December 2016 | Physician Magazine

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DECEMBER 2016

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DEC EM B ER 2 0 1 6 | TAB LE OF C ON T EN T S

Volume 147 Issue 12

8

9

ON THE INSIDE 4 President’s Letter | Vito Imbasciani, MD

FEATURE

12

The State of Healthcare

With the inauguration of a new president in January and a new Congress, physicians here and elsewhere could be facing major changes in the country’s healthcare policy. A number of issues are especially concerning, most of all what’s ahead for the Affordable Care Act (ACA), including the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).

6 What a Year It Has Been | Gustavo Friederichsen 8 LA Healthcare Awards 9 House of Delegates Tackles 6 Major Issues 10 LACMA Partner Spotlight | JNT Tek IT Solutions 16 Election Coverage 2016

Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 04 Copyright ©2012 by LACMA Services Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. POSTMASTER: Send address changes to Physician Magazine,801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Advertising rates and information sent upon request.

D E C E M B ER 2016 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 1

EDITOR GRAPHIC DESIGN

Sheri Carr 858.226.7647 | sheri@physiciansnewsnetwork.com Rob Davis 916.709.2007 | sherlockmedia@gmail.com ADVERTISING SALES

DISPLAY AD SALES / DIRECTOR OF SALES CLASSIFIED AD SALES EDITORIAL ADVISORY BOARD

Christina Correia 213.226.0325 | christinac@lacmanet.org Dari Pebdani 858.231.1231 | dpebdani@gmail.com David H. Aizuss, MD Troy Elander, MD Thomas Horowitz, DO Robert J. Rogers, MD HEADQUARTERS

The Los Angeles County Medi-

physicians from every medical

Physicians News Network Los Angeles County Medical Association 801 S. Grand Avenue, Suite 425 Los Angeles, CA 90017 Tel 213.683.9900 | Fax 213.226.0350 www.physiciansnewsnetwork.com

specialty and practice setting

LACMA OFFICERS

cal Association is a professional association representing

as well as medical students, interns and residents. For more than 100 years, LACMA has

PRESIDENT PRESIDENT-ELECT TREASURER SECRETARY IMMEDIATE PAST PRESIDENT

LACMA BOARD OF DIRECTORS

been at the forefront of current medicine, ensuring that its

RESIDENT/FELLOW COUNCILOR CMA TRUSTEE COUNCILOR – DISTRICT 2

members are represented in the

ALTERNATE RESIDENT/FELLOW COUNCILOR

areas of public policy, govern-

COUNCILOR – DISTRICT 3

ment relations and community relations. Through its advocacy efforts in both Los Angeles County and with the statewide California Medical Association, your physician leaders and staff strive toward a common goal— that you might spend more time treating your patients and less time worrying about the challenges of managing a practice.

Vito Imbasciani, MD William Averill, MD C. Freeman, MD Sion Roy, MD Peter Richman, MD

DISTRICT 1 COUNCILOR ALT. MEDICAL STUDENT COUNCILOR/UCLA COUNCILOR – DISTRICT 5 COUNCILOR-AT-LARGE ETHNIC PHYSICIANS COMMITTEE REP COUNCILOR – DISTRICT 17 COUNCILOR – USC YOUNG PHYSICIAN COUNCILOR COUNCILOR – DISTRICT 7 CHAIR OF LACMA DELEGATION COUNCILOR – DISTRICT 6 COUNCILOR-AT-LARGE COUNCILOR – ALLIED ALLIED PACIFIC COUNCILOR-AT-LARGE COUNCILOR – SCPMG COUNCILOR – DISTRICT 14 COUNCILOR – DISTRICT 10 MEDICAL STUDENT COUNCILOR/USC COUNCILOR – SSGPF VLGPF TRUSTEE COUNCILOR-AT-LARGE DISTRICT 9 COUNCILOR COUNCILOR-AT-LARGE

Jerry Abraham, MD David Aizuss, MD Emil Avanes, MD Erik Berg, MD Robert Bitonte, MD Stephanie Booth, MD Amanda de la Cerda Troy Elander, MD Samuel Fink, MD Hector Flores, MD Sidney Gold, MD Stephanie Hall, MD Po-Yin Samuel Huang, MD David Hopp, MD Marvin Kaplan, MD Kambiz Kosari, MD Jeffery Lee, MD Paul Liu, MD Maria Lymberis, MD Ashish Parekh, MD Jinha Park, MD Anantjit Singh, MD Stacy Songco Heather Silverman, MD Diana Shiba, MD Nhat Tran, MD Omer Deen, MD Theressia Washington, MD

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.

SUBSCRIPTIONS Members of the Los Angeles County Medical Association: Physician Magazine is a benefit of your membership. Additional copies and back issues: $3 each. Nonmember subscriptions: $39 per year. Single copies: $5. To order or renew a subscription, make your check payable to Physician Magazine, 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. To inform us of a delivery problem, call 213-683-9900. Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

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P RES IDEN T ’S LET T ER | VIT O IM B AS C IANI, M D

Changes to the Affordable Care Act?

“A sudden repeal by the new Congress is certainly possible, but that would require enabling legislation to be crafted, and that could take years to accomplish.”

The election of any American president would be cause for the medical community to take stock of the present state of the financing of healthcare and to wonder what, if anything, will change during the next administration. Certainly this is the case with our new president-elect.

Health plans, hospitals and physicians in every mode of practice are wondering how to assess possible changes to the present system. They are beginning to mobilize their advocacy forces and their members, but it is quite clear at this point (one week after the election at the time of this writing) that no one has any clear idea what changes will occur, if any.

Everywhere one looks for guidance in order to discern how the Affordable Care Act (a.k.a. Obamacare) might change, one sees contradictions, inconclusiveness and even outright befuddlement.

Many of the plans to “repeal and replace” the ACA are internally inconsistent with other such plans; the new Congress and the new administration haven’t come to any agreement either.

The president-elect seems to favor maintaining the prohibition on discrimination against persons with pre-existing medical conditions and to allow young adults to stay on their parents’ policy up to age 26. What was not included in the original ACA legislation, the individual mandate, would have expanded the insurance pool greatly, and thus reduced premiums for all; its absence required federal subsidies for 9.4 million citizens who make less than 400% of the federal poverty level.

Federal law, along with several state laws here in California, implemented the expansion of the ACA. Early comments from state leaders bolster their commitment to ensure as much security for Californians as possible. No one experienced in the Medicare/ Medicaid world sees the curtain coming down abruptly on the ACA on January 20, 2017, the first day of the new president’s term. Even the most assertive proposals by Mr. Trump and others would necessitate a gradual phase-down. A sudden repeal by the new Congress is certainly possible, but that would require enabling legislation to be crafted, and that could take years to accomplish.

Complicating the issue further is the expansion of Medicaid that 31 states took advantage of, resulting in great numbers of previously uninsured citizens accessing healthcare through insurance.

Many governors will be urging great caution against any precipitous overturning of such a complicated program without having a replacement plan in effect.

As I write this, California is in the midst of its annual ritual called open enrollment where patients choose the plan (read: contract) for the upcoming year. Nothing is going to change substantially come January. Patients will still need care, and physicians and hospitals will continue to deliver that care. Think of it this way: This is the 50th anniversary of Medicare and Medicaid, and we’re still tinkering with it after five decades. It’s not perfect; it’s not finished; it’s had its ups and downs. This is just another cycle. We’ll all get through this.

4 P H Y S I C I A N M A G A Z I N E | D E C E M B ER 2016

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WHAT A YEAR IT HAS BEEN AND WHAT A YEAR IT WILL BE.

I arrived at LACMA in March and would like to share LACMA’s successes and opportunities and, most importantly, recognize those who have shown consistent leadership since my arrival.

“Considering that MACRA continues to pose a threat to our members, we took the initiative of launching the MACRA Mobilization campaign where we shared the voices of members on this important law and related new rules.”

A special thanks to the LACMA Board of Directors — Peter Richman, MD; Vito Imbasciani, MD; David Aizuss, MD; and William (Bill) Averill, MD — for giving me the chance to lead LACMA into a new, more vibrant chapter in its long history.

Our districts and committees continue to do exceptional work across the region. Much thanks goes to the Asian-American Pacific Islander Physicians Advisory Committee and its leadership team, Jinha Park, MD, and Young-Jik Lee, MD. This group hosted a MACRA education event featuring Ashby Wolfe, MD, chief medical officer, Region IX, CMS. Considering that MACRA continues to pose a threat to our members, we took the initiative of launching the MACRA Mobilization campaign where we shared the voices of members on this important law and related new rules. A special thanks to Stephanie Booth, MD (District 3 president), and her board members who partnered with us to fund the video series. The Young Physicians Committee was also extremely active in 2016 and will continue to push the envelope when it comes to innovative ways to engage up-and-coming physicians. Thank you to Nhat Tran, MD, and Jerry Abraham, MD, for their unwavering commitment to supporting young physicians.

The past year also saw the first of many LACMA signature events such as the African-American Physician: A Searing Journey. Nearly 100 physicians attended this transformative and, at times, cathartic event.

Special thanks to Lemmon McMillan, MD, Rick Baker, MD, and Toni Chavis, MD, for embracing efforts to support primary and family practice providers serving the most vulnerable populations.

Hector Flores, MD, who recently was honored with the Independent Physician Award at the 2016 LA Healthcare Awards event, continues to be the voice of reason when it comes to supporting the region’s MediCal providers. And David Kim, MD, was awarded the 2016 Robert D. Sparks, MD, Leadership Achievement Award at the CMA President’s Reception & Awards Gala in recognition of his extraordinary commitment to patients and public health.

I would like to recognize those LACMA members who stood out as constant examples of engagement.

These individuals let their actions speak louder than their words. Of special note is Emil Avanes, MD, for leading District 2. There wasn’t a day, a week or a month where Dr. Avanes wasn’t sharing invaluable insights.

I’m encouraged by the efforts of all district presidents this past year, and I look forward to a consolidated effort to grow membership in each district in 2017.

The leaders within the organization, whom I

6 P H Y S I C I A N M A G A Z I N E | D E C E M B ER 2016

affectionately call Team LACMA, deserve an immense amount of credit for staying the course during the CEO transition. Lisa Le, Ellie Tran, Eva Moravcik and Priscilla Alcantara continue to demonstrate focus while adjusting to my leadership style. I also want to recognize our stable of talented consultants and advisors: Joy Simmons, Luis Ayala, Randy Taylor, Bonnie Lewis, Deborah Stambler, Reo and Sheri Carr, Cheryl Bradley and Grant Richman (intern). In 2017, we will expand our outside consulting team to include Clyde Fontenette, an accomplished videographer. We ended 2016 with a stronger financial performance than previous years, and we begin 2017 with a balanced budget.

We embarked on unique partnerships to address climate change and its impact on communities of color; we launched an Uber partnership to provide free transportation for retired physicians and physicians in crisis. The year 2016 saw our new website go “live” to enhance the member experience as we continue to rebrand, and our redesigned magazine, aptly named “Los Angeles Medicine,” will launch in early 2017.

Earlier in the year, we held our first strategic planning session, “Charting the Course,” to identify five simple goals for 2017-2019. We now move into “Staying the Course” whereby we chart how well we are doing relative to growth, member retention, member experience, community impact and financial health. I will share with all membership the progress that has been made in these essential categories. In 2016, for example, thanks to the efforts of CMA and LACMA leadership, we secured Los Angeles County Department of Public Health physicians as our newest member group. We had several renewals as well, namely Southern California Permanente Medical Group, Allied Pacific IPA, City of Hope Medical Group, Seoul Medical Group, Facey Medical Group and the University of Southern California, to name a few. Much work remains as we transition to a member service model, away from the reactionary sales model. We also attracted an entirely new group of sponsors to enhance our member portfolio. CSC (Computer Sciences Corporation), JNT Tek, IMAT Solutions and Taylor Digital joined our already existing sponsors, the Cooperative of American Physicians, Wells Fargo, Mercer, City of Hope, LA Care, RPM Mortgage and MUN CPAs, to name a few. Cerner will join us in early 2017.

My goal is to deliver each day customized deliverables for each member and group. We will begin the year from a position of financial strength, a clear focus on what’s important and a closer alliance with CMA.

Gustavo Friederichsen Chief Executive Officer

D E C E M B ER 2016 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 7

healthcare

awards

Healthcare Leadership Award recipient Daniel F. Kelly, MD, with Howard Krauss, MD

Master of ceremonies for the evening Troy Elander, MD, with 2016 Healthcare Champion Richard Merkin, MD

Women’s Guild Cedars-Sinai President Gina Furth and Bruce Gewertz, MD, Chair, Department of Surgery, Cedars-Sinai

Hector Flores, MD, winner of the Independent Physician Award, with president of the Patient Care Foundation, Troy Elander, MD

O N C E A Y E AR the Patient Care Foundation and LACMA host a special evening to recognize members of the healthcare community who have made significant contributions to improving access to quality healthcare in Los Angeles County. This year the event was held in early November at the Beverly Wilshire Hotel.

Richard Merkin, MD, president and CEO of Heritage Provider Network, was honored as the 2016 Healthcare Champion. Daniel F. Kelly, MD, professor of neuroscience and neurosurgery at John Wayne Cancer Institute and director of the Brain Tumor Center and Pituitary Disorders Program at Providence Saint John’s Health Center, was awarded the Healthcare Leadership Award.

“In the neurosciences,” Dr. Kelly said, “we are continually challenged by such daunting problems as malignant and benign brain tumors, stroke and movement disorders. So, it is an honor to be recognized by my colleagues and peers, and I share this award with them because it takes a collective effort to continue enhancing patient access to high-quality innovative medical care.”

Hector Flores, MD, who practices family medicine at White Memorial Medical, was awarded the Independent Physician Award.

Jean Morgan was in attendance to see two scholarships awarded in her late husband’s name. The Marshall T. Morgan, MD, Memorial Scholarship awards funding to students studying emergency medicine. “The evening was designed to honor healthcare persons in Los Angeles County, and it surpassed its goal,” she said about the event.

8 P H Y S I C I A N M A G A Z I N E | D E C E M B ER 2016

“With the setting elegant, food and service excellent, this led the way for a spectacular evening. The speakers and honorees were engaged and kept the audience appreciative that they were included.”

In commenting on the Women’s Guild Cedars-Sinai receiving the Innovation Award, Guild President Gina Furth said, “The award from LACMA to the Women’s Guild Simulation Center for Advanced Clinical Skills brings a new layer of credibility to us. All the awards given out that evening were inspirational.”

LACMA CEO Gustavo Friederichsen agreed, saying, “It was a sensational evening for a variety of reasons, from the caliber of physician leaders to the extraordinary stories of perseverance and triumph. I was heartened to witness the incredible accomplishments from some of the most humble innovators in healthcare. Regardless of the tumultuous changes occurring in healthcare, our industry is in good hands.”

Thank you to Dr. Troy Elander and the Patient Care Foundation for their hard work putting together the LA Healthcare Awards!

The full list of winners is available on the LACMA website.

HOUSE OF DELEGATES

TACKLES

MAJOR

ISSUES

T H E CALIFOR N IA MED ICA L ASSO CI ATI O N held the 145th session of the House of Delegates in Sacramento in October. The two-day conference offered a focus on six major issues. Those issues are as follows: 1. MACRA — Discussion included the workability of the new policy and plans for continued recommendations from CMA.

2. Opioids — Discussion of strategies and policies to promote safe prescribing and use of these medications while reducing the risk of abuse and overuse, which remains a major issue in the state.

3. Physician Wellness and Burnout — Discussion included addressing the needs of the medical community to recognize and respond to signs of burnout in physicians.

4. Affordable Care Act, Section 1332 Waiver — The Waiver allows for states to deliver care in ways different from the federal administration’s vision. CMA will consider recommendations related to the Waiver for California.

This is the first year where HOD focused on six issues in this way.

In further changes to the session format, there will be year-round talks about resolutions with quarterly reviews. Lisa Le, Los Angeles County Medical Association (LACMA) director of governance, said that the final actions of HOD have yet to be issued but can be accessed by members through the CMA website.

Marvin Kaplan, MD, led the delegation from LACMA. Dustin Corcoran, CEO of CMA, recognized Gustavo Friederichsen, LACMA CEO, for contributions he made in his first year at LACMA.

MEDICAL BOARD HOSPITAL STAFF F R A U D / A B U S E MEDI-CAL/M E D I C A R E

MEDICAL PRACTICE PURCHASES, SALES AND MERGERS

5. Maintenance of Certification — Delegates will consider various models and proposals regarding maintenance and recertification of specialty board certification with continued high standards based on education, training, experience and ethical criteria.

6. 5 Year Public Health Plan — CMA will continue to champion public health initiatives benefiting the community. A particular focus will be placed on campaigns dealing with prevention and treatment of chronic disease and support for healthy, safe communities.

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D E C E M B ER 2016 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 9

LACMA Partner Spotlight:

Ask the

RECENTLY I ATTENDED A LACMA DISTRICT 3 meeting in Long Beach and was

asked some great questions by the doctors in attendance. I thought I would share

them in the hope that if you face the same IT challenges, you’ll find the information helpful for your practice as well.

Dr. Kaplan asked: How can doctors spend less time staying in compliance with MACRA?

Dr. Lee asked: Why would I pay for a CRM or EMR when there is free service available?

The first answer is that there is no easy answer to that question. But here are a few thoughts that can help: Depending on the CRM (software you currently use for billing and patient records), modules will be available that can capture the data needed to file compliance forms, eliminating the need to fill out duplicate forms or datamine your patient records. It’s kind of like Autofill for your records.

The free services offer a limited suite of products and in some cases your practice will benefit from the enhanced service available. This includes functions such as billing, collections and patient record archiving.

You can also consider what hospitals you are credentialed at and see what systems they use; many times you can get discounted licenses through their network.

Dr. Booth asked: What is a normal time frame to refresh the computers in my practice?

Please keep the questions coming. I can be reached at Dave@JNTtek.com or call direct (310) 560-7449.

This gets into life cycle management and greatly depends on each individual office’s workflow.

An industry standard answer is three to five years. However, with some upgrades (to RAM) and leveraging cloud resources, that time frame can be stretched. It’s important to make sure the network is secure and systems are backed up.

One last thought—MACRA will bring changes that can, in part, be addressed through the system you use and you can expect companies to reach out trying to sell you their latest and greatest that will make your life easier. I can help you sort through the offers to figure out what will work best for your practice.

1 0 P H Y S I C I A N M A G A Z I N E | D E C E M B ER 2016

Small business

year-end

financial checklist

B

E F O R E T H E H U S T L E A N D B U S T L E of the holiday season approaches, it is a good time for small-business owners to take stock of their finances and plan for the coming year. By making time now to assess your business’s financial health you will be better prepared for success in 2017.

How profitable was your business in 2016? What goals are you hoping to achieve over the next 12 months? These are important questions to ask yourself today, and a financial checklist can guide you through the sometimes overwhelming process. Here are five tips to help get you started: 33Develop an actionable 2017 financial plan. From establishing your annual business budget to updating your sales projections, creating an actionable plan with defined business goals will help you stay on target in the coming year. Start by reviewing the list of goals you hoped to achieve in your business at the beginning of 2016 and document your progress. Are you on track to achieve each one? Based on your progress, adjust expectations and forecasts for the year to come.

33Review expenses. Check all of your business accounts to make sure you have categorized expenses correctly, and take a look at how your costs compare monthly and yearly. Remember: Many expenses are tax-deductible, and an efficient expense tracking process will not only save you time, but it could also save you money at yearend. There are a number of expense tracking tools for business owners available online and through leading banks and financial institutions.

33Prepare for year-end tax reporting. Meet with your accountant to review your business profits and expenses, and make adjustments to your budget as necessary. Evaluate your business tax records to ensure that everything is in order and be aware of tax filing

deadlines so you can plan ahead. Now is also a good time to discuss your estimated tax payments and find out if there’s anything you can do to minimize the taxes you’ll owe before the end of the year.

33Meet with your banker. It’s a good idea to organize an annual review meeting with your banker to discuss your current business needs and review your accounts.

To prepare for this meeting, review your small-business loan accounts to track payment progress, and reconcile your bank and credit card accounts so you can head into the new year in good standing. Also take time to anticipate how your sales goals or hiring plans might impact your need for a new a deposit account, loan or line of credit, and be prepared to discuss available options with your banker.

33Analyze your business’s cash flow. One of the most important things for a business owner to track is cash flow: How much cash your business earned and how much you spent. If you have trouble maintaining steady cash flow to cover expenses, make sure your financial plan includes specific actions to remedy the issue, such as cost reductions or new revenue sources. Take time to ensure that you fully understand and can forecast cash flow, especially if you have a seasonal business.

Setting aside time now to create a strong financial plan for 2017 is important for every business owner. Visit WellsFargoWorks.com for more tips and guidance that will help you take your small business to the next level.

D E C E M B ER 2016 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 11

The State of Healthcare

By Marion Webb

WITH THE INAUGURATION OF A NEW PRESIDENT in January and a new Congress, physicians here and elsewhere could be facing major changes in the country’s healthcare policy. A number

of issues are especially concerning, most of all what’s ahead for the Affordable Care Act (ACA), including the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).

In this issue we take a close look at where ACA and MACRA

Sandra R. Hernández, president and CEO of the California

may be heading in light of the new administration. We’ve also

Health Care Foundation (CHCF), in a Nov. 11 article posted on

consulted the experts on how the final MACRA rule and electronic

the CHCF website, said she was proud of California, which has

health records (EHR) requirements could potentially impact your

led the nation in harnessing the ACA to make the state a better

practices and what you can do today to prepare for tomorrow.

place to live and work.

She vowed that the CHCF will work with public officials,

THE AFFORDABLE CARE ACT

consumer advocates and industry leaders to ensure Californians will continue to have access to needed healthcare.

Under the ACA, 91% of California residents now have coverage;

On Nov. 9, the day after the election and Donald Trump’s win, more than 100,000 Americans rushed to buy healthcare

Medi-Cal enrollment has risen to roughly 14 million, providing necessary coverage for one in three Californians, she wrote.

under the Affordable Care Act, the biggest turnout during this

Meanwhile, policy experts told the New York Times that the

year’s sign-up period. Candidate Trump had repeatedly vowed

part of the law that Trump is rethinking that prevents insurers

to repeal ACA, or Obamacare, but President-elect Trump told the

from refusing to cover people with pre-existing conditions only

Wall Street Journal he was reconsidering his stance after meeting

works financially if healthy people also buy insurance. If only

with President Obama on Nov 10.

sick people enroll, premiums will soar. The existing law includes

Trump indicated that he would like to keep two of the most

generous subsidies to encourage healthy people to enroll.

popular benefits of the ACA, the one that forces insurers to cover

Industry executives reportedly will make it their first priority

people with pre-existing conditions and the one that allows

to persuade Trump and the new Congress to replace the law with

parents to cover their children into their mid-20s under their

some way for people to keep coverage.

plan, the New York Times reported on Nov. 11.

Without a 60-vote supermajority in the Senate, Republicans

On his presidential transitional website, Trump laid out

are unlikely to repeal the entire ACA, but they can eliminate

new plans that deviate from his original proposal during the

several consequential provisions through a special budgetary

campaign, and he added ideas that seemed to more closely align

process called reconciliation. Trump hasn’t given details on his

with the mainstream Republican agenda, the report said.

plans, which, industry leaders said, has prevented them from developing strategies to address issues.

1 2 P H Y S I C I A N M A G A Z I N E | D E C E M B ER 2016

MACRA, MIPS AND MEDICARE PAYMENTS

By Arthur N. Lurvey, MD, FACP, FACE

fee schedule itself will be neutral for a few years. The current three incentive programs, plus a new one — Practice Improvement — will be rolled into a single Merit-based Incentive Payment System (MIPS). The four aspects will be Quality (formerly PQRS), Resource Use (formerly VBM), Advancing Care Information (formerly MU) and the new Clinical Practice Improvement

On April 16, 2015, President Obama signed into law the

Activities. Almost all physicians in the regular FFS Medicare

widely bipartisan Medicare and CHIP Reauthorization Act

program will have three choices: Be part of the MIPS program;

(MACRA). The 300-plus-page document covered many aspects

become part of a qualified Alternative Payment Model (APM)

of healthcare, including ending the sustainable growth rate

through a qualified accountable care organization, an approved

(SGR) formula for Medicare payment to physicians — which

shared savings program or one of several other risk-sharing

could have resulted in a 30% or more drop in reimbursement

models from the CMMI; or stay outside the programs and take a

— and started what the government intends to be a shift from a

4% to 9% drop in annual reimbursement.

volume-based physician reimbursement system to one based on quality and cost.

The Centers for Medicare and Medicaid Services (CMS) had already started reimbursement incentive programs for “quality” that included the Physician Quality Reimbursement Program (PQRS), Volume Based Modifier (VBM) for physicians in groups, and Meaningful Use (MU) for physicians using electronic health records. Payment is adjusted upward or downward, up to 10% in either direction, based on reports from the three incentive programs. In addition, the Center for Medicare and Medicaid Innovation (CMMI) started demonstration programs for alternate payment models such as accountable care organizations, bundled payment models, and shared savings programs that involved groups sharing cost savings and risks.

In the regular Medicare fee-for-service (FFS) program (and many other insurance programs), physicians are reimbursed

There are three exceptions to the MIPS provision of the law: • Physicians in their first year of Medicare Part B participation • Physicians billing Medicare Part B less than $30,000 per year OR seeing less than 100 Medicare patients per year • Physicians enrolled in a qualified Alternative Payment Model with various reporting requirements Most physicians will either be in the MIPS reporting system or choose to not report and lose 4% to 9% reimbursement between 2019 and 2022. Those in a qualified Alternative Payment Model will receive a 5% incentive bonus each year.

according to a fee schedule, which is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers.

Each covered service is ascribed a code using a Current Procedure Terminology (CPT) five-digit code maintained by the American Medical Association (AMA). Each diagnosis is ascribed an ICD10 (International Classification of Disease) code maintained by

Almost all physicians in the regular FFS Medicare program will have three choices.

the World Health Organization.

Nearly every CPT physician service is priced by CMS under the Medicare Physician Payment Schedule based on national uniform relative value units (RVUs) that take into account the relative resources used in furnishing a service: physician work, practice expense, and professional liability. The RVUs are based on actual AMA collected physician data, adjusted for locality of practice and multiplied by a CMS dollar conversion factor.

This process will continue for physicians in the original fee-forservice Medicare program.

Starting in 2019, MACRA fee adjustments will take place. The

So, what information is required from physicians in the MIPS program?

• Quality reporting: Physicians choose six measures to report to CMS that best reflect their practice.

• Advancing

care

information:

Physicians

report

elements from and about certified electronic health record (EHR) technology and, for a bonus, participate in a clinical data registry or report public health measures — nine measures for 90 days.

D E C E M B ER 2016 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 1 3

• Practice improvement: Physicians attest to four

• Review the quality measures and decide on what to

activities best suited for their practice for a minimum

report for your practice. Consider participation in a

of 90 days; small practices need to report two

qualified clinical data registry put together by some

activities for at least 90 days.

specialty societies.

• Resource use: CMS will calculate these measures based on administrative claims that will include all costs (including hospital, pharmaceutical, and other costs) for services provided to beneficiaries.

Physicians are not required to submit any data.

All this information is explained in detail in a relatively new CMS website: www.qpp.cms.gov. This website will walk you through all the elements of the required submissions and has various tools to make reporting easier. It also explains all the current qualified Alternative Payment Models.

To assist small, solo and/or rural practices, CMS has put aside $20 million per year for five years and has hired groups to help educate and initiate the MIPS program for small practices. In addition, CMS, your Medicare contractor (Noridian), AMA, the California Medical Association and your county and specialty medical societies and associations all have educational modules and programs to help. These programs are free for members, but there are also many outside consultants offering help for a fee.

Collection of information begins on Jan. 1, 2017, but CMS has simplified the first year: Try MIPS. Submit any data starting nearly anytime in 2017 and there will be no negative payment penalty in 2019. Submit 90 days of payment data and there will be neutral or small positive payment adjustment. Submit all necessary data for a full year and get up to a 4% bonus. There is also an additional bonus for stellar data.

Although data collected annually will be weighted differently for the first few years, in 2017 your cost data will not be used to calculate incentive bonuses. In 2017, quality will make up 60% of your weighted score; advancing clinical information will be 25%, and practice improvement will be 15%. By 2022 quality and resource use will each be 30% of the total weight, advancing care information 25% and clinical practice improvement 15%.

What you should do NOW to prepare.

• Evaluate your EHRs, your vendor and its support for MIPS data.

• Are you exempt from MIPS (low volume, new to practice, in qualified APM)?

• Which clinical practice improvement activities is your practice already doing, and consider ways your practice can report at least one unique patient for each advancing care information measure.

• Check your data accuracy and your use of ICD-10-CM. • Check the support for solo and small groups.

• Review the program at www.QPP.CMS.GOV.

More information is also available at the CMS Quality Initiatives Site: www.cms. gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Value-BasedPrograms/MACRA-MIPS-and-APMs/QualityPayment-Program.html

Arthur Lurvey is a board certified internist and endocrinologist, and a Medicare Contractor Medical Director for 20 years—initially working for the California Part B Carriers Transamerica Occidental Life Insurance Company, National Heritage Insurance Company, National Government Services, Palmetto GBA and currently for Noridian Healthcare Solutions, the Medicare Contractor in California Jurisdiction JE. He was in clinical practice for over 35 years.

Dr. Lurvey received his MD degree from the University of Illinois, and had his postdoctorate and fellowship training at Los Angeles County-USC Medical Center.

• Understand MIPS and decide what best suits your

He is a delegate to both the California Medical Association and

practice: Is your best fit MIPS, or should you choose

American Medical Association, has been a past hospital chief of staff and

to be outside of the program and accept the penalty,

served on the quality and CHART committees of the Hospital Council

or choose to be in an Alternative Payment Model?

of Southern California. He also is on the Board of the California Region

• CMS has quality data on many aspects of your practice,

the American Association of Clinical Endocrinologists. Dr. Lurvey was a

and you can learn where you stand at www.cms.gov/

member of the American College of Physician Executives. Other medical

Medicare/Quality-Initiatives-Patient-Assessment-

activities include service as a CMA surveyor for both the JCAHO hospital

Instruments/PQRS/AnalysisAndPayment.html.

survey program and the CME accreditation program in California.

1 4 P H Y S I C I A N M A G A Z I N E | D E C E M B ER 2016

of the American College of Physicians and on several committees of

MEDICARE

MACRA & EHRs

While the new plans don’t mention anything about reining in high

Practices that aren’t using certified EHR

technology

should

consider

doing so, CMS said. Starting in 2018,

drug prices, which Trump advocated for months, new language was added about modernizing Medicare, which could potentially support congressional efforts to give people vouchers toward buying private health insurance, the New York Times reported.

physicians must use EHR technology

In a recent interview with Fox News Channel, House Speaker

that is certified for 2015 instead of 2014.

Paul Ryan said: “Obamacare rewrote Medicare, rewrote Medicaid.

However, that represents a problem for more than 75% of providers

If you are going to repeal and replace Obamacare, you have to address those issues as well. What a lot of folks don’t realize is this 21-person board called the IPAP is about to kick in with price controls

participating in the Medicare EHR

on Medicare. What people don’t realize is because of Obamacare,

Incentive Program who, as of July,

Medicare is going broke, Medicare is going to have price controls

had 2014-certified edition technology,

because of Obamacare; Medicaid is in fiscal straits. You have to deal

according to the Office of the National Coordinator for Health Information Technology.

with those issues if you are going to repeal and replace Obamacare.

Medicare has serious problems [because of] Obamacare. Those are part of our plan.”

According to the LA Times, Ryan intends to replace traditional

That’s because the MACRA ruling doesn’t apply to vendors of EHR, leaving it up to physicians to do the required update, even if their vendor doesn’t offer it.

Medicare with a privatized program and a federal voucher program to help seniors pay premiums charged by commercial insurance plans.

Opponents are concerned that vouchers would rise at less than the rate of healthcare inflation, and since the costs of private insurance typically rise faster than those of Medicare, an ever-larger share of healthcare costs would land on seniors’ shoulders, according to the

Robert Tennant, director of health

LA Times. When Ryan first proposed this change in 2011, the Kaiser

information policy for the Medical

Family Foundation calculated that, by 2022, healthcare spending

Group

Management

Association,

said the certification rule “proposes a

would consume roughly half of the typical 65-year-old’s Social Security check, compared to only 22% under the existing Medicare system.

potential hardship for smaller practices

According to Medicare’s trustees, the Part A trust fund, which is

that may have invested in one of the

the costliest component of Medicare, covering hospitalization, will be

smaller EHR vendors” that don’t plan to

depleted in 2028 if no changes are made to rein in costs or increase

recertify their technology in time.

The

hope

is

that

the

vendor

funding. The fund will still be able to pay 87% of Part A costs after that time through a dedicated payroll. Prior to the passage of the Affordable Care Act, it was projected that fund would go broke in 2017.

community will come together and support physicians’ needs, open up the playing field to make solutions that make value-based care easier and offer interoperability, said CMS Acting Administrator Andy Slavitt.

For a summary of the final MACRA rule, visit cms.gov.

CONCLUSION While the only thing that seems to be clear is that there are more questions than answers about the state of healthcare in California and what is coming in 2017, Physicians News Network, Physician Magazine and the Los Angeles County Medical Association will be here to provide news, resources, information and support every step of the way.

D E C E M B ER 2016 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 1 5

THE PRESIDENTIAL ELECTION HAS BEEN DECIDED, but what does a Donald Trump presidency mean to the country’s future healthcare policy?

President-elect Trump has been vocal about his plans to completely repeal the Affordable Care Act (ACA), including the individual mandate to have coverage.

“We will work with Congress to make sure we have a series of reforms ready for implementation that follow free market principles and that will restore economic freedom and certainty to everyone in this country,” according to the Donald Trump website. ”By following free market principles and working together [we will] create sound public policy that will broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans.”

The result of a full repeal without a comparable replacement would leave an estimated 20 million Americans currently covered through the ACA without health coverage, including 1.4 million Californians.

Trump says he would promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply. Trump would promote the use of health savings accounts (HSAs) and specifically would allow tax-free transfer of HSAs to all heirs.

He would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for healthcare procedures and other services.

Medicaid seems to be a part of his larger plan, as he has said he would cover the low-income uninsured through Medicaid after repealing the ACA and offer states a choice between a Medicaid per capita allotment or a block grant.

“Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of

1 6 P H Y S I C I A N M A G A Z I N E | D E C E M B ER 2016

Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources,” according to his website.

On the issue of rising prescription drug costs, Trump supports allowing safe reimportation of prescription drugs from other countries as long as they are priced lower than in the U.S. In terms of reproductive health, Trump has promised to appoint pro-life justices who seek to overturn Roe v. Wade to the Supreme Court. He has called for defunding Planned Parenthood if it continues to provide abortions and would redirect its funding to community health centers. He states he is pro-life but with exceptions when the pregnancy is a result of rape or incest or “the life of the mother is endangered by pregnancy.”

To address the current opioid epidemic, Trump has said that his plan to build a wall on the U.S.-Mexico border will “stop the inflow of opioids into the U.S.” “We’re going to have borders again, and we’re going to work with you people to help you solve that very big problem,” Trump said during his primary-victory speech in New Hampshire in February, referring to plans to secure “the Southern border.”

According to Trump, cost savings is the driver behind many of his planned policies, as is reiterated on his website: “There are other reforms that might be considered if they serve to lower costs, remove uncertainty and provide financial security for all Americans. And we must also take actions in other policy areas to lower healthcare costs and burdens. Enforcing immigration laws, eliminating fraud and waste and energizing our economy will relieve the economic pressures felt by every American. It is the moral responsibility of a nation’s government to do what is best for the people and what is in the interest of securing the future of the nation.”

Election Coverage 2016 AS WE GO TO PRESS with our last issue of Physician Magazine for 2016, the election results are still dominating the news media and conversation for many people. It is uncertain if President-elect Trump will go through with his campaign promise to repeal the Affordable Care Act. Since the election, he has indicated that there are parts of ACA that he may keep.

This includes allowing children to remain on their parents’ insurance plan until age 26 and not allowing insurance companies to refuse coverage due to a pre-existing condition.

The players in the Trump administration are still

it amended. We also asked what positive health trends

shifting, and it remains to be seen how other legislation

you’re seeing. Diagnostics and more people having

around healthcare that impacts physicians may be

insurance were listed as positives, but unfortunately most

changed. Issues that bear watching include opioid abuse,

people who responded wrote NONE. We’d like to change

women’s reproductive rights and abortion, Medicare, food

that here at LACMA.

safety, environment and climate regulations, vaccines and funding for medical research (including NIH funding).

Please join us in the coming months as the presidentelect starts rolling out policy measures. At LACMA, we’ll continue to keep news and updates coming your way

After the American Medical Association’s Interim Meeting held a week after the election, the AMA issued a statement that included the following: “Delegates adopted a resolution voicing ‘firm commitment’ to current AMA policy on health care reform. In its discussions with the Trump administration and Congress, the AMA will continue efforts to cover the uninsured and work to assure that future proposals do not result in loss of coverage for patients currently insured.”

In the meantime, we wrapped up our series of three

from CMA, AMA and a variety of sources. Voting may be over, but your voice is still important.

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W E ’ R E PLEA SED TO A NNOUNCE that a new LACMA website is coming your way! Thank you to the LACMA staff and the Taylor Digital Team for their collaborative efforts and all their hard work.

LACMA continues to grow and evolve, and it’s clear that we need a dynamic website to not only tell our story, but to provide a platform for you to participate as well.

The new site is more interactive. You can fully participate in our social media efforts, easily find information about events and read up on all the newest advocacy efforts. In addition, content will be updated regularly, giving you more news stories, ways that you can be involved and highlights of our districts and members.

And this is just the beginning. Moving forward, we are planning to add a Member Portal with resources for physicians in solo/small practices and for those practicing with larger groups. These features will be exclusively offered to LACMA members. We’ll keep you updated as these changes become available.

In the meantime, if you have news to share, we would love to hear it! Just let us know so we can add it to the website. Be sure to share our website on social media and with your colleagues!

Send news stories, events, feedback and info to Deborah at deborah@lacmanet.org.

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