ACCMA May/June 2019 Bulletin

ACCMA BULLETIN Serving East Bay physicians since 1860

May/June 2019

SPECIAL ISSUE: Health Care Costs and Affordability ACCMA History – Medical Care for All, Regardless (p. 9) The Importance of Advance Care Planning (p. 20)

Updates on 2019 Opioid Laws (p.25) Local Community Involvement: An ACCMA Member’s Advocacy at Work (p. 29)

A L A M E D A

C O U N T Y

Helping People in Our Community Since 1996

www.alamedaalliance.org

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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 Alexander Kao, 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. 3

Serving East Bay physicians since 1860

NEWS & COMMENTS

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PRESIDENT’S PAGE ACCMA to Form East Bay Clinician Wellness Consortium

By Lubna Hasanain, MD, ACCMA President 9

ACCMA’s History of Preserving Access to Care

By Donald Waters, ACCMA Executive Director (2009-2017) 13

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CMA House of Delegates Major Issue Report: Addressing the Cost of Health Care

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Improving Utilization Through Improved Care Delivery

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Enhancing Competitiveness in the Health Care Market

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Reducing Administrative Burdens

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Addressing the Costs of Pharmaceuticals

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End-of-Life Considerations: The Importance of Advance Care Planning

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45th Annual Legislative Advocacy Day

25 Updates on 2019 Opioid Laws 29

An ACCMA Member’s Advocacy at Work

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California For All: Governor Newsom’s Commitment to Improving Pediatric Care

By Scott Coffin, CEO, Alameda Alliance for Health 32

Growing the Physician Pipeline

By the California Medical Association

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NEW MEMBERS

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CLASSIFIED ADVERTISING

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Consolidated Health Care Markets Contribute to High Health Care Costs

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

ACCMA BULLETIN | May/June 2019

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NEWS & COMMENTS

Alameda County Measles Alert The California Department of Public Health has released an updated Measles Healthcare Exposure Investigation Quicksheet, which can be viewed online. Local health care providers should be alert to the possibility of measles in patients of any age, with common symptoms including fever and rash, as well as runny nose, red eyes, and a cough. Any suspected measles cases in Berkeley should immediately be reported to the Communicable Disease Prevention and Control Unit (CDPC) at (510) 981-5292.

For all other Alameda County residents, contact the Alameda County Public Health Department Communicable Disease Section at (510) 267-3250. View the CDPH Measles Quicksheet at https://bit.ly/2Kt1FwW.

Anthem Modifier 25 Policy Per the new policy, Anthem will deny an E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record for the same provider. The policy took effect March 1, 2019, for commercial claims, and April 1, 2019, for its Medi-Cal line of business. It will also apply to Medicare Advantage claims processed on or after May 1, 2019. The California Medical Association, CMA, has been in direct discussions with Anthem regarding concerns with this policy and the adverse impacts of this new policy upon physician members. Read more at https:// bit.ly/2wFrVvK.

Anthem Fee Schedule Notification Anthem Blue Cross recently announced changes to its Prudent Buyer Participating Physician Agreement and fee schedule effective July 1, 2019. According to a notice issued to approximately ½ of its PPO network, the plan will be increasing payment for the more commonly billed Evaluation and Management (E/M) services. Some physicians, however, have reported decreases in payment for other services. Also included in the notification is a change to the Anthem Workers’ Compensation reimbursement language reducing reimbursement for those physicians who participate in this product line with Anthem. ACCMA encourages physicians to carefully review this proposed amendment and associated fee schedule change to determine the financial impact upon their practice. Physicians do have the right to terminate their agreement (within the specified timeframe) if they choose to not accept the amendment. Physicians with questions or concerns can contact the ACCMA at (510) 654-5383.

Read more at https://bit.ly/2HXiHBS.

Changes to Medical Board Licensure Application The Medical Board of California has made changes to its physician license application with new language changing the way physicians are asked to disclose impairments (physical, mental, substance abuse, etc.) that may impact their ability to practice safely. These changes are aimed at removing stigma around getting diagnosed and treated for conditions that may impair practice, if left untreated. The changes will likely be implemented on paper applications by the end of June. Changes to the online application are expected to be completed by the end of the year. Read more at https://bit.ly/2Kt7xXc.

DHCS Release Prop 56 Payments to MediCal Managed Care Plans Physicians who have a capitated contract with either a Medi-Cal managed care plan or one of its delegated groups for eligible services must submit encounter data to the payor to receive supplemental funds. There is no additional action required by providers who are reimbursed on a fee-for-service basis.

The California Department of Health Care Services (DHCS) has received federal approval of its plan to increase Medi-Cal managed care physician payments for the 2018-2019 fiscal year. The supplemental payments – made possible by the Proposition 56 tobacco tax funding – raises payments for a total of 23 CPT codes, including 10 new preventive codes. As was the case with fee-for-service, DHCS increased the supplemental payment amount for the previously eligible CPT codes to 85% of Medicare (a 34% average increase in payments for these eligible codes compared with 2017-2018 payment levels).

The 10 newly added preventive CPT codes will be paid at 100% of Medicare. Read more at https://bit.ly/2ZbSi99.

How to Report Unfair Payment Patterns Under AB2674 for DMHC Annual Review In 2000, legislation was passed as an attempt to stop unfair payment patterns from health plans by allowing providers to submit complaints to the Department of Managed Health Care (DMHC). However, there was no requirement that DMHC review the complaints. A new CMA-sponsored bill, AB 2674, effective July 1, 2019, requires that DMHC annually reviews complaints filed by providers who believe a plan is engaging in an unfair payment pattern. Physician practices are urged to closely monitor their accounts receivable to ensure that they have been paid properly and to report any violation to DMHC through its provider complaint portal (https://bit.ly/2WeXYwW) or by calling the Help Center at (888) 466-2219. Read more at https://bit. ly/2IlMiDH.

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

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ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

NEWS & COMMENTS

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

Managing Pain Safely: NonPharmacological Modalities for Pain

Managing Pain Safely Online Webinar

Addressing Social Determinants Through Whole Person Care

Friday, July 19 | 8:30 AM – 12:30 PM John Muir Health – Concord Campus 2540 East Street, Room: Concord I & II, Concord CME/CE FREE FOR MEMBERS

Friday, September 6 | 12:15 – 1:30 PM CME FREE FOR MEMBERS

Can You Hear Me Now? PhysicianPatient Communication Online Webinar Tuesday, September 17 | 12:15 – 1:30 PM CME FREE FOR MEMBERS

HIPAA: Critical Updates to Maintain Compliance Online Webinar Wednesday, September 18 | 12:15 – 1:15 PM CME FREE FOR MEMBERS

Wednesday, September 18 | 6:30 – 8:30 PM (Dinner Included) ACCMA Offices, 6230 Claremont Ave., Oakland CME FREE FOR MEMBERS

Thursday, September 26 | 7:30 – 9:30 AM (Breakfast Included) ACCMA Offices, 6230 Claremont Ave., Oakland CME FREE FOR MEMBERS

Medication Assisted Treatment – Waiver Eligibility Training

Monday, September 30 | 10:00 AM – 2:00 PM (Lunch Included) ACCMA Offices, 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.

UPCOMING EVENTS State of Medicine Lunch and Learn Event Tuesday, July 30 12:15 – 1:30 PM (Lunch Included) John Muir Medical Center, Epstein 1 & 2 1601 Ygnacio Valley Rd., Walnut Creek

Beyond the Project: 5 Critical Success Factors for Your Team’s Success Thursday, August 8 12:00 – 2:00 PM (Lunch Included) ACCMA Offices; 6230 Claremont Ave., Oakland

Winding Down Your Practice: Strategies for a Successful Retirement Monday, September 23 6:00 – 8:00 PM (Dinner Included) ACCMA Offices; 6230 Claremont Ave., Oakland

To view a full list of upcoming events and to register online, visit accma.org/Events!

ACCMA BULLETIN | May/June 2019

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PRESIDENT’S PAGE

ACCMA to Form East Bay Clinician Wellness Consortium

By Lubna Hasanain, MD

Lubna Hasanain, MD

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he Alameda-Contra Costa Medical Association (ACCMA) is proud to announce a recently formed collaboration to promote physician wellness and prevent burnout.

The ACCMA is joining forces with the East Bay Health Workforce Partnership (EBHWP), an employerled coalition that is working closely with community and education leaders to meet the health care workforce needs of employers, expand opportunity for local residents, and strengthen the economic and social well-being of the East Bay. Along with EBHWP, ACCMA will be launching a clinician wellness consortium to bring physician and other provider organizations to the table to share best practices, identify common needs, share resources, and develop a roadmap for addressing the system drivers of physician burnout.

Our efforts to develop a comprehensive physician wellness

program commenced on June 6th, when ACCMA and EBHWP co-hosted an initial convening of approximately 40 participants representing a broad segment of the local medical community, including representatives from Kaiser Permanente, Sutter, John Muir, Vituity, Alameda Health System, Contra Costa Health Services, community clinics, solo and small group independent practitioners, allied health professionals, and others. Information was shared about resources that are currently available to support clinician wellness, as well as those that are under development. We heard from Well Physician California, a statewide physician wellness program that is being developed by CMA in collaboration with Stanford that will include leadership development, intensive wellness retreats, and access to mental health services via telehealth, among other things. We also heard about two Bay Area-based organizations doing work in this area: Renew, which supports physician wellness by facilitating informal discussion groups; and Recharge MD, which helps executives address systemic drivers of burnout.

It was heartening to see how many efforts are already underway to promote physician wellness. While we were able to acknowledge and appreciate the work that is already being done, there remained a unanimous agreement of the need for increased collaboration across organizations. To the extent we can compare notes, share resources, and develop a common framework for addressing physician burnout, the better off our patients and community will be

by maintaining a robust and vibrant health care workforce.

ACCMA also has, or is in the process of developing, several programs and services that will serve as valuable tools in combatting burnout and promoting wellness. These include: • Physician Leadership Program – In partnership with UC Berkeley, ACCMA developed a manageable, high quality, affordable leadership skills program. Registration for Fall 2019 opens in July.

• Resource List of Mental Health Providers/Coaches – ACCMA is developing a vetted list of mental health providers who are experienced in working with clinicians, which will be available on the ACCMA website in summer 2019.

• Confidential Assistance for Wellbeing and Litigation Stress – ACCMA physician leaders provide confidential assistance to physicians, colleagues, and families dealing with impairment issues, and confidential peer support to physicians undergoing litigation.

• MIEC/Mayo Physician Wellbeing Index – ACCMA’s endorsed professional liability carrier MIEC has launched a confidential, private online self-assessment tool from the Mayo Clinic that provides a personalized dashboard with links to wellness resources and allows physicians to monitor wellness over time.

• Opportunities to Lead, Advocate and Improve the Health of Our Community – ACCMA has continued on next page ACCMA BULLETIN | May/June 2019

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CALHEALTHCARES PRESIDENT’S PAGE continued from previous page

numerous opportunities for collaborative problem-solving through our committees and our community health projects addressing opioid misuse, advance care planning, hypertension, and others.

To learn more about these programs and services, visit www.accma. org or call 510-654-5383.

Through our partnership with EBHWP, we look forward to bringing our local medical community together to chart a path toward restoring joy to the practice of medicine. We seek to effect long-lasting and measurable change by ensuring the right people are at the table, obtaining support from leaders of the medical community, and leveraging the range of resources available in our community as we promote physician wellness and tackle the root causes of burnout.

Practice & Liability CONSULTANTS Health Care Practice Management In a special arrangement with Practice & Liability Consultants, ACCMA members may purchase the following practice management kit at a reduced price: • Office StaffPersonnel Policies an d Procedures Manual

Practice consulting services available.

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461 Second Street, Suite 229 San Francisco, CA 94107 (415) 764-4800 Fax (415) 764-4802 www.practiceconsultants.net

ACCMA HISTORY

ACCMA’s History of Preserving Access to Care

ACCMA’s First Formal Program to Preserve Access to Care – Creation of the “Alameda Part-Pay Plan” During The Great Depression

By Donald Waters, ACCMA Executive Director (2009 – 2017)

This is a two-part article and will be continued in the July/August Issue.

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ccess to care is a fundamental issue of focus for the medical profession, and the Alameda-Contra Costa Medical Association (ACCMA) has taken a leadership role in developing solutions to limited access on behalf of physicians and patients in the East Bay. Following is a description of the unfolding of the first formal programs developed by the then Alameda County Medical Association (ACMA) to preserve access to care for patients with limited financial means (the ACMA amalgamated with the Contra Costa County Medical Society in 1950 to become the Alameda-Contra Costa Medical Association).

Leading into the 1930s private physicians and the Alameda County health system worked closely together. Private practicing physicians, virtually all of whom were members of the Alameda County Medical Association (ACMA), had since the early 1900s devoted part of their practices to working in county and citysponsored clinics and county hospitals to render care to indigent and other patients. Moreover, many of them served on the boards that managed

the local clinics and some served on the Alameda County Institutions Commission, formed by the Alameda County Board of Supervisors in 1917 as a community-based board to oversee the operations of County-owned health care facilities.

By the early 1930s, as with all things during The Great Depression, health care was becoming less affordable. In some quarters, the call for a government solution to this problem was being renewed, harking back to a California proposal in 1918 patterned after European models of government-controlled health care systems. That proposal was defeated with almost three to one in opposition. The membership of the Alameda County Medical Association (ACMA) desired to meet the medical needs of their community as was demonstrated by their participation in the county and city-sponsored health care facilities.

They were also cognizant of rumblings for a government solution, which they believed would interfere with their relationships with their patients and their ability to practice high quality medicine. They were also wary of hospital-dominated pre-payment health plans that were being considered across the country at that time.

Virtually all actively practicing members of the ACMA participated in the new program.

In August 1932, facing increasing demands to provide medical care in county-funded clinics, the Alameda County Board of Supervisors voted to discontinue providing care to nonindigent patients in its facilities. This left a large population of patients who had limited ability to pay for care with no place to go. ACMA members, who were already directly involved in the care of both indigent and semiindigent patients in those county clinics, immediately proclaimed: “…the medical profession realizes the need of maintaining a service for patients that are not able to pay a full fee…”

The ACMA Council resolved “… to establish a list of physicians who will volunteer to accept calls from such classes of patients and to render service when called…” The ACMA, working with Alameda County health and social service agencies, established the “Alameda Part-Pay Plan,” and within a month of the County announcing the restriction in access to its facilities the ACMA Council approved a letter to be sent to its membership encouraging their participation in the part-pay plan. In the letter the ACMA Council reported the County’s action and explained that there would therefore be a large number of patients in need of care, most of whom will be unable to pay physicians’ full fees. The Council stated that these patients should be cared for at a fee they can afford, and, also that doing so “…will be a long step toward continued on page 11

ACCMA BULLETIN | May/June 2019

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ACCMA HISTORY

(continued from page 9)

MEDICATION ASSISTED TREATMENT

Monday, September 30, 2019

WAIVER ELIGIBILITY TRAINING

10:00 AM – 2:00 PM (lunch included) ACCMA Offices, 6230 Claremont Ave., Oakland Free | CME Available*

This will be a four hour in person training for qualified prescribers (including physicians, Nurse Practitioners and Physician Assistants) to receive half of the 8 hours of training required to obtain a Medication Assisted Treatment (MAT) waiver for treatment of Opioid Use Disorder (OUD). Primary care physicians, addiction specialists, psychiatrists, NPs and PAs are encouraged to attend! Open to members and non-members of the ACCMA. Counts for 4 CME credits. Lunch included!

Doctor Chwen-Yuen Angie Chen is a Clinical Professor of Medicine in Primary Care and Population Health and Psychiatry and Behavioral Sciences at Stanford University with over 25 years of experience working with those who have substance use disorder in both clinical and non-clinical settings. Doctor Chen is board certified by the American Board of Internal Medicine, is a Diplomate of the American Board of Addiction Medicine, is an active member of the California Medical Association and is a board member of the California Society of Addiction Medicine. In her private practice, Doctor Chen provides both primary care and addiction treatment.

AT THE COMPLETION OF THIS ACTIVITY, THE LEARNER WILL BE ABLE TO: • • • • •

Recognize the history and causes of the opioid epidemic Recognize the pharmacology of relevant buprenorphine and how it is used to treat OUD Assess, screen, and monitor patients starting or continuing treatment Design an appropriate, safe treatment plan for patients with OUD Exemplify increased empathy and reduce stigma surrounding OUD

* Non-ACCMA members who wish to claim CME credits for this program will be charged a $99 admin fee to help cover the costs of providing CME. ACCMA members will receive the CME free-of-charge as part of their membership benefits.

REGISTRATION Four ways to register: (1) Online at http://www.accma.org/events; (2) email rsvp@accma.org; (3) fax this form to (510) 654-8959; (4) call (510) 654-5383.

Practice Name / Med Group: _________________________________________________________________ Attendee 1: ________________________________________ Email: ___________________________________ Attendee 2: ________________________________________ Email: ___________________________________ Fax: ________________________________________________ Phone: __________________________________ FOR NON-MEMBERS REQUESTING CME: Credit Card Number:_______________________________ Security Code:___________ Exp.:___________ Name as it appears on card: __________________________________________________________________ Billing address: ________________________________________________________________________________ Accreditation Statement: ACCMA is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education.

Credit Designation Statement: ACCMA designates this live activity for a maximum of 4.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Funding for this initiative was made possible (in part) by grant no. 5U79TI026556 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

ACCMA HISTORY

the solution of some of our medicoeconomic problems and will help to prevent the forcing of some form of state medicine upon us, or the introduction of an undesirable insurance plan.” Virtually all actively practicing members of the ACMA participated in the new program.

A key component of the program was the close working relationship that existed between community physicians and the Alameda County Social Services Department, which would serve as the gateway through which part-pay patients would be referred to ACMA members. The County was pleased with this approach, as it enabled the referral of part-pay patients who continued to seek care at county clinics and hospitals. The county’s medical social workers also played a key role in addressing any social issues that would impact referred patients’ health care. Referrals on a rotating basis to ACMA members were also initiated through several community organizations and arrangements were made for managing confirmed and suspected TB patients.

ACMA members provided the full

ACMA members provided the full range of medical services at a significantly reduced fee, ranging from 50 cents to $1.50 for office visits or home calls.

(continued from page 9)

It was nationally acclaimed in the news media, within organized medicine, and in the halls of the U.S. Congress as “The Alameda Plan.”

range of medical services at a significantly reduced fee, ranging from 50 cents to $1.50 for office visits or home calls. The ACMA adopted the State’s industrial fee schedule as the basis on which discounts off full fees would be determined. The ACMA enlisted the participation of local pharmacists, x-ray and clinical laboratory services, and specialized clinics, who all agreed to reduce their fees for these patients.

To minimize the administrative burdens for participating physicians, all referrals for ancillary services were coordinated through the county social services department. Private hospitals chose not to participate, as they indicated that they were in discussions about creating a hospital pre-payment plan (see discussion about health plan below), mirroring a national trend among hospitals. Some hospitals did, however, establish clinics to care for patients with limited means. In the event that a patient’s medical needs were beyond the physician’s ability to provide, such as hospitalization, the County social service department made arrangements to obtain that care in County facilities. The treating physicians in the community maintained privileges to render care at the county hospitals (Highland and Fairmont Hospitals) and would continue to follow patients in those facilities.

The Alameda Part-Pay Plan operated for ten years, then became virtually dormant during World War II as demand for it faded away.

As an example of its impact in the

community, records for the timeframe of 1932 through 1939 indicate that a total of 11,999 patients were referred by the County Social Services Department to ACMA members. In 1947, the Part-Pay Plan was reactivated to further enhance a program the ACMA initiated in 1945 to “guarantee” medical care to all Alameda County residents. Under the mantra – “Medical Care for All, Regardless,” that program became a model for county medical societies to provide universal access to care to an entire community. It was nationally acclaimed in the news media, within organized medicine, and in the halls of the U.S. Congress as “The Alameda Plan.”

William Guertin, ACCMA Executive Director from 1984 to 2009, consulted on this article. Donald Waters worked for the Alameda-Contra Costa Medical Association for 35 years, serving as its Executive Director from 2009 until his retirement in 2017.

Sources: Minutes of Committee, Council and Membership Meetings of the Alameda County Medical Association – 1932-1936 A History of the ACMA, authored by ACMA historian Milton Shutes, MD, and published by the Alameda County Medical Association, 1946 Fifty Years In Law and Medicine – Howard Hassard, An Oral History, published by Hassard, Bonnington, Rogers and Huber, 1985 Memo titled “An Outline of the Plan for Distribution of Medical Care, Formulated In 1932 by the Alameda County Medical Association and the Alameda County Institutions Commission,” by Marguerite L. Spiers, Chief Medical Social Worker, Alameda County Institutions; August 16, 1948

ACCMA BULLETIN | May/June 2019

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MARKET CONCENTRATION

Consolidated Health Care Markets Contribute to High Health Care Costs Reprinted with permission from UC Berkeley School of Public Health

C

alifornia insurer and provider markets are becoming more concentrated, leading to a steep rise in the amount consumers pay for health care, according to a new study from policy experts in the UC Berkeley School of Public Health.

The study, from the Nicholas C. Petris Center on HealthCare Markets and Consumer Welfare, analyzed the relationship between market concentration and health care procedure prices, as well as Affordable Care Act premiums between 2010 and 2016. The analysis was published in March in a report called Consolidation in California’s Health Care Market 2010-2016: Impact on Prices and ACA Premiums.

Of California’s 58 counties, 44 had highly concentrated hospital markets—which the report defined as California counties. Additionally, the study found 12 counties had highly concentrated primary care markets, 20 counties had highly concentrated orthopedics markets, 22 counties had highly concentrated cardiology markets, 24 counties had highly concentrated hematology/oncology markets, and 26 counties had highly concentrated radiology markets.

“Our research suggests that health care consolidation has continued at a rapid pace and consumers are paying higher prices for hospital and physician procedures and insurance premiums as a result,” said Richard Scheffler, the study’s lead author, director of

the Petris Center, and Distinguished Chair in Health Economics and Public Policy at the UC Berkeley School of Public Health and Goldman School of Public Policy.

Price and premium differences between Northern California and Southern California are particularly striking, Scheffler said.

Inpatient prices were 70 percent higher, outpatient prices were 17 to 55 percent higher and ACA premiums were 35 percent higher in Northern California than in Southern California due to a larger market concentration in the State’s northern region. Medical procedures, the study found, were 20 to 30 percent higher in Northern California compared to Southern California, even when adjusted for cost of living.

“Hospital systems have been consolidating in California for years, and we were aware that a lot of it was going on in Northern California in particular, but we were still surprised at the magnitude of the price and premium differences between Northern and Southern California,” Scheffler said.

According to the report, “the vast majority of counties in California warrant concern and scrutiny, according to the DOJ/FTC Guidelines.

It continued, “Consumers are paying more for health care as a result of market consolidation. It is now time for regulators and legislators to take action.”

The report used the HerfindahlHirschman Index, or HHI, to measure market concentration, which is the standard statistical model employed by the U.S. Department of Justice and Federal Trade Commission. Markets with HHI’s in excess of 2,500 points are considered highly concentrated, and any merger that pushed the HHI in a market by more than 200 points is assigned “the highest concern and scrutiny.”

Fourteen counties 14 counties qualify for the list of high concern and scrutiny under the HHI model.

For instance, the hospital HHI in Stanislaus County increased from 3,361 in 2010 to 5,172 in 2016. In Contra Costa County, the hospital HHI jumped more than 500 points during the same time period.

Scheffler says the market consolidation trend isn’t expect to slow any time soon, particularly with respect to hospitals buying physician practices. However, there are potential solutions.

“Stronger antitrust enforcement is one obvious potential solution, but there are numerous others as well, such as premium rate review or the active purchaser model that Covered California uses to negotiate the premium rates that insurers participating on Covered California offer to consumers,” Scheffler said. “More and closer monitoring of these trends is a must and the Petris Center will continue to do just that.”

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HOUSE OF DELEGATES MAJOR ISSUE REPORT

CMA House of Delegates Major Issue Report: Addressing the Cost of Health Care

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he following is an excerpt from the Major Issue Report to the 2018 CMA House of Delegates on Addressing the Cost of Health Care.

The recommendations adopted by the House are included at the end of this report. To read the full report, go to https://www.cmadocs.org/hod.

The CMA Board of Trustees adopted the recommendation of the CMA Committee of Delegation Chairs (CDC) to designate addressing the cost of health care as a major issue for discussion and action for the 2018 CMA House of Delegates meeting.

This informational report provides the context for the development of the four reports that comprise the Major Issue Report on Addressing the Cost of Health Care.

Increasing health care costs impacts everyone—patients, providers, health plans, employers, governments and labor and there is overwhelming agreement that health care is becoming increasingly unaffordable for patients, employers, and the government.

Many economists argue that the rising costs of California’s and the nation’s health care system are limiting our ability to address other important needs and remain competitive in a global economy. There is growing evidence that health care is simply becoming unaffordable for families, employers and the government.

The share of California’s Gross State Product (GSP) consumed by health care continues to grow and will rise from 15.4 percent in 2012 to a projected 17.1 percent in 2022. U.S. health care spending reached $3.3 billion in 2016 and accounted for nearly 18 percent of 14

Gross Domestic Product (GDP).

Despite essential health care reforms brought about by the Affordable Care Act (ACA), issues still remain post-ACA, such as health care coverage falling short of universal coverage, instability in the individual marketplace, and rising healthcare costs. National health spending grew by 4.3% in 2016, slightly lower than the 5.8% growth in 2015. US health spending reached $3.3 trillion in 2016, or $10,348 per capita, and accounted for 17.9% of gross domestic product (GDP).

Medicare spending has nearly doubled from $550 billion in 2012 to a projected $1.1 trillion in 2022 representing 4.3 percent of GDP.2 While the growth in health care costs have slowed recently to 3 to 4 percent (particularly for physician services), it is increasing and projected to grow faster than GDP. The growth in Medicare spending 1 is principally caused by new health care technologies and the aging baby boomers with multiple chronic conditions. The sheer number of seniors enrolling in Medicare and their associated health care costs as they age account for one-third of the increase in total spending for all major federal health care programs.

There also has been a massive growth in Medicaid spending from $253 billion in 2012 to a projected $592 billion in 2022 because of the Affordable Care Act expansion of Medicaid coverage. In California, one-third of the population is now enrolled in Medi-Cal making it the second largest expenditure in the California state budget behind K-12

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

education. However, covering the previously uninsured population is not the major driver of spending.

While Medi-Cal is one of the most cost-effective Medicaid programs in the country, limited access is a major driver of spending. With 57 percent of physicians not accepting new MediCal patients, emergency department utilization and hospital costs are high and thereby are driving spending.5 Spending for both the Medicare and Medicaid programs will strain federal and state budgets.

The California State Legislature and Congress are aggressively seeking ways to slow the rise in health care costs and spending. Physicians, as the center of the health care system, must lead health care delivery reform.

Any health care cost containment proposals must include the entire health care sector. It is paramount for physicians to examine ways to bend the cost curve in all sectors of the health care system. There are significant opportunities to improve health care delivery, create efficiencies, and improve health care outcomes, including through addressing social determinants of health and expanding telehealth services.

Health care cost containment solutions have been proposed by many stakeholders, but in most cases attempts to develop a “silver bullet” solution have been unsuccessful because the magnitude of the problem and consideration of the many downstream impacts and trade-offs have made clear that a comprehensive solution must address the many cost drivers that create incentives for higher continued on page 27

IMPROVING UTILIZATION

Improving Utilization through Improved Care Delivery The recommendations that were adopted at the 2018 CMA House of Delegates on Addressing the Cost of Health Care: Improving Utilization Through Improved Care Delivery are summarized here. To view the full report and recommendations adopted by the House, please visit: https://www. cmadocs.org/hod.

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he overriding goal is to achieve optimal health care outcomes for patients at the most affordable cost for families, employers, insurers, and government programs. To achieve this, the focus should be on addressing utilization and health care delivery reforms for the 5% of Californians that account for 53% of all the states’ health care expenditures. By targeting the highest cost patients, there is the greatest opportunity for reducing costs and improving the quality of care. The emphasis should be access to primary care supported by coordinated care systems with chronic disease management and access to specialists, for three categories of high-cost, vulnerable patients: Medicare-Medicaid dual eligibles, patients suffering from one or more chronic conditions, and patients near the end-of-life. The main goal of the recommended strategy is to reduce avoidable emergency department visits and unnecessary hospitalizations. This is where the greatest cost savings can be achieved in the physician sector for these high cost patients.

That CMA support health care delivery and payment system reforms that target the costs incurred by the 5% of California patients who account for more than half of the state’s health care expenditures.

That CMA evaluate and promote innovative health care delivery reforms through physician-led integrated organizations or virtual groups of independent practices that support physicians in large, small, and solo practices to improve quality and efficiency of care.

That CMA evaluate and encourage programs to have better coordination of domestic care, physician care, and medication adherence, including working with the State of California to develop a health care delivery shared savings model with the California In-Home Support Services (IHSS) program for low-income persons.

That CMA support payment and delivery reforms for treating MedicareMedicaid dual eligible patients to reduce costs.

That CMA support long-term financial modeling of new health care legislation and other reforms on health care delivery and payment to better understand the long-term benefits of investment in initiatives.

That CMA support physician collaboration within their health care system, and with their local community, to improve population health and forge strong clinical-community linkages.

That CMA support a comprehensive assessment of California’s efforts to address social needs and health behaviors and examining how payors are implementing policies based on social determinants of health.

That CMA advocate for a statewide entity to coordinate, identify and evaluate successful pilot programs that address social determinants of health and support local & state policy that addresses social determinants of

health.

That CMA prioritize data collection and quality improvement metrics that capture the diversity of all populations in clinical practices to fully understand the health status and needs of all individuals.

That CMA support increased funding for telehealth infrastructure, including improving the broadband network throughout California, and other upfront and ongoing costs associated with telehealth technology.

That CMA support the use of consistent and uniform telehealth standards across payors, including interoperability, and support reimbursement for telehealth modalities without restrictions on originating sites.

That CMA support the use of electronic consultation, without a face-to-face patient encounter with the consultant, expand payment for telehealth services, and support that the physician determines when telehealth services would be most appropriate and beneficial for the patient.

That CMA advocate for risk-based funding and payment models that incentivize health care delivery and innovation for patients with chronic physical, mental and/or behavioral health conditions.

That CMA support expanding access to telehealth services while preserving protections for geographic network adequacy.

That CMA will support limiting the profit of health plans and health insurance companies. to 2%, above which, rebates must be given to patients through mechanisms like Affordable Care Act regulations when medical loss ratio limits are exceeded.

ACCMA BULLETIN | May/June 2019

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ENHANCING COMPETITIVENESS The Frank E. Staggers, Sr., M.D. Hypertension Project, an initiative of the Alameda-Contra Costa Medical Association, presents:

ADDRESSING

SOCIAL DETERMINANTS

THROUGH WHOLE PERSON CARE

Thursday, September 26, 2019

ACCMA Offices, 6230 Claremont Ave., Oakland 7:30 – 8:00 AM: Registration and Breakfast 8:00 – 9:30 AM: Programs Cost: FREE (CME Available!)* RSVPs REQUIRED to Reserve Your Seat

PRESENTERS:

Sara Levin, MD Emily Parmenter Contra Costa County Whole Person Care

Kathleen Clanon, MD Alameda County Whole Person Care

Whole Person Care (WPC) is a statewide waiver pilot program for vulnerable Medi-Cal recipients aimed at improving health outcomes and reducing utilization of high-cost services. Alameda and Contra Costa Counties are among the 19 counties participating in the program, with the goals of improving linkages and services outside of the health system into the larger community. During this program, experts from Alameda County and Contra Costa County will share how each of our East Bay counties is addressing social determinants of health under the WPC waiver program.

• • •

Participants will learn about:

Health care disparities in our community and the impact of social determinants of health Different approaches to addressing social determinants through “whole person care” County programs and services addressing social determinants for vulnerable patient

Join us for our quarterly series to network and share best practices with colleagues and other health care experts.

REGISTRATION

Three ways to register: (1) Online at http://www.accma.org/events; (2) email rsvp@accma.org; (3) call (510) 654-5383. *Non-members who wish to claim CME credits for this program will be charged a $75 admin fee to help cover the costs of providing CME. ACCMA members will receive the CME free-of-charge as part of their membership benefits.

Accreditation Statement The Alameda-Contra Costa Medical Association is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians.

Credit Designation Statement The Alameda-Contra Costa Medical Association designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ENHANCING COMPETITIVENESS

Enhancing Competitiveness in the Health Care Market The recommendations that were adopted at the 2018 CMA House of Delegates on Addressing the Cost of Health Care: Enhancing Competitiveness in the Health Care Market are summarized here. To view the full report and recommendations adopted by the House, please visit the following: https://www. cmadocs.org/hod.

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he following is an overview of the impacts of the various market trends, a summary of the antitrust principles that apply to physician-led, integrated models of care, a discussion of strategies for physicians to achieve the benefits of clinical integration without aligning with a hospital, hospital system, or larger group, and an explanation of the reasoning behind the recommendations for enhancing competition that follow.

That CMA support efforts to require state regulatory approval for all proposed mergers, including vertical and horizontal mergers, and that any related proceedings and findings be made public consistent with federal and state anti-trust laws.

That CMA support efforts to ensure that California’s state health insurance regulators have the appropriate and necessary expertise to enforce the laws and monitor the products under their jurisdiction.

That CMA continue to pursue strong enforcement of California laws and regulations prohibiting health

consolidation without improving access, quality, or cost.

That CMA support efforts to make it more feasible for all physicians to participate in delivery and payment reforms. As well as, improving capital access for solo physicians and members of small practices to invest in the tools and resources necessary to succeed in new delivery and payment models and expanding sharedservices initiatives that are efficient for physician practices.

plan and insurer predatory behavior.

That CMA support governmental actions designed to assure hospital market competition, promote access and affordability and assure quality of care. This includes the authority of the appropriate governmental agencies to disapprove hospital mergers and acquisitions whenever such mergers and acquisitions are expected to have negative consequence.

That CMA support efforts to eliminate incentives that drive

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ACCMA BULLETIN | May/June 2019

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REDUCING ADMINISTRATIVE BURDENS

Reducing Administrative Burdens The recommendations that were adopted at the 2018 CMA House of Delegates on Addressing the Cost of Health Care: Reducing Administrative Burdens are summarized here. To view the full report and recommendations adopted by the House, please visit the following: https://www.cmadocs.org/hod.

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ver time, the level of administrative activity (and the associated cost) involved in healthcare has dramatically increased, placing significant costs and burdens on the healthcare system. While physicians may be especially concerned with the excess administrative activity that occurs in their practices, it should be noted that shifting the responsibility and cost for administrative activity between various players in healthcare will likely not have an impact on overall health care costs. Elimination of all administrative tasks is also unlikely. Meaningful reform to significantly reduce health care costs will require changing how and when health care-related administrative tasks occurs.

CMA will support administrative tasks be evaluated using the following criteria:

That the administrative activity has a clear intent and is useful for improving quality of care and outcomes for the patient population and the information requested, processed, or transmitted is not duplicative of an existing process or source.

The benefits to the healthcare system of the information collected or provided outweighs the total acquisition costs to the healthcare system and the responsibility/cost for accomplishing an administrative task

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is appropriately distributed across all parties.

Any appropriate new and existing administrative tasks are established through collaboration between healthcare entities and not unilaterally imposed and that they be evaluated for its detrimental effect on physician wellbeing.

CMA will support efforts to simplify and streamline administrative tasks, that include:

Credentialing Supporting a single provider submission process for provider credentialing that is used by all plans, insurers, hospitals, and practices, as well as, a timely process for provider credentialing.

Eligibility and Billing First supporting a standard and transparent set of claims edits developed with physician input to be used by all plans and insurers. Second, the establishment of real-time claims payment by all plans and insurers, which allows a claim to be submitted and paid in full before a patient leaves the office or hospital. Third, improve and modernize California Medicaid Management Information System (CAMMIS), with the aim of ensuring that the Department of Health Care Services, health plans, and their delegated entities can issue timely and accurate payments to physicians participating in the Medi-Cal program.

Lastly, improve Automated Eligibility Verification System (AEVS) and to ensure that physicians in the MediCal program are provided with realtime, accurate and complete eligibility information.

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Prior Authorization First, supporting the creation and use of a standardized electronic prior authorization process that physicians can use in addition to other methods. Second, the elimination of prior authorization, with physician input, for medications, procedures, and lab tests that no longer warrant prior authorization. Third, making prior authorization requirements and other formulary information accessible to physicians in real-time at the pointof-care. Lastly, peer-to-peer review be done by a like specialist and at a time convenient to and provided by the prescribing physician and not the reviewer.

Quality Measurement and Reporting First, supporting a physicianapproved, standardized, and evidencebased set of core quality measures and reporting requirements across all payors, whether public or private. Second, quality measures be updated regularly or when new evidence is developed, and that when new quality measures are adopted, others are sunset. Third, that Electronic Health Records (EHR) have the functionality to automatically capture and report data for quality measurements required by public and private payors. Last, reducing administrative burdens in reporting to disease registries and other government regulated reporting programs, as well as reducing administrative burdens associated with prescription drug monitoring programs.

Medical Records First, supporting increased physicianinformed oversight over EHR technology vendors by state and federal continued on page 23

ADDRESSING COST OF PHARMACEUTICALS

Addressing the Costs of Pharmaceuticals The recommendations that were adopted at the 2018 CMA House of Delegates on Addressing the Cost of Health Care: Addressing the Costs of Pharmaceuticals are summarized here. To view the full report and recommendations adopted by the House, please visit the following: https://www.cmadocs.org/hod.

C

alifornia has significant and progressive laws that address pharmaceutical costs. However, more can be done. There are potential incremental steps California can take to further address the rising costs of prescription drugs. It is important to note, however, that the options are limited given the limitations imposed by the U.S. Constitution on the state’s ability to regulate matters that are within the federal purview or that impact interstate commerce. Moreover, the complexity and range of drivers of the cost of prescription drugs means there is no single policy solution that can address the increasing costs of prescription drugs.

That CMA support drug price transparency laws that provide the public and policymakers with the information necessary to fully understand how drug prices are set by pharmaceutical companies in relation to the costs of development, manufacturing, and marketing.

That CMA support transparency in the prices negotiated by pharmacy benefit managers (PBMs) with manufacturers, plans and insurers, and pharmacies, to promote competitive practices among PBMs and drug manufacturers and to better understand whether the business activities of PBMs benefit patients and consumers by reducing the cost of prescription drugs.

That CMA support efforts to ensure state regulators have the rationale and the evidence for the inclusion or exclusion of drugs on the formulary, and information from PBMs, to determine whether formularies are being developed to benefit patients and consumers.

That CMA support efforts by the Department of General Services (DGS) to consolidate drug procurement or engage in other joint activities with other state agencies and the private sector that will result in cost savings.

That CMA support strong enforcement of California’s Unfair Competition Law against pharmaceutical companies and PBMs that engage in anticompetitive business practices.

That CMA support pharmaceutical manufacturers establishing fair list prices and limiting unnecessary price increases.

That CMA support efforts to prevent pharmaceutical manufacturers from imposing unjustified year over year price increases or increases that are greater than the Consumer Price Index for Medical Care.

That CMA support efforts to encourage more competition in the market by eliminating patent-extending tactics, additional exclusivity periods, and behaviors limiting generic / biosimilar, and oppose legislative or regulatory efforts that lessen competition in the market.

That CMA support basing

cost-sharing on the post-rebate amount negotiated by pharmacy benefit managers, plans, and insurers so that patients benefit from such price reductions directly.

That CMA support the development and use of prescriber tools that make prescription drug price and comparative-effectiveness information available to prescribers at the point of care.

That CMA support that hospitals covered under the 340B program be required to reinvest 340B revenues in services for low-income patients and submit annual reports describing their investments.

That CMA support efforts to explore innovative options to reduce drug-spending in Medi-Cal, including through the use of the 1115 Waiver process to permit alternative price negotiations outside of the Medicaid Drug Rebate Program.

That CMA support efforts to eliminate incentives that increase the cost of prescription drugs without improving access, safety, or efficacy.

That CMA develop a study having the state of California contract with all pharmaceutical manufacturers for uniform reduced costs for all FDA approved medications for all California residents.

That CMA support efforts to create transparency with regards to hospital billing practices for pharmaceuticals for their outpatient and inpatient clients.

Put Your ACCMA Membership to Work!

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

ACCMA BULLETIN | May/June 2019

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IMPORTANCE OF ADVANCE CARE PLANNING

End-of-Life Considerations: The Importance of Advance Care Planning

W

ith the percentage of aging Americans continuing to increase dramatically, the need for advance care planning (ACP) is more important than ever. ACP, which may be part of a broader palliative care delivery model, aims to facilitate discussion between patients, their families, and often their physicians, to express and document the patient’s preferences for their end-of-life care.

This can be especially important when the aging patient reaches a point where they are no longer able to properly express their needs or make their own decisions. According to a recent study, it is estimated that up to 29% of aging patients who require decision making at the end of life are unable to communicate their desires or lack decision-making capacity.1 Other studies estimate that this number is closer to 45%-70% of older adults.2 ACP is a way to address these, and many other, challenges that may arise when coordinating end-of-life care for a patient.

In 1969, an Illinois attorney, Luis Kutner, introduced the concept of a “living will,” conceived as a document authored by an individual in order to specify the types of treatment they would be willing to receive should they be incapable of participating in the decision-making process at a later time.3 A few years later, in 1976, California became the first state to pass the Natural Death Act, also known as the Death with Dignity Act, which granted living wills the power of law.3 These laws also acknowledged the rights of terminally ill patients to refuse medical treatments and interventions. While living wills proved to be a valuable first step, physicians and 20

family members soon acknowledged the need for a more comprehensive way of addressing end-of-life care.

Some challenges associated with living wills include: the content of the will being unclear, an individual’s documented preferences not being inline or relevant to their current condition, with many aging adults having drafted their living will years earlier, and physicians or health care providers not having access to the living will at the critical decision-making moment.2 Through that need, the new concept of Advance Care Planning (ACP) emerged and gained traction among aging populations. In contrast to living wills, where the patient simply completes and signs a legal form, ACP embodies a larger, life-long communication process with multiple components, including having physician “facilitators” assist individuals and their families in articulating their preferences for end-of-life care, as well as a more systemic implementation tactic that allows the plans to be honored across all healthcare institutions.

ACP often includes a living will and a durable power of attorney for health care (DPAHC), however emphasis is put on the importance of also having an informal conversation with family members and care providers to most effectively communicate a patient’s end-of-life values.

Recently ACP has begun to favor POLSTs (Physician Orders for Life Sustaining Treatment) over living wills, which aim to address the limitations associated with living wills and DPAHC.2 POLSTs are forms completed by a patient, facilitated and signed by a health care provider, indicating

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specific treatments to be administered or withheld in end-of-life scenarios.

Because POLST is completed during a consultation with a health care provider, it remains in the patient’s medical records, so is often more accessible than a living will. Recent studies have demonstrated that comprehensive ACP interventions may be more effective than advance directives (such as living wills) alone in ensuring compliance with an individual’s end-of-life (EOL) decisions.4 The goal of ACP is to simplify the complex process typically associated with end-of-life care and to ease the burden of family members and physicians. End-of-life care can be costly to family members in many ways; it is often found to cause depression and anxiety among caregivers who are organizing care for their loved one, it can be time-consuming and expensive to both family members and medical institutions, and, without advance care planning, end-oflife care may not accurately reflect the patient’s wishes.5 While medical expenditures are expected to increase towards the end of an individual’s life, with many patients requiring additional prescriptions, in-hospital treatments, etc., studies have shown that a disproportionate amount of money is spent on end-of-life care. One study in particular found that last-year-of-life expenses constituted 22% of all medical expenditures, 26% of Medicare, 18% of all non-Medicare expenditure, and 25% of Medicaid expenditures.6 “While only 5% of elderly Medicare beneficiaries have died annually, the percentage of elderly Medicare expenditures spent on persons in the last

IMPORTANCE OF ADVANCE CARE PLANNING

year of life fluctuates between 27% and 31%”.6 While lowering health care costs is not the goal of ACP, aggressive and expensive medical care is often not consistent with patients’ treatment preference; studies have found that patients who complete advance directives typically opt for limited care (92.7%) or comfort care (96.2%) rather than all care possible (1.9%).1 Comparatively, individuals who did not complete advance directives were much more likely to receive all care possible, which often correlates to aggressive treatments, major surgical procedures, and expensive medical technologies.1 Studies have shown that these more aggressive treatment options often increase the length of a patient’s life, but do not necessarily correlate to an increase in the patient’s quality of life.2 ACP has increased the number of do-not-resuscitate orders and has decreased hospitalizations, admissions to ICUs, and rates of cardiopulmonary resuscitation, mechanical ventilation, and use of tube feeding.3 When ACP discussions have taken place, patients often receive care that is more in-line with their wishes, and patients who complete advance directives overwhelmingly choose limited or comfort care versus costly and aggressive treatments.1 Through a study centering on 444 patients who had completed living wills and 552 patients who had not completed living wills, it was determined that 27.7% of those who did not complete living wills received “all care possible”, which correlated to more aggressive and costly treatments and procedures, versus only 8.1% of those who did complete living wills.1 A review of evidence found that advance care planning led to reductions in hospital death and intensive care unit use, hospitalizations, length of stay and 30-day readmissions, hospital deaths, ICU

admissions and aggressive treatments, ICU use for patients readmitted after the index hospitalizations, hospitalizations for nursing home residents, ICU use and major surgical treatments, and ICE use, reduced length of stay and billable procedures.7 As a result of the decrease in costly treatments following advance care planning, studies have found reductions in costs of care ranging from $1,041 to $64,827 per patient when patients engaged in advance care planning.4 Again, the goal of ACP is not to limit health care expenditures during end-of-life care, but to follow directives that conform with the patient’s wishes, and patients who express their wishes through advance directives were less likely to choose costly treatment routes and were more likely to opt for palliative care.

Studies estimate that only onethird to one-half of all adults in the U.S. have completed advance directives, although rates are higher among aging adults and individuals with terminal illness.2 As the number of aging Americans continues to grow, it is becoming increasingly important for physicians to address advance care planning with their adult patients.

Physicians are a vital part of the conversation, as they often facilitate the discussion between patients and family members, as well as can offer input on prognosis and treatment vs. nontreatment options. Advance care planning is a means of facilitating meaningful discussion between patients and families to help relieve their anxiety and improve the decision-making process, and even without a documented advance directive, it allows for an informal conversation where patients can highlight their end-of-life values and wishes. In late 2015, the Centers for Medicare and Medicaid Services (CMS) released regulations allowing Medicare to reimburse physicians for ACP consultations with their patients, so physicians can engage in consultations with patients at no cost to themselves. In addition, a wide variety of resources exist for health care providers to learn more about advance care planning, POLST, living wills, and how to effectively address these topics with patients, including online templates, booklets, instructional videos, in-person seminars, and more. endnotes on page 27

East Bay The ACCMA is proud to support the East Bay Conversation Project, a coalition of individuals and organizations who are passionate about promoting advance care planning in the local community. The Conversation Project, which was developed in 2010 by the nonprofit Institute for Health Care Improvement, provides a litany of resources to facilitate “The Conversation”. The ACCMA’s East Bay Conversation Project offers quarterly workshops to train health care providers on becoming advance care planning champions and facilitating conversations. For more information on the East Bay Conversation Project and to view upcoming Advance Care Planning Trainings, visit www.ACCMA. org/EBCP.

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LEGISLATIVE ADVOCACY DAY

45th Annual Legislative Advocacy Day

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n April 24, 2019, more than 40 ACCMA members joined over 600 physicians, medical students, and residents from all over California for the 45th Annual California Medical Association (CMA) Legislative Advocacy Day in Sacramento. Over the course of the day, physicians heard from key legislative leaders and CMA’s legislative advocates, attending multiple meetings with members of the State Legislature who represent the East Bay in order to discuss pending California health care legislation.

This year’s Legislative Advocacy Day focused on public health, in particular two bills that would impact all medical practices in California.

The event was attended by physicians, residents, and students from across California

SB 276

Senator Richard Pan’s bill, SB 276, sponsored by the CMA, proposes to strengthen oversight of the medical exemption process by requiring statelevel public health approval of all medical vaccine exemptions. A previous CMA sponsored bill, SB 277, removed the personal belief vaccination exemption, granting exemptions solely to those with medical documentation.

This, however, led to a drastic increase in the number of medical exemptions granted in the state of CA..SB 276 aims to close the loophole that led to a spike in medical exemptions by

22

holding physicians accountable who are practicing outside of the accepted standard of care and endangering public health in the process. This bill includes four strategies to strengthen oversight of the medical exemption process: Medical exemptions will only be granted by the California State Health Officer and their designees. Physicians will submit information to the CA Department of Public Health (CDPH) on the patient’s behalf and will grant exemptions when vaccination is contraindicated per CDC guidelines.

To apply for an exemption, physicians must include the reason for the exemption, certify that they have examined the patient, and must provide their own name and medical license number on the application.

CDPH will create and maintain a database of medical exemptions, and parents will be required to send a copy of existing medical exemptions to the department. CDPH will make the data available to the county health departments, the Department of Education, and the Medical Board of California.

The State Health Officer and County Health Officers will have the authority to revoke medical exemptions granted by licensed physicians if they are found to be fraudulent or inconsistent with contraindications to vaccination per CDC guidelines.

ACCMA members pressed legislators to vote in favor of SB 276, advocating in support of childhood vaccinations. ACCMA and CMA recognize the crucial need for childhood vaccinations, and are proud to support SB 276, which has since passed the Senate Health Committee and has been referred to the Committee on Appropriations.

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ACCMA and CMA members meet with Senator Bill Dodd

AB 764

AB 764, authored by Assemblymember Rob Bonta and sponsored by the CMA, prohibits manufactures from offering discounts or other price reductions or promotions on any sugar-sweetened beverage, which are used to lower prices and increase consumption. This bill stops the predatory practice the soda industry uses to target communities with large discounts that ultimately increase consumption of sugar-sweetened beverages. These discounts disproportionately affect lower-income neighborhoods and often target specific communities, leading to barriers to healthy diets among low-income families.

ACCMA members explained that sugary drinks make up nearly half of all added sugars in the American diet, and it is no surprise that discounts on unhealthy products, like soda, create a disproportionately affect low-income families. With manufacture subsidies, soda often becomes less expensive than bottled water, which drives up consumption of sugary beverages in targeted neighborhoods. For consumers, the real costs of discounts and promotional prices are a substantial increase in calorie consumption and resulting health complications.

This bill has also been referred to the Committee on Appropriations. continued on next page

LEGISLATIVE ADVOCACY DAY

Proposition 56 Budget Request

Proposition 56 was adopted in 2016, increasing the state excise tax on cigarettes and other tobacco products by $2 per pack, applying the same tax to e-cigarettes. The measure directs 82 percent of the revenue generated from the increased tobacco taxes to fund health care services and treatment for Medi-Cal beneficiaries. The 20192020 California State Budget proposed

by Governor Newsom returns all of Prop 56 revenue ($1.05 billion) to support increased access for Medi-Cal beneficiaries. The proposal includes three new programs that are supported by CMA – a new Value Based Payment Program, developmental and trauma screenings, and additional family planning supplemental payments for Medi-Cal. ACCMA members lobbied local Senators and Assemblymembers, explaining that the legislature should adopt a budget action directing the Department of Health Care Services (DHCS) to submit a three-year federal State Plan Amendment (versus the current single year approval) to make the Proposition 56 revenue stream supporting increased access to health care for Medi-Cal beneficiaries more predictable for health care providers and administrators.

The ACCMA wishes to acknowledge and thank members who participated in the CMA Legislative Leadership Conference in Sacramento:

ACCMA members meet with local Assemblymember Rebecca Bauer-Kahan

Guest Speakers

CMA President David H. Aizuss, MD opened the program by greeting attendees and getting physicians fired up to lobby legislators about public health. Following, Dr. Aizuss’ welcome, Senior Vice President of Government Relations, Janus Norman, provided an advocacy overview of SB 276, AB 764, and the Proposition 56 Budget Request. Mr. Norman also explained the do’s and don’ts of a how to lobby your legislator. The afternoon program included CMA’s CEO, Dustin Corcoran, who welcomed the attendees back and introduced the Legislative Day key note speaker.

The key note speaker was Governor Gavin Newsom. Governor Newsom discussed his strong commitment to increasing access to care for all Californians.

REDUCING ADMINISTRATIVE BURDENS regulatory agencies without additional administrative and cost burdens to physicians.

Second, the principle of a uniform retention period for healthcare records by the custodian of the records across all payors and healthcare provider systems. Third, educate physicians of their legal obligations when creating, maintaining and providing access to medical records. Fourth, require

(continued)

(continued from page 18)

payors to use other data sources such as claims data when conducting audits to reduce the burden on physician practices of records requests from payors. Last, reaffirm existing policy that supports efforts to harmonize standards and specifications that would enable interoperability of electronic health record systems and facilitate the exchange of health information among health care providers.

Jacques Corriveau, MD Harshkumar Gohil, MD Lubna Hasanain, MD Terry Hill, MD Jeffrey Klingman, MD Mark Kogan, MD Evelyn Li, MD Michael Melewicz, MD Myngoc Nguyen, MD Juan Ordonez, MD Katrina Peters, MD Jeffrey Poage, MD Thomas Powers, MD Jonathan Savell, MD Frank Staggers, Jr., MD Thomas Sugarman, MD Clifford Wong, MD Robyn Young, MD Kaiser Pediatric Residency: Betsy Hayes, MD (Faculty) Christine Yeh, MD (Faculty) Lucia An, MD Samuel Backus, MD Alexia Charles, MD James Hall, MD Anqi Li, MD Lydia Maleknia, MD Kara Mesznik, MD Eva Padilla, MD Ruby Patel, MD Sara Patrizi, MD Molly Rabinowitz, MD Arielle Randolph, MD Shweta Sujit, MD Vanessa Wong, MD UCSF Benioff’s CHO Residency: Sabrina Darwiche, MD Stephanie Fong Gomez, MD Anna Kaplan, MD Jasmine Mikami, MD Maya Raman, MD

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HOD ENHANCING

Wednesday, September 18, 2019 |6:30 - 8:30 PM Free Seminar | CME Available*| Dinner Included

MANAGING PAIN SAFELY Non-Pharmacological Modalities for Pain As the opioid epidemic continues to negatively impact communities, it is important to educate physicians on the non-pharmacological alternatives for pain management. Many physicians are uncomfortable integrating alternative modalities for pain management into their practice or referring out for such modalities. This seminar will assist in increasing access to non-opioid modalities for pain management and can reduce the patient’s risks of becoming opioid dependent.

AT THE COMPLETION OF THIS ACTIVITY, THE LEARNER WILL BE ABLE TO: Consult local non-pharmacological professionals on the appropriate utilization of non-pharmacological alternatives to opioids for pain management.

Utilize the information to refer patients to alternative therapies such as acupuncture, physical therapy and chiropractic treatment.

Effectively discuss the benefits of non-pharmacological therapies with patients experiencing pain.

SPEAKERS Irina V Williams, M.D. is board certified in Pain Management and Anesthesiology, and is practicing in Oakland, CA. Dr. Irina V. Williams affiliates with Alameda Health System and is a Medical Director of AHS Interdisciplinary Pain Medicine Program.

Amy Matecki, M.D. is the co-founder and President of the International Center for Integrative Medicine (ICIM) and the Chief of Integrative Medicine in the Department of Medicine at Highland Hospital, AHS.

Dennis Barker, D.C. has been in private practice as a Doctor of Chiropractic for 28 years in Walnut Creek.

Having suffered from two lumbar disc herniations, he has had nearly every treatment for lower back pain including surgery.

John Lang, Ph.D. maintains a private practice where he specializes in clinical neuropsychology, chronic pain management, cognitive-behavioral therapy, behavioral management, and psychological assessment.

*Non-ACCMA members who wish to claim CME credits for this program will be charged a $49 admin fee to help cover the costs of providing CME. ACCMA members will receive the CME free of charge as part of their membership benefits.

REGISTRATION Four ways to register: (1) Online at http://www.accma.org/events; (2) email rsvp@accma.org; (3) fax this form to (510) 654-8959; (4) call (510) 654-5383.

Practice Name / Med Group: _________________________________________________________________ Attendee 1: ________________________________________ Email: ___________________________________ Attendee 2: ________________________________________ Email: ___________________________________ Fax: ________________________________________________ Phone: __________________________________ FOR NON-MEMBERS REQUESTING CME: Credit Card Number:_______________________________ Security Code:___________ Exp.:___________ Name as it appears on card: __________________________________________________________________ Billing address: ________________________________________________________________________________ Accreditation Statement: ACCMA is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education.

Credit Designation Statement: The Alameda-Contra Costa Medical Association designates this live activity for a maximum of 1 AMA PRA Category 1 Credits(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

2019 OPIOID LAWS

Updates on 2019 Opioid Laws

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he California Legislature had an active 2018 passing new laws on drug prescribing and dispensing.

Below are highlights of the new laws likely to impact physicians in 2019 and beyond.

AB 315 (Wood) Pharmacy benefit managementCMA Position: Sponsor

Requires a pharmacy to inform a customer at the point of sale for a covered prescription drug whether the retail price is lower than the applicable costsharing amount for the prescription drug unless the pharmacy automatically charges the customer the lower price. If the customer pays the retail price, the bill requires the pharmacy to submit the claim to the plan or insurer in the same manner as if the customer had purchased the prescription drug by paying the cost-sharing amount when submitted by the network pharmacy. Requires pharmacy benefit managers to notify and disclose specified information to exercise good faith and fair dealing, including, but not limited to, notifying purchaser of conflicts of interest, and information regarding prescription product benefits, disclosing to pharmacy network providers and contracting agents any material changes to a contract provision. Establishes a pilot program in Riverside and Sonoma counties to assess the impact of health care service plan and pharmacy benefit manager prohibitions on the dispensing of certain amounts of prescription drugs by network retail pharmacies.

Imposes additional requirements on health care service plans with regard to contracted pharmacy providers and pharmacy benefit managers.

AB 1751 (Low) – CURES database: Interstate data sharing

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

AB 1753 (Low) – Controlled substances: Security form

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

AB 1948 (Jones-Sawyer) – Interception of electronic communications

Adds fentanyl to the list of controlled substances for which interception of

wire or electronic communications may be ordered by a judge when there is probable cause to believe an individual is committing a crime related to controlled substances.

AB 2037 (Bonta) – Pharmacy: automated patient dispensing systems

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

AB 2086 (Gallagher) – Controlled substances: CURES database

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

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

CMA Position: Neutral Authorizes a physician and surgeon continued on next page

ACCMA BULLETIN | May/June 2019

25

2019 OPIOID LAWS

(continued from page 25)

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

AB 2783 (O’Donnell) – Controlled substances: hydrocodone combination products

Reclassifies specified hydrocodone combination products as Schedule II controlled substances under the California Uniform Controlled Substances Act.

AB 2789 (Wood) – Health care practitioners: prescriptions: electronic data transmission

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

AB 2859 (Caballero) – Pharmacy: safe storage products

Requires a pharmacy that dispenses Schedule II, III, or IV controlled substances to display safe storage products in a place on the building premises that is located close to the pharmacy, unless the pharmacy meets requirements related to the ownership and management of the pharmacy.

26

AB 3112 (Grayson) – Controlled substances: butane

Makes it unlawful to sell to any customer any quantity of non-odorized butane. Exempts from the prohibition certain consumer items such as lighters and small containers of nonodorized butane used to refill these items. Authorizes a civil penalty to be assessed for the violation of these provisions and specified local and state officials to bring a civil action to enforce these provisions.

SB 212 (Jackson) – Solid waste: pharmaceutical and sharps waste stewardship

CMA Position: Support Establishes a stewardship program, under which a manufacturer or distributor of covered drugs or sharps, or other entity defined to be covered by the bill, is required to establish and implement, either on its own or as part of a group of covered entities through membership in a stewardship organization, a stewardship program for covered drugs or for sharps, as applicable. Imposes various requirements on a covered entity or stewardship organization that operates a stewardship program, including submitting aproposed stewardship plan, an initial stewardship program budget, an annual budget, annual report, and other specified information to CalRecycle.

SB 1021 (Wiener) – Prescription drugs

Extends existing provisions related to formularies for outpatient prescription drugs by health care service plans or health insurers and cost-sharing for covered outpatient prescription drugs until January 1, 2024. Prohibits, until January 1, 2024, a drug formulary maintained by a health care service

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plan or health insurer from containing more than 4 tiers, as specified.

Requires a prescription drug benefit to provide that an enrollee or an insured is not required to pay more than the retail price for a prescription drug if a pharmacy’s retail price is less than the applicable copayment or coinsurance amount, and the payment rendered by an enrollee or insured would constitute the applicable cost-sharing.

Extends until January 1, 2023, coverage requirement to antiretroviral drug treatments that are medically necessary for the prevention of AIDS/HIV, as specified.

SB 1109 (Bates) – Controlled substances: Schedule II drugs: opioids

CMA Position: Support Requires training and continuing education under the Medical Practice Act, Nursing Practice Act, Physician Assistant Practice Act, Dental Practice Act, Osteopathic Act, and the Optometry Practice Act to include risks of addiction associated with the use of Schedule II drugs. Requires pharmacy or practitioner dispensing an opioid to a patient for outpatient use to display a notice on the label or container that warns of the risk of overdose and addiction as specified. Requires a prescriber to discuss specified information with the minor, the minor’s parent or guardian or other adult authorized to consent to the minor’s medical treatment before directly dispensing or issuing for a minor the first prescription in a single course of treatment for a controlled substance containing an opioid.

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

2019 OPIOID LAWS

SB 1254 (Stone) – Hospital pharmacies: medication profiles or lists for highrisk patients

CMA Position: Neutral Requires a pharmacist at a hospital pharmacy to obtain an accurate medication profile or list for each highrisk patient upon admission of the patient under specified circumstances.

Authorizes an intern pharmacist or a pharmacy technician to perform the task of obtaining an accurate medication profile or list for a high-risk patient if certain conditions are satisfied. Requires the hospital to establish criteria regarding who is a highrisk patient for purposes of the bill’s

provisions and determine a timeframe for completion of the medication profile or list, based on the populations served by the hospital.

spending.

These reports and recommendations are intended to be a set of health care cost containment proposals which, in conjunction with existing CMA policy, clearly states the types of health care containment proposals that CMA believes are actionable through legislation, regulation and stakeholder partnerships and can

pharmacist at all times. Exempts certain pharmacies from its provisions.

SB 1447 (Hernandez) – Pharmacy: automated drug delivery systems

SB 1442 (Wiener) – Community pharmacies: staffing

Beginning on July 1, 2019, repeals existing provision related to automated drug delivery systems (ADDS) located in a health facility. Instead requires an ADDS, as defined, to meet specified requirements in order to be installed, leased, owned, or operated in the state, including a license for the ADDS issued by the California State Board of Pharmacy to a pharmacy licensee.

Prohibits a community pharmacy from requiring a pharmacist to engage in the practice of pharmacy at any time the pharmacy is open to the public, unless either another employee of the pharmacy or, if the pharmacy is located within another establishment, an employee of the establishment within which the pharmacy is located is made available to assist the

HOUSE OF DELEGATES MAJOR ISSUE REPORT

(continued)

(continued from page 14)

improve care delivery and achieve significant cost reductions to the health care system as a whole.

Due to the volume of reforms that would be required to effect meaningful health care cost containment, the proposed reforms will be discussed across four domains with each summarized in a separate article within this Bulletin issue:

• • • •

Improving Utilization through Improved Care Delivery; Enhancing Competitiveness in the Healthcare Market; Reducing Administrative Burdens; and Addressing the Costs of Pharmaceuticals.

IMPORTANCE OF ADVANCE CARE PLANNING (continued from page 21) Notes 1 Silveira, Maria J., et al. “Advance Directives and Outcomes of Surrogate Decision Making before Death.” New England Journal of Medicine, vol. 362, no. 13, 1 Oct. 2010, pp. 1211–1218., doi:10.1056/nejmsa0907901.

2 Carr, Deborah, and Elizabeth A Luth. “Advance Care Planning: Contemporary Issues and Future Directions.” Innovation in Aging, vol. 1, no. 1, 1 Mar. 2017, doi:10.1093/geroni/igx012.

3 Liantonio, John, et al. “Advance Care Planning: Making It Easier for Patients (and You).” Clinician Reviews, Sept. 2017, pp. 47–51., www.mdedge.

com/clinicianreviews/article/145271/hospicepalliative-medicine/advance-care-planning-makingit-easier.

4 Klingler, Corinna, et al. “Does Facilitated Advance Care Planning Reduce the Costs of Care near the End of Life? Systematic Review and Ethical Considerations.” Palliative Medicine, vol. 30, no. 5, 2015, pp. 423–433., doi:10.1177/0269216315601346.

5 Bond, William F., et al. “Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs.” Journal of

Palliative Medicine, vol. 21, no. 4, 1 Apr. 2018, pp.

489–502., doi:10.1089/jpm.2017.0566.

6 Hoover, Donald R, et al. “Medical Expenditures during the Last Year of Life: Findings from the 1992-1996 Medicare Current Beneficiary Survey.” Health Services Research, vol. 37, no.

6, Dec. 2002, pp. 1625–1642., doi:10.1111/14756773.01113.

7 Dixon, Josie & Matosevic, Tihana & Knapp, Martin. (2015). The economic evidence for advance care planning: systematic review. Palliative medicine. 29. 869-884.

10.1177/0269216315586659.

ACCMA BULLETIN | May/June 2019

27

ALAMEDA ALLIANCE

Alameda-Contra Costa Medical Association

ATTENTION: Physicians, Practice Managers & Office Staff

The State of Medicine July 30, 2019 ∙ 12:15 - 1:30 PM John Muir Medical Center ∙ Walnut Creek East Bay Medical Practice Forum Please join the Alameda-Contra Costa Medical Association (ACCMA) for this “lunch and learn” program.

This is a great chance to connect with other physicians, practice managers and office managers in your area, while getting up to speed on the latest news and information impacting medical practices. Lunch will be provided.

Presented By:

Joe Greaves Executive Director Alameda-Contra Costa Medical Association

July 30, 2019 ∙ 12:15 - 1:30 PM John Muir Medical Center Epstein 1 & 2 1601 Ygnacio Valley Rd., Walnut Creek

Presentation Topics: Reimbursement News What’s New with Medicare and Medi-Cal Legislative Update Practice Management Tips Physician/Medical Practice Trends

LUNCH INCLUDED

For more information or to register over the phone, please call the ACCMA at (510) 654-5383, or email rsvp@accma.org.

Register online at www.ACCMA.org/Events Call the ACCMA at (510) 654-5383 OR complete and fax this form to (510) 654-8959

TO REGISTER Attendee #1: _______________________________________

Attendee #2: _______________________________________

Physician Office/Group: _____________________________

Physician Office/Group: _____________________________

Office Address: _____________________________________

Office Address: _____________________________________

Work Phone: _______________________________________

Work Phone: _______________________________________

Email: ____________________________________________

Email: ____________________________________________

P: (510) 654-5383

rsvp@accma.org

F: (510) 654-8959

MEMBER’S ADVOCACY AT WORK

An ACCMA Member’s Advocacy at Work

O

n November 8, 2016, California voters passed Proposition 64, also known as the Adult Use of Marijuana Act, with a vote of 57% to 43%, effectively legalizing the sale and distribution of cannabis in multiple forms. Advertising and marketing restrictions specific to recreational use of cannabis were codified pursuant to Proposition 64. Among other advertising restrictions, the proposition states that a licensee shall not advertise or market cannabis or cannabis products on an advertising sign within 1,000 feet of a day care center, school providing instruction in kindergarten or any grades 1 to 12, inclusive, playground, or youth center.1

Advocacy: What Can Be Done

The ACCMA is proud to serve as a representative and source of legislative advocacy for East Bay physicians.

Since Proposition 64 became law, several ACCMA physician members have reached out to ACCMA regarding the billboard advertisement of market cannabis or cannabis products, specifically near schools or areas that are highly populated with children.

According to a study by RAND Corporation, adolescents who view more advertising for medical marijuana are more likely to use marijuana, express intentions to use the drug, and have more-positive expectations about the substance.2 The study, which tracked adolescents’ viewing of medical marijuana ads over a seven year span, demonstrates that an increase in marijuana advertising may lead to an increase in marijuana usage among young people.

Proposition 64 states that billboard ads cannot be placed within

1,000 feet of places that are likely to have children present. If you notice a market cannabis or cannabis product billboard ad that is within a 1000 feet of a day care center, school providing instruction in kindergarten or any grades 1 to 12, inclusive, playground, or youth center, you may do the following: • Contact your local city council – most local city councils regulate the advertisement of billboard ads and have the authority to remove an illegal billboard ad.

• Contact ACCMA – if you notice a billboard that is within the designated area, you can contact, Mr. David Lopez, ACCMA Associate Director of Advocacy and Policy, who will provide you with

•

information on metrics and the information about your local city council. Mr. Lopez can be reached by phone at (510) 654-5383 or by email at dlopez@accma.org.

Contact your local representatives – any subsequent legislation related to cannabis would need a 2/3 majority approval because it was a ballot initiative. For a complete list of your county, and state legislators, please check out the ACCMA Legislative Guide, available online at www.ACCMA. org/.

Notes 1 https://leginfo.legislature.ca.gov/faces/codes_ displayText.xhtml?lawCode=BPC&division=10.&tit le=&part=&chapter=15.&article 2 https://www.rand.org/news/press/2018/05/17. html

DR. SABA’S NARRATIVE “Around the end of January this year, I was dismayed to see a giant billboard advertising marijuana at a major intersection approximately 1.5 blocks from my kids’ high school. Not only that, but this school has 2 campuses and students walk between the campuses, directly under that billboard, several times a day. I pulled out Google Maps, and used the “measure distance” feature to measure the birds’ eye view from the billboard to the edge of the school property -and sure enough, it was well under the 1,000 feet required by law. I took a photo of the billboard and emailed it with a letter to my city councilman, with the billboard company name and billboard number (both displayed at the bottom of the billboard), as well as the name of the marijuana company and its license number (also displayed on the billboard). I quoted the law and asked what my city councilman would do about this billboard, which was clearly out of compliance with the law.

Furthermore, I stated that I am a pediatrician who cares for many kids in our community, cited the real statistics about marijuana addiction in teens from the National Institute on Drug Abuse, and quoted the school’s principal, who has called marijuana “the crack of this generation.”

The councilman responded by the next day. He had contacted the billboard company, who said they would remove the advertisement, noting that that location would be restricted going forward. The marijuana advertisement came down within 3 days and was replaced by a public service ad against teen drinking and driving.”

ACCMA BULLETIN | May/June 2019

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ALAMEDA ALLIANCE

California For All: Governor Newsom’s Commitment to Improving Pediatric Care

By Scott Coffin, CEO, Alameda Alliance for Health

Scott Coffin

A

lameda Alliance for Health (the Alliance) is honored to serve nearly 260,000 children and adults in Alameda County. In this edition you will learn about Governor Gavin Newsom’s focus on improving children’s health outcomes. You will also learn about the Governor’s plans to increase oversight on pediatric screening, diagnosis, and treatment of children across California.

On January 10, Governor Newsom released his 2019-2020 “California For All” state budget. While we are still likely to see many changes before the final budget is adopted in June, one focus that we expect to hold strong involves efforts to improve the health and education of California’s children. Governor Newsom’s first proposal includes $60 million for early developmental health screenings for children covered by Medi-Cal, nearly $110 million to expand home

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visiting programs that support pregnant women and their families, and $260 million to extend full MediCal coverage to undocumented young adults ages 19 through 25 years old.

Additionally, the budget focuses on reducing health disparities in early childhood by providing additional funding to improve the detection of adverse childhood experiences, as well as significantly increasing funding for new state-subsidized preschool slots for low-income 4-years-olds. At the Alliance, we understand that access to quality health care and education is linked to stronger outcomes for our youngest residents, and we commend the Governor for his efforts that will change the landscape of services provided to children and families for years to come.

Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT)

The EPSDT benefit was enacted through a federal statute in 1967 as a part of Medicaid, and today the benefit is designed to ensure that eligible MediCal members receive early detection and preventive care in addition to medically necessary treatment services, so that health problems are either averted or diagnosed and treated as early as possible. With the Governor’s focus on supports and services for California’s children, the Department of Health Care Services (DHCS) is increasing oversight on

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the EPSDT benefit to ensure that Medi-Cal managed care plans such as the Alliance are performing required services and that we are strengthening our coordination efforts with entities such as the Regional Center of the East Bay and California Children Services on all EPSDT services that they provide to our youngest members.

The DHCS is currently developing additional resources and expanding information regarding the EPSDT benefit, including increasing the amount of EPSDT information on their website, providing a more detailed description of EPSDT services in the member handbook, and adding new EPSDT-focused material in the Medi-Cal Provider Manual.

The Alliance will be working internally on our processes to ensure that we are properly overseeing EPSDT services that local health entities provide to our members.

For more information on EPSDT and covered services, visit the DHCS website at www.dhcs.ca.gov/services/ pages/EPSDT.aspx.

Advancing Care Quality Oversight

In addition to expanding supports and services to children, the Governor is committed to efforts that advance and improve the state’s process for monitoring and overseeing the quality of health care provided to children covered by Medi-Cal. As part of his commitment to early childhood continued on next page

ALAMEDA ALLIANCE

development, the Governor directed the DHCS to review all pediatric measures and identify health measurements that require improvement.

Consequently, the DHCS determined that changes were needed to strengthen quality oversight for MediCal managed care plans, including adding a new set of measures in children’s health, women’s health, behavioral health, and acute and chronic disease management. This new set of measures is based on the Centers for Medicare & Medicaid Services’ Adult and Child Core Sets that are evidencebased and assess the quality of care.

Additionally, the DHCS has raised the minimum performance level by 100% on a statewide basis, resulting in managed care plans and providers working collaboratively to target

quality improvement opportunities.

These quality benchmarks have been retroactively implemented to January 1, 2019, and will be reported to DHCS in May 2020.

At the Alliance, we understand that improving the quality of our services is a continuous process that includes laying out priorities, measuring outcomes and setting interventions to improve performance.

Since 2015, the Alliance has steadily improved its quality measures by 30 percentage points, in large part due to the hard work and dedication of our community providers. We are confident that by working with our community providers, and with a strong commitment from our Alliance employees, we will be able to exceed the state’s new quality standards.

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 260,000 low-income children and adults through National Committee for Quality Assurance (NCQA) accredited Medi-Cal and Alliance Group Care programs.

NEW MEMBERS

NEW & RETURNING MEMBERS Nancy Bryant, MD, MBA 13847 E 14 St., #110, San Leandro th

Walailuk Chaiyarat, MD Solano Hematology Oncology 100 Hospital Drive, #110, Vallejo Magdalena Ciurlik, MD East Bay Anesthesiology Medical Group, Inc. 3000 Colby St., #205, Berkeley Caroline Hastings, MD Pediatric Hematology Oncology Med Group 747 52nd St., Oakland John Hayward, MD Alameda Health System 1411 E 31st St., Oakland Mustafa Kazemi, MD East Bay Cardio Vascular Thoracic Group 5401 Norris Cyn Rd., #308, San Ramon

NEW MEMBERS

Aravind Rangaraj, MD California Cardiovascular Consultants and Medical Associates 200 Jose Figueres Ave., #225, San Jose Ronald Jay Robinson, MD Sutter East Bay Medical Group 305 Hawthorne Ave., Oakland Rakesh Safaya, MD, FACS Fremont Vascular & Vein, Inc. 1900 Mowry Ave., #404, Fremont Shailinder Jeet Singh, MD Santa Cruz Medical Group 4767 Soquel Dr., Soquel The Permanente Medical Group Umber Ahmad, DO Joy Anyanwu, MD David Brandt, MD Frank Chen, MD Clara Chu, MD Sarah Cox, MD Suzanne Dela Cuesta, MD

(continued)

Harita Devireddy, MD Anh Do, MD Jessica Gould, MD Marcy Haas, MD Najm Haque, MD Jonathan Hernandez, MD Hamta Jafari, MD Jenna Kanter, MD Thuy-Tien Le, MD Kai Li, MD Mary Moreno, MD Binh Nguyen, MD Elizabeth De La Portilla, DO Iqbal Rashid, MD Prashanti Reddy, MD Kirsten Regalia, MD Saswat Sahu, MD Amal Sawires, MD Betty Tsai, MD Agnieszka Wisniewska, MD Chengyu Xu, MD

ACCMA BULLETIN | May/June 2019

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PHYSICIAN PIPELINE

Growing the Physician Pipeline By the California Medical Association (CMA)

A

robust, diverse and well-trained workforce is essential to meeting the health care demands of all Californians. While California has made great strides since the passage of the Affordable Care Act in extending health insurance to millions of residents who were previously uninsured, our state is currently facing a critical physician shortage.

California’s underserved communities are already facing a severe shortage of physicians, which will exponentially worsen as the population continues to grow, diversify and age.

This will be further compounded as physicians move toward retirement faster than the replacement rate.

This year, the California Medical Association’s (CMA) foundation, Physicians for a Healthy California (PHC), launched two new projects that will make real progress in growing and strengthening the physician pipeline to meet the demands of California’s growing patient population, with a focus on medically-underserved areas and populations.

CalMedForce: GME Grant Program

PHC’s CalMedForce program is committed to growing a diverse physician workforce by supporting, incentivizing and expanding graduate medical education (GME) in California.

The program was made possible by the Proposition 56 tobacco tax, which was sponsored in 2016 by CMA, the California Hospital Association and Service International Employees Union-United Healthcare Workers West. The University of California is the designated recipient of the

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funding and has contracted with PHC to administer the annual grants.

“These CalMedForce grants will help California grow and strengthen the physician pipeline to meet the demands of our state’s growing and changing patient population,” said Lupe Alonzo-Diaz, MPAff, PHC president and CEO. In the inaugural cycle of CalMedForce in January 2019, PHC awarded $38 million to GME programs across the state to fund approximately 150 physician residents. In total, PHC received funding requests for nearly 600 residency positions from 131 residency programs, totaling more than $147 million!

The 73 programs that received awards in the first cycle represent residency positions in both urban and rural areas. Programs that focus on medically-underserved areas and populations were given priority. Of the 156 residency positions funded, 74 are existing residency slots that could have been eliminated if not for this funding. Eighty-two of the positions funded are brand new – 60 of them in new residency programs and 22 at existing programs.

“The demand for these funds is a clear indicator of the statewide need for this funding and an example of how the new tobacco tax will help improve access to care in California,” said Cathryn Nation, M.D, associate vice president for health sciences in the UC Office of the President.

Every dollar invested into expanding residency slots in California is significant, considering one primary care resident can conduct approximately 600 patient visits per year.

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Why Is GME Funding So Important?

Sadly, California is a mass exporter of medical students. Every year, hundreds of graduating medical students do not find a residency slot in California to continue their training.

“Inadequate funding for medical residency programs forces talented young doctors who want to stay and practice in California to train in other states,” said CMA President David H. Aizuss, M.D. The data shows that most physicians set down roots in the areas where they train and remain there after their training to care for their communities.

When California-educated medical students leave to another state for a residency program, they often do not return. Overall, 54.2% of individuals who completed residency training from 2008-2017 are practicing in the state of where they trained. California ranks the highest of all states, with a 77.7% rate for in-state retention. We can grow our physician workforce by expanding the number of California residency positions.

CalHealthCares: Loan Repayment Program

Ample research demonstrates that the Medi-Cal system is struggling from persistent underfunding. As a result, California ranks among the lowest in the nation in payments to providers.

These chronically low reimbursement rates have a direct effect on Medi-Cal patients’ ability to receive timely treatment from a physician.

Compounding the problems is the fact that physicians often enter practice with hundreds of thousands of

PHYSICIAN PIPELINE

dollars in educational debt. This debt burden, coupled with low reimbursement rates, makes it unsustainable for many physician practices to take on a significant number of Medi-Cal patients.

In April 2019, the California Department of Health Care Services (DHCS) launched a new loan repayment program—CalHealthCares, which incentivizes physicians to provide care to Medi-Cal beneficiaries by repaying educational debt up to $300,000 in exchange for a five-year service obligation. DHCS has contracted with PHC to administer the program.

CalHealthCares was also made possible by Proposition 56, which provided a one-time allocation of $220 million for state loan repayment programs.

The first round of applications for the new CalHealthCares statewide loan repayment program attracted more than 1,200 applications from physicians and dentists who agreed to see more of California’s 13 million Medi-Cal patients in exchange for repayment of their student loans.

In all, requests totaled more than $300 million, reflecting tremendous interest in the five-year program.

CalHealthCares expects to award approximately 125 physicians and 20 dentists in this first award cycle, to be announced by June 30.

All awardees will be required to maintain a patient caseload of 30% or more Medi-Cal beneficiaries. The program is open to physicians who graduated from a residency program and/or completed a fellowship within the past five years (on or after January

(continued)

1, 2014). There are no geographic limitations—providers may be located in any California county.

With more than 13 million Californians relying on Medi-Cal programs to provide basic and specialty care for serious diseases, the stakes are high.

“The CalHealthCares program promises to have a real and immediate impact on access to care for Medi-Cal patients,” said Dr. Aizuss. “Especially for new enrollees, who often struggle to access to timely and quality care.”

For more information about CalMedForce and CalHealthCares, visit the PHC website at phcdocs.org.

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

CalHealthCares Loan Repayment Funds Requested Total Applications Submitted: 1,276 | Total Funds Requested: $300,626,830

Physicians 928 | $212,275,967 Dentists 217 | $55,699,133 Practice Support Grants 14 | $3,328,511

Medical Students | 107

Dental Students | 10 Students 117 | $29,323,219

Total Applications | 1,276

Total Student Applications | 117

ACCMA BULLETIN | May/June 2019

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CLASSIFIEDS

OFFICE FOR RENT – 3

UPTOWN OAKLAND MEDICAL OFFICE SPACE: Close to public transportation/BART, and easy freeway access. Large exam rooms, lovely waiting room, office for consultations, kitchen, and conference room. Available full days Mondays, Wednesdays, and Fridays from 9 am to 5:30 pm, and half days on Tuesdays and Thursdays from noon to 5:30 pm. Contact Elena DeLeon at edeleon@ebplasticsurgery.com or (510) 451-6950. (3 – May/June – July/ Aug)

OFFICE FOR SALE – 4

MEDICAL OUTPATIENT CLINIC IN CONTRA COSTA COUNTY FOR SALE Located about 20 miles outside

of SF and just off a major highway on a busy main street in an affluent area, the practice is adjacent to a number of excellent referral sources and other specialty practices. 1700 s.q. ft. office in a professional/medical building with four exam rooms, sterilization lab, private doctor’s office. Doctor works 24 hours a week, grossing about $400K. Steady patient flow with minimal local magazine advertising; referrals make up 20% of the patient stream. 60% PPO; 25% Medicare; 10% HMO; 5% cash. Seller currently sublets the space with another doctor, leaving great room for growth for a buyer. Asking $235K. Call Charles White, ProMed Financial, at 888-2776633 (listing ref. MD274). (4 – May/June – July/Aug)

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

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

IN MEMORIAM ROBERT D. GRANT, MD (1947-2019), of Alamo,

EDWARD WALLER, MD (1929–2018), passed

California, passed away on Easter Sunday, April 21, 2019.

Robert was born in Oakland, CA, on July 18, 1947. Robert grew up in the Bay Area, graduating from UC Berkeley with a Bachelor’s degree in psychology before following in his father’s footsteps and receiving his medical degree from UCSF in 1972.

He joined the Kaiser Permanente Medical Group in 1975, serving as chief of the Department of Medicine for 10 years before joining the newly formed Hospitalist service for the remainder of his career, retiring in 2014. Robert is survived by his wife, Barbara, and his two children, Lisa Grant and Ross Grant, both of whom followed him into the medical field. Doctor Grant was an ACCMA member for 9 years.

away peacefully in his home on September 27, 2018. Doctor Waller was born in Metter, Georgia in 1929. He lived in Savannah until age twelve, when his family moved to Oklahoma City. He attended the University of Oklahoma, majoring in premed, before attending Northwestern University Medical School in Chicago. While in medical school, Doctor Waller met his future wife, Susan Lyon, and they married shortly before his graduation in 1955. After an internship at Parkland Memorial Hospital in Dallas, Doctor Waller spent two years in the U.S. Army Medical Corps, where he was commissioned a Captain and sent to the Army dispensary in Garmisch, Germany.

Following his Army discharge, he and Sue moved to Oakland, California, where Doctor Waller began a residency program in Internal Medicine at Highland Hospital. Doctor Waller went into practice in Berkeley in 1961 and served on various medical staffs, practicing medicine for over forty years. During that time, he also served on Alta Bates Hospital’s Board of Trustees and as President of the Medical Staff. Doctor Waller was a member of the ACCMA for 56 years and attended the Annual Meeting for many years.

KATHRYN J. BENNETT LOUGHRAN, MD (1947–2018) was born in Oakland on December 11, 1947 and passed away at home on January 26, 2018 after a brief battle with cancer. She was a third-generation UC Berkeley graduate, graduating with honors in 1969 as a member of Prytanean, Women’s “C” Society, and president of Mortar Board. She graduated from USC School of Medicine in 1973 and completed her MBA in 2006 at St. Mary’s College. Doctor Bennett practiced family medicine in Pleasant Hill from 1976 until retiring from medicine in 2001. She served as the chief of staff for both Contra Costa County Hospital in 1981 and Mt. Diablo Medical Center in 1999. She returned to what is now John Muir Health as Chief Medical Information Officer until her retirement in 2015. Doctor Bennett is survived by her husband Tom Loughran; her mother Virginia; two siblings; two daughters, Molly and Mayra; three step-children, Chris, Matt, and Megan; four grandchildren; and two nieces and one nephew. Doctor Bennet was a member of the ACCMA for 34 years.

34

H. MILTON WATCHERS, MD (1933–2019), died on February 14, 2019 at his home in Walnut Creek.

While attending medical school he married Margaret Tarp in the Presbyterian Church. He is survived by Margaret TarpWatchers, son Gregory Watchers, daughters Elizabeth Macy, Ann Engelhardt, Carol Powell and six beloved grandchildren.

Doctor Watchers was a member of the ACCMA for 56 years.

ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

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

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is pleased to offer the following FREE workshop:

CONVERSATIONS COUNT

Friday, July 19, 2019 8:30 am - 12:30 pm

East Bay Conversation Project

East Bay www.eastbayacp.org

A WORKSHOP ON ADVANCE CARE PLANNING John Muir Health - Concord Campus 2540 East Street, Room: Concord I & II Concord, CA 94520 Cost: Free - CME/CE Available!*

Advance care planning enhances quality of life by ensuring that plans are developed to address end-oflife care decisions in accordance with personal wishes. Join Janet Thompson, senior living counselor at St. Paul’s Towers, to learn more about methods to engage others in this important conversation and to teach it effectively.

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

3.75 CME Hours Available* Approved by the Nursing Home Administrator Program for 3.75 CE credit hours Provider approved by the California Board of Registered Nursing, Provider # CEP17013 for 3.75 contact hours.

Provider approved by the California Association of Marriage and Family Therapists, Provider #143582 for 3.75 contact hours CE provided in collaboration with “Yes! Press Consulting and Education"

RSVP Information Please RSVP online - no login required. RSVP at www.accma.org/membership/events.

Or complete and FAX this form to 510-654-8959. Questions: please call (510) 654-5383.

Attendee: Phone:

Organization: Email:

Funded by Alameda County Measure A Essential Health Care Services Initiative and the Thomas J. Long Foundation. *Non-ACCMA members who wish to claim CME credits for this program will be charged a $187.50 admin fee to help cover the costs of providing CME. ACCMA members will receive the CME free-of-charge as part of their membership benefits.

Accreditation Statement: The Alameda-Contra Costa Medical Association is accredited by the Institute for Medical Quality/California Medical Association (IMQ/ CMA) to provide continuing medical education for physicians.

Credit Designation Statement: The Alameda-Contra Costa Medical Association designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credits(s)™.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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

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