January 2014

T h e O f f i c i a l P u b l i c a t i o n o f t h e Lo s A n g e l e s Co u n t y M e d i c a l A s s o c i a t i o n

REPORTING ON THE ECONOMICS OF HEALTHCARE DELIVERY

A PUBLICATION OF PNN www.PhysiciansNewsNetwork.com

The Business of Being a Doctor

JANUARY 2014

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A N o r c A l G r o u p c o m pA N y

N o r c A l m u t u A l .c o m

JA NUA RY 2014 | TA B LE OF CONT ENT S

Volume 145 Issue 1

COVER STORY

16

the business of being a doctor

Industry experts and physicians offer

their tips on how doctors in private offices can implement a team approach

and social media marketing and use technologies such as electronic medical records and apps in order to con-

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tinue to run a successful business.

DEPARTMENTS 6 Front Office | Practice Management Tips, hints, advice and resources

10 Balance | Lifestyle & Wellness

News, studies, tips and opportunities to help physicians maintain a balanced lifestyle

10

12 transitions | career management

A look at the questions and challenges associated with various stages of your medical career

14 PNN | NEWS IN REVIEW

The latest headlines impacting the economics of healthcare delivery in Southern California

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24 United We Stand | AT WORK FOR YOU

cal mediconnect: Rebalancing California’s long Term Support and Services

LACMA and CMA membership at work for you

From Your Association

Physicians and healthcare professionals who treat dual-eligibles

4

Medi-Cal) can expect big chang-

27 LACMA News | Association Happenings

(patients receiving Medicare and es when California, as part of the Affordable Care Act.

President’s Letter | marshall morgan, MD

26 CEO’s Letter | Rocky Delgadillo

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Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 707 Wilshire Boulevard, Suite 3800, 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, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 9001 7. Advertising rates and information sent upon request.

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LACMA Officers President

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than 100 years, LACMA has

Immediate Past President

been at the forefront of current medicine, ensuring that its members are represented in the

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Councilor - District 9

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County and with the statewide

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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.

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David Aizuss, MD William Averill, MD Boris Bagdasarian, DO Erik Berg Stephanie Booth, MD Steven Chen, MD Jack Chou, MD Troy Elander, MD Hector Flores, MD Carlotta Freeman, MD Sidney Gold, MD William Hale, MD David Hopp, MD Paul Kirz, MD Lawrence Kneisley Kambiz Kozari, MD Howard Krauss, MD Maria Lymberis, MD Carlos E. Martinez, MD Nassim Moradi, MD Ashish Parekh, MD Jennifer Phan Heidi Reich, MD Peter Richman, MD Sion Roy, MD Michael Sanchez, MD Nhat Tran, MD Erin Wilkes, 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, Executive Assistant, at lisa@lacmanet.org or 213-226-0304.

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P R ES ID ENT ’S LET T ER | MA R S HA LL MOR GA N, MD

Damned if You Don’t, Then Damned if You Do

As recently as the late 90’s, opiates were used almost exclusively for post-operative pain, cancer, and end of life care. They were seldom prescribed for chronic non-cancer pain because clinicians believed that they were dangerous medications, potentially lethal in overdose, and potentially addictive when given over long periods.

Over the past 15 years that situation changed. The NIH reported that 100 million persons in the United States suffered from chronic pain. There was a consensus that most patients with chronic, non-cancer pain were not receiving adequate analgesia. Influential pain specialists argued that prevalent beliefs (that treatment of non-cancer chronic pain with opioid drugs was unsafe and ineffective) were erroneous, that concerns about opiods were overstated, and that these patients could benefit from chronic opioid therapy.

These advocates for better pain treatment, aided by support from the manufacturers of opioid medications, found ready allies among regulators and lawmakers. In 2000, the VA and the Joint Commission for the Accreditation of Hospitals issued standards for pain assessment and control, identifying pain intensity as the “5th Vital Sign”.

In 2001, a civil lawsuit, brought under California’s “Elder Abuse” statute resulted in a $1.5 million dollar judgment against a physician for failure to adequately treat a patient’s pain.

Also in 2001, the California legislature adopted legislation that required every California physician (radiologists and pathologists excepted) to endure a mandatory 12 hour course on pain management and end-of-life care. Those of you who took those courses during the 2000’s will recall the strong emphasis on the physician’s responsibility to alleviate pain, and the contention that opioids were useful and appropriate therapy for non-malignant chronic pain.

In 2004, the Federation of State Medical Boards adopted a Model Policy for the Use of Controlled Substances for the Treatment of Pain. That policy recognized the widespread “inadequate treatment of pain” and emphasized the obligation of government to “ensure the availability of controlled substances” for legitimate medical purposes.

The policy specifically stated that the under-treatment of pain was a departure from an acceptable standard of care.

Predictably in this environment, there was a major increase in opioid prescriptions, fueled by the development of new more potent and longer acting products accompanied by intensive advertising by drug companies. (According to the New York Times the dollar volume of opoid sales increased 110% between 2001 and 2012.)

The first indication that there was a problem with this 4 PHYSICIAN MA G A Z INE | J A N UA RY 2014

well-intended change in practice came in a paper published in 2005 in the American Journal of Industrial Medicine which examined opiate prescribing patterns and deaths attributable to opioid use in the Washington State workers compensation system. That study documented markedly increased daily doses of opioids for work-related injuries in the years 1995-2002 and 32 deaths attributed to opioid overdose. This finding triggered closer tracking by authorities of rates of opioid prescription and adverse events including addiction, overdose and overdose-related deaths.

According to the CDC, prescription drug overdoses tripled between 1990 and 2008, and now account for more deaths than motor vehicle accidents. The great majority of drug related deaths are caused by opioids.

The adverse effects of increased opioid prescribing, and the widespread public and professional awareness of those effects has had consequences. Guidelines designed to limit the opioid use are being developed. Some have been created by professional associations and ad hoc groups of physicians (my specialty, Emergency Medicine, has been particularly active in this regard). At least one large multispecialty group has created mandatory prescribing guidelines; physicians who will not follow them have been fired. One state government has mandated consultation with pain specialists in certain patients on high doses of opioids.

The message from the medical literature, physician opinion leaders, governmental regulators and courts to practicing doctors has changed: we are no longer being told: “It is your duty to treat and control pain, with opioids if necessary, and you may be punished severely if you don’t”. We now hear: “It is your duty to closely control and decrease the use of opioids, and you may be punished severely if you don’t.”

Undertreated pain is a significant problem for millions of Americans, which must be addressed. Although there is still disagreement about the best way to do so, it’s clear that the pre-1990 clinicians who did not prescribe opioids for chronic pain had a point: these are dangerous drugs, potentially lethal in overdose and potentially addictive with prolonged use. In an attempt to alleviate chronic pain, we appear to have made prescription drug abuse, which is arguably an iatrogenic disease, very much worse.

The point of all this? There are several: Prevailing medical standards, even pathophysiological “facts” change, and often enough turn out to be wrong… “Caveat emptor”.

Opioid drugs are dangerous and if used to treat chronic pain should be prescribed with great care.

There has been a collision between the effort to alleviate the problem of undertreated chronic pain and the subsequent lethal epidemic of prescription drug abuse; the development of appropriate medical and social policy to deal with these issues is a work in progress. We should monitor developments and work toward rational policies which protect both doctors and patients.

Marshall Morgan, MD, is a professor and chief of emergency medicine at the Ronald Reagan UCLA Medical Center and director of emergency medicine center at the David Geffen School of Medicine at UCLA. He is the 142nd president of the Los Angeles County Medical Association.

P R ACT I CE M A NAG EMENT | FR ONT OFFICE

Are You a Photocopier Away From a $1 Million Fine?

New HIPAA Rule Goes Into Effect CMA Staff

6 PHYSICIAN MA G A Z INE | J A N UA RY 2014

ing the Health Insurance Portability and Accountability Act (HIPAA), putting private patient data at risk and opening yourself up to massive fines and other penalties. Many of these copy machines have an internal memory that, unless proper safeguards are in place, may allow unauthorized people to access patient data.

The U.S. Department of Health and Human Services (HHS) recently released new regulations that made important changes to the privacy and security requirements under HIPAA. These new regulations, known as the HIPAA Omnibus Rule, implement many of the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The new rules took effect in March and physicians had until Sept. 23, 2013, to update practice policies and procedures to comply with the new regulations. Are your policies and procedures up to date?

While the copier infraction is not new, it does illustrate how physicians and medical office staff must think about potential risks to protected patient health information and identify and improve privacy and security vulnerabilities in office business practices.

In this instance, a New York health insurer called Affinity Health Plan really got a shock when it was informed by CBS Evening News that, as part of an investigatory report, it had purchased a photocopier previously leased by Affinity that still contained protected health information (PHI) for more than 300,000 patients.

In August 2013, the federal Office for Civil Rights (OCR), which is charged with enforcing the HIPAA privacy laws, settled with the plan for $1 million. The investigation revealed that Affinity failed to incorporate the electronic PHI stored on the photocopier hard drives in its analysis of risks and vulnerabilities as required by the HIPAA security rule and failed to implement policies and procedures for securing or deleting that data when returning the photocopiers to its leasing agent.

If you think that you are too small a practice to run afoul of HIPAA, think again. Small practices are not exempt from the HIPAA requirements, and any physician practice that uses electronic means to engage in designated transactions — including health claims, remittance or payment advice, claim status inquiries, eligibility inquiries, enrollment and disenrollment, referral certification and authorization, and coordination

of benefits or health plan premium payments — is a covered entity and must comply with HIPAA or be subject to enforcement actions.

But Will OCR Come After the Little Guys?

OCR has initiated enforcement actions on practices big and small. Last year, a small cardiac surgery practice in Arizona agreed to pay a $100,000 settlement fine after it was found to have been sending PHI through an unsecured, web-based email program. In addition to using unsecured email to send PHI, the practice was also posting patient appointments on an Internet-based calendar, which was publicly accessible. With a careful assessment of their business practices and risks, physicians should be able to implement HIPAA compliance plans in their practices to protect patient information and reduce their risks of violating HIPAA and state privacy and security laws.

What’s New? Some of the key changes made by the HIPAA Omnibus Rule include, but are not limited to, an updated definition of a business associate, new rules surrounding certain permitted uses and disclosures of PHI, such as the sale of PHI and the use of PHI for fund-raising and marketing, and rules controlling how patients can obtain medical records that are kept by a physician electronically. It also made significant changes to the PHI breach notification rule.

Physician offices will, at a minimum, need to review and update their business associate agreements, office privacy and security policies, and notice of privacy practices in order to bring their offices into compliance with the new rule.

In the end, your practice doesn’t have to be locked down like Fort Knox, but you must be able to demonstrate that your practice has taken “reasonable” measures to protect the privacy and security of PHI. Each practice will differ in some detail. As doctors and staff learn more about HIPAA, your staff should be able to determine what you need to do if you have not already

pract i ce management | front off i ce

Do yo u or your staff scan patient health records on a leased copy machine? You might be violat-

P R ACT I CE M A NAG EMENT | FR ONT OFFICE

implemented your safeguards.

This means using appropriate and reasonable administrative, technical, and physical safeguards for all health information. Every staff member has an obligation to protect this information. This includes keeping doors properly locked, keeping computer passwords secret, securely transporting and using portable and mobile computers and devices that access PHI, and speaking softly when discussing medical information in publicly accessible areas. The law also requires every practice to designate a Privacy and Security Official, whether it is the physician, an associate, or staff member, to oversee the practice’s HIPAA compliance

If you think that you are too small a practice to run afoul of HIPAA, think again. Small practices are not exempt from the HIPAA requirements, and any physician practice that uses electronic means to engage in designated transactions is a covered entity

plan. This person will be key to developing and implementing policies and procedures, receiving complaints, and knowing where documentation of your processes are kept; he or she will be responsible for thinking ahead about compliance, and can help or lead your office through an audit. This person needs to understand computers, but does not have to be a “techie.” They will, however, require some education and some support. Information technology (IT) is involved, but this is NOT an IT project. Keeping your practice in compliance with HIPAA will ultimately require the whole organization’s cooperation and support.

Where Can We Get Help?

The California Medical Association (CMA) has a number of resources that are useful in understanding and for getting medical practices up to par on the HIPAA rules. These and other resources are available at www.cmanet.org/hipaa.

• Sample Documents: For more information and for an updated sample notice of privacy practices and business associate agreement, see the California Medical Association’s (CMA) ON-CALL documents #4101, “HIPAA ACT SMART: Introduction to the HIPAA Privacy Rule,” and #4103, “Business Associates.” These documents are available free to members. Nonmembers can purchase documents for $2 per page.

• On-demand Webinar: CMA recently hosted a webinar, “HIPAA Compliance: The Final HITECH Rule,” available for on-demand playback at your convenience.

• Frequently Asked Questions: CMA has produced a brief resource document, “HIPAA Omnibus Rule Compliance Frequently Asked Questions,” which answers common questions about the new HIPAA regulations.

• HIPAA Compliance Toolkit: The CMA/ PrivaPlan HIPAA Toolkit is a comprehensive online resource to assist physicians in complying with the HIPAA privacy and security rules and California law. It contains detailed sample forms, policies, procedures for compliance tailored for California physicians, training materials, and resources to help physicians with implementation and planning. LACMA-CMA members can purchase the toolkit from PrivaPlan by calling (877) 218-7707 or visiting PrivaPlan’s website at www.privaplan.com. The cost is $325 per practice for members or $495 for nonmembers. Annual updates to this program cost $75 for LACMA-CMA members. A coupon code is required to access this discount. Visit www.cmanet.org/benefits or call CMA’s member service center at (800) 786-4262 to obtain the code.

• HIPAA Training Tool: PrivaPlan also offers an online HIPAA Training Tool that is an easy and affordable way to train staff. This comprehensive course can be taken online at any time, anywhere. It features videos and online quizzes to help just about anyone understand HIPAA and what policies and procedures must be put into place. LACMA-CMA members can purchase the HIPAA Training Tool for $129 for LACMA-CMA members or $169 for nonmembers.

For more information and resources, visit www.cmanet.org/hipaa.

The California Medical Association (CMA) represents more than 38,000 physicians in all modes of practice and specialties. CMA is dedicated to the health of all patients in California.

8 PHYSICIAN MA G A Z INE | J A N UA RY 2014

Save Your Practice Thousands of Dollars CMA Staff

Th e b e ginning o f a new year means calendar year deductibles and visit frequency limitations

start over. Remember, with open enrollment there may be changes to patients’ benefit plans, or they may even be insured through a new payer. Physicians are urged at this time of the year to be diligent in verifying patients’ eligibility and benefits to ensure that you will be paid for services rendered.

2014 also brings a host of other challenges that could affect your ability to be paid:

• Medicare patients can modify their enrollment choices from October 15 through December 7, allowing them to switch between Medicare fee-for-service and Medicare Advantage (MA), or switch from one MA plan to another.

• Under the Affordable Care Act (ACA), California opted to expand Medi-Cal eligibility to childless adults ages 19-64 with incomes up to 138% of federal poverty level, effective January 1, 2014. The state estimates an additional 1.6 million individuals may become eligible for Medi-Cal/Medi-Cal managed care under the ACA expansion.

• In 2013, over 900,000 children transitioned out of the Healthy Families program into MediCal managed care, while another 274,000 transitioned from fee-for-service Medi-Cal into Medi-Cal managed care through the rural expansion project. Many of these enrollees transitioned toward the end of 2013.

• With the ACA requirements on minimum benefit levels that must be offered by plans, approximately 900,000 individuals have received policy cancellation notices from their current health plans. Many of those patients will have different plans and/or benefits effective January 1, 2014.

• Approximately 600,000 patients previously insured through the Low Income Health Program will be transitioned into Medi-Cal managed care plans on January 1, 2014.

• It is estimated that anywhere from 150,000 to 450,000 individuals will enroll in an exchange plan through Covered California in 2014.

And don’t forget that under the ACA, patients receiving premium assistance through federal tax subsidies are given a 90-day grace period in which to pay their portion of the premium.

During the first 30 days of the grace period, the plans must pay for services incurred. However, during days 31-90 of the grace period, plans are allowed to suspend the patient’s coverage.

If the patient doesn’t true-up by day 90, the plan can terminate the policy, potentially leaving 60 days worth of unpaid claims. While physicians can pursue the patient for the balance incurred during days 31-90 of the grace period, it seems unlikely a patient would be able to pay a doctor’s bill if unable to pay for the plan premium.

This reinforces the importance of verifying patient eligibility—particularly for exchange patients—each time they are seen. If the exchange patient’s eligibility verification states coverage is suspended, the practice can treat the situation as it would any other patient who has had a

lapse in coverage. For non-emergency services, patients would have the option to either pay cash to see the physician or not be seen. The grace period issue applies only to exchange enrollees receiving federal tax subsidies; however, information on whether or not they are receiving subsidies will not be noted on their ID cards.

(More information on the grace period issue can be found in CMA’s exchange toolkit, “CMA’s Got You Covered,” available free to members at www.cmanet.org/exchange.)

Don’t get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit.

Taking proactive steps to protect your practice by preventing denials, delays in payment and disgruntled patients goes a long way toward ultimately saving time and money.

pract i ce management | front off i ce

Verifying your patients’ eligibility and benefits in 2014 may

balance | li festyle & wellness

The Changing Face of Medicine:

How Is Change Affecting You? Liz Ferron, MSW, LICSW

M a ny phys i cia n s to day feel that an implicit contract they made with society has been broken.

In a 2004 article published in the American Medical Association Journal of Ethics, the terms of that contract were described: “Society granted physicians status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards on the expectation that physicians would be competent, altruistic, moral, and would address the healthcare needs of individual patients and society.”1 not experiencing worry and stress as a result.

Unpleasant Side Effects of Change Physicians who showed almost super-human capabilities to perform under stress during medical school are often surprised when stress takes a toll later in their careers. Doctors are not immune to change-related reactions, such as: Resistance to change: Did you seize the last place on the sign-up list for Electronic Medical Record training?

Health concerns: Does a level of stress that didn’t affect you as a medical student now cause symptoms ranging from headaches and digestive disorders to short temper and depression?

Decreased tolerance: Have your colleagues suddenly become idiots, your patients noncompliant and staff completely incompetent?

What’s changed since then? Almost everything.

Healthcare reform, EMR, ACOs, medical homes— and at the same time a major shift away from private practices.

Physicians are drawn to hospital or HMO employment by reduced administrative responsibilities and overhead, more predictable hours or call schedules, and state-of-the-art diagnostic tools and medical resources. In gaining those advantages, many physicians have lost the autonomy and self-regulation they formerly had. However, while they may have committed to this new way of practicing medicine, it doesn’t necessarily mean they like it or that they’re 1 0 PHYSICIAN MA G A Z INE | J A N UA RY 2014

Self-protection and distrust: When asked to pitch in, have you become more apt to say, “What’s in it for me?” than “How can I help?”

There are many ways of responding to change— some healthier than others. Fighting the system is almost always a losing battle. The momentum for change in the medical workplace will continue.

Some physicians are opting for flight—by retiring early or looking at non-medical or non-clinical careers.

Yet, the vast majority are soldiering on.

Most physicians remain committed to the practice of medicine—even though 87% reported being moderately to severely stressed or burned out on an

WE TREAT DOCTORS RIGHT!

average day in a representative survey conducted by Physician Wellness Services and Cejka Search in 2011.

Changing the Way You React to Change Change is inevitable but stress and worry aren’t. How do you manage a situation or fact that can’t be changed? Start by challenging the assumption that there’s no way to modify or limit the extent of the change before you begin adjusting to it.

Healthcare administrators aren’t infallible. They may not be aware of potential downsides that seem evident to you—and may be open to suggested improvements in their plan. In our work with physicians, we advise them to: • Be your own advocate • Ask for what you want and need • Suggest ideas for working together more effectively The second phase of adapting to change begins as you explore what the future will look like with this change, accept the inevitability that change will occur, search for solutions that meet your needs and commit to making those changes.

• A study3 published in the Archives of Internal Medicine suggests that doctors who really believe in the core mission of their profession—a calling to help others—are more likely to be satisfied with their jobs.

Remind yourself why you chose medicine, reflecting on the ways these elements are still a part of your daily work experience.

• Accept the fact that there is not going to be a perfect way to practice medicine right now. Many of the decisions you make related to your practice will have a positive side and a potential negative side. Make sure the scale is tipping toward your needs and interests being met.

• Join—or start—a provider support group or find a mentor or peer coach who can help you find and focus on the best approach for you.

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Liz Ferron, MSW, LICSW, Senior Consultant and Manager of Clinical Services, Physician Wellness Services 1 Cruess, Sylvia R. MD, and Cruess, Richard L. MD Professionalism and Medicine’s Social Contract with Society, American Medical Association Journal of Medical Ethics/Virtual Mentor, April 2004,Volume 6, Number 4

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3 Rasinski, Kenneth A. PhD; Lawrence, Ryan E. MD, MDiv;Yoon John D., MD; Curlin, Farr A. MD A Sense of Calling and Primary Care Physicians’ Satisfaction in Treating Smoking, Alcoholism, and Obesity, Archives of Internal Medicine. 2012; ():1-2. doi:10.1001/archinternmed.2012.3269

J A N UA RY 2014 | 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

balance | li festyle & wellness

transi t i ons | career managem ent

Recycling Physicians to Meet the Future Shortage Rebecca Ostrander

A ll across th e United States, healthcare facilities are in need of doctors. Many of these are

community health centers with very diverse needs but without the ability to support a staff of specialists. In many cases, their needs would be met by the availability of full-time or even part-time physicians with a broad range of medical skills. Unfortunately, this is just the kind of doctor that is hardest to find, and it’s especially difficult for smaller medical centers without deep pockets and fancy facilities to attract people from the limited pool of general practitioners available.

There is a current shortage of more than 33,000 primary care physicians, a number that is likely to double in the next 10 years or so. If you want more alarming details, check out the statistics from the Centers for Disease Control and Prevention (CDC). As of 2009-2010, specialty physicians outnumbered generalists, yet demand for the latter resulted in them working longer hours, including evenings and weekends, more than twice as often as specialists. However, according to the Association of American Medical Colleges (AAMC) Center for Workforce Studies, supply is falling well short of demand. Although annual medical school enrollments are increasing, according to AAMC, first-year enrollments in 2013 were just under 20,000 (compare with the current PCP shortage alone), and more than half of those who graduate are likely to go into specialties. Some of the PCP shortage has been met by foreign-educated physicians, physician assistants, and nurse practitioners, but the gap between supply and demand is still large and still growing.

Into this gap steps Physician Retraining and Reen-

1 2 PHYSICIAN MA G A Z INE | J A N UA RY 2014

try, Inc., or “PRR.” Founder Leonard W. Glass, MD, and his associates envisioned the ever-growing shortage of primary care physicians escalating with the approach of the Affordable Care Act and its offspring, as well as the growing number of Americans eligible for Medicare. They also envisioned a solution: Get retired physicians to return to the medical workforce—even if only part time. But doing so means that they will need some retraining to learn about the most up-todate drugs, equipment, and techniques, allowing them to strengthen their knowledge acquired years earlier.

In the case of former specialists, they will need more generalized knowledge than they may have had since medical school. So now there’s a new need: re-education.

The founders brought in partners and consultants experienced in medical business management to help them get off to the right start. Both economically and in terms of geographic distribution of potential students, the obvious vehicle was the Internet. They collaborated with the University of California, San Diego, and especially with two practicing faculty members William Norcross, MD, and David Bazzo, MD, to develop a curriculum. Others at UCSD joined in to develop PRR’s educational materials, exams, and a competence assessment required for graduation. The result is the only online educational retraining program designed to transform any doctor, regardless of specialty or field of practice, into an adult outpatient general practice physician.

Why would a specialist want to transform himself or herself into a general practitioner? There are any number of reasons—such as the surgeon whose auto accident left him with less-than-optimum manual dexterity or the oncologist whose chain of terminally ill patients left her burned out and frustrated. But the largest pool of potential students are among the thousands of physicians who retired at a relatively young age, often because they wanted to take advantage of their retirement nest egg while healthy and active enough to enjoy it. Now, for one reason or another, they would like to re-enter the medical workforce without the

skills in a medical environment prior to re-entering practice can take advantage of a shadowing program offered as a supplement to the PRR coursework. And when all that is done, PRR’s job placement service can assist them with interviews for part-time or fulltime adult outpatient general practice jobs virtually anywhere in the United States, from federally and privately funded community clinics to medical schools, VA facilities, and retail providers. Learn more about PRR from their website, prrprogram.com.

Although the anticipated main audience for PRR is retired physicians, it is certainly not the only one.

Any medical practitioner who wants more exposure to the field of outpatient general practice will benefit from PRR’s program. The ultimate goal is to reduce the shortage of general practitioners looming in the future of U.S. medical services. This promises to be one step in that direction.

Rebecca Ostrander, Marketing, Physician Retraining & Reentry, admin@prrprogram.com References “Ambulatory Care Use and Physician Visits” FastStats web page, Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/fastats/ docvisit.htm; “Workforce Data and Reports” web page, Center for Workforce Studies, Association of American Medical Colleges: https://www.aamc.org/data/workforce/ reports; Physician Retraining & Reentry website: http://prrprogram.com/

BACK TO WORK 1 OR MORE DAYS/WEEK ?

We train all specialties on-line for adult outpatient general practice.

In collaboration with UNIVERSITY OF CALIFORNIA @ SAN DIEGO SCHOOL OF MEDICINE

(858) 240-4647 www.prrprogram.com

J A N UA RY 2014 | 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

transi ti ons | career m anage m ent

overwhelming demands of their own private practice.

Some found out that their nest egg wasn’t going to last as long as they were. Others got bored. But many just found themselves missing interaction with patients and the fulfillment they found from helping those in need of their services. But their “time off” has left them somewhat out of touch, and they just don’t know how to make the leap back into the healthcare workforce.

PRR’s online educational module makes it possible for such doctors to make the transition affordably and in a reasonably short time. Because the program is self-paced, it can accommodate individual personal demands and limitations, so the time frame depends on the student, but a determined person can complete the course in less than four months, with a full year as a maximum. Although the course is Internetbased, faculty are available for direct assistance via email. Students must pass an exam for each class and at the end for the entire course (including a one-day, on-campus practical exam), leading to a certificate of completion and around 100 hours of CME credits from the UCSD School of Medicine. Any program graduate wishing to polish his or her newly acquired

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Read Full Stories and Subscribe to the PNN eNews BulletinS at www.PhysiciansNewsNetwork.com A SERVICE OF

NEWS NETWORK

The LOS ANGELES County Medical Association

PNN | LOCAL • TIMELY • RELEVANT

reporting on the economics of healthcare delivery READ the full story on page 28

Questions Remain about Dual-Eligibles Project Los Angeles County Medical Association (LACMA) and Los Angeles County Podiatric Medical Society (LACPMS) held a meeting recently to bring physicians up to date on the issues regarding the status of the Cal MediConnect demonstration project in Los Angeles County that affects the dual-eligible population.

Legislation Aimed at Repealing the Medicare SGR Approved December 12, the Senate Finance Committee and the House Ways and Means Committee unveiled revised legislative proposals to repeal the Medicare sustainable growth rate (SGR) and establish a new payment system.

According to CMA, this is good news for California physicians, who have been working with both committees to revise the initial draft of the legislation since it was introduced in October.

Local Doctors Explore Alternative Practice Model Dozens of Los Angeles County physicians recently attended an event to learn more about concierge medicine, an alternative practice model that is being discussed more broadly in light of health reform.

In concierge medicine, patients pay a monthly or annual fee for enhanced services, including same-day appointments, 24/7 access to their doctor, email consultations and longer appointment times. To make more time for patients, concierge doctors typically carry smaller patient loads.

A survey conducted by Merritt Hawkins of 13,575 physicians nationwide showed that 6.8% of doctors are considering switching to concierge medicine.

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Cedars-Sinai Strikes Deals with UCLA, Sports Medicine Groups Longtime rivals Cedars-Sinai Medical Center and UCLA Health System recently announced an unprecedented partnership to open a 138-bed rehabilitation facility in Century City, according to news reports.

Cedars-Sinai also announced they have signed a letter of intent to form a new partnership with two sports medicine groups.

Both deals are a sign of the times where big institutions, faced by the pressures of health reform, are pooling their efforts to provide patient care to cut costs.

Competition for Patient Safety Award Open to Residents and Young Physicians The Doctors Company Foundation in partnership with the Lucian Leape Institute at the National Patient Safety Foundation (NPSF) is accepting entries from medical students and residents for its 2014 Young Physicians Patient Safety Award.

Entrants must submit a 500- to 1,000-word essay describing an instructional patient safety event they experienced during a clinical rotation that resulted in a personal transformation. Essays are due by 5 p.m.

(ET) Feb. 3, 2014. More information and online entry forms are available at http://bit.ly/PtSafetyAward A total of six $5,000 awards will be given and the winners will also receive travel to the Association of American Medical College’s Integrating Quality meeting June 12-13, 2014, in Chicago, where, where the awards will be presented.

The contest is sponsored by The Doctors Company Foundation in partnership with the Lucian Leape Institute at the National Patient Safety Foundation (NPSF). Entries will be judged by a panel selected by the NPSF.

USC’s Keck Medicine Outpatient Clinic Has New Location Keck Medicine of USC recently opened its relocated 7,000-square-foot downtown outpatient clinic on Flower Street, which will offer thousands of newly insured and existing patients in Los Angeles convenient access to a range of medical services.

The clinic, located on 830 S. Flower St., will focus on primary care but also offer patients orthopedic surgery, imaging and digital mammography, cardiac stress testing and a pharmacy, according to news reports.

The clinic, which for the past nine years was located at 333 Hope St., will have a staff of multiple doctors, one registered nurse, two licensed vocational nurses and two front office staff members who are expected to serve some 15,000 people in 2014, according to reports. That is up from 1,800 patients a year at its old location.

The clinic will have nine exam rooms and rooms for X-rays, mammograms and cardiac testing.

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reporting on the technology of healthcare delivery

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UCI Med Center Testing Google Glass Apps

Kyle Samani, founder and CEO of Pristine, a startup company that develops Google Glass apps for surgeries, hopes that doctors and nurses at the University of California, Irvine, Medical Center who are currently testing his devices in live surgeries will see it — literally — as the future of healthcare. UC Irvine surgeons are currently using Pristine’s EyeSight, which streams live audio and video to and from Google Glass devices, smartphones and tablets, for teaching and training and remote consults, Samani told PNN. Happtique Announces Inaugural Class of Certified Health Apps Happtique, a mobile health solutions company, announced it has certified 19 health and medical apps through its Health App Certification Program (HACP).

This inaugural class is the first group of apps in the country to pass the rigorous HACP standards announced earlier this year. Each app that receives certification has passed both technical testing—the verification of privacy, security, and operability standards by global testing leader Intertek—and content testing, as completed by relevant, independent clinical experts.

Wellness Reinvented With Smart Socks

Heapsylon (the maker of Sensoria Fitness) is betting that in the near future most pieces of clothing will come with embedded microelectronics and sensors.

Heapsylon has taken this idea and developed a smart sock that works with an electronic anklet that snaps onto the cuff of the sock and transmits the info to a smartphone app, providing real time guidance through audio cues during a workout.

The Sensoria Fitness app will be available for iPhone (iOS 6 and above), Android (OS 4.3) and Windows Phone 8.x and provide home dashboard used without a phone.

news i n rev i ew | phys i c i ansnewsnetwor k . co m

Low Latino Exchange Enrollment Concerns LACMA, Other Health Leaders The currently low enrollment numbers of Spanish speakers into the California health exchange has Latino lawmakers and health leaders, including LACMA’s chairman of the Latino advisory committee, voicing concerns over current tactics being used to reach the Spanishspeaking community in Los Angeles County.

According to news reports, fewer than 1,000 Spanish speakers signed up in the health law’s first month.

Advocates have identified the following problems, which they believe contribute to California’s lagging Latino enrollment: There are no paper applications in Spanish for a population that doesn’t have access to computers or isn’t using them. There are not enough bilingual phone operators to help Spanish speakers. There aren’t enough counselors to explain the process in person in clinics and community settings to a population that often doesn’t trust people with their personal information.

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feature | t he bus i ness of be i ng a d octor

by marion webb

Healthcare reform will bring sweeping changes for physicians this year. While many uncertainties remain, undoubtedly certain effects of the Affordable Care Act (ACA)—from doctors being rewarded for providing quality care based on outcomes to the rising influx of newly insured—will change the way physicians run their medical practices. In this article, industry experts and physicians offer their tips on how doctors in private offices can implement a team approach and social media marketing and use technologies such as electronic medical records and apps in order to continue to run a successful business.

The

business

of being a doctor

feature | t he bus i ness of be i ng a d octor

Electronic Medical Records The Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the government’s 2009 economic stimulus package, set the groundwork for healthcare reform.

It provided $27 billion in Medicare and Medicaid incentive payments to go to doctors and hospitals that adopted electronic medical records (EMR) under federally established guidelines, according to news reports.

To receive payments, doctors and hospitals must show that their systems are being used to improve patient care.

Experts say that doctors who began participating in the program can receive as much as $44,000 from Medicare and up to $63,750 from Medicaid.

Furthermore, doctors who choose to participate in the Medicare program after 2015 can also receive payments, but at a reduced rate.

As of December 2013, healthcare experts estimated that two-thirds of family doctors were using electronic healthcare records.

William Averill, MD, LACMA’s District 9 president and a cardiologist in private practice in Torrance, considers himself an early adopter of electronic medical records.

“I’m also on the IT committee for the Torrance Memorial Medical Center,” Averill said. “I can download all hospital records and do 95% of all prescriptions via e-prescribing, which is more accurate and more rapid (than writing them by hand).”

He said, to date, his patients don’t have access to the EMR portal at the practice.

Under meaningful use requirements, physicians who implement a patient portal—for giving patients access to their medical records, making appointments or getting prescription refills—have to consider privacy issues.

Experts believe that patients will be hosted on the practice’s website, which would lend itself to doctors implementing mechanisms for allowing patients to do things from scheduling appointments to sending secure emails.

One IT expert recommends that solo practitioners or small medical practitioners should outsource most of their technology needs altogether.

Kyle Samani, founder and CEO of Austin, Texas-based start-up Pristine, which develops Google Glass apps for surgeries that are currently being tested at the University of California, Irvine, Medical Center, said “small doctor practices spend too much time in trying to use EMRs and managing EMRs.” “Athena Health (which provides cloud-based services for EMR, practice management and care coordina-

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Apps While the idea of medically prescribed apps is still relatively new, some people believe that they may provide an answer to tracking especially chronically ill patients.

This could help reduce doctor office visits while improving outcomes with doctors tracking patients without

actually seeing them.

Among the pioneers in the prescription-app field is a company called WellDoc. Its DiabetesManager system, which patients use through their smartphone apps, cell phone or desktop computer, collects information about a patient’s diet, blood sugar levels and medication regimen.

Patients can enter the data manually or link their devices wirelessly with glucose monitors and then also get advice on best foods after recording glucose levels.

The U.S. Food and Drug Administration cleared the device, and two insurance companies agreed to pay the bill for patients whose doctors ask them to use the device, according to published reports.

However, issues regarding safety and privacy remain.

Experts believe that apps and Web-based information have given physicians—especially younger ones who gravitate toward technologies—new ways to diagnose and treat disease and communicate with patients.

While there is no shortage of innovators creating apps, one company, MobileHealthMarketplace.com., recently created a directory of mobile health and medical apps focusing on solutions that connect patients and medical professionals with company health, wellness, workers’ compensation and safety programs.

A prescreened directory of apps is grouped into 33 categories.

They focus on the treatment of chronic diseases, illnesses and injuries, including diabetes, cancer and heart conditions; employer and individual health and wellness efforts; and new medical technology platforms.

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tion) is among the biggest medical billing company in the country,” Samani said. “I think that kind of wholly managed model is the way to go for small medical practitioners.”

He feels that companies that specialize in all issues related to EMRs—from practice management to patient engagement—provide doctors’ offices a service that’s more cost-effective and efficient.

“This is all cumbersome overhead of doing business that can be outsourced,” Samani said.

One doctor, however, noted that he still prefers keeping his own EMR system, because it allows him to have more control over billing.

Ultimately, he said, doctors are held responsible for inaccuracies in billing.

feature | t he bus i ness of be i ng a d octor

For each app listed, MobileHealthMarketplace.com summarizes key information in a standard format, which makes it easy to compare different options.

One of the biggest challenges for doctors, Samani predicts, will be trying to find apps they’d actually want to recommend to their patients in the ever-growing sea of available medical apps.

His recommendation: “Try them on your own and use ratings to find good apps.”

Team-based Approach The rising emphasis on a team-based approach where doctors work as part of a team to deliver high-quality care while improving efficiencies is often part of the discussion in hospital settings.

But experts believe that the same approach has a place in medical practices too.

One way to put the model into practice is to get the back office and front office to work more efficiently together to address patient inquiries, from booking appointments and pricing of medical procedures to payment options.

For others, a team-based approach could mean creating a multidisciplinary practice where doctors work side-by-side with other health professionals, such as registered dieticians who can counsel patients on their dietary needs, acupuncturists and chiropractors.

Dr. Emil Avanes, who opened his Glendale-based multidisciplinary practice, Harmony Health MD, last September, considers this changing healthcare environment a good time for doctors to go it alone.

“The previous model is being changed and is asking every single doctor how we can best take care of our patients, and those who figure it out will be rewarded in the future,” he said.

The multispecialty group, Caduceus Medical Group, announced last month that it will open an all-nurse-practitioner women’s clinic in Yorba Linda.

The new clinic will be staffed by three female nurse practitioners who will assist patients with basic medical services, such as wellwomen exams and physicals, which will be covered by insurers under the ACA. Gregg DeNicola, MD, CEO and chairman of Caduceus Medical Group, which operates sites in Yorba Linda, Irvine and Laguna Beach, said the ACA with its focus on containing cost while providing quality care, reimbursement issues and the rising influx of newly insured women seeking preventive care all played a role in the decision to open up an all-nurse-practitioner clinic.

“When we tried to staff the women’s clinic with two full-time doctors, it was very difficult to recruit and make financial sense,” DeNicola said. “With government payers paying sub-optimally, private health plans cutting back and the exchanges in California paying just a little over Medi-Cal, we made the choice to recruit nurse practitioners.”

DeNicola said that nurses will refer patients who require the attention of a physician to the gynecologist and family doctor on staff.

He predicted that patient volume will rise starting this January when health reform kicks in and women, especially those who weren’t insured or were underinsured in the past, will be able to seek preventive care under their health plan.

“The previous model is being changed and is asking every single doctor how we can best take care of our patients, and those who figure it out will be rewarded in the future”

Marketing Through Social Media Experts believe that doctors will need to become more business savvy to be successful and think of their patients more as customers.

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With consumers becoming more vocal in how they want to spend their healthcare dollars and increasingly turning to the Internet to do “comparison shopping” for pricing of medical care, physicians who take the initiative in getting patients involved in their own health and well-being will have a competitive edge.

This also means that reputation management will become increasingly important.

Experts predict that consumers will pick doctors based on reviews just like they would a restaurant or movie.

There are various health consulting and IT companies specializing in helping doctors improve and manage their online presence to retain existing patients and draw new ones as competition rises.

With 30% of practices’ revenue stream coming from patient responsibility—including copays, deductibles, co-insurance and self-pay for services, practices have a responsibility to their patients to collect all their revenue to which they are entitled.

At the same time, practices that offer more transparency upfront on pricing for different procedures and services could also have a competitive edge.

This is a principle that the Caduceus Medical Group has long believed in, according to Tina Franklin, Caduceus’ marketing director.

“Under the Affordable Care Act, a lot of services will be covered under preventive benefits,” Franklin said.

“But we have always provided a cash price list on our website.”

On the website, the group said (as of December 17) that “cash prices offered require payment at the time of service, and are available to only those patients without health insurance coverage for the service.”

Among the services offered are a routine office visit, which costs $89, a well-woman exam for $150 and a removal of a wart, which costs $139.

With private companies increasingly publishing pricing and price comparisons for medical procedures in different cities, economists believe that more hospitals and doctors will provide patients with detailed price lists upfront.

To draw patients in the rapidly changing health environment, more doctors are also expected to use social networking to market their practices.

Indeed, experts say that doctors who write blogs providing critical education to patients can drive traffic to their website and ultimately patients into their practices.

Some people see Facebook as another great vehicle for doctors to announce promotions and news, and promote pages as well as provide free medical information.

Engaging patients will be key in the new healthcare environment, so will EMRs and other innovative technologies.

But no technology can be a substitute for physicians, said Kourosh Parsapour, MD, who is the CEO of healthcare technology firm 5plustherapy.com.

“Telemedicine is like any other communication tool, like a telephone,” Parsapour said. “Telemedicine is neither designed nor meant to replace a healthcare provider—it relies on the presence of a trained individual.”

While DeNicola hopes his new all-nurse-practitioner group will pave the way to continued successes, he also relies on physicians to serve patients with more complex medical needs.

“The ledger, the documentation requirements with EMRs and the administrative demands make financial success with any privately owned group very challenging,” he said.

Still, Averill said in spite of all the changes ahead, he remains committed to staying in private practice.

“I just signed another 10-year lease,” Averill said. “I love having my own practice and the interaction with patients and staff that private practices offer.”

Cal MediConnect: Rebalancing California’s Long-Term Support and Services

by Jason Bloome

Phys i cia n s a n d h e a lth c a r e professionals who treat dual-eligibles (patients

receiving Medicare and Medi-Cal) can expect big changes when California, as part of the Affordable Care Act, implements Cal MediConnect (CMC) in 2014. CMC is a three-year pilot program in eight counties (Los Angeles, Riverside, San Bernardino, Orange, San Diego, Alameda, Santa Clara and Mateo) in which an estimated 456,000 dual-eligibles will be contracted with healthcare plans (HMOs) to manage their care services.

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Medi-Cal services (including long-term care and In Home Supportive Services, etc.) for all dual-eligibles will be managed by a CMC HMO. Medicare services will be provided by a dual-eligible’s existing Medicare provider or if he/she chooses, by the CMC HMO as well.

CMC is expected to improve quality outcomes, streamline healthcare delivery, and contain Medicare/Medi-Cal costs. CMC’s primary goals include enhancing the ability of consumers to self-direct their care and rebalancing California’s long term support and services (LTSS), from skilled nursing facilities (SNFs) to home and community base care settings, such as Residential Care Facilities for the Elderly (RCFEs).

Small RCFEs comprise a large part of California’s care continuum. Of the estimated 7,500 RCFEs in California, 80% are houses where two staff assist four to six residents with 24-hour custodial care needs (e.g., require help with dressing, bathing or incontinence; are nonambulatory; have dementia or Alzheimer’s).

The CMC Memo of Understanding allows HMOs to pay for care services provided in RCFEs (8 out of 10 dual-eligibles are 65+). Dual-eligibles migrating to these settings will come from home (e.g., when their care needs exceed the maximum allowable IHSS hours: 283 hours/month or nine hours/day); from hospitals (e.g., at the point of discharge, when they require too much care to return home but do not need skilled nursing care); and from SNFs (e.g., for patients eligible for nursing home transition, also known as Money Follows the Person - MFP).

California has a dismal record in regard to MFP and has spent millions of dollars without producing significant results. Since 2008, it has spent more than $41 million in grants awarded the state by the Centers for Medicaid and Medicare Services and has only transitioned 828 MFP patients (Kaiser Health News, May 2012). In comparison, Texas, as of August 2012, has transitioned more than 6,072 SNF patients back into the community (Kaiser Foundation: Money Follows the Person Issue Paper, February 2013).

While not every eligible senior will want to participate with MFP, many, if given the choice, will choose to receive their care in RCFEs. The 2008 California

Pathways/MFP study found in two of the participating SNFs, a large percentage of patients (25% and 56%, respectively) expressed a strong preference for transition.

The AARP/SCAN 2011 Long Term Care State Report Card predicts, if California improved its performance to the level of the highest performing state, 11,000 new users of Medi-Cal LTSS would benefit from nursing home diversion and 9,800 current SNF residents with low-level care needs would be eligible for nursing home transition.

Paying for SNFs for patients who do not need to be there will be an expensive proposition once CMC HMOs, which are paid a capitated rate, are fiscally responsible for a patient’s Medi-Cal expenses. MediCal currently reimburses SNFs $5,300/month. The average cost for RCFEs is $2,200/month for a shared room. Allowing current SNF residents or patients at risk of institutionalization to use Medi-Cal dollars to reside in RCFEs will save money and promote MFP expansion in the future.

Community-based care funding will have other positive outcomes as well. In 2013, the Centers for Medicare and Medicaid Services (CMS) levied $227 million in Medicare fines against U.S. hospitals that readmitted patients too soon after discharge (1 in 5 patients discharged from a hospital are readmitted within one month). Low-income elderly patients who bounce back to hospitals because they have insufficient care support at home would benefit from the option of residing in RCFE settings.

Physicians and healthcare professionals oftentimes have no choice but to recommend SNFs for low-income patients who require 24-hour custodial care but do not have skilled nursing needs (e.g., have a G-tube, IV, ventilator, require rehabilitation). CMC offers the bright promise of change in the future: a chance for California to rebalance its long-term support and services, the ability of consumers to self-direct where they would like to receive their care and, for thousands of low-income seniors eligible for MFP, pathways from institutions back into the community.

CMC passive enrollment begins in April 2014 and will roll out over a 12-month period. More information about CMC can be found at: www.calduals.org.

Jason Bloome is owner of Connections. More about us at 800-330-5993 or www. carehomefinders.com.

CMC offers the bright promise of change in the future: a chance for California to rebalance its long term support and services, the ability of consumers to self-direct where they would like to receive their care and, for thousands of low-income seniors eligible for MFP, pathways from institutions back into the community.

un i te d we stand | at wor k for you

CMS Publishes 2014 Medicare Fee Schedule O n Nov e m b e r 27, the Centers for Medicare and Medicaid Services (CMS) released the 1,369-

page 2014 Medicare Physician Fee Schedule final rule, which was published in the December 10 Federal Register. Most provisions take effect January 1, 2014, although a few issues are open for public comment by January 27, 2014. The American Medical Association (AMA) has published a summary of the final rule. Below are a few key points:

Although the final rule contains the 23.7% physician payment cut called for under the sustainable growth rate (SGR) formula, Congress has also as part of the federal budget negotiations agreed to a threemonth SGR patch that will stop the cut that would otherwise take effect January 1, 2014—and replace it with a 0.5 percent payment raise—which will give lawmakers a little more time to finalize the long-term Medicare payment reforms.

After strong opposition from organized medicine, CMS will not be capping non-facility practice expens-

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es for over 200 physician services at the lower rates for ambulatory surgical centers or hospital outpatient departments. The caps were below crucial supply costs for some procedures.

CMS plans to pay for monthly chronic care management services beginning in 2015, at about $82 per month per beneficiary (using the 2013 conversion factor).

For Physician Compare, CMS will begin reporting in 2015 measures collected for groups that participate in the 2014 Group Practice Reporting Option (GPRO) of the Physician Quality Reporting System (PQRS).

CMS plans to correct errors identified during the preview period, prior to publication.

2014 is the last year physicians can qualify for an incentive payment of 0.5 percent under PQRS; starting in 2015, there will only be penalties for failure to achieve satisfactory reporting. Physicians will only have to report on 50 (versus 80) percent of applicable patients. Individual reporters must report on at least nine measures to receive incentives, and must report on more than one measure or measures group—and cannot use the administrative claims option—to avoid the PQRS penalty. Measures groups will only be reportable via registry. The GPRO will still be available to practices of 25-99 eligible professionals.

Over strenuous objections from organized medicine, CMS will expand the Value-Based Payment Modifier to groups of 10 or more physicians and other health professionals in 2016. Based on how their 2014 costs and quality compared to national averages, physicians in these groups could see a yet-tobe-determined increase or cuts of up to 2 percent in their 2016 payments. CMS is required by law to apply the Value Based Modifier to all physicians by 2017.

The California Department of Health Care Services (DHCS) has delayed passive enrollment for three of the eight counties affected by the state’s “pilot project” to redesign care for Medicare/MediCal dual eligibles. The project in these three counties—Alameda, Santa Clara and Los Angeles—will begin instead with a voluntary period, during which patients can choose early enrollment with a MediCal managed care plan, or wait until the automatic passive enrollment period, which will begin no earlier than July 1, 2014.

The project—known as Cal MediConnect—was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that would see a large portion of the state’s dual eligible beneficiaries transition to managed care plans. The project will impact approximately 450,000 duals in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara.

Once the passive period begins, individuals in all counties except San Mateo will be automatically enrolled over a 12-month period based on birth month. (San Mateo will have a hard start date of January 1, 2014, rather than a 12-month rollout.)

Patients have the option to select a specific plan of their choosing or to opt out of the project by notifying the state of this choice.

For more information, visit www.cmanet.org/ duals and www.calduals.org.

Congress Approves a Three-month Medicare Payment Update Until SGR Fix is Completed Congress has adopted a 0.5 percent update to Medicare payments for three months, following a bipartisan vote of 64 to 36 in the U.S. Senate. The payment increase staves off a 24% cut required by the failed sustainable growth rate (SGR) formula and buys three months for Congress to complete its work on SGR repeal legislation without further disruption to the Medicare program. The House Ways and Means Committee and the Senate Finance Committee recently passed bills to eliminate the SGR, which has plagued policymakers and physicians for more than a decade, and replace it with a stable payment system for future generations of physicians and the patients they serve.

Unsuccessful Electronic Prescribers Face Payment Cuts in 2014 Physicians and group practices who were not successful electronic prescribers under the 2012 or 2013 Medicare eRx Incentive Program will be subject to a negative payment adjustment of 2 percent in 2014 on all Medicare Part B claims paid under the physician fee schedule.

The Centers for Medicare and Medicaid Services (CMS) has notified physicians and group practices that did not meet the requirements and will be subject to the 2014 payment adjustment.

If you believe this determination to be in error, CMS has implemented an informal review process through which reconsideration can be requested. Informal review requests will be accepted through February 28, 2014, and can be submitted via email only to eRxInformalReview@cms.hhs.gov. CMS will make an informal review decision within 90 days of the original request. Please note that the informal review decision will be final, and there will be no further review or appeal.

For complete instructions on how to submit an informal review request, see CMS’s “2014 eRx Payment Adjustment Informal Review Made Simple.”

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at work for you | un i te d we stand

Duals Demonstration Project Delayed in Three Counties

associ at i on ha ppen i ngs | lacm a news

ceo’s letter

The Affordable Care Ac t dominated much o f LACM A’s initiatives in 2013 As we’re heading into 2014—the start of the most significant change in American medicine in more than half a century—we will continue our efforts to unite doctors all over Los Angeles County.

We will continue to fight for physicians’ rights and protect the patients they serve.

I’m proud of the tremendous successes our association achieved last year and want to thank you for your hard work. Your support is pivotal to our success.

While there are too many accomplishments to list in this letter alone, I would like to take this opportunity to thank our physician advisory committee members for all of their hard work.

LACMA’s committees are instrumental in representing the diverse interests of every practicing physician in Los Angeles County as well as our up-and-coming physicians.

In 2013, LACMA’s Latino Physician Advisory Committee developed an actionoriented agenda of projects that will lay the groundwork for this year.

The Committee’s participation in Covered California forums was pivotal to protect the interests of Latino healthcare professionals against the perils of narrowing networks.

For this year, LACMA’s African-American Physician Advisory Committee already announced its plans to meet with key legislators, which will ensure that our voice will be heard. Among physicians’ ongoing concern: the state’s plan to reduce certain Medi-Cal payments by 10%.

LACMA’s Women Physician Advisory Committee plans to focus on education, events and elections this year.

Women physicians in leadership roles is crucial to a united medical profession.

LACMA will continue its efforts to increase overall membership as well. We hope that large groups will continue to join our mission to advocate for the patients we serve.

Last November, 200 physicians from Keck Medicine of USC, the university’s medical enterprise, joined LACMA—the largest group to join LACMA in the last 15 years. LACMA is now 200 members stronger.

We will continue to raise awareness in the community.

Our 2013 HealthCare Awards and physician honorees elevated LACMA’s profile in Los Angeles and helped us cultivate the next generation of physicians who will practice medicine in our dynamic community.

This year, LACMA will continue its fight to address critical issues such as MediConnect and the looming fight to protect MICRA. To do so effectively and successfully, we need the support of all physicians in Los Angeles County. We hope that our efforts will inspire all physicians to help make our organization even stronger.

Let’s continue to inspire change by standing strong behind the NEW LACMA.

Rocky Delgadillo

Rocky Delgadillo Chief Executive Officer

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LACMA provides access to relevant and important online and local events that are CMEaccredited. Topics include healthcare reform and issues facing physicians and their practices.

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is the best time to join LACMA and CMA For more information on member benefits and resources, visit lacmanet.org/Membership or call (213) 226-0356 Los Angeles County Medical Association  707 Wilshire Blvd, Suite 3800 RY Los Angeles, (213) 226-0353 J A N UA 2014 | w w w.CA p h y s i90017 c i a n s n e wFAX: snet w o r k .c om 27

associ at i on ha ppen i ngs | lacm a news

Questions Remain About Dual-Eligibles Project Los Angeles County Medical Association (LACMA) and Los Angeles County Podiatric Medical Society (LACPMS) held a meeting last week to bring physicians up to date on the issues regarding the status of the Cal MediConnect demonstration project in Los Angeles County that affects the dual-eligible population.

Jane Ogle, deputy director of the department of Healthcare Delivery Systems, answered questions raised by physicians about the pilot project, such as passive enrollment strategy, losing patients during the transition period, lack of provider education about the process, as well as reimbursement fees.

In terms of passive enrollment, Ogle emphasized that patients have the option to choose the enrollment plan they want to be in (L.A. Care, Healthnet, or other participating plans) within the first 30 days; otherwise they will be passively enrolled in a plan.

Dr. Anantjit Singh, who attended the meeting, brought up concerns about patients and physicians receiving information that seems to communicate the message that patients will lose their health care if they do not enroll in Cal MediConnect. The phone calls are supposedly being made by the health plans.

Ogle said that no one should be receiving anything official from Cal MediConnect yet, so any communications of that nature cannot be coming from the department.

Alberto Tovar, COO of LACMA, encouraged physicians to contact LACMA when these cases occur so LACMA can advocate for physicians and their patients.

Another issue addressed by physicians during the meeting was the need to raise reimbursement fees when asked to see more patients and provide quality care. Ogle indicated that these questions should be brought up with the health plans that will be participating in Cal MediConnect.

While Ogle did attempt to ease some of the concerns, it was clear that more dialogue is needed.

LACMA and the health plans will continue their communication regarding this issue so that physicians know exactly how care will be handled for the patients who will be enrolled in Cal MediConnect.

Ogle also reviewed the history of Medi-Cal, and a process of expanding Medi-Cal managed care across the state. According to Ogle, “organized care provides better care and services” and the purpose of the Cal MediConnect program is to integrate Medi-Cal and Medi-cal services.

District President Urges Membership for Stronger Voice Dr. Nassim Moradi, chairwoman of LACMA’s Women Physician Committee and president of District 10, which encompasses East/Southeast Los Angeles, hopes that more doctors will join LACMA to help support and address the many critical issues under health reform.

“The most important issue for us is to increase our membership so we can have a stronger and more unified voice,” Dr. Moradi told PNN. “We will have a better voice to approach MICRA and be ready for the Affordable Care Act.” District 10, which includes cities such as Artesia, Bell, Bellflower, Montebello, La Mirada and Whittier, has a large underserved community that will become eligible for healthcare services under the Affordable Care Act. Many of LACMA District 10 members work in hospital settings; others are in private practice.

Dr. Moradi, who was born in Iran, is an anesthesiologist at Torrance Memorial Medical Center. She earned her medical degree at Tehran University of Medical Sciences in 2000 and completed her postgraduate residency in surgery and anesthesiology at King/Drew Medical Center in Los Angeles and Harbor-UCLA Medical Center.

Dr. Moradi’s sister is also a physician in LA. Both women grew up with a physician father, an obstetrician/gynecologist and clinical professor at Tehran Medical School.

“He introduced me to the world of medicine,” Dr. Moradi said. “Through his experiences, I learned the joys and responsibilities of a physician and the difference that one can make in people’s lives, often the difference between life and death.”

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LACMA NEWS | A S S OCIAT I ON H A PP ENI NG S

L o s An g e l e s C o u n t y M e d i c a l As s o c i a t i o n

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Mail your invoice and payment to: 707 Wilshire Blvd, Suite 3800; Los Angeles, CA 90017 For a copy of your renewal invoice please email Margaret Vieira, margaret@lacmanet.org

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By The Numbers Running a Business

1% Only 1% physicians currently satisfied with practicing medicine find running a business the most satisfying factor about practicing medicine

Physicians identify the trade-offs between larger (e.g., large medical groups, health systems, hospitals, and health insurance plans) versus solo practices: Larger practices are perceived to be better placed to secure superior third-party payer contracts and offer the greatest financial success potential, whereas solo practices are perceived to offer greater clinical autonomy.

73% 73% of all physicians believe that HIT will improve the quality of care provided in the longer term – higher among physicians with 10 or less years in practice (81%) and those in larger practices (80%)

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The HIT journey is expensive, and costs go beyond vendor contracts for hardware, software, and technical support. The lion’s share of HIT costs is operational - in particular, eliminating the major drivers of avoidable costs, such as redundant processes and paperwork, quickly and without disruption.

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3 2 PHYSICIAN MA G A Z INE | J A N UA RY 2014

31% EHRs

31% of solo practitioners have an EHR system that meets MU Stage 1 requirements, compared to 62% of midsize practices, and 82% of larger practices.

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