Mar/Apr 2018 | Los Angeles Medicine

OFFICIAL PUBLICATION OF THE LOS ANGELES COUNTY MEDICAL ASSOCIATION

W E ’ R E

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T H I S

T O G E T H E R

THE VALUE OF ADVOCACY

NEW LAWS, PROGRESS MADE & WHAT’S IN THE WORKS

PLUS: Success at The Saving Private Practice Consortium

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EDITOR Sheri Carr | editors@physiciansnewsnetwork.com ADVERTISING SALES Dari Pebdani 858.231.1231 | dpebdani@gmail.com EDITORIAL ADVISORY BOARD David H. Aizuss, MD Troy Elander, MD Thomas Horowitz, DO Robert J. Rogers, MD

VOLUME 149 ISSUE 2 | MAR/APR 2018

HEADQUARTERS LOS ANGELES COUNTY MEDICAL ASSOCIATION 1055 West 7th Street, Suite 2290 | Los Angeles, CA 90017 Tel 213.683.9900 | Fax 213.226.0350 www.losangelesmedicine.org LACMA OFFICERS PRESIDENT | William K. Averill, MD PRESIDENT-ELECT | C Freeman, MD TREASURER | Sion Roy, MD SECRETARY | Diana Shiba, MD IMMEDIATE PAST-PRESIDENT | Vito Imbasciani, MD

William K. Averill, MD

LACMA BOARD OF DIRECTORS COUNCILORS-AT-LARGE Jerry Abraham, MD (1) Samuel Fink, MD (6) Jeffery Lee, MD (6) Maria Lymberis, MD (5) Nhat Tran, MD (9)

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PRESIDENT’S LETTER

TRUSTEES & CHAIR DELEGATION Peter Richman, MD, CMA Trustee Jack Chou, MD

SUCCESS at the

Saving Private Practice Consortium Protecting Deferred Action for Childhood Arrivals (DACA)

COUNCILORS Robert Bitonte, MD, JD (D1) Stephanie Booth, MD (D3) Troy Elander, MD (D5) David Hopp, MD (D7) Omer Deen, MD (D9) Christine Phan, MD (D10) Sidney Gold, MD (D17) Roxana Yoonessi, MD, JD (SCPMG) Heather Silverman, MD (SSGPF) Po-Yin Samuel Huang, MD (1, YP Councilor) Hector Flores, MD (1, EPC Chair) Laura Halpin, MD (Resident Councilor) Erik Berg, MD (Alt. Resident Councilor) Ali Tafreshi (Student, USC) Gwendolyn Lee (Alt. Student, UCLA)

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THE VALUE OF ADVOCACY

LACMA’s Board of Directors consists of a group of 30 dedicated physicians who are working hard to uphold your rights and the rights of your patients. They always welcome hearing your comments and concerns. You can contact them by emailing or calling Lisa Le, Director of Governance, at lisa@lacmanet.org or 213-226-0304.

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L ACMA PRE S I D E N T

W I L L I AM K . AV E R I L L , MD

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THE SECOND SAVING PRIVATE PRACTICE CONSORTIUM was held on Saturday, March 3, in downtown Los Angeles. Kudos to LACMA staff who worked hard to make this event a success. The keynote speaker was Paul Merrild, senior vice president, athenahealth, who presented “Anatomy of a Successful Private Practice: Leveraging Technology to Work for You, Not Against You.” Athenahealth is one of LACMA’s Preferred Partners and offers a powerful tool to physician practices to assist in reducing the burden from administrative tasks, working to drive automation and efficiency to documentation processing, medical coding, and authorization management.

With regard to authorization management, high wait times for preauthorized medical care have consequences for patients. According to a recent survey by the American Medical Association, more than 9 in 10 physicians (92%) said that the prior authorization process delays patient access to necessary care, and nearly four in five physicians (78%) report that prior authorization can sometimes, often or always lead to patients abandoning a recommended course of treatment.

A significant majority of physicians (84%) report that the burdens associated with prior authorization were high or extremely high, and a vast majority of physicians (86%) believe burdens associated with prior authorization have increased during the past five years.

The survey shows that every week a medical practice completes an average of 29.1 prior authorization requirements per physician, which take an average of 14.6 hours to process — the equivalent of nearly two business days. To keep up with the administrative burden, about a third of physicians (34%) rely on staff members who work exclusively on the data entry and other manual tasks associated with prior authorization.

This year, the California Medical Association (CMA) is sponsoring legislation to increase penalties on the Department of Managed Health Care regulated health plans that engage in unfair payment patterns including abuse of the prior authorization process. Thanks to all our LACMA members who have shared feedback regarding health plans that are routinely engaging in unfair payment patterns, the types of violations, and physician efforts to resolve the issues. Stay tuned as LACMA’s Legislative Committee continues to track these issues with CMA.

Thanks to all our LACMA members who have shared feedback regarding health plans that are routinely engaging in unfair payment patterns, the types of violations, and physician efforts to resolve the issues.

And stay tuned as LACMA’s Legislative Committee continues to track these issues with CMA.

William K. Averill, MD President, Los Angeles County Medical Association

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“With the partners present and the connections made, it has paid for the membership.

Why didn’t I do this earlier?”

- Regina Edmond, MD

Gynecologist & Obstetrician, West Hollywood www.reginaedmondmd.com New member Dr. Regina L. Edmond is a private practice gynecologist and obstetrician in West Hollywood. Known for her caring nature and willingness to listen to and respect patients’ concerns about their most intimate problems without judgment, she has become a trusted resource for many. She was a first-time attendee at the Consortium and joined LACMA and CMA at the event.

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March 3 marked the 2nd Annual Saving Private Practice Consortium. With nearly 200 physicians, practice administrators, and partners in attendance, the event marked yet another pivotal turning point for physicians in solo/small group practice.

The event opened with a powerful keynote from Paul Merrild, senior vice president of sales at athenahealth, who shared some eye-opening data about private practice practitioners in California and ways technology can play an important role in helping struggling and overburdened independent physicians.

Attendees spent the morning moving between four different breakout sessions and individual consults with nearly 20 different partners to gather information and advice on issues doctors in private practice are facing.

Reimbursements, collections and billing, marketing, concierge medicine, and electronic medical records were all popular areas of interest, but all of our industry partners, including those covering healthcare IT, healthcare and employment law, clinical communications, malpractice coverage, real estate, business insurance and more, were busy with back-to-back appointments.

!

Our lunch panelists, David H. Aizuss, MD, Hector Flores, MD, Srinivas Sarma, MD, and Janus Norman from CMA, delivered an empowering discussion on how physicians of all practice backgrounds can work together to improve access to quality care and stand as the leading voice for the future of healthcare in California. The common denominator among all physicians, after all, is the patient, and that is what unifies physicians in organized medicine. The key takeaway is that no other organization can provide that unity or shared voice like LACMA and CMA. Throughout the afternoon, physicians and practice administrators continued their participation in private consults and/or attendance at eight more breakout sessions. There was a wide variety of sessions to choose from, including those addressing the impact of tax reform, how to be a better advocate for yourself and your patients, and how to collect unpaid monies and increase your revenue.

Physicians had the chance to tell their stories, share their struggles, connect with other physicians and, most importantly, get free assistance with everything pertaining to a private practice operation.

By the end of the day, many physicians reported that they had received real help in the areas where they needed it and were thrilled to learn about what LACMA and CMA have to offer. One physician joined on the spot and told us: “With the partners present and the connections made, it has paid for the membership. Why didn’t I do this earlier?”

There are so many to thank for helping to make this event a success: our sponsors Comerica Bank, CAP, Mercer and 1st Century Bank; our exhibitors; our partners; LACMA and CMA leadership; and all those who attended. We thank you for your participation and look forward to your feedback!

Visit losangelesmedicine.org for more information.

“During the Consortium I was impressed by CMA and LACMA’s commitment to help physicianowned practices in California. This event made it easier for me to connect with the tools and business experts to succeed in private practice, and there was tremendous value provided during the Keynote, the group discussions and breakout sessions with the consultants. By the end of the day, it was obvious to me I needed to become a member of such an organization.”

- Luis Gomez Villalobos, MD New member Dr. Luis Gomez Villalobos is an internal medicine physician, who completed his medical degree at the University of Southern California Keck School of Medicine. In his private practice, Dr. Villalobos helps patients with chronic medical conditions to safely reduce or eliminate prescription drugs.

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Protecting Deferred Action for Childhood Arrivals

DACA

With the U.S. Senate still deadlocked on what to do with the Deferred Action for Childhood Arrivals (DACA) program and the fact that the chamber will likely reprise the fight ahead of the next and presumably final deadline to avoid another government shutdown, the LA County Medical Association stands with the county’s medical schools and residency programs in protecting the members of our community who would be negatively impacted by the potential end to the DACA program. We acknowledge that this is a very difficult time for physicians in training who might be affected by the uncertainty of upcoming legislative changes.

Removing DACA individuals will exacerbate healthcare provider shortages, particularly for rural and other underserved areas. More than 94% of the 800 health-career-bound DACA Dreamers want to provide healthcare in underserved areas.

Because LACMA and CMA represent the practice of medicine and support those who have a dream and desire to become physicians as California faces a physician shortage, the right thing to do is to support our institutions and our residents as they face unthinkable challenges.

Without DACA, they cannot access healthcare, work or pursue college and graduate degrees. They are not eligible for federal financial aid, and there is no sustainable funding mechanism. Medical students also face the possibility of being denied residency. In fact, without DACA or a reasonable solution, undocumented medical students are unable to submit ERAS applications and subsequently may never obtain a medical license.

California ranks 32nd in physician access and needs 8,243 additional primary care physicians by 2030 – a 32% increase. As mentioned above, more than 94% of 800 health-career-bound Dreamers want to practice healthcare in underserved areas, and the number of Dreamers accepted into medical school has steadily increased.

DACA physicians are more likely to work in high-need areas where communities face challenges in recruiting physicians. These individuals are also more likely to be bilingual, come from diverse cultural backgrounds and understand challenges in certain ethnic communities.

LACMA and CMA support solutions that do not needlessly punish young and innocent immigrants and would preserve patient access to care, alleviate our nation’s physician shortage and encourage healthcare workforce diversity.

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ADVOCACY

THE VALUE OF

Physicians are feeling increasingly helpless when it comes to managing costs, insurance contracts and reimbursements, changing regulations, reporting requirements, and so much more. It is no wonder that wellness has become a prevalent issue for those who are experiencing burnout. Symptoms such as emotional exhaustion, interpersonal disengagement, and a low sense of personal accomplishment are simply not treated with a daily dose of sunshine, exercise and the occasional “take two pills and call me in the morning.” It is becoming clear that the growing threat to physicians’ well-being also directly threatens the quality of care that they deliver as well as the health and effectiveness of the organizations in which they practice.

Has the economics, politics and bureaucracy of healthcare become too much to bear? If so, what can be done? To fight the growing epidemic that is physician burnout, doctors must start tackling systemic change, unifying to reach common goals and setting policy agendas that make physicians the most credible source of expertise, not only when it comes to the science of medicine, but also when it comes to optimal, efficient and effective healthcare delivery no matter the setting.

Numerous surveys have indicated that while physicians endorse advocacy activities, they do not actively engage in them. But when it is the physician who is on the front lines of patient interaction, well-being, suffering, social injustices and the failures of health policy, who should be speaking up to protect what is best for the physician and the patient? The answer is you.

When it comes to advocacy, what role should a physician play? Is membership in your specialty society enough? It will take more than teaming up with those in your respective practice specialties to begin tackling the root causes of healthcare delivery inefficiencies. California’s physicians are stronger when they stand together.

Yet many still do not understand the value or importance of advocacy, and many still ask the question, “What do LACMA and CMA do for me?” The answer is not what do we do for you, but how do we elevate physicians’ voices to effectively influence those who are setting the policies that can negatively or positively impact the way you practice medicine.

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AB 40 (SANTIAGO): CURES DATABASE: HEALTH INFORMATION TECHNOLOGY SYSTEM | Obtained amendments to re-

move the Department of Justice’s ability to influence the electronic health record (EHR) vendor market by establishing a narrow vendor list of EHRs allowed to interface with the Controlled Substance Utilization Review and Evaluation System (CURES), and unilaterally dictating the terms of being able to interface.

AB 120 (TING): PROPOSITION 56 TOBACCO TAX FUNDS | Ap-

propriates Proposition 56 funds to the Department of Health Care Services (DHCS) and contains language allocating over $700 million ($325 million plus the federal match) in funding to physicians. Additional provisional language states that provider payments may be adjusted up to $800 million in the 2018-19 fiscal year. The bill was signed by the Governor in June as part of the Budget Act of 2017.

AB 221 (GRAY): WORKERS’ COMPENSATION | Defeated this

workers’ compensation legislation that would have broadly limited payments to physicians for treatment provided to workers suffering from occupational cumulative trauma injuries.

AB 387 (THURMOND): MINIMUM WAGE: HEALTH PROFESSIONALS: INTERNS | For the purposes of paying mini-

mum wage, AB 387 expanded the definition of employer. CMA obtained amendments to mitigate the impact of the bill on physician practices by excluding all practices. The bill was ultimately defeated in the Assembly.

AB 700 (JONES-SAWYER): PUBLIC HEALTH: ALCOHOLISM OR DRUG ABUSE RECOVERY | Stopped this measure that

would have required physicians who provide substance use disorder services to get certified by DHCS, in addition to their medical license, to provide these services in programs authorized by DHCS.

AB 715 (WOOD): WORKGROUP REVIEW OF OPIOID PAIN RELIEVER USE AND ABUSE | Worked with the author to

avoid the creation of duplicative opioid prescribing guidelines, which could have created further confusion and complication around prescribing for chronic pain, narrowing the bill to create a guideline focused exclusively on acute prescribing.

AB 1250 (JONES-SAWYER): COUNTIES: CONTRACTS FOR PERSONAL SERVICES | Obtained amendments that exempt

physician services from newly proposed stringent requirements for a county and a third party to enter into a contract to provide government services. AB 1250 was defeated in the Senate.

AB 1312 (GONZALEZ FLETCHER): SEXUAL ASSAULT VICTIMS: RIGHTS | Obtained amendments to remove a require-

ment that physicians provide sexual assault victims information about the investigation process, evidentiary process and the rights of victims under criminal laws.

AB 1316 (QUIRK): PUBLIC HEALTH: CHILDHOOD LEAD POISONING: PREVENTION | Obtained amendments to

remove mandatory universal lead screening for all young children.

SB 43 (HILL): ANTIMICROBIAL-RESISTANT INFECTION: REPORTING | Obtained amendments to remove a pro-

posed new requirement to list antimicrobial-resistant infections as a cause of death on a person’s death certificate.

SB 189 (BRADFORD): WORKERS’ COMPENSATION FIX | Effective July 1, 2018, all owners of medical corporations will be able to exempt themselves from workers’ compensation coverage, regardless of percentage ownership, as long as they submit a waiver and have health insurance coverage. This will result in thousands of dollars in premium savings for physician practices.

RECENT LEGISLATIVE VICTORIES

When it comes to answering the age-old question “What do LACMA and CMA do for me?” continue reading to learn about what your fellow physician members have expressed as top-priority areas at the local and state levels and how LACMA and CMA are working to protect and inform all physicians on issues that impact the medical community.

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measure that would have created additional administrative reporting requirements on physician practices.

SB 419 (PORTANTINO): MEDICAL PRACTICE: PAIN MANAGEMENT | Defeated this measure that would

have legislated the practice of medicine by preventing physicians’ ability to appropriately prescribe pain relief medications.

AB 334 (COOPER): SEXUAL ASSAULT/FORENSIC MEDICAL EXAMS | Obtained amendments to remove

provisions that would have increased physician liability by allowing forensic medical exams on unconscious patients without the patient’s consent.

AB 859 (EGGMAN): ELDERS AND DEPENDENT ADULTS: ABUSE OR NEGLECT | Obtained amendments that

exempt physicians from a proposed lowering of the standard of review in elder abuse cases from “clear and convincing” to a “preponderance of the evidence” if the court found that a defendant intentionally destroyed evidence. The bill was vetoed by the Governor.

SB 636 (BRADFORD): ADDICTION TREATMENT: ADVERTISING: PAYMENT | Stopped this measure that

would have created an additional disciplinary process for physicians providing substance use disorder treatment in DHCS-certified programs.

SB 640 (HERTZBERG): SALES TAX ON SERVICES | Obtained an exemption for health care services in this proposed services tax legislation.

SB 790 (MCGUIRE): HEALTH CARE PROVIDERS: GIFTS AND BENEFITS | Defeated this measure that would

have unfairly curtailed what expenses a pharmaceutical company could provide a physician, including all those expenses connected to educational seminars, research and events.

AB 889 (STONE): SECRECY AGREEMENTS | Defeated

this measure that would have prevented certain confidentiality agreements from being enforced if keeping the information secret presented a “public health hazard” or “environmental danger.” CMA was concerned about how this law would affect medical malpractice settlement agreements.

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RECENT LEGISLATIVE VICTORIES

SB 199 (HERNANDEZ): THE CALIFORNIA HEALTH CARE COST, QUALITY AND EQUITY ATLAS | Defeated this

AB 1422 (DALY): WORKERS’ COMPENSATION INSURANCE: FRAUD | Obtained amendments to ensure

due process protections for workers’ compensation physicians facing certain types of fraud accusations.

SB 33 (DODD): ARBITRATION AGREEMENTS | Obtained

amendments to exempt physician arbitration agreements from a new consumer protection that invalidates arbitration clauses in contracts upon a showing of fraud.

SB 219 (WIENER): LONG-TERM CARE FACILITIES: RIGHT OF RESIDENTS | Obtained amendments to ensure

that physician liability would not be increased for those practicing in long-term care facility settings acting in the best medical interests of their patients.

AB 595 (WOOD): HEALTH CARE SERVICE PLANS: MERGERS AND ACQUISITIONS | Obtained amendments to

ensure that the Department of Managed Health Care and the Department of Insurance, for any health care service plan merger, consider the impact on physicians’ ability to secure competitive contracts and patient access to care prior to approving the mergers.

SB 350 (GALGIANI): INCARCERATED PERSONS: HEALTH RECORDS | Obtained amendments ensuring

consistency in medical information privacy laws to limit confusion on when medical information and records can be disclosed. The bill was ultimately defeated in the Senate.

SB 349 (LARA): CHRONIC DIALYSIS CLINICS: STAFFING REQUIREMENTS | Obtained amendments to

remove liability for medical directors of chronic dialysis clinics related to the proposed staffing requirements.

SB 617 (BRADFORD): WORKERS’ COMPENSATION |

Stopped workers’ compensation legislation that would have required outreach reports to physicians without sufficient privacy protections.

SB 538 (MONNING): HOSPITAL CONTRACTS | Defeated

this measure that allowed health plans and health insurers to eliminate the Provider’s Bill of Rights, which helps guard a physician’s ability to negotiate fair and reasonable contracts and break up integrated health care systems.

CURRENT ISSUES TO WATCH

Legislation Introduced to Combat Opioid Crisis Assemblymember and emergency physician Joaquin Arambula, MD (D-Fresno), has introduced a bill (AB 2384) that would remove some of the largest barriers to Medication Assisted Therapy for opioid addiction, such as prior authorization requirements and coverage limits. “As an emergency physician, I saw the impact that opioid abuse has on families, and I believe we need to reduce the availability of prescription medications that may be misused or diverted,” said Dr. Arambula. “We are one of the states leading the country in multi-year reduction of overdose deaths from prescription opioids, and now we have a chance to lead in providing critical recovery services as well.”

Physician-conducted Autopsies State Senators Richard Pan, MD, and Cathleen Galgiani have introduced Senate Bill 1303, which would require counties with populations of 500,000 or more residents Bennet Omalu, MD to replace the office of the coroner with an office of the medical examiner. Current law allows non-medically trained individuals to conduct autopsies, and SB 1303 would require that the medical examiner be a licensed physician and surgeon duly qualified as a specialist in pathology.

The legislation is the result, in part, of a highprofile case in San Joaquin County. In December 2017, the county’s longtime chief medical examiner, Bennet Omalu, MD, and forensic pathologist, Susan Parson, MD, resigned over the “routine practice” of interference from Sherriff-Coroner Steve Moore.

Moore, according to Dr. Omalu, regularly interfered with death investigations and used his political office to protect law enforcement officers in cases of persons who died while in custody or during arrest.

SB 1303 is sponsored by the California Medical Association (CMA) and the Union of American Physicians and Dentists (UAPD). Nationally, California is one of the last states to make the change to a medical examiner system.

“In addition to preventing the improper influence or corruption of autopsies, SB 1303 is smart and responsible policy as it only applies to the largest counties that have the resources to establish an independent medical examiner’s office,” said San Joaquin Medical Society (SJMS) President R. Grant Mellor, MD. “California is facing a physician shortage, which is felt acutely in San Joaquin County, and we must retain these talented physicians and get Drs. Parson and Omalu back to work as soon as possible.”

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New Universal Access Proposal

The California Medical Association (CMA) is applauding legislation that sets a clear and realistic path forward to achieve universal access and improve affordability to health care in California. Key components of the legislative package will help increase access to care and expand access to undocumented patients.

While the announcement represents a significant step forward, a truly successful universal access plan cannot be achieved without addressing the health care workforce shortage facing a majority of counties. As the recent University of California, San Francisco report commissioned by the California State Assembly recommended, any successful legislative proposal to achieve universal health care must ensure that California has a strong physician workforce.

The bill package contains provisions that CMA supports including a state individual mandate, subsidy relief for individuals purchasing insurance on the Exchange/individual market and allowing income-eligible undocumented immigrants to enroll in Medi-Cal.

CMA also recommends the legislative package to be expanded to include: • Increase Physician Workforce and Encourage Physicians to Practice in Primary Care. California should increase funds available for loan repayment and increase residency slots, and institute policies that encourage physicians to work in primary care and under-served settings.

• Strengthen State Laws Regarding Oversight of Mergers of Health Insurance Plans. Consolidation leads to higher prices, and California should take a more robust oversight role in this area.

• Administrative Simplification: Standardize quality measures and institute a single process for provider credentialing that applies to all health plans, hospitals, etc., as well as establish electronic authorization policies for payers.

• Increase Medi-Cal Reimbursement Rates to Medicare Levels to help increase access for the nearly 14 million Californians currently covered by Medi-Cal.

YOUR ROLE concern and passing a law.

If you serve as a grassroots advocate, your level When it comes to matters of health, you are the of participation can range from simply becoming informed on an issue and attending a training session specialist and the lawmaker is a generalist. Legislators don’t need to know everything you know about to meeting with your elected officials and providing a particular issue – they just need to know enough testimony at a public hearing. Also, you can encourto be convinced to take action. age your colleagues, family, friends, and even your As a member of LACMA and CMA, you play a patients to join you in your efforts. critical role in the formation of health policy. You Advocacy, simply put, is the application of prescan become involved on many different levels, sure on the people and institutions that have the from working as a key contact to becoming a media power to give you what you want. spokesperson, to writing resolutions and directly Grassroots advocacy is a “bottom up” approach lobbying with elected officials. It is only through the to social change that utilizes real people from the participation of our members that we can continue community, rather than paid staff or lobbyists, to to be successful in fighting on behalf of physicians shape public policy. Grassroots advocates have a and patients. special power relationship with elected officials because, as voters, they have the power to hire or LEARN MORE AT CMANET.ORG/ISSUES-AND-ADVOCACY/ fire lawmakers. Grassroots advocacy harnesses the power of effective one-on-one relationships multiplied over and over. So the goal of any grassroots program is to build a critical mass of supporters – the more the better.

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Malpractice coverage is provided by Clinic.

Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred.

Contact Us: Visit our website at www.vistacommunityclinic. org Forward resume to hr@ vistacommunityclinic.org or fax resume to 760-414-3702.

Supporting Southern California Physicians Since 1983 Call for a Courtesy Consultation

818-693-7055

avishorr@gmail.com OPPORTUNITY WANTED

RADIOLOGIST

Board certified. Have own malpractice insurance. Available for part-time position or film reading.

Call 310-477-4257.

PRACTICE FOR SALE

PAIN MANAGEMENT PRACTICE FOR SALE Robb Pain Management Group N. Hollywood/Valley Village area Call 818-506-5197. Ask for Mark.

EEO/AA/M/F/Vet/ Disabled

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