May 2013 by Los Angeles County Medical Association

T h e N e w O f f i c i a l P u b l i c at i on o f t h e Lo s An g e l e s Co u nt y M e d i c a l A s s o c i at i on REPORTING ON THE ECONOMICS OF HEALTHCARE DELIVERY

A PUBLICATION OF PNN www.PhysiciansNewsNetwork.com

LACMA Hosts a Conversation With

Mayoral Candidate Eric Garcetti

the Annual

Practice Management issue

MAY 2013

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M AY 2013 | TA BLE OF CO NT ENT S

Volume 144 Issue 05

FEATURE

Practice Management

With healthcare reform well under way and deadlines already in place we bring you a comprehensive overview on how to make the most of electronic health records, avoid common pitfalls of the new ICD-10 codes, stay compliant with the new HIPAA rules and implement strategies to keep staff motivated and productive throughout these challenging transitions.

PNN SPECIAL COVERAGE

DEPARTMENTS

LACMA event provides the opportunity for Los Angeles mayoral candidate Eric Garcetti to discuss a range of topics regarding health care and quality of life issues that impact Angelenos.

Tips, hints, advice and resources

CONVERSATION WITH A CANDIDATE

6 Front Office | Practice Management

8 transitions | Career Management

A look at the questions and challenges associated with various phases of your medical career 10 Balance | Lifestyle & Wellness

News, studies, tips and opportunities to help physicians maintain a balanced lifestyle 18 United We Stand | AT WORK FOR YOU

LACMA and CMA membership at work for you

From Your Association 4

President’s Letter | Samuel Fink, MD

24 CEO’s Letter | Rocky Delgadillo 25 LACMA News | Association Happenings

22 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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efforts in both Los Angeles

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County and with the statewide

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California Medical Association,

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Samuel I. Fink, MD Marshall Morgan, MD Pedram Salimpour, MD Peter Richman, MD Troy Elander, MD

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strive toward a common goalâ&#x20AC;&#x201C;

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that you might spend more time

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treating your patients and less

Councilor-at-large

Councilor Councilor cma trustee (resident)

David Aizuss, MD William Averill, MD Erik Berg Stephanie Booth, MD Steven Chen, MD Jack Chou, MD Hector Flores, MD Sidney Gold, MD William Hale, MD Shelley Han Vito Imbasciani, MD Paul Kirz, MD Lawrence Kneisley Howard Krauss, MD Gideon Lowe, MD Carlos E. Martinez, MD Nassim Moradi, MD Ashish Parekh, MD Jeffrey Penso, MD Heidi Reich, MD Bob Rogers, MD Sion Roy, MD Pejman Salimpour, MD Robert Bitonte, MD Erin Wilkes, MD

time worrying about the challenges of managing a practice.

LACMAâ&#x20AC;&#x2122;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.

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, 707 Wilshire Boulevard, Suite 3800, 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 R ESIDE NT ’S LE T T ER | SA M UEL FINK , M D

G r e e t i n g s f r o m Sac r a m e n t o , where I am

representing you at the California Medical Association’s Legislative Leadership Conference. The New LACMA meets with your state representatives on an ongoing basis. However, once a year, representatives from all of the county medical associations meet in Sacramento to lobby aggressively on your behalf! The most pressing threat (beyond the ever present MICRA challenges) to our patients this year is Scope of Practice legislation. Senator Ed Hernandez has introduced Senate Bills 491, 492 and 493, which attempt to create new “doctors” by legislative fiat. SB 491 grants nurse practitioners the right to practice independently and open their own practices — without following any standardized protocols, and without the guidance of a supervising physician. They would essentially have a license to practice as medical doctors. This is despite the fact that nurse practitioners may have as little as two years of additional training beyond their RN degree, no internship or residency program, and only 500-800 hours of direct patient contact within their NP program — which most of us had already achieved by the third month of our internship! SB 492 allows optometrists to practice ophthalmology. It permits optometrists to treat and diagnose any disease that is related to the eye or has ocular manifestations, perform any surgical procedure that can be performed with topical anesthetic, and prescribe drugs, including controlled substances. So, optometrists could provide comprehensive care for patients with diabetes, myasthenia gravis, or even HIV disease! A group of LACMA leaders and I met with Senator Hernandez today; we asked him to withdraw all three of these bills, which he flatly refused to do. Did I mention that both Senator Hernandez and his wife are optometrists? SB 493 allows pharmacists to become “doctors” as well — writing their own prescriptions, ordering lab tests and even performing their own physical assessments! Wow! The supposed impetus for these bills is the fact that Obamacare will provide health insurance for up to 3 million additional Californians, and there is pressure to provide immediate solutions that will expand access to care. But there is no evidence that these bills will provide increased access to patients that actually need good doctors. Instead, they represent power grabs and financial gain. Physical therapists, midwives and physician assistants have introduced similar legislation as well. Everyone wants to be a doctor without going to medical school! There is no question that these ancillary providers

4 PHYSICIAN MA G A Z INE | M AY 2013

have a significant role to play in delivering healthcare to Californians. But, allowing “legislative doctors” to provide care that is beyond their scope of practice or training can lead to increased costs through incorrect prescribing, over utilization and excessive referrals. This isn’t just wrong — it’s dangerous! LACMA and the CMA believe that the answer to the primary care shortage is to encourage more physicians to serve in needed areas. To that end, we have sponsored bills in both the California Assembly and Senate that would provide $15 million annually to the new UC Riverside School of Medicine, which will enroll its first four-year class beginning this fall. One of the school’s missions will be to produce primary care physicians that will remain in underserved communities. One bill has been introduced that would expand loan forgiveness to physicians who practice in underserved parts of the state, and another bill would create a funding source for new primary care residency positions. There is good news to report on the topic of the Medi-Medi dual eligibles! The Los Angeles “demonstration” project has been reduced from 370,000 patients to 200,000 patients. Furthermore, patients will be able to opt out from managed care on a monthly basis, rather than only once a year. Physicians who care for these patients will have a six-month grace period after their patients are passively transferred to continue to provide reimbursed care, and to assist their patients in opting out from this unfair and potentially dangerous program. I was told that patients can opt out on their own by calling 1-800-MEDICARE, and we are encouraging the state to provide all physicians with instructions and forms that will expedite this process. While we are “halfway there,” LACMA continues to believe that 200,000 patients are 200,000 too many — a full 10% of the national demonstration project of 2 million patients — and we will continue to use our best efforts to take Los Angeles OUT of this poorly planned experiment! When I became the president of LACMA, one of my primary goals was to develop new programs that would save our members at least the cost of their membership. To that end, I am pleased to announce a members-only purchasing agreement with Provista and Medline that is projected to save our doctors at least 10% on their supply costs. If you spend $10,000 per year on supplies, your savings should cover the entire cost of your LACMA membership. We are currently beta-testing this program in two LACMA districts, but as a reward for actually reading my column, you can join the beta-test now by calling Carol Chaker in our downtown office at 1-213-226-0313 and start saving immediately! Let me know how this program is working for you (president@lacmanet. org). I look forward to hearing your comments! Until next month... Samuel Fink, MD, is an internist in private practice in Tarzana. He is the 141st president of the Los Angeles County Medical Association.

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F RONT OFFICE | P R AC T ICE M ANAGEM ENT

Malpractice Claims Consume Years of a Physician’s Career each physician spends 50.7 months, or approximately 11% of an average 40-year career, on resolving medical malpractice cases, the majority of which end up with no indemnity payment. That’s the conclusion of a recent study1 by the RAND Corporation based on data provided by The Doctors Company, the nation’s largest medical malpractice insurer. Researchers found that 70% of the time physicians spend on claims is spent defending claims that end in no payment to the plaintiff. O n av e r ag e ,

Key findings of the study include

Physicians experience additional stress, work, and reputational damage from the time spent defending claims.

To help prevent claims that can take up years of your career, follow these key tips to promote patient safety: 1. Communicate with Patients • Understand the new vital sign: health literacy. • Do not ask patients if they understand; instead, ask them to repeat the information back to you. • Document patient understanding of instructions. • Provide the patient with written instructions. • Use a translator when necessary.

Fighting claims takes time away from practicing medicine and from the opportunity for the physician to learn from his or her medical 2. Document Carefully errors. and Objectively The lengthy time required to resolve claims also negatively impacts patients and their families.

• Do not point fingers at other staff or providers. • Do not impeach the integrity of the medical record by altering it. • Use only approved abbreviations. • Review patient information that is automatically populated in the EMR. 3. Monitor Hand-offs and Ensure Follow-ups • Establish a formal tracking system for missed appointments. • Follow up with patients to reschedule. • Document missed appointments in the patient record. • Send a letter to patients who repeatedly miss appointments. • Explain the importance of follow-up care. • Refer the patient to another physician, if necessary.

6 PHYSICIAN MA G A Z INE | M AY 2013

4. Avoid Medication Errors • Keep prescription pads secure. • Document samples in the medical record. • Check allergies at every visit and document in the same place in the record. • Review and reconcile medications at every patient visit. • Be aware of LASA (lookalike sound-alike) medications. 5. Follow HIPAA Regulations • Avoid unauthorized release or breaches of PHI (protected health information). • Safeguard against lost or stolen PHI through laptops or drives. • Examine office practices and layouts that may compromise confidentiality. • Assess your methods to protect electronic communications. • Follow federal requirements and know your state regulations, which may be stricter. The effect of malpractice claims on physicians’ careers is discussed further by Richard E. Anderson, MD, FACP, Chairman and CEO of The Doctors Company, in two short videos that can be viewed at www.youtube.com/doctorscompany. 1. Seabury SA, Chandra A, Lakdawalla DN, Jena AB. On average, physicians spend nearly 11% of their 40-year careers with an open, unresolved malpractice claim. Health Affairs. 2013;32(1):1-9. Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

The children’s hospital of the future is here. Introducing the new standard in pediatric care.

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new pediatric ED, new surgical suites and cardiac cath labs, and features some of the most advanced imaging and technology in pediatric care, complete with a 3 Tesla MRI for precision imaging while minimizing radiation exposure to children. Our academic affiliation with the University of California, Irvine, is driving better patient outcomes by allowing us to partner on translational research and innovative new pediatric therapies. What’s more, the new CHOC Children’s is defining pediatric care with an innovative, serene and healing environment, designed to accommodate our patients and the medical professionals that treat them today, tomorrow and beyond. And because of this, children’s futures are brighter than ever. Discover the new CHOC Children’s at choc.org/bright 1201 W. La Veta Ave. Orange, CA 92868

Orange County’s new CHOC Children’s Bill Holmes Tower ushers in a new era of pediatric medicine — one where clinical care, research and education blend seamlessly to create a truly unique environment that allows medical professionals to do what they do best: treat children. By teaming with leading medical professionals and listening to their day-to-day concerns and technological needs, we were able to transform their vision of the hospital of tomorrow into one of the most advanced, safest hospitals in existence. In fact, we are one of the nation’s leaders when it comes to information technology. Our Health Information Exchange (HIE) and Electronic Medical Records (EMR) are designed to give every provider, including referring physicians, trackable information with real-time, remote access to patient records and results, ensuring collaborative care, patient safety, and most importantly, better outcomes. With four centers of excellence: the Heart, Neuroscience, Orthopaedic and the Hyundai Cancer Institutes, CHOC Children’s includes a

tr a n s i t i on s | ca reer M ANAGEM ENT

Do You Qualify for EHR Incentives? of EHRs rapidly expanding, driven in part by Medicare and Medicaid incentive programs, doctors ought to review their practice’s contracts to see if they qualify for incentive payments. Physicians can earn up to $44,000 through the Medicare incentive program, and up to $63,750 in the Medicaid counterpart, by selecting one of the two programs. The payment amount depends upon when physicians began “meaningful use” of an EHR system.What constitutes meaningful use and its various stages is set out by CMS regulations. With the use

It is therefore imperative that every medical practice take the legal steps to ensure that the practice can retain the earned incentive pay. For practices that apply a compensation formula that charges doctors with a portion of practice overhead related to establishing and maintaining the EHR system, equity may dictate that the doctor also keep a portion of the incentive pay, which is also recommended by the CMS. To ensure these issues are handled properly, the experts recommend the following:

While these incentives reward EHR use, they also open up a host of contractual issues in terms of how a practice chooses to treat the distribution of income. Most physician groups reportedly inform physician employees that the incentive programs mandate meaningful use payments be made to the practice, not individual physicians. However, a physician may challenge a practice’s right to retain incentive payments given that the incentive programs actually require individual doctors to enroll in the programs. Moreover, it also requires that the income earned be paid to the enrolled doctor unless he or she designates that the income be paid to the practice. This is true even if the practice is responsible for the costs associated with establishing the EHR system.

8 PHYSICIAN MA G A Z INE | M AY 2013

1. Review all existing employment/contractor agreements to see if the practice’s right to retain income includes keeping incentive pay as well. Many agreements allow the practice to retain income only from “professional services,” excluding incentive pay. 2. Existing agreements should be amended to allow the practice to enroll physicians into an incentive program and to receive payment assignment (subject to adjustment based on actual physician compensation formulas). 3. Any new physician agreement should be prepared to contain this language at the outset. Use of EHRs are increasingly becoming a necessity to operate the most productive medical practices, and incentive pay can certainly motivate doctors and practices to incorporate an EHR into a practice model. According to health experts, as of January 2012, some 43 states launched Medicaid EHR incentive pay programs. During that time, 33 states, including California, were ramping up programs.

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Organizational Culture: Addressing the Satisfaction Gaps Around Cultural Fit Robert Stark, MD

when physician engagement is critical in effectively addressing the changes impacting healthcare, organizational culture is an important factor that physicians tell us is central to their sense of engagement and overall satisfaction. At a t i m e

ment approach to errors and mistakes (tied at 8.5) • Transparent communication (8.4)

Physician Wellness Services and Cejka Search recently completed a nationwide, multi-specialty survey on organizational culture with over 2,200 physicians (82% of whom were either in a hospital, group practice or academic medical center). The survey presented 14 cultural attributes, measuring their importance to physicians’ overall satisfaction, and gaps between attributes that were important to them and their satisfaction with their organizations’ focus on the attributes. It also explored the importance of cultural fit to physicians as they evaluated and made decisions around new practice opportunities versus remaining in their existing practices. The 14 cultural attributes fell into four major areas: work environment, organization, leadership and management, and communication. A notable initial finding was that all the cultural attributes were important to physicians. All but one fell into the upper quartile for importance to physician satisfaction as measured on a 10-point Likert scale, well above the 3.0 to 7.0 mid-range. The top cultural attributes were: • Respectful communication (8.6 average score) • Patient-centered care focus and supportive manage1 0 PHYSICIAN MA G A Z INE | M AY 2013

Physicians gave lower marks for how well they felt their organizations demonstrated competence around the attributes; average scores ranged from 5.8 to 7.6, falling more in the mid-range. The highest scores were for patient-centered care focus and clear mission and values (tied at 7.6) and respectful communication (7.2). The lowest score was for transparent communication (5.8). Physicians scored even lower for satisfaction with their organizations’ focus on these attributes, with average scores ranging from 5.7 to 7.0. The biggest concern is the gap of 3.0 to 4.3 points between the ideal—a 10 score—and their satisfaction scores with their organizations, indicating considerable room for improvement. Regarding their own cultural fit, physicians scored 7.0 on average—at the high end of the mid-range. When asked how much cultural fit influenced their job satisfaction, the average score was a more robust 8.4, indicating they clearly felt this factor was important. Asked if their expectations around cultural fit had been a determining factor in accepting a practice or job opportunity, the average score was 7.7, showing that cultural fit was a significant factor in evaluating prospective opportunities. Finally, asked if lack of cultural fit had prompted physicians to leave a practice or job, the score was 6.5, with 27.1% who scored 10. Over 50% of respondents felt lack of cultural fit had a greater influence on their decision to leave than not. This significant finding may be understated, given comments by some physicians who wanted to leave but stayed in their present jobs due to concerns around family and location preference, career stage, or economic concerns relating to the poor economy. Ultimately, the influence of cultural fit on behavior is key, and the study highlighted several areas where physicians and administrators can work together to close gaps between expectations vs. reality that can lead to dissatisfaction. Robert Stark, MD, is a consulting physician for Physician Wellness Services.

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PNN SPECIAL COVERAGE

County Medical Association hosted “Conversation with the Candidate,” on April 30 at Good Samaritan Hospital in Los Angeles.The event provided the opportunity for Los Angeles mayoral candidates Eric Garcetti and Wendy Greuel to offer their perspectives on a range of topics regarding health care and quality of life issues that impact Angelenos. Garcetti sat down with LACMA CEO Rocky Delgadillo in an interview-style format to discuss hot-button issues such as adult and childhood obesity, gun violence, physician shortages, immigration reform, gross receipts tax, the Cal MediConnect Program (dual demonstration project), homelessness and traffic.

T h e Lo s A n g e l e s

Top: LACMA President, Samuel Fink, MD, LACMA CEO Rocky Delgadillo, Mayoral Candidate Eric Garcetti and Andrew Leeka, CEO of Good Samaritan Hospital Right: Mayoral Candidate Eric Garcetti shares his perspectives. RIGHT PAGE Top Left: members of LA County Medical Association, staff members from Good Samaritan Hospital and representatives from event sponsors Anthem Blue Cross, Cooperative of American Physician and USC Keck School of Medicine. Good Samaritan Hospital listen intently. Bottom Left: Candidate Garcetti with Sam Fink, MD, Rocky Delgadillo. Right: Rocky Delgadillo interviews candidate Eric Garcetti.

1 2 PHYSICIAN MA G A Z INE | M AY 2013

s pec i a l cov er age | phys i c i a n s n ews n et work .com

Wendy Greuel also was invited to the event, but was unable to attend. This event is an extension of LACMA’s public affairs and advocacy program. In the past year, LACMA has refocused and redoubled their efforts, speaking out and taking action on a range of timely medical issues. As the organization representing the largest number of medical and health care experts in our area, LACMA believes it is important that they be at the forefront of the discussion of health care and quality of life, addressing some of today’s most pressing issues and their impact on individuals, families and our communities. LACMA President Dr. Samuel Fink and Good Samaritan Hospital CEO Andrew Leeka also offered remarks during the evening’s event. The audience included members of LA County Medical Association, and physicians, nurses and other staff members from Good Samaritan Hospital as well as representatives from event sponsors and partners such as Anthem Blue Cross, Cooperative of American Physician and USC Keck School of Medicine. Good Samaritan Hospital provided a wonderful venue for both the VIP cocktail reception and the program. M AY 2013 | 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 MAN With healthcare reform well under way and deadlines already in place for many practice management issues, doctors who prepare early for the many changes ahead will have less pain crossing the finish line next October. Here’s a comprehensive overview on how to make the most of electronic health records, avoid common pitfalls of the new ICD-10 codes, stay compliant with the new HIPAA rules and implement strategies to keep staff motivated and productive throughout these challenging transitions.

EHR Data Analytics With doctors being both financially incentivized to computerize patients’ electronic health records and, starting in 2015, likely to face penalties under Medicare for not using EHRs, adopting technology for “meaningful use” is a top goal under health reform. Supporters of EHRs say it will lead to increased quality of care while lowering costs and errors. Critics say that clinical data in EHRs is often unstructured, incompatible with other systems, and facing regulatory hurdles that have yet to be resolved. However, technology experts believe that with the shifting focus from pay-for-service to payfor-performance, the data derived from EHRs will be key for doctors to report how effectively they’ll be meeting key measures. The simplest and most direct solution to identify and correct potential gaps early on is to capture data properly using analytics, according to an article in EHR Intelligence. “In an ideal case, you actually bring analytics live as soon as you bring your EHR live,” said Kyle Murphy, Ph.D., in an article focusing on using analytics to improve EHRs. Moore offered the following four tips on how to use Murphy said that having high-quality Excel charts (using EHRs) to unearth and solve problems. data is critical for providers themselves as 1. Reduce No-shows - By noting “no-shows” and using Excel to crewell as for organizations that rely on this ate a chart that shows the number of days from schedule date to information in an actionable way, includappointment date, a practice can see when no-shows spike. Moore ing health information exchanges, acnoted that in one case, physicians told patients to come back in countable care organizations and patientfour weeks if the problem persisted, without relaying that information centered medical homes. to the administrative staff. It turned out that was the reason why noshows spiked for appointments booked 28 days prior to that date. Neil Moore, health consultant and president of Moore Solutions, agreed that 2. CPT Codes - Using billing charges can be a great way to analyze learning how to mine and analyze data common procedures, reimbursement rates, payer mix and productivfrom EHRs can help doctors in multiple ity, including how many procedures a doctor did per hour. ways, including improving their bottom line and making them a more valuable 3. Cost of Care for Different Patients - Combining clinical data with practice management allows doctors to find out the cost of care partner in an increasingly team-based for different patient demographics. Payers and potential care-model healthcare environment while allowing partners will be impressed by doctors who can compare cost of care them to provide the highest-quality care with the cost of high-quality care in the changing health environto the neediest patients. ment, Moore said. 4. Identify Trends - Looking at data fields such as patient ID and telephone numbers allows physicians to catch trends, including how often a practice interacts with a payer’s claim denial hotline.

1 4 PHYSICIAN MA G A Z INE | M AY 2013

NAGEMENT by marion webb

To help providers establish a game plan, here are five common pitfalls to avoid: 1. Not-so-ready Technology - Before practice management systems, EHRs and other technology can be implemented, all systems need to be 5010-ready. Practices should check with their vendors early on to ensure that these companies have enough hardware storage to house the new codes and then develop close communication with vendors to assist them down the road. 2. Train Yourself and Your Staff - Experts recommend that anyone who will be playing a role in using ICD-10, from the billers to the physicians and support staff, should understand the new codes and know the differences between ICD-10 and ICD-9. There are dozens of ICD-10 seminars and workshops offered by coding associations, CMS and medical associations.

ICD-10 With the ICD-10 deadline being a mere 17 3. Physician Errors - Physicians will be the practice’s greatest liability and greatest months away, this is the asset in the ICD-10 world. To avoid errors, consider using “cheat sheets,” or super time to reach out to venbills, a document that contains most of the commonly used codes, based on the dors and payers and enmost common diagnoses per specialty, which can be installed on their desktop sure that they are propcomputer, the experts recommend. erly preparing for the 4. Get a Document to Support the Claim - One of the most common reasons new technical requirefor a rejected claim is that the documentation doesn’t support the claim. A good ments involved in the way to avoid discrepancies is to work with the IT staff to create rules engines in their conversion process. practice management systems and EHRs to alert users of combination of codes Ideally, providers that will trigger denials. should have already 5. Double-Check Codes - Double-checking codes and the supporting documenstarted the process of tation will increase productivity early on and translates to fewer claims clearingpreliminary planning, edhouses and insurance plans. ucating staff and testing of the new ICD-10 CM (clinical modification) codes and ICD-10 PCS (inpatient procedure) codes, which will replace the existing ICD-9 numerical codes with more than five times as many alphanumeric codes. The consequences of not being ICD-10 ready by October 2014 include claims rejections, denials of payment, and challenges in coordinating care with other medical professionals.

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New HIPAA Rule — What It Means For Your Practice Under health reform, small practices will face more scrutiny regarding HIPAA policies, documentation and procedures. While March 26 marked the effective date for the 563-page “omnibus” privacy and security rule, most aspects of the rule won’t become effective until Sept. 23. However, an exception to the general compliance deadline covers the portion of Here are eight tips to deal with the new HIPAA policies early on: the rule on business associates, including agreements with vendors of remote-hosted 1. Assess your policies and procedures and update them, EHRs and office-based physicians. if needed Here is what you need to know: Doctors who had a HIPAA-compliant business 2. Monitor your procedures to ensure they are working associate agreement in place before the new 3. Ensure your staff knows what constitutes a breach and rule’s Jan. 25 official publication date in the how to handle it Federal Register, and that contract doesn’t need to be renewed between March 26 and 4. Train and retrain staff on HIPAA compliance Sept. 23, have a one-year grace period; those who didn’t have a contract in place prior to 5. Assess how well your staff is retaining HIPAA knowledge by quizzing them Jan. 25, 2013, need to get a contract compliant with the new rule in place by Sept. 23. 6. Institute disciplinary standards for potential violations Another big change involves the policies and technologies needed to comply with a 7. Pay close attention to the security rules patient consent management provision. Un8. Stay current regarding HIPAA developments der the ARRA, a patient who pays out of pocket for treatment can ask a provider not to share a record of that treatment with the patient’s health insurance plan and a provider must comply with that request, which means staff needs to be made aware and trained to never pass on that information. With the government likely to focus on more audits as an educational tool, doctors are well served to stay prepared. To learn more about the HIPAA audit program, visit http://bit.ly/HIPAA-Program.

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the practice is planning to take. Having an open-door policy allows staff members to pop in and address their concerns.

Plan Ahead Allowing adequate time to plan, staying organized and being flexible enough to delay, if an original timeline appears unrealistic, help minimize disruptions. According to one expert, a proper EHR installation requires at least one year of prep work, which, in turn, allows time to create a task force or committee, explore alternative products and to study the impact on the workforce to act as their advocate. Explain Yourself It is also important to enumerate to the staff why proposed changes are necessary and how they will affect them. Showing the financial benefit to your organization and to staff members can help ease the transition. One organization implemented a bonus system where medical assistants were rewarded for ensuring proper documentation and asking patients about vaccinations, etc., after launching their EHR system. By making them part of the process, the assistants felt empowered and rewarded. Trading Places To help the back office better understand the front office, “trading spaces” for a week every year, when staff members observe each other or actually perform the other person’s job, has shown to be beneficial in dispelling miscommunication and minimizing strain. People working in the back office may underestimate how stressful the front office can be with answering phones and checking in patients, whereas the front office may not realize how much time and work it takes billers to correct errors or rebill patients. By deploying some of these practice management strategies early, doctors are well under way to prepare for the many changes ahead while keeping staff morale high in their practices.

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Effectively Managing Staff Through Change The push for quality improvement as a benchmark for reimbursement is likely going to be unsettling to your staff. Whether it’s adopting technology to better manage patient care, a merger with a large medical practice or joining an accountable care organization to pursue shared-savings payment, change is bound to cause disruption, anxiety and low morale among staff members. Some people may be worried about their workload and job satisfaction; others may be worried about taking a cut in Here are a few tips to navigate your staff through the difficult changes ahead. pay and losing their status, or worse—losing their jobs. Be an Open Book Whenever you have any sort of change, most managers like to focus on tangibles—the timetables and training classes—when integrating an organizaExperts have found that tional change. It’s equally important to consider the impact on your practice’s culture. If planning ahead, open and you’re adopting EHRs, for instance, stress your commitment to bring each staff member honest communication, emup to speed at their own pace and emphasize your willingness to shuffle schedules to pathy and sympathy, negoaccommodate training sessions. Older staff members may be particularly concerned tiating with employees who about learning the new software system fast enough to keep up with younger techresist change and motivating savvy individuals. If you’re switching to a compensation model that employs quality metrics, explain the impact on your staff members’ paychecks—for better or worse. staff can go a long way to Managers should solicit staff’s input and hold regular meetings to discuss the direction ease the pain.

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CMA: Federal Update April 2013 cma staff

CMA Physician Leaders meet with congressional, CMS and White House leaders in Washington, D.C. - During the AMA National Advocacy Conference, CMA Executive Committee Physician Leaders, County Medical Society Physician leaders and California residents and medical students joined forces to deliver CMA’s advocacy message to Capitol Hill. Priorities included: Stopping the budget sequestration cuts, adopting an alternative to the Medicare SGR FFS payment system, opposing further cuts to Medicare Advantage, updating the Medicare payment localities (GPCI), expanding the number of J-1 VISA physician positions, banning assault weapons, supporting the Medicare private contracting legislation; and the CMS regulatory issues which included the Medicare-Medicaid dual eligibles demonstration project and the Medicare carrier transition from Palmetto to Noridian. CMA also dedicated time to discussing the implementation of the Health Benefits Exchange and the State Medicaid expansion.

tical Areas (MSAs) for 3-4 years. It would hold the rural county physicians harmless from Medicare payment cuts for that period using administrative cost savings from the formation of a Medi-Cal County Organized Health System (COHS) in Alameda County. Once the funding is exhausted, the localities would revert back to their existing configuration. CMA is hosting a Congressional GPCI Summit on May 6.

Budget Sequestration Cuts Take Effect April 1, 2013 - All Medicare services will be cut 2%–FFS, Medicare Advantage, and GME. Vaccines for Children and other public health programs cut. Medicaid and the VA are exempt. See the CMA Sequestration FAQ on the CMA website which includes the Medicare billing guidance from CMS. CMA is fighting the sequestration cuts and organized medicine’s efforts are paying off. The recently adopted Senate Budget resolution eliminates the Medicare 2% sequestration cuts.

Medicare Private Contracting Bill Introduced –H.R. 1310 (Price R-GA) - On March 28, the California Medical Association (CMA), the American Association of Neurological Surgeons and other physician organizations sent a letter to Congress in support of the “Medicare Patient Empowerment Act,” which was just reintroduced by Rep. Tom Price (R-GA). The bill would allow patients and physicians – without penalty – to enter into arrangements known as “private contracts” for services covered by Medicare. It would stipulate that Medicare pay its fair share of the services and allow patients, who voluntarily agree, to pay the rest. Under current law, seniors who wish to privately contract with a physician must forgo their Medicare benefits and physicians must opt-out of Medicare entirely for two years. CMA has long sought a private contracting option for Medicare patients.

MEDICARE ISSUES

House Committees begin hearings on the Medicare SGR payment alternatives - The AMA SGR Task Force is meeting to further develop the AMA’s proposal with the state and specialty associations on April 30 in Washington, D.C. CMA is an integral part of the SGR Task Force and its workgroups. With the cost of eliminating the SGR reduced to a mere $138 billion, Congressional Committees are focused on passing a package that repeals the SGR and transitions to alternative payment models where physicians may select the most appropriate payment methodology and quality projects in which to participate. Medicare Payment Locality Update. - A bipartisan team of California House Members, led by Representatives Sam Farr (D-Santa Cruz) and Darrell Issa (R-San Diego), have agreed on a compromise plan to update the California payment localities. The plan has been approved by House Whip, Representative Kevin McCarthy (R-Bakersfield). Reps Farr and Issa are expected to introduce the bill after the spring recess. It would update the California payment localities to Metropolitan Statis1 8 PHYSICIAN MA G A Z INE | M AY 2013

CMA nominates former Trustee, Dr. Larry DeGhetaldi, to MedPAC - The Medicare Payment Advisory Commission (MedPAC) is an influential body that advises Congress on all Medicare payment matters. CMA and Dr. DeGhetaldi garnered letters of support from CHA, Sutter Health, Palo Alto Medical Foundation, CAPG, the Medi-Cal California Alliance for Health Care and the California Congressional delegation. Dr. DeGhetaldi is now on the list of finalists and will be interviewed by GAO.

PUBLIC HEALTH AND PHYSICIAN SHORTAGE ISSUES

J-1 VISA Expansion in the Immigration Reform bill. - CMA continues to aggressively work to get an expansion of the J-1 VISA program into both the House and Senate Immigration Reform bills. The J-1 VISA program allows foreign medical students to remain in the U.S. and practice in underserved areas. California is only allotted 30 physicians and is asking Congress to expand the number of positions nationally to help address physician shortages and access to care problems. California Judiciary Committee Members, Reps Issa and Lofgren, are working closely with CMA. Senator Feinstein’s Assault Weapons Ban S. 150 not in Senate Gun Legislation - CMA is supporting Senator Feinstein’s S. 150. Due to lack of widespread support, it will not be included in the Senate Demo-

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cratic Majority’s Gun Legislation which is scheduled for floor debate after the April recess. Senator Feinstein is deeply disappointed. However, Senator Reid has agreed to allow Senator Feinstein to offer amendments to the package to 1) fully ban assault weapons and 2) ban large capacity magazines. CMA and others in the medical community will continue to work with her and Representative Mike Thompson, who is chairing the House Task Force on gun violence, to reduce gun violence and improve access to mental health services

New IOM Study Agrees with CMA - Major Victory for California Physicians The Institute of Medicine just released a new study concluding that the Medicare value index adopted by Congress and other geographic spending-based payment methodologies won’t prompt physicians to deliver more efficient care. CMA presented testimony to the IOM for this study. IOM emphatically concluded that this payment methodology will not improve care. “Decisions about care are made at the provider level rather than the regional level, and providers within regions do not spend consistently on care or routinely deliver the same quality care,” said the IOM committee. The problem with a regional expenditure index is that it could penalize physicians who are efficient and providing high quality care and reward those who are not. In the on-going fight between physicians in different geographic regions, the Midwest providers convinced Congress to adopt a Medicare value index to pay physicians. The index starts in 2015 and will pay physicians who spend less than the national average per Medicare patient MORE and physicians who spend more than the national average LESS. However, CMA secured amendments to ensure the payments are adjusted for local practice costs (California has 9 of the highest cost regions in the country) and risk-adjusted for health status. In another IOM report where CMA prevailed, IOM showed that once the Medicare expenditure data is cost and risk adjusted, California physicians are efficient and overall spend less than the national average. This is a huge win for CMA physicians because it will help to influence Congress as they establish alternative Medicare payment systems. It will help to ensure that quality and efficiency incentives are tied to individual physicians and physician groups rather than physician spending at the regional level.

Congresswoman Jackie Speier: Gun Violence Health Care Trust Fund Act - This month, Representative Speier (D-San Mateo) intends to introduce legislation to increase the excise sales tax on firearms and ammunition to fund medical treatment provided to gun violence victims through the Medicaid program. CMA is supporting the bill. CMS REGULATORY ISSUES

Medicare-Medicaid Dual Eligibles Project Approved by CMS with Limits - CMS has issued an MOU with the State of California to allow MedicareMedicaid Dual Eligibles to enroll in the demonstration program managed care plans in 8 counties under certain conditions. CMS has established additional conditions on the state and the participating health plans that must be met in a negotiated three-way contract 2 0 PHYSICIAN MA G A Z INE | M AY 2013

before the project can continue to move forward. The program has been renamed, CalMediConnect. CMS-Proposed Payment Cuts to Medicare Advantage Plans Reduced - In a new payment rule for 2014, CMS proposed major 7-8% payment cuts to the Medicare Advantage rates depending on the region, the enrollees and the plan. These cuts are in addition to the rate reductions in the Affordable Care Act and the 2% Medicare budget sequestration cuts that took effect April 1, 2013. In an unprecedented move, CMS agreed NOT to factor the projected 25% Medicare FFS physician SGR cuts into the Medicare Advantage payment formula for 2014 under the assumption that Congress will stave-off the doctor payment cuts as they have in past years. Therefore, the 2014 payment cut has been reduced to ~1.75-2.75%. CMA opposed these additional payment cuts because of the negative impact on California’s medical groups and contracting physicians. CONGRESSIONAL BUDGET ACTION

Senate Budget Bill Passes with Bipartisan Health Care Amendments to Change the ACA, and eliminate the Medicare SGR and Medicare Sequestration Cuts - The U.S. Senate recently passed its first budget in four years. Several bipartisan healthcare amendments were adopted and could foreshadow compromises with the House Republicans in the future. Several of the amendments repeal parts of the ACA. Senator Patty Murray (D-WA), chair of the Senate Budget Committee, authored a provision that passed and would repeal the Medicare sustainable growth rate (SGR) formula and stop the 2% sequestration cut to Medicare reimbursement. The Murray resolution factors in the $138 billion cost of maintaining Medicare rates at their current level for 10 years.The plan features a deficit-neutral reserve fund for replacing SGR with another payment arrangement. Three bipartisan amendments that would amend parts of the ACA were successful. These include: an overhaul of the Medicare wage index used to determine payments to hospitals, which would cut payments to California hospitals; a provision to repeal a cap on flexible spending accounts (FSA) that would also kill the ACA requirement that patients have prescriptions to buy over-the-counter drugs with FSA/HSA funds and a repeal of the 2.3% medical device tax. House Adopts Budget Plan that Repeals the ACA, Block Grants Medicaid and Converts Medicare into a Premium Support Program - The House Budget was adopted on a largely partisan vote but was soundly defeated by the Democratically controlled U.S. Senate. It is largely the same plan that Rep Ryan introduced last year. The CMA delegation to the AMA worked to formulate the AMA’s final HOD policy on Medicare Premium Support. The final AMA policy calls for the premium increases to be tied to a credible

President Obama Introduces Budget that Cuts Social Security and Medicare - Recently, President Obama introduced his 2014 budget which reduces the deficit by $4 trillion and reduces the growth in Medicare spending by $371 billion. Below is a summary of the proposed changes to Medicare: - Eliminates the 2% budget sequestration cuts to Medicare. - Budget expresses support for Congress eliminating the SGR and developing new payment system with a stable transition period. Wants to reward care coordination, efficiency, and quality. - Expands the data available to physicians to make decisions. - Requires wealthier beneficiaries to pay higher premiums.

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- Require wealthier beneficiaries to pay higher copays and deductibles. - Requires pharmaceutical manufacturers to pay high rebates. - Closes the Part D Doughnut hole earlier but requires patients to pay more. - Establishes 15% surcharge on MediGap supplemental insurance premiums to discourage overutilization. - Cuts Indirect Medical Education (IME) payments by $11 billion. - Reduces Medicare payments to hospitals to cover bad debt. - Allows Independent Medicare Payment Advisory Board (IPAB) cuts to Medicare when Medicare spending hits GDP + 0.5% vs. the ACA target of GDP + 1%. - Reduces reimbursement for physician-administered drugs from 106% of Average Sales Price to 103% of ASP. - Allows self-referral if certain accountability standards are met. The Senate budget now goes to the House, where it is not expected to pass. The Senate recently voted down the Republican House Budget. The two budget proposals and the third one offered by the President will likely be used as a basis for future negotiations between the parties on budget, entitlement programs and healthcare issues.

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healthcare cost index rather than GDP + 0.5% which is the current Ryan plan. CMA is concerned that if the premium subsidies do not keep pace with the cost of premiums it will harm access to care. President Obama’s Independent Medicare Payment Advisory Board (IPAB) must also keep Medicare spending growth to GDP + 1%. CMA/AMA are concerned that neither proposal keeps pace with healthcare cost increases which could negatively impact seniors and physicians.

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Physician Leaders Converge on the Capitol for CMA’s 39th Annual Lobby Day Medical Association (CMA) member physicians, medical students and physician supporters gathered in Sacramento on April 16 to bring the voice of medicine to legislators. During CMA’s 39th annual Legislative Leadership Conference, physicians discussed the many threats – and opportunities – facing the practice of medicine in California. Ov e r 4 0 0 C a l i fo r n i a

During Legislative Leadership Day key bills were discussed that impact physicians in Los Angeles County and elsewhere in California. Physicians raised concerns about many issues and the way they are being addressed by legislators, including the shortage of physicians caused by the implementation of the Affordable Care Act (ACA). Luis Ayala, LACMA’s director of government affairs, said members had expressed concern about the bills that would expand scope of practice. “LACMA members met and lobbied over 25 legislators on our positions regarding various legislative proposals,” said Ayala. “I am very proud of the way our physicians articulated the issues and used personal experiences to drive the points home”. “The problem with workforce is a complicated one,” said Paul Phinney, MD, president of the California Medical Association. “Not only do you need enough doctors, you need them in the right place.”

Six of the eighteen scope of practice bills that were introduced this session 1. Physical Therapist - AB 1000 (Wieckowski) and SB 198 (Price) – addresses the physical therapists’ desire to have direct access to patients without a physician referral. 2. Midwives – AB 1308 (Bonilla) - Midwives are looking for easier access to supplies, tests, etc. The historic issues of liability and supervision continue to exist for physicians. 3. Nurse Practitioners - SB 491 (Hernandez) – They have communicated their desire to eliminate the physician supervision requirement in current statute. 4. Optometrists - SB 492 (Hernandez) – Prevailing opinion is that optometrists want to render more services for diseases such as glaucoma and diabetes. 5. Pharmacists – SB 493 (Hernandez), SB 643 (Price), SB 690 (Price) – Pharmacists are expected to seek ability to provide primary care services, including the ability to prescribe medications or make therapeutic substitutions without physician involvement. 6. Physician Assistants – SB 494 (Monning) – The physician assistants’ proposal will expand patient panels and define them as primary care providers.

2 2 PHYSICIAN MA G A Z INE | M AY 2013

by placing a small fee on the stateâ&#x20AC;&#x2122;s health plans. To relieve some of the financial burden of high student loans, Assembly member Rudy Salas, D-Bakersfield, has authored AB 565, which would expand and strengthen the The Steven M. Thompson Physician Corps Loan Repayment Program, which offers repayment help to doctors practicing in underserved areas. Assembly Bill 1288, by Assembly member V. Manuel Perez, D-Coachella, would set priorities for licenses for physicians going on to practice in underserved areas of the state.

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Several bills not related to the scope of practice have been introduced by members of the state legislature to address this issue and to help physicians and medical students. A bill by Sen. Richard Roth, D-Riverside, and Assemblyman Jose Medina, D-Riverside, would allocate $15 million annually in state funds to the operation and expansion of the UC Riverside School of Medicine. To address the shortage of residency slots, Assembly members Raul Bocanegra, D-Pacoima, and Rob Bonta, D-Alameda, have authored AB 1176, which would help fund and expand residency programs in California

a s s o c i at i on ha pp eni ngs | l ac ma news

ceo’s letter

The Future of the Medical Profession -One Student at a Time In my position as CEO of the Los Angeles County Medical Association, I take the opportunity to reach out to students throughout Los Angeles County, especially those concentrating on the sciences, to tout the good works and life-changing contributions that physicians make every day. I recently had a wonderful, heart-touching experience when I visited South Region High School #9 in South Gate. I was greeted with enthusiasm and genuine hospitality. I knew the students were serious, eager to learn, and ready to make a difference. I shared with students my school experiences and challenges. I told them first-hand stories and they listened. I concluded our conversation by encouraging them to dream big and to go for it…..and when they do…..I made them promise to return to their community and pass the dream along. The student who introduced me at the student assembly is ASB president Francisco Marquez. I was so proud of him. In him, I saw the character of a determined young leader. After my talk, I asked him to write my next monthly CEO letter for Physician Magazine. Of course, he accepted the challenge and opportunity, and here it is.

Written by Francisco Marquez, 11th grade When students at STEAM (Science Technology Engineering Arts Math) and VAPA (Visual and Performing Arts), the unique special schools within the South Region High School #9 campus, received news that Rocky Delgadillo would be visiting our school to share how we can become physicians, various students, myself included, were flooded with excitement. Being a part of a science and technology high school, I felt ecstatic about being able to meet someone who was the former Los Angeles city attorney, attended Harvard University and Columbia Law School, and who is currently the chief executive officer of the Los Angeles County Medical Association. Due to where I live, this was the first time that I was able to meet someone in such an incredible, prestigious position. And, he was here to inspire us to pursue a career in medicine. As student body president, I had the privilege of introducing Mr. Delgadillo using solely information provided by his published biography. When he began his presentation, I was astonished. This man was not only a CEO, former city attorney, and a graduate of prestigious universities, Mr. Delgadillo was a living demonstration of someone who went through countless daunting tasks and overcame a plethora of obstacles in order to become the person he is today. I immediately realized that this man did not value a prestigious, well-known position, he valued the things he could do with the position he holds. Specifically, the changes that his position would allow him to make that could ultimately save lives and support those who are in need. This incredible quality leapfrogged at me when he shared that after graduating from Harvard, he returned to the community where he grew up—regardless of how difficult it would be to make positive transformations—to face head-on social challenges and dilemmas. It was then that I concluded that Mr. Delgadillo is not only a CEO, he is a hero. This inspired students like Jolene Aragon and Valerie Espinosa to follow their dreams to attend Harvard and to become physicians who make a difference in the community. Rocky exhibited several characteristics that I had never seen before, and for the first time in my life I thought, “I want to be like him. I want to come from nothing and change lives. I want to save people.” Words cannot express the immense gratitude that South Region High School #9 students have for Mr. Delgadillo. He made us believe that someone like us can become a physician if we choose to pursue that dream. And, we are. Thank you, Rocky!

2 4 PHYSICIAN MA G A Z INE | M AY 2013

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Dual Eligibles Demonstration: What’s Next? Take Action to Protect Your Patients O n M a r c h 2 8 t h , t h e C e n t e r s fo r M e d i c a r e a n d M e d i c a i d S e r v i c e s (CMS ) a ppr ov e d t h e S tat e o f C a l i fo r n i a’ s “Co o r d i n at e d C a r e I n i t i at i v e ” pr o j e c t, e f f e c t i v e ly s h i f t i n g M e d i c a r e / M e d i - C a l d ua l e l i g i b l e pat i e n t s i n t o M e d i - C a l m a n ag e d c a r e pl a n s .

LACMA will continue to advocate for the preservation of patient rights. LACMA believes that 200,000 patients is too many for a true demonstration project to be effective or safe for patients. To empower our physician members and their patients with as many resources as possible on the dual eligible project, we have drafted 2 patient letters for our members’ use. These letters are a great tool for physicians to communicate with their patients about the possible upcoming passive enrollment and to inform them about continuing the valued doctor patient relationship. Access to these letters is reserved for members only. To access the letters, please visit

www.lacmanet.org Members can log in using their license number as their log in and their password as the first initial of the first name and last name with the first two letters capitalized, example if your name is John Smith, your password would be JSmith) Please call 213-226-0313 for additional information and assistance.

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a s s o c i at i on ha pp eni ngs | l ac ma news

Attention LA County Medical Association Members

T h e 14 2 n d A n n ua l El e c 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 ss o c i a t i o n w i ll b e h e l d i n J u n e 2 013 . T h i s y e a r , t h e r e a r e t h r e e vac a n c i e s fo r t h e p o s i t i o n o f L ACMAâ&#x20AC;&#x2122; s Co u n c i lo r - At- L a r g e .

Active members of LACMA and CMA have the privilege of voting for their preferred candidate. Below are campaign statements from each candidate running for the Councilor-At-Large position. When reviewing each statement, it is important to remember that the ultimate responsibility of the Councilor-At-Large includes serving as the advisor and advocate for LACMA

and its members to the LACMA Board of Directors. At the end of May, you can expect to receive a voting ballot via email and you will be able to cast your vote for your preferred candidate. Please be sure to keep an eye out for your ballot and submit your vote. For additional information about the candidates or the election process, please call 213-226-0304.

Maria T. Lymberis, MD These are critical times as the future of medical practice is at stake. I am honored for the opportunity to serve you as your LACMA Councilor-at-Large and bring a broad perspective & fresh ideas to address these challenges. I am Greek born and US educated, starting as a foreign student, a graduate of USC School of Medicine in solo private practice in LA since the completion of my training in Neurology, Psychiatry, Child/Adolescent Psychiatry and Psychoanalysis. I am known as a clinician and educator, now an Honorary Clinical Professor of Psychiatry at UCLA. I first joined the AMA as a student. Since then, I have built a solid track record of active service & leadership in organized medicine at the AMA, CMA, LACMA & APA. Currently I serve you in both the CMA & AMA House of Delegates. I have wide experience in Legislative, Public Affairs and have served in numerous leadership positions at the local, state and national levels. My website: www.lymberis.com details my professional work. Los Angeles is a vibrant, ethnically and culturally diverse city with a population that is bigger than most countries in the world. As physicians, dedicated to provide care and address the health & wellbeing of individuals and that of our various LA communities, we daily face the challenges of access and quality of care, poor reimbursement for physician services as well as numerous serious daily stressors and environmental risks to health. Solutions to such complex problems demand dedication to our core ethical values, teamwork in creative partnerships and cooperation between and amongst diverse groups. I seek your vote. You deserve full accountability & VALUE for your dues. As your representative on the LACMA Board I intend to ensure you receive both.

Nhat Tran, MD My American dream began in 1980 when our family immigrated to the United States when I was six years old. We fled Communist Vietnam in search of freedom and a better way of life, and eventually settled down in Southern California. I pursued a career in medicine after contracting Guillain-Barre Syndrome at the age of 17. At that time, despite being paralyzed from the neck down, I was able to continue my education and eventually graduated from UCLA with a degree in biology. I witnessed the events of 9/11 first hand while attending medical school at New York Medical College. My journey continued with residency in Physical Medicine and Rehabilitation at Tufts in Boston and Non-operative Interventional Spine Fellowship at Marshfield Clinic in Wisconsin. Having completed 2 8 PHYSICIAN MA G A Z INE | M AY 2013

my fellowship, I worked for an orthopedic group in Stockton, CA for a year before deciding to come back home to Los Angeles in 2011. When I arrived back home in Los Angeles, I had aspirations of starting my own private practice. I literally started with zero capital and had to grow my private practice from scratch. Along the way, LACMA has been very instrumental in providing help and guidance as I maneuver around the politics of healthcare. LACMA continues to be a valuable resource as I grow my practice and move forward with my medical career. The neurologist who treated me when I was 17 years old is also a LACMA member. 20 years later, I am honored to be considered one of his colleagues. It is with utmost humility that I seek the position of LACMA Councilorat-Large. I hope to serve LACMA honorably while representing LACMA’s past and present, as we move forward during this dynamic time in U.S. healthcare.

Michael Sanchez, MD I believe there is no time more important than the present to become actively involved in the Los Angeles County Medical Association. I have been a Primary Care Internist with Facey Medical Group in the San Fernando Valley for 19 years. I have seen the practice of medicine evolve and value that the medical care we deliver is quality driven. During my career at Facey Medical Group I have been successful in delivering high quality care with the utmost cost effectiveness. In addition I believe we in the practice of medicine deserve to be compensated appropriately. I believe that these two aspects go hand in hand. With the advent of health care reform, I appreciate the opportunity to address the health disparities that exist in the U.S., California and here in Los Angeles County. I believe as a Councilor-At-Large I can actively represent the interests of my fellow colleagues in L.A. County without compromising the quality care we all strive to deliver.

Robert Bitonte, MD, JD I am seeking your vote for Councilor-at-Large to the Los Angeles County Medical Association. My focus has been, and is, vigorous and vocal advocacy for our members and the patients they serve. This includes public support and education, legislation and litigation if warranted. Under my Chairmanship of the Legal Affairs Committee, we have filed suit on our members behalf for unlawful intimidation of physicians, and unlawful denials of medically necessary care. I am unapologetic for my fervor in physician advocacy. I have been so while my service on the board and as Past President of the Los Angeles County Medical Association. If you as a member want undivided loyalty to physician advocacy, I need your vote to continue to serve you.

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Sources: http://www.athenahealth.com/PSI/benefits-of-ehr-implementation.php; http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_chs_2013SurveyofUSPhysicians_031813.pdf

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