 $ 2! 0+ Ćœ#$0 1*" %. , 5)!*0 ,. 0% !/ (+*!Ĺ * $!(,Ĺ

Members can call on CMA’s practice management experts for free one-on-one help with contracting, billing and payment problems. Assistance ranges from coaching and education to direct intervention with payors or regulators. CMA has recovered $29 million on behalf of its physician members over the past 10 years.

For more information, visit cmadocs.org/tips.

.+1 (! !00%*# % Ĺ… * !(,ĹŠ Call (800) 786-4262 or email economicservices@cmadocs.org.

EAST BAY PROGRESS

East Bay Making Progress on Opioid Epidemic

By Thomas Sugarman, MD and Kathleen Clanon, MD

Thomas Sugarman, MD

T

Kathleen Clanon, MD

he opioid epidemic continues to ravage communities across the nation. According to the most recent data from the Centers for Disease Control and Prevention, prescription and illicitly obtained opioids killed more than 49,000 people in 2017, more than any year on record.

Behind these numbers are countless family members, friends and neighbors devastated by the loss of a loved one and those patients still struggling with opioid-use disorders. As physicians, we recognize the role that the health care industry has played in contributing to the opioid epidemic.

In the East Bay, however, key indicators are starting to move in the right direction.

Between 2015 and 2017, opioid prescriptions dropped by 14 percent in both Alameda and Contra Costa counties. Additionally, co-prescriptions of opioids and benzodiazepines, which can be especially risky when used in combination, are down roughly 25 percent in both counties.

Health systems and medical groups are implementing comprehensive policies to prevent overprescribing and provide safer, more effective

pain management. Physicians and other health care providers are becoming increasingly educated on how to safely treat and manage patients’ pain without the use of opioids.

But we also know that more can be done to prevent overprescribing. As of Oct. 2, all physicians in California are required to check the CURES (Controlled Substance Utilization Review and Evaluation System) database prior to prescribing opioids to view their patients’ prescription histories. This will help physicians have a better understanding of a patient’s prescribing history and identify cases of doctor shopping.

Physicians also have a critical role to play in providing solutions to the opioid epidemic and providing evidence-based treatment that gives patients who abuse or are dependent on opioids the opportunity to recover.

The East Bay is leading the way in implementing innovative practices for treating those patients and improving access to medication treatments.

Oakland’s own Highland Hospital was recently profiled in The New York Times for its innovative program of medication-assisted treatment for emergency department patients and connection to follow-up care in community clinics. Prescriptions for buprenorphine, a highly effective treatment drug, are increasing in both counties, indicating that more are gaining access to this life-saving treatment.

Despite the progress we have made as a community, we still have a long way to go toward ending the opioid

epidemic in the East Bay. A recent analysis from the Urban Institute estimated that up to 15,000 patients in Alameda and Contra Costa counties have problems of opioid dependence or abuse but are unable to access medication treatments.

Patients who cannot access effective treatment that helps them stop misusing opioids are at high risk of having an overdose. Unfortunately, the process of accessing medication treatments can be extremely frustrating, complex, and time consuming for patients.

High costs, varying coverage and eligibility rules, and health plan policies that limit access to care make it very difficult for patients to get the treatment they need. Reducing or eliminating barriers to medicationassisted treatment is critical to successfully helping patients who misuse opioids.

While overdose deaths are reaching new highs across the nation, they declined by double digits in the East Bay from 2015-17. We are making progress and we cannot rest on the current state. We continue to lose too many members of our community to overdose or the ongoing struggle with opioid misuse.

We have more work to do before attaining our goal of zero overdose deaths and we call on our colleagues to advance the great work we are collectively achieving. We must change prescribing practices to improve pain management for patients and remove barriers to treatment for the many continued on page 18

ACCMA BULLETIN | March/April 2019

9

CODING CORNER

Coding Corner: How to Report a Consult Service When Your Payor Doesn’t Accept Consult Codes By the California Medical Association

M

edicare has not accepted claims for either outpatient or inpatient consultations for almost ten years, and now private payors are following suit. Health Net no longer reimburses consultation services and UnitedHealthcare is intending to do the same. How are providers to bill for consultation services that can’t be reported as consultations?

Outpatient Alternatives In the office or outpatient setting, in place of consultation codes 9924199245, you should report the appropriate Outpatient Services code (e.g., 99201-99215 for office outpatients).

The service must be supported by the key components of history, exam and medical decision-making (MDM), or time, if counseling and/or coordination of care dominate the encounter.

For example, a surgeon sees a new Medicare patient in the office for a consultation for another provider in the area. The surgeon will bill the consultation visit as a new patient visit at the appropriate level using 99201-99205. For instance, to report 99203 Office or other outpatient visit for the evaluation and management of a new patient, the physician would need to document—at a minimum—a detailed history, a detailed examination and low-complexity MDM. Or, the physician may report 99203 if counseling and/or coordination of care comprise 50 percent or more of a visit lasting 30-44 minutes, and the content of the visit is properly documented.

10

Inpatient Alternatives You should report inpatient consultation services using an Initial Hospital Care code (99221-99223) for the initial evaluation, and a Subsequent Hospital Care code (99231-99233) for subsequent visits.

In some cases, the service the physician provides may not meet the documentation requirements for the lowest level initial hospital visit (99221).

According to Centers for Medicare & Medicaid Services (CMS) guidance, you may report subsequent hospital care codes (99231-99233) in these cases: Q. How should providers bill for services that could be described by CPT inpatient consultation codes 99251 or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes 99221 through 99223 are not met?

A. There is not an exact match of the code descriptors of the lowlevel inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes 99251 and 99252, respectively, requires “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT code 99221 requires “a detailed or comprehensive history.”

Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code 99221 may be reported

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

for an [evaluation and management (E/M)] service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

Modifier AI Distinguishes Inpatient Providers When a Medicare patient is admitted, and another physician provides a consultation for that patient, the situation may arise in which both the admitting physician and consulting physician would report an initial inpatient service (e.g., 99221-99223). To differentiate between the two physicians’ services, and to prevent a claims denial for duplication of services, the admitting physician should append modifier AI Principal physician of record to the initial inpatient service code.

For example: A patient presents to the emergency department (ED) with chest pain. The ED physician evaluates the patient and codes an ED visit (99281-99285). He also requests a consult from a cardiologist. The cardiologist evaluates the patient and continued on page 18

MAT WAIVER TRAINING

East Bay Safe Prescribing Coalition MAT Waiver Training

O

n January 17, 2019 nearly 30 physicians, nurse practitioners, and physician assistants attended a training on the use of Medication Assisted Treatment (MAT) to treat Opioid Use Disorder (OUD) at the AlamedaContra Costa Medical Association (ACCMA) offices. The ACCMA cosponsors the East Bay Safe Prescribing Coalition, a collaborative of the East Bay medical community, consumers, and community leaders that organized the training. Attendees came from as far away as Modesto and received 4 of the 8 hours required to prescribe buprenorphine.

MAT combines behavioral therapy with medications such as methadone, buprenorphine, and naltrexone for use in the treatment of substance use

disorders, including OUD. As the opioid epidemic has increased in recent years, physicians and other health care providers have increasingly joined the fight against the opioid epidemic, helping opioid-dependent patients by providing MAT in outpatient settings.

Widespread access to buprenorphine is becoming increasingly recognized as a crucial component in addressing the opioid epidemic by helping patients living with OUD stop using opioids and begin to get their lives on track. Under federal law, physicians are required to undergo 8 hours of training on buprenorphine use prior to being able to prescribe buprenorphine for OUD, while NPs and PAs are required to undergo 24 hours of similar training. These requirements can

sometimes deter physicians and other health care providers from pursuing the necessary training, thus limiting the number of health care providers trained in MAT. The recent MAT Waiver training was conducted by Doctor Jeffrey Devido, Chief of Addiction Medicine at Marin County Health and Human Services and an addiction psychiatrist by training. Doctor Devido began the training by noting that attendees were about to learn more about buprenorphine than they have ever learned about any other drug. He noted the irony that prescribers who want to help patients with OUD are required to go through 8 hours of training and receive a special license in order continued on page 13

BUPRENORPHINE IN MEDICATION ASSISTED TREATMENT Treatment with buprenorphine has been proven effective in opioid addiction, decreasing mortality by approximately 50%. Patients treated with buprenorphine show improved social functioning with increased retention in treatment (67% at one year) compared to drug-free treatment (7% to 25% at one year), reduced criminal activity, lower rates of illicit substance abuse, and reduced risk of HIV and hepatitis infection. In the context of MAT, buprenorphine is recommended to be delivered as part of a comprehensive treatment approach. Experts emphasize the importance of behavioral health services, such as cognitive-behavioral therapies, counseling, and mindfulness training, combined with medication treatment. They also emphasize that patients should not be refused buprenorphine treatment if they cannot, or will not, access behavioral treatment. Although buprenorphine can be used in short-term detoxification programs, experts increasingly discourage this approach and encourage maintaining MAT over the

long term. Studies have shown that patients who stop taking buprenorphine during the first few months of their treatment experience high rates of relapse, even with intensive behavioral support.

One frequently cited Swedish study randomized a heroin-using population to buprenorphine or placebo, after a detoxification period; both groups received cognitive-based therapy, individual counseling, and drug screens. Four out of the 20 patients in the placebo group died during the one-year study; none of the patients in the buprenorphine arm died and 75% of them stayed in treatment. Studies comparing methadone and buprenorphine show that methadone leads to better treatment retention, but do not show a major difference in mortality or illicit drug use. Also, methadone cannot be prescribed for addiction outside of a licensed opioid treatment program, while buprenorphine is available to primary care physicians.

Excerpt from California Health Care Foundation Report, Buprenorphine: Everything You Need to Know.

ACCMA BULLETIN | March/April 2019

11

The convenience of CMEs and webinars anytime, anywhere via app or desktop

empowers you to…

practice

INSIGHT

Risk Management Industry-Leading CME offerings and educational opportunities

Medical Professional Liability Insurance Flexible coverage that’s right for you

Professional Wellness Self-care resources for healthcare practitioners

844.4NORCAL | NORCAL-GROUP.COM

© 2019 NORCAL Mutual Insurance Company | ng5125 NORCAL Group includes NORCAL Mutual Insurance Company and its affiliated companies.

MAT WAIVER TRAINING

to prescribe buprenorphine while no such requirement exists for prescribing opioid medications, which are currently driving the worst addiction epidemic in American history. Physicians who want to prescribe buprenorphine for OUD face significant barriers to do so, which has tangible consequences for patients in our community. A study by the Urban Institute on opioids in California estimated that in 2016, up to 15,000 people in Alameda and Contra Costa counties had OUD but could not access MAT. They estimate that, statewide, there were as many as 245,000 people who did not have access to appropriate MAT. Doctor Devido’s presentation educated attendees on the history of MAT

in treating opioid dependence, going back to the Harrison Narcotics Tax Act of 1915, which outlawed the use of opioids in the treatment of opioid dependence. Beginning in the early 1970s, methadone was approved for detoxification, and later for treatment of OUD, through Opioid Treatment Programs, effectively prohibiting most physicians from offering OUD treatment. It was not until the passage of the Drug Addiction and Treatment Act (DATA 2000) that qualified physicians were permitted to offer Office Based Opioid Treatment (OBOT) to patients. This law established the waiver requirement that training attendees are now beginning to follow in order to offer this critical treatment to patients

(continued from page 11)

in need. Doctor Devido also provided a summary of the effectiveness of buprenorphine compared to no treatment, demonstrating that overdose death rates are more than three times higher for patients receiving no treatment. His presentation also covered the pharmacology of buprenorphine, best practices for initiating and maintaining patients on buprenorphine treatment, case studies, clinical tools and how to begin treating patients once you have received your waiver.

The ACCMA and the East Bay Safe Prescribing Coalition will continue to provide MAT Waiver Eligibility Trainings as a service to physicians and other health care providers continued on page 18

PHYSICIAN PERSPECTIVE: KELLY PFEIFER, MD Historically, addiction treatment was considered “someone else’s job,” since few clinicians had any training, experience, or knowledge about managing substance use disorders, noted Doctor Kelly Pfeifer, Director of High-Value Care at the California Health Care Foundation. “There are not enough addiction specialists to manage the problem. If not us, who?” Primary care providers can be part of both sides of the solution, she said, by decreasing the quantity of opioids prescribed, thus exposing fewer patients to the risk of addiction, and by ensuring that those with addiction have access to treatment.

Doctor Pfeifer said she became an advocate of MAT after studying the direct impacts of opioids on the brain. “I learned Neurobiology 101. When you use opioids, dopamine floods the brain; each use produces less of a response, until people need opioids just to feel normal.” Buprenorphine’s value is that it stabilizes the dopamine system; allowing people to escape the cycle of withdrawal and craving that prevent them from making different choices. Buprenorphine has the potential to prevent deaths and to reduce the suffering of addiction—but very few people who need it can find it, she said. Doctor Pfeifer noted that many clinicians

think buprenorphine induction is difficult, or will take up too much of their time, or they fear being overwhelmed by unmet need in their communities.

Many physicians continue to work under the misunderstanding that buprenorphine is difficult to obtain on Medi-Cal, despite the fact that the TAR (treatment authorization request) requirement for buprenorphine was removed in 2015. One meeting participant heard a provider say, “I prescribe buprenorphine, but don’t tell anybody,” because of their fear of becoming the de facto addiction treatment provider in the community and being overrun by challenging patients. Prescribers also hesitate to provide MAT if there are not enough counseling resources around, said Doctor Pfeifer. She added that conditions do not have to be perfect to get started with MAT. Although counseling in coordination with buprenorphine induction is the standard of care, she said, buprenorphine can be initiated even if the counseling component is not yet in place, and the meta-analyses looking at the impact of behavioral health added to buprenorphine.

Doctor Kelly Pfeifer is a current ACCMA Member and the Director of High-Value Care at the California Health Care Foundation.

Excerpt taken from CHCF report, Remedy for the Rural Opioid Epidemic: Leaders Discuss MedicationAssisted Addiction Treatment in Primary Care

ACCMA BULLETIN | March/April 2019

13

XXX

XXX

OPIOIDS LEGISLATION

Latest Federal Legislation on Opioids By the California Health Care Foundation

O

pioids killed an estimated 49,000 Americans in 2017, including nearly 2,200 Californians.

They harmed many more, including children forced into the foster care system, babies born with neonatal abstinence syndrome, young adults who overdosed from dangerous new street drugs like fentanyl, and countless others who became addicted to opioids while trying to manage chronic pain.

In early October, Congress overwhelmingly passed bipartisan opioid legislation, including more than $3.3 billion in authorized spending over 10 years. The Senate approved the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also known as the SUPPORT for Patients and Communities Act (HR 6), by a vote of 98-1, while the House approved it 396-14. President Trump signed the 660-page bill into law on October 24, 2018.

The legislation is an amalgamation of more than 70 bills introduced

by Republicans and Democrats. The package aims to ease the epidemic by increasing access to effective treatment within Medicaid and Medicare, expanding alternative non-opioid pain management options, reducing overprescribing, educating patients, identifying best practices that can effectively address the epidemic in the future, and more. Here are some of the key components.

medication-assisted treatment (MAT), as well as the number of patients each provider is allowed to treat. The bill grants physician assistants and nurse practitioners permanent authority to prescribe MAT, and authorizes, for a five-year period, nurse specialists, nurse midwives, and nurse anesthetists to prescribe MAT. Expanding who can prescribe MAT is the second largest projected expenditure in the bill—$395 million over 10 years. This includes grants for Federally Qualified Health Centers and rural health clinics to cover the cost of training providers in the use of the medications to treat opioid use disorders.

The bill authorizes $25 million a year from 2019 through 2023 to fund loan repayment agreements with substance use disorder (SUD) professionals in mental health professional shortage areas or in areas most affected by the epidemic. When funded, this will help expand the number of available providers.

Extending Reimbursement

Expanding Access to Recovery Drugs and Treatment

Requiring Medicaid Coverage of MAT. The bill requires states’ Medicaid programs to cover MAT, including drugs, biological products, counseling services, and behavioral therapy, unless it is not feasible to do so due to a shortage of qualified providers or treatment facilities. The requirement applies for five years. In California, Medi-Cal currently covers MAT both through the county-administered Drug Medi-Cal system (including the Organized Delivery System operating in 19 counties) and through Medi-Cal fee-for-service.

HR 6 expands the type of health care providers who can prescribe or dispense

Advancing

16

Telehealth

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

in

Public

Programs. Medicare beneficiaries with substance use and mental health disorders will have expanded access to treatment via telehealth technology.

Providers will be eligible for Medicare reimbursement even when services are provided within a beneficiary’s home, something that is currently difficult. Within a year, the Centers for Medicare & Medicaid Services (CMS) is required to issue guidance to states on how federal reimbursement can fund telehealth services within Medicaid, including school-based services and services for high-risk individuals, such as Native Americans, adults under 40, people with a history of overdose, and individuals experiencing a serious mental illness along with a SUD. Federal reimbursement will be allowed for telehealth services including assessment, MAT, counseling, medication management, and medication adherence.

Ensuring Safe Medications Medicare providers are required to use e-prescribing for opioids, and Medicare prescription drug plans are required to establish drug management programs for at-risk enrollees.

The Food and Drug Administration (FDA) can now require drug manufacturers to alter opioid packaging so doctors can prescribe smaller quantities, such as a three- or seven-day supply, rather than the traditional 30-day supply. The FDA can now also require manufacturers to give patients safe options for disposing of medications, such as charcoal bags that can be used to destroy unneeded medications at home, thus reducing the risk of medications being misused later. continued on page 26

NALOXONE UPDATES

Updates on Naloxone Policies and Distribution

A

s the opioid epidemic continues to ravage the nation, more and more people are becoming aware of the risks that opioids pose to individuals and communities. Increasing availability and distribution of Naloxone (brand name Narcan) is a current area of focus for community members and institutions interested in promoting harm reduction. Naloxone is an opioid receptor antagonist that reverses the effects of an opioid overdose, posing no potential for addiction or abuse. If administered to someone having an adverse reaction to opioids or who is experiencing an overdose, its effects can take hold in a matter of minutes. A study of Emergency Medical Services (EMS) data regarding Naloxone administrations in Massachusetts between 2013 and 2015 found that, of the nearly 12,200 suspected overdoses that led to the administration of Naloxone, 93.5% of patients survived, demonstrating how effective Naloxone can be for reversing opioid overdoses.

Although Naloxone was previously prescribed exclusively to patients, the paradigm has shifted towards allowing family members, friends, and even concerned citizens access to the rescue dose. Policymakers and institutions are also taking steps to improve accessibility of Naloxone to patients through health care providers such as primary care physicians, nurses, and other allied healthcare professionals.

In addition, there is an increased effort to expand Naloxone distribution and education to law enforcement agencies, as police officers often encounter cases of opioid overdoses while on the job. Other entities are

interested in widespread Naloxone distribution to public institutions and community members.

New California Laws for 2019 California recently passed two laws aimed at increasing the availability and distribution of Naloxone. The first law, Assembly Bill 2760, Article 10.7, states that prescribers must offer Naloxone to patients who meet any of the following conditions: (1) the patient is at an increased risk for overdose, (2) their prescription dosage totals 90 or more morphine milligram equivalents (MMEs) across all active prescriptions, and/or (3) the patient is being co-prescribed a benzodiazepine.

If a patient does accept the prescription, the provider is required to provide basic education and overview to the patient, and anyone designated by the patient, about overdose prevention and directions for administering Naloxone.

The second law, Assembly Bill 2256, authorizes pharmacies, wholesalers, and manufacturers to provide naloxone to law enforcement agencies. The law enforcement agency would be responsible for training their own employees on how to use the opioid antagonist, maintaining a detailed record of acquisition and distribution, and ensuring the destruction of expired opioid antagonists. As police officers and other first responders are typically first on the scene following a 911 call, it is essential that they are equipped and properly trained to use life-saving overdose reversal drugs such as Naloxone.

Naloxone Distribution Project The Substance Abuse and Mental Health Services Administration (SAMHSA) is funding the Naloxone Distribution Project, with the goal of distributing Naloxone to as many community partners as possible and in turn to reduce overdose deaths.

Started in October 2018, the project, administered by the California Department of Health Care Services (DHCS), will provide 12 or more free units of naloxone to qualifying institutions that submit an application.

Examples of qualifying organizations include first responders, emergency medical services, homeless programs, libraries, schools and universities, and many more. These institutions must also be trained on prevention and treatment. Relevant employees of these organizations must also be able to provide training to those they distribute Naloxone to.

Narcan for Outgoing Inmates Locally, Alameda County has adopted a new policy aimed at reducing overdoses among the most at-risk populations: individuals leaving incarceration at Santa Rita County Jail, the county’s sole detention facility.

Jail officials now offer Narcan to atrisk inmates upon their release from county custody. Along with the nasal spray, the outgoing inmate is educated on overdose prevention, harm reduction, and how to administer Narcan.

Inmates with Opioid Use Disorder (OUD) are a cohort of our population continued on page 26

ACCMA BULLETIN | March/April 2019

17

SAFE DISPOSAL

Rx Drop Boxes Let Contra Costa Residents Safely Dispose of Unwanted Medicine

C

ontra Costa residents with unwanted prescription medicines can safely dispose of them at 27 CVS Pharmacy locations in the county, thanks to new, secure drop boxes added through the county’s Safe Drug Disposal Ordinance. The ordinance, passed in 2016, requires pharmaceutical drug manufacturers to provide collection services for unused drugs, to protect the environment and prevent accidental poisonings or intentional misuse of drugs such as prescription opioids.

“Safe storage and disposal of medications is one of the easiest and most important ways that each of us can help turn our country’s opioid abuse epidemic around,” said April

EAST BAY PROGRESS

(continued from page 9)

East Bay residents that misuse opioids but cannot get the care they need.

Dr. Tom Sugarman is immediate past president of the 4,600-member Alameda-Contra Costa Medical Association. Dr. Kathleen Clanon

CODING CORNER

is medical director of the Alameda County Health Care Services Agency.

They are co-chairs of the East Bay Safe Prescribing Coalition.

This piece originally ran as an Op-Ed in the East Bay Times and can be read at https://bayareane.ws/2E4gRgJ

(continued from page 10)

decides to admit him. The admitting cardiologist would report an initial hospital visit (99221-99223) with modifier AI appended.

If the patient also has uncontrolled diabetes, and the admitting physician (the cardiologist) requests a consult from an endocrinologist, the endocrinologist might also select an initial hospital visit code, depending

18

Rovero, founder of the National Coalition Against Prescription Drug Abuse and Chair of the Contra Costa County MEDS Coalition.

The drop-box service is free, secure and confidential. The medications can be disposed of at the sites even if they weren’t purchased at CVS. Most medications are accepted in their original containers or in sealed bags.

Drugs and packaging placed in drop boxes will be safely destroyed. In addition to CVS Pharmacy locations, 10 Kaiser facilities in Contra Costa also have the drop boxes.

“This new medication disposal program will help save both lives and our environment by making appropriate disposal as easy as

on the level of service he provides, to report his consultation. But the endocrinologist would not append modifier AI because he is not the admitting physician overseeing the patient’s overall care.

Complete guidelines with extensive coding examples can be found in MLN Matters® Number: MM6740 Revised.

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

stopping by a nearby CVS Pharmacy or Kaiser Permanente,” said Contra Costa County Supervisor Diane Burgis.

“We are pleased to work with the County to help provide access to safe medication disposal sites in Contra Costa County as part of our company’s commitment to helping prevent and address prescription opioid abuse and misuse,” said Tom Davis, R.Ph., Vice President, Professional Services, CVS Pharmacy.

Visit cchealth.org/safe-drugdisposal for more information about the ordinance and a link to a searchable database of Contra Costa locations with drop boxes.

MAT WAIVER TRAINING (continued from page 13)

interested in learning more and being able to provide MAT in their practice.

Trainings are free for ACCMA members and non-members alike, with four hours of CME credit provided free of charge to ACCMA members. Waiver eligibility trainings are also available to be completed entirely online free of charge at https://pcssnow.org/education-training/webinar-events/. For a schedule of future in-person trainings and other ACCMA-sponsored educational programs, go to www.accma. org/Events.

MEMBER SPOTLIGHT

Member Spotlight: Ruben Kalra, MD

Ruben Kalra, MD

R

uben Kalra, MD is an Interventional Pain Specialist who started his own group practice in the Bay Area, specializing in the treatment of chronic pain and general pain management. Recently Doctor Kalra stepped into a new field: the health care technology industry. Through their work with chronic pain and opioid management, Doctor Kalra and his partners discovered the need for a more in-depth tool to help physicians better understand and treat pain. Drawing on their many years of experience in anesthesiology and pain management, they started a new venture—a company called Wellbrain that serves as a digital chronic pain management platform, allowing physicians to track the psychosocial indicators of chronic pain. Wellbrain offers physicians a menu of tests and risk assessment tools to evaluate patients for anxiety, depression, substance use disorder, and other factors

that may contribute to and exacerbate chronic pain. Doctor Kalra noted that in patients experiencing depression, anxiety, and chronic pain, the research suggests that the pain component can be best managed after first treating their anxiety and depression. In line with Pain Medicine Consultants’ pain management practices, Wellbrain seeks to maximize the use of nonpharmacological modalities and allow physicians to give patients a mindful meditation program to treat anxiety, depression, and other conditions that may contribute to chronic pain.

Doctor Kalra also noted how the changing regulatory environment for physicians treating chronic pain has been a part of Wellbrain’s services for physicians. This change is also impacting who their primary customers are.

He said, “We’re getting more and more primary care doctors who want to use the platform because it serves to help them stay in compliance with the California Medical Board guidelines that mandate patients receive psychological testing if they’re being prescribed opiates.” Wellbrain is also currently being used in a trial program at Kaiser Hospitals for patients undergoing knee surgery, and Doctor Kalra said other hospitals have expressed interest in using the platform. The whole team is looking forward to seeing the results of Wellbrain’s use in hospital settings.

Doctor Kalra founded his small group practice, Pain Medicine Consultants, with two other physicians—William Longton, MD and Richard Shinaman, MD—who are also members of the ACCMA. Each partner has an extensive background in

anesthesiology and pain management.

Doctor Kalra completed his residency in anesthesiology, followed by a pain management fellowship at Harvard’s Brigham and Women’s Hospital. He maintains dual board certification in anesthesiology and pain management.

From 2010 through 2015, Doctor Kalra led the pain management team at John Muir Health, coordinating efforts at both the Walnut Creek and Concord campuses. Pain Medicine Consultants aims to provide pain management services and treatments to patients experiencing the full spectrum of pain, all while limiting the use of opioids.

Their practice treats everything from short-term acute pain to long-term chronic pain, providing over 30,000 patient consultations and treatments per year to patients from the entire Bay Area.

As a founder of Pain Medicine Consultants, Doctor Kalra understands the pressures that solo and small group practice physicians currently face, stating, “Doctors are extraordinarily busy and we created a platform that take that into consideration and really try to minimize clinician time spent using the platform.” Running a company and a medical practice has been no easy feat for Doctor Kalra and his partners. “It’s been extraordinarily challenging to operate a practice, take care of patients, and run a business as well, but we’ve been lucky to have a really good team helping us out on the business side.” As communities come together to address the opioid epidemic, physicians such as the team at Pain Medicine Consultants are offering innovative solutions to help manage pain safely and more effectively.

ACCMA BULLETIN | March/April 2019

19

The Alameda-Contra Costa Medical Association's (ACCMA)

RA T E D JA N

.

East Bay

East Bay Conversation Project

71

PO

18

O

R

ASSOCIATION

IN C

DA–C ON TR AME AL

A COS1T8 6 0MEDIC

AL

A

is pleased to offer the following FREE workshop:

MAKING

CONVERSATIONS COUNT 5IVSTEBZ .BZ BN QN

www.eastbayacp.org

A WORKSHOP ON ADVANCE CARE PLANNING "MBNFEB $POUSB $PTUB .FEJDBM "TTO $MBSFNPOU "WF SE 'MPPS 0BLMBOE

Cost: 'SFF $.& $& "WBJMBCMF

"EWBODF DBSF QMBOOJOH FOIBODFT RVBMJUZ PG MJGF CZ FOTVSJOH UIBU QMBOT BSF EFWFMPQFE UP BEESFTT FOE PG MJGF DBSF EFDJTJPOT JO BDDPSEBODF XJUI QFSTPOBM XJTIFT +PJO +BOFU 5IPNQTPO TFOJPS MJWJOH DPVOTFMPS BU 4U 1BVM T 5PXFST UP MFBSO NPSF BCPVU NFUIPET UP FOHBHF PUIFST JO UIJT JNQPSUBOU DPOWFSTBUJPO BOE UP UFBDI JU FGGFDUJWFMZ After attending this training, attendees will be able to: Identify the concepts and benefits of advance care planning.

Utilize the tools available to engage in discussion of advance care planning Distinguish the importance and characteristics of an effective Health Care Agent Complete and assist others with advance health care directives and POLST forms

y y y

$.& )PVST "WBJMBCMF "QQSPWFE CZ UIF /VSTJOH )PNF "ENJOJTUSBUPS 1SPHSBN GPS $& DSFEJU IPVST 1SPWJEFS BQQSPWFE CZ UIF $BMJGPSOJB #PBSE PG 3FHJTUFSFE /VSTJOH 1SPWJEFS /VNCFS $&1 GPS DPOUBDU IPVST $& QSPWJEFE JO DPMMBCPSBUJPO XJUI i:FT 1SFTT $POTVMUJOH BOE &EVDBUJPOw

RSVP Information Please RSVP online - no login required 3471 at www."$$.".org FWFOUT 0S complete and '"9 this form to 510-654-8959. Questions: please call (510) 654-5383

Attendee: Phone:

Organization: Email:

'VOEFE CZ "MBNFEB $PVOUZ .FBTVSF " &TTFOUJBM )FBMUI $BSF 4FSWJDFT *OJUJBUJWF /PO "$$." NFNCFST XIP XJTI UP DMBJN $.& DSFEJUT GPS UIJT QSPHSBN XJMM CF DIBSHFE B BENJO GFF UP IFMQ DPWFS UIF DPTUT PG QSPWJEJOH $.& "$$." NFNCFST XJMM SFDFJWF UIF $.& GSFF PG DIBSHF BT QBSU PG UIFJS NFNCFSTIJQ CFOFGJUT "DDSFEJUBUJPO 4UBUFNFOU 5IF "MBNFEB $POUSB $PTUB .FEJDBM "TTPDJBUJPO JT BDDSFEJUFE CZ UIF *OTUJUVUF GPS .FEJDBM 2VBMJUZ $BMJGPSOJB .FEJDBM "TTPDJBUJPO *.2 $."

UP QSPWJEF DPOUJOVJOH NFEJDBM FEVDBUJPO GPS QIZTJDJBOT $SFEJU %FTJHOBUJPO 4UBUFNFOU 5IF "MBNFEB $POUSB $PTUB .FEJDBM "TTPDJBUJPO EFTJHOBUFT UIJT MJWF BDUJWJUZ GPS B NBYJNVN PG "." 13" $BUFHPSZ $SFEJUT T ™ 1IZTJDJBOT TIPVME DMBJN POMZ UIF DSFEJU DPNNFOTVSBUF XJUI UIF FYUFOU PG UIFJS QBSUJDJQBUJPO JO UIF BDUJWJUZ

CALIFORNIA BRIDGE PROGRAM

California Bridge Program Selects 31 Health Facilities to Expand MAT for Opioid Use Disorder By the Public Health Institute

T

he Public Health Institute’s Bridge program has selected 31 health facilities from across the state to participate in the California Bridge Program, an accelerated training program for healthcare providers that will enhance access to around-theclock substance use disorder treatment in California communities hit hardest by the opioid epidemic. Program sites will collectively receive more than $8 million, along with training and technical assistance, to improve and increase access to treatment and referral of acute symptoms of substance use disorders hospital-wide.

The Bridge program is funded through the Substance Abuse and Mental Health Services Administration (SAMHSA) State Targeted Response to the Opioid Crisis Grant to the California Department of Health Care Services (DHCS).

A referral to an addiction treatment program has been the most that hospitals have generally been able to provide for patients identified as needing treatment for opioid use disorder. The Bridge model treats emergency rooms and acute care hospitals as a critical window for initiating treatment. When patients in opioid withdrawal come seeking medical care, including for reasons not related to opioid use, they will be offered a dose of medication such as buprenorphine to ease severe symptoms of withdrawal, and then they will be connected with outpatient treatment in the community. Studies

have shown that patients given this option of medication designed for addiction treatment are more likely to remain in care than those who are given referral information alone.

“By suppressing withdrawal long enough to create a bridge for patients to enter and remain in treatment, physicians can save lives,” said Andrew Herring, MD, Director of Emergency Department Services for the Bridge Program. “We know this model works, and now we are bringing it to hospitals and emergency rooms all across the state that are anxious for real solutions to address the enormous pain and suffering they see every day caused by the opioid epidemic.”

Though California ranks only 37th in the country for prescription opioid deaths, the death rates in 16 rural California counties are high enough to put them in the top 10 for the whole nation, and overdoses by synthetic opioids were up 44 percent in California in 2017.

Facilities selected for participation in the California Bridge Program are in regions facing some of the greatest need for substance use disorder treatment. Last month, Enloe Medical Center in Chico treated nearly a dozen people from a single mass overdose event that authorities suspect was caused by drugs containing fentanyl.

St. Joseph Hospital in Eureka and Howard Memorial Hospital in Willits serve rural northern counties that consistently experience some of the highest opioid overdose death rates

in the state. In Southern California, Arrowhead Regional Medical Center and Apple Valley Hospital treat patients in an area that has seen overdose deaths increase almost 50 percent in recent years.

The 18-month California Bridge training program will ensure that any interaction a patient has with the healthcare system can be a potential opportunity to enter into treatment. It approaches substance use disorder as a treatable chronic illness—creating an environment that welcomes disclosure of opioid use, provides rapid evidencebased treatment, and enables patients to enter and remain in treatment.

There will be three types of sites in the California Bridge program: Star Sites, centers of excellence for initiating treatment of substance use disorders from anywhere in the hospital; Rural Bridge Sites, where treatment will begin primarily in the emergency department with the support of substance use navigators; and Bridge Clinics, ‘low-threshold’ follow-up clinics patients can visit after starting treatment in the hospital setting.

“The Bridge program’s approach has the potential to radically change the trajectory of this epidemic,” said Mary Pittman, DrPH, president and CEO of the Public Health Institute.

“Because our state leadership is driven by science instead of stigma, this program will be able to dramatically expand access to lifesaving treatment continued on page 26

ACCMA BULLETIN | March/April 2019

21

COUNCIL REPORTS

JANUARY 17, 2019 The meeting was called to order by Doctor Lubna Hasanain, President.

Doctor Hasanain presented a plaque of appreciation to former California Assemblywoman Catherine Baker to recognize her support of physicians and health care bills supported by the ACCMA and CMA while she served in office.

The Council approved the reappointments of Doctors John Heine and Vin Sawhney for a three-year term to the ACCMA Bylaws Committee; the appointments of Doctors Patricia Austin, Sharon Drager, Michael Ranahan, and Steven Una to three-year terms on the Judicial Council; the re-nominations of Doctors Basil Besh, Katrina Peters, and Jeffrey Poage to the CALPAC Board of Directors; the appointments of Doctor Russ Granich to serve as District 2 Councilor and Doctor Renee Wachtel to serve as District 7 Alternate Councilor-B. Doctor Hasanain asked the Councilors in Districts 3, 4, 7, 10, and 12 to nominate members for their districts to fill the open Alternate Councilor positions. Doctor Robert Edelman was nominated for the Councilor-at-Large position.

Doctor Hasanain announced that the AIMS Panel was looking for additional committee members. Doctor Albert Brooks was nominated to serve on the panel.

Doctor Steven Una discussed the recommendations from the Medical Services & Quality of Care Committee concerning the Alameda County Measure A Oversight and Accountability Report for the 2015–16 fiscal year to the Board of Supervisors. The Council approved advocating to the Alameda County BOS for greater transparency and accountability of Measure A in accordance with the Oversight Committee recommendations.

Doctors Kogan and Dutta provided a report on AMA activities. Doctor Kogan discussed issues that were discussed at the AMA interim meeting held in November 2018. The AMA’s policy on sexual harassment was discussed, and a resolution was passed for an independent evaluation. Doctor Dutta reported that

22

resolutions were discussed regarding the code of ethics for physician aid in dying. A resolution was also passed to oppose immigration policy that separates children from their families.

Mr. Lopez briefly discussed the CMA HOD Q1 Reports. Doctor Arthur Chen requested ACCMA support for an amendment to resolution 301-19 – Establishment of Member Interest Groups/Chat Rooms. The Council approved ACCMA support of this resolution.

Mr. Lopez announced that the CMA Legislative Day would be held in Sacramento on Wednesday, April 24, 2019.

Mr. Greaves updated the Council on the CMA collaboration with the Stanford Medicine WellMD Center to create the CMA Physician Wellness Services Program. CMA has signed a contract with Stanford. CMA’s program will be a comprehensive effort to increase physician wellness as a vehicle to improve the quality of care to patients and to help alleviate the stresses that drive physicians to leave the profession or move from the state.

Mr. Lopez discussed the 2018 midterm election results. He noted that Assemblymember Catharine Baker lost her seat to Rebecca Bauer-Kahan.

Mr. Greaves provided the legislative update. He stated that Governor Newsom has ambitious plans to tackle health care priorities in the areas of drug pricing, laying the groundwork for a single payer health care system, a commitment to spending Prop 56 money as intended, and expanding programs for undocumented immigrants.

Mr. Lopez discussed a new law, AB 1753, that took effect on January 1, 2019. This law requires all security prescription forms to be updated with a uniquely serialized number. The CMA is asking physicians to contact their representatives on the Senate and Assembly Business and Professions Committees to share the impacts this new law is having upon patients and their practices.

Mr. Greaves reported on the outcome of the Alameda County Board

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

of Supervisors (BOS) action on the RFPs for exclusive operating area (EOA) for emergency ambulance response and transport. The ACCMA had sent a letter to the Alameda County BOS encouraging the board to select a bid to maintain the EOA to continue to mandate a high level of service to all Alameda County residents regardless of their ability to pay.

The BOS acted in accordance with the ACCMA’s request to maintain Alameda County’s exclusive EOA and voted in favor to contract with Falck Northern California for five years.

Doctor Hasanain announced that the Ethnic Health Institute (EHI) was sponsoring the annual Frank E. Staggers, Sr., MD Hypertension and Wellness Sunday on February 24, 2019.

Ms. Lum reported to the Council on ACCMA membership recruitment efforts for 2018. She stated that ACCMA membership increased by 16% over 2017. Ms. Lum presented the upcoming ACCMA seminars and webinars.

There being no further business, the meeting was adjourned.

FEBRUARY 14, 2019 The meeting was called to order by Doctor Lubna Hasanain, President.

Ms. Lum provided a walkthrough of the new ACCMA website, which was launched on February 1, 2019.

The Council approved the following appointments: Robert Edelman, MD, Councilor-At-Large; Katrina Saba, MD, District 10 Councilor-B; and Harshkumar Gohil, MD, District 12 Councilor-B. The Council approved the nomination of Suparna Dutta, MD as an At-Large Delegate to the AMA California Delegation.

The re-scheduling of the September Council meeting to September 19, 2019 was approved.

Mr. Greaves provided a report from the ACCMA Child Welfare Committee.

There are concerns regarding changes at USCF Benioff Children’s Hospital of Oakland (CHO) since the affiliation of UCSF with CHO occurred. The committee recommended that a letter be sent to the Alameda County Board of continued on page 23

NEW MEMBERS

NEW & RETURNING MEMBERS Sudhathi Chichili, MD, Hematology Epic Care 400 Taylor Blvd #201, Pleasant Hill Kathleen Anne Clanon, MD, Internal Medicine Alameda County Health Care Services Agency 1411 E 31st St., Oakland James Bruce Florey, MD, Pediatrics Children First Med Group 6425 Christie Ave., #110, Emeryville

Stephen Rishon Levinson, MD, Emergency Medicine

Sherry Wu, MD, Endocrinology, Diabetes and Metabolism

Vituity 2540 East St., Concord

The Permanente Medical Group 200 Muir Rd., Martinez

Blema Sadikovic, MD, Neurology

NEW RESIDENT MEMBER

Information Technology & Healthcare Staffing PO Box 4671, Walnut Creek

Maura Elizabeth Olcese, MD Kaiser Permanente Nor Cal Residency Program PD – Oakland

Marron Cathleen Wong, MD, Obstetrics and Gynecology The Permanente Medical Group 39400 Paseo Padre Pkwy., Fremont

NEW STUDENT MEMBER Joshua Pepper, UCB – UCSF Joint Medical Program

COUNCIL REPORTS

(continued from page 22)

Supervisors (BOS) to request that an independent analysis of the impact of the UCSF-CHO affiliation on pediatric care in our community be conducted to determine the effect of these changes on the quality of care in the community.

The Council approved the recommendation to send the letter to the BOS. The committee recommendation to promote Dignity Health educational programs on Human Trafficking with Medical Staff Presidents, Coordinators and Physiciansin-Chief was also approved.

Doctor Sugarman and Mr. Greaves discussed the CMA request to oppose SB 290. CMA opposes efforts to establish government reimbursement rates in the private sector. The Council directed staff to gather more information on this bill and refer to the Executive Committee or review at the March Council meeting before taking a position on this bill.

The AMA Delegates stated that there was no new business to report. Doctor Kogan provided the CMA Trustees report. He stated that, at the Board of

Trustees Retreat, the 2019 organizational priorities were discussed, which included leadership development, the physician wellness program, the sugar-sweetened beverage tax, and a focus on subsidiary activities. He also reported that the feedback submitted from the 2018 HOD was discussed and many comments were made regarding extending the HOD by half a day in order to provide more time for discussion and debate.

Mr. Lopez reminded the Council of the upcoming CMA Legislative Day scheduled for April 24, 2019. He advised the Council that the Q2 HOD resolutions and materials would be available soon.

Mr. Greaves reviewed the CMAsponsored bills and priorities. He updated the Council on AB 149, which addresses the flawed implementation of the original security prescription pad law. The ACCMA had sent out an alert, encouraging physicians to contact their legislators to vote Yes on AB 149.

Mr. Lopez announced that meetings with local legislators were being

scheduled. There will be a meeting with Assemblymember Buffy Wicks on March 1, and an announcement for a meeting with Assemblymember Rebecca BauerKahan will be emailed to the Council.

Doctor Hasanain asked Council members to consider contributing to the ACCMA political action committee, ACCPAC. Doctor Staggers reminded the Council that the Ethnic Health Institute’s annual Frank E. Staggers, Sr., MD Hypertension & Wellness Sunday would be held on February 24.

Ms. Lum provided a report on ACCMA membership. She asked Councilors to review the non-renewed members report and to contact those they might know to encourage continuation of their membership. Ms. Lum presented the upcoming ACCMA seminars and webinars.

There being no further business, the meeting was adjourned.

Put Your ACCMA Membership to Work! Go to www.accma.org > Member Resources, or call ACCMA at (510) 654-5383 for help.

ACCMA BULLETIN | March/April 2019

23

ALAMEDA ALLIANCE

Reducing Opioid Misuse and Increasing Prop 56 Supplemental Payments

By Scott Coffin, CEO, Alameda Alliance for Health

Scott Coffin

A

lameda Alliance for Health (the Alliance) is proud to serve nearly 270,000 children and adults in Alameda County. In this article, you will learn about the Alliance’s efforts to address the opioid epidemic in Alameda County. You will also learn about Governor Newsom’s proposals on health care and receive an update on Proposition 56 supplemental payments.

The Alliance’s Efforts to Address the Opioid Epidemic Over the last few years, health care organizations and government entities across the United States have been working hard to develop strategies to address the ongoing opioid epidemic.

According to the Centers for Disease Control and Prevention, between 1999 and 2016, more than 630,000 people died from a drug overdose in the

24

United States. In Alameda County, opioid prescriptions were written at a rate of 53.63 prescriptions per 100 residents in 2015, representing nearly half of all prescriptions. While opioidrelated deaths in Alameda County are lower than state and national rates (the California rate is double the county rate and the U.S. rate is about three times the county rate), the county has seen an increase in the last few years.

In order to address the growing rates in opioid-related usage and deaths, the Alliance has developed various initiatives utilizing our continuum-of-care approach that are focused on prevention, recovery support, and intervention and treatment efforts.

The Alliance has begun to partner with local organizations to educate and equip our providers with best practices and tools. We have also conducted community outreach through the Alliance’s Member Advisory Committee and local health care stakeholders, and have developed pharmacy safeguards, such as implementing formulary limits. Our intervention and treatment efforts include member education on the risks of opioids and information on available resources, as well as expanding access to alternate pain management therapies, such as acupuncture and chiropractic services. Lastly, as part of recovery support, we are working to develop targeted case management programs that engage and provide supportive services to members with substance use disorders.

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

The Alliance’s Health Care Services team, led by Dr. Steve O’Brien as Chief Medical Officer, continues to work closely with our provider partners, county leadership, and other safety net providers to support programs that reduce prescription drug abuse in our community. Ultimately, we hope that our efforts will support our providers, properly assist members who have been diagnosed with substance use disorders, and promote the wellbeing of our members while effectively managing their pain. We remain committed to helping reduce opioid misuse and to promoting appropriate standards of care throughout Alameda County.

Governor Newsom’s Health Care Proposals for California On January 10, newly elected Governor Gavin Newsom submitted his 2019– 2020 “California for All” budget proposal to the state legislature.

The proposed budget includes investments and changes in early childhood education and health care that would benefit many of the community members whom we serve.

Governor Newsom proposed to increase the Medi-Cal budget by $2.2 billion, which includes proposals such as extending supplemental payments to Medi-Cal providers and expanding full-scope Medi-Cal coverage eligibility to young adults aged 19–26, regardless of immigration status. continued on next page

ALAMEDA ALLIANCE

Other budget proposals in health care include funding for the Whole Person Care pilot, increasing and expanding subsidies through Covered CA, and investments for mental health services.

Additionally, Governor Newsom announced an executive order to create a single purchaser system for prescription drugs. The executive order tasks the Department of Health Care Services (DHCS) and other state agencies with transitioning all pharmacy services from Medi-Cal managed care into a fee-for-service benefit by January 2021. Through this executive order, private and public purchasers would negotiate prescription drug prices with pharmaceutical companies. The Alliance is actively coordinating with industry leaders and subject matter experts to understand the implications of carving out this important health benefit, and further recognizes that many of our safety net provider partners participating in the 340B program could be negatively impacted through a reduction in revenues for prescription drugs. The Alliance will continue to monitor and take positions as needed in response to state legislation that impact our members and safety net partners.

and June 30, 2018. DHCS is currently proposing to extend supplemental payments for another 12 months. If approved, 10 eligible procedure codes will be added and rates for the current 13 eligible codes will be increased by DHCS for services rendered between July 1, 2018 and June 30, 2019. For example, the current rate for procedure code 99205, an office visit for the evaluation of a new patient, is $50; under the DHCS proposal, the rate would increase to $107. Pending federal approval, we anticipate payments will be received from DHCS at the end of April and the Alliance will follow with issuing payments to providers for rendered services.

For more information on qualifying services and eligibility, please visit the DHCS website at www. dhcs.ca.gov.

(continued)

About Alameda Alliance for Health Alameda Alliance for Health (Alliance) is a local, public, not-forprofit managed care health plan committed to making high-quality health care services accessible and affordable to Alameda County residents.

Established in 1996, the Alliance was created by and for Alameda County residents. The Alliance Board of Governors, leadership, staff, and provider network reflect the county’s cultural and linguistic diversity. The Alliance provides health care coverage to nearly 270,000 low-income children and adults through National Committee for Quality Assurance (NCQA) accredited Medi-Cal and Alliance Group Care programs.

Tracy Zweig Associates INC.

A

REGISTRY

&

PLACEMENT

FIRM

Physicians Nurse Practitioners ~ Physician Assistants

Proposition 56 Supplemental Payments Update In November 2016, California voters passed Proposition 56, which increased the tax rate on cigarettes and other tobacco products. A state bill followed to appropriate Proposition 56 funding for specified DHCS health care expenditures.

Since July 2018, the Alliance has issued payments to providers who rendered services for 13 eligible procedure codes between July 1, 2017

Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 41 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

t z we i g @ t r a c y z we i g . c o m www. t r a c y z we i g . c o m

ACCMA BULLETIN | March/April 2019

25

CLASSIFIEDS

POSITIONS AVAILABLE – 1 STAFF PHYSICIAN FOR PRIMARY CARE CLINIC: A Bay Area federally qualified health center/primary care clinic is looking to hire a staff physician, fulltime or part-time. The applicant must be board certified, or eligible, in Internal Medicine or Family Practice. Duties include: • Provide medical services in the clinic setting • Diagnose diseases, conditions, and illnesses • Review X-rays and laboratory findings • Prescribe the appropriate type of medicine and treatment • Refer patients for special types of diagnostic treatments or medical procedures • Coordinate plans for treatment

• Provide medical leadership supervision and consultation to mid-level practitioners on prevention, diagnosis, care, and treatment of health problems • Maintain accurate and up-todate medical records, review and countersign charts as required, consult with other members of the staff, correctly codes all services provided • Attend all medical staff meetings and other meetings, as required • Remain current on the policies and procedures of the clinic and in the practice of medicine Necessary qualifications include: graduation from an accredited school of medicine with a MD or DO degree, board certified or eligible in family practice or

To place a classified ad, go to www.accma.org > About Us > Advertising,or call our office at (510) 654-5383.

OPIOIDS LEGISLATION (continued from page 16)

Conclusion: More Is Needed This bill represents a positive step towards curbing the opioid epidemic.

It is, however, an incremental step rather than a silver bullet, and critics argue that it falls significantly short of what is needed to solve a crisis of this magnitude. Many called for sustained, robust funding like the Ryan White HIV/AIDS program enacted to combat an epidemic of similar size, and this bill is far from that.

This article was excerpted from the California Health Care Foundation blog, “The 660-Page Opioids Bill Is Now the Law. Here’s What’s in It.” The entire article can be accessed at https:// bit.ly/2CmOFUV.

26

internal medicine, valid certification as a physician or surgeon issued by the state of California, current controlled substance registration certificate issued by the U.S. Drug Enforcement Administration.

Competitive salary and benefits. Apply online at www.davisstreet.org. (1 – Jan/ Feb – Mar/Apr) PHYSICIAN IN EAST BAY: Fremont Urgent Care is seeking a primary care physician and/or PA-C/FNP to join our busy primary care practice in Fremont.

This is an outpatient-only clinic practicing Urgent Care, Occupational Medicine, and Workers’ Compensation. Full-time or part-time options are available. Please send CV, contact information, and inquiries to carole@fremonturgentcare. com. (1 – Jan/Feb – Mar/Apr)

ACCMA members can place a classified ad for four months online and in two issues of the ACCMA Bulletin at NO CHARGE.

NALOXONE UPDATES

(continued from page 17)

who experience a higher risk for overdose due to numerous aggravating factors. During their stay within a detention facility, an inmate’s body can adapt to the absence of opioids, and they will subsequently lose the tolerance they had previously built up to opioids. Upon exiting the detention facility, their likelihood for overdosing increases, if they administer the same dose of opioids they had used prior to their incarceration, for which they now have very low tolerance. In

addition, recently released inmates are less likely to have health insurance coverage upon leaving a detention facility, which may make it difficult to obtain Narcan. Offering Narcan to outgoing inmates is one of many necessary steps towards improving health care practices for those suffering from OUD within detention facilities.

If you have questions about complying with the new California laws on distributing Naloxone, please contact the ACCMA at (510) 654-5383.

CALIFORNIA BRIDGE PROGRAM in California while demonstrating for the rest of the country the critical role the medical system can play in a broad public health response to the opioid crisis.”

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

(continued from page 21)

This article was originally published by the Public Health Institute, and can be accessed here: https://bit. ly/2TG13Kj

Alameda-Contra Costa Medical Association 6230 Claremont Avenue P.O. Box 22895 Oakland, California 94609-5895

PRSRT STD US POSTAGE PAID 85719 PERMIT NO 271

ADDRESS SERVICE REQUESTED

New look, same protection.

Serving the professional liability needs of physicians since 1975.

The look is new but our mission hasn’t changed, to deliver innovative and cost-effective medical professional liability protection and patient safety services for physicians and other healthcare professionals. To learn more about becoming an MIEC policyholder, or to apply, visit miec.com or call 800.227.4527.

Insurance by physicians, for physicians.

800.227.4527 miec.com