August 2014 | Physician Magazine

T H E O F F I C I A L P U B L I C AT 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 AT I O N

REPORTING ON THE ECONOMICS OF HEALTHCARE DELIVERY

A PUBLICATION OF PNN www.PhysiciansNewsNetwork.com

HOW DO WE COMPARE? TELEMEDICINE • READMISSIONS • OBESITY & DIABETES

Making the Transition to EHRs Annuities: On Your Road to Retirement Income?

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NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Visit norcalmutual.com, call 877-453-4486, or contact your broker.

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AUGUST 2014 | TA B LE OF CONT ENT S

Volume 145 Issue 8

6 DEPARTMENTS

14 16

6 FRONT OFFICE | PRACTICE MANAGEMENT 8 TRANSITIONS | CAREER MANAGEMENT

COVER STORY

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HOW DO WE COMPARE?

Healthcare reform is reshaping the economics of healthcare delivery nationwide, but not all providers will be affected equally. In this issue we will take a closer look at some of the key factors impacting healthcare delivery -- telehealth services, readmissions, overall healthcare costs and skyrocketing obesity and type 2 diabetes rates -- and how they compare in different regions and states.

FEATURES 14 Annuities: On Your Road to Retirement Income?

FROM YOUR ASSOCIATION 4

PRESIDENT’S LETTER | PEDRAM SALIMPOUR, MD

17 CEO’s LETTER | ROCKY DELGADILLO

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as well as medical students, interns and residents. For more

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Pedram Salimpour, MD Peter Richman, MD Vito Imbasciani, MD William Averill, MD Marshall Morgan, MD

than 100 years, LACMA has been at the forefront of current medicine, ensuring that its members are represented in the areas of public policy, govern-

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efforts in both Los Angeles County and with the statewide California Medical Association, your physician leaders and staff strive toward a common goal– that you might spend more time treating your patients and less time worrying about the chal-

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lenges of managing a practice.

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

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People are living longer these days, but as life expectancies increase, so does the risk of serious health problems that could require long-term care. In fact, at retirement age, 70% of Americans will need long-term care and 35% will enter a nursing home.1 And with the average cost for nursing home care in a private room equating to more than $87,600 per year, that could literally cost

Long-Term Care Resources LACMA is pleased to announce that members now have access to an interactive and educational Long-Term Care evaluation tool to help you make the best decisions for your specific situation. To learn more, visit: www.myltcplan.com/lacma.

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PR ES I D ENT ’S LET T ER | PED R A M S A LI MPOUR , M D

Dear LACMA Member, Today, in Los Angeles County, a doctor saved a life, advocated for a patient, and promoted healthy living. We do it all. The Los Angeles County Medical Association (LACMA) is a voice that is being heard, and the state of our association is strong.

This year, LACMA has its work cut out. In addition to saving lives, advocating for patients and promoting healthy living, we have four major opportunities: membership, MICRA, Cal MediConnect duals demonstration pilot project, and the continuing physician shortage.

First, it appears that our 143-year-old organization has reversed a trend. For the first time in many years, rather than membership numbers declining, they are climbing.

While this is good news, like any momentum shift, now is the time to capture the future.

We must make our voices heard with our fellow physicians so that the membership numbers continue to grow. The most powerful voice is the united voice, and LACMA’s voice is rising. I ask you to dedicate the time, energy and resources to gather up more and more physicians to make our association the voice of physicians and the patients we serve.

Second, the Medical Injury Compensation Reform Act (MICRA) has helped contain health costs and reduce frivolous lawsuits, but now MICRA is under attack.

We need to vote NO on the deceptive ballot measure, Proposition 46, that will increase healthcare costs for all Californians and decrease access to care for patients across the state. We need to join the campaign coalition to protect MICRA by opposing this dangerous ballot measure at the November 2014 ballot box.

Together, we can make a difference and let the public know that we stand for them and against this deceptive, costly measure.

Third, LACMA joined other stakeholders, including three independent living centers and Dr. Puig-Llano, in filing a lawsuit in Sacramento Superior Court seeking to, among other things, halt the implementation of the ill-conceived Cal MediConnect demonstration project, part of the state’s Coordinated Care Initiative.

The state is planning to enroll approximately 450,000 duals – about half of the 1.1 million Californians who qualify for both Medicare and Medi-Cal benefits into Medi-Cal managed care plans. This is the most vulnerable population in State— the elderly, the poor and the disabled. Without their knowledge, consent or understanding, patients are being passively assigned away from their current doctors. LACMA will continue to stand by the patients we serve and will continue to consider all options for preventing the bureaucracy from implementing this potentially dangerous program.

Last, but very important, we face an unprecedented challenge. Los Angeles County will continue to face a shortage of physicians, which is compounded by the additional patients that are eligible for healthcare under the Affordable Care Act. A recent special issue of Academic Medicine is devoted entirely to the challenge of matching the physician workforce to the needs of the patient population. We need to encourage and mentor young adults to pursue their dreams of careers as doctors, and work with medical schools and residency programs to keep more of those young men and women here in Los Angeles.

LACMA is doing all of this in part by putting doctors in positions of leadership and by empowering them to lead. Because we have much to do. LACMA will continue its 143-year-old tradition of taking on these challenges and fighting for what is right. And we look forward to working with each and every doctor in this vast Los Angeles County to do just that.

Respectfully, Pedram Salimpour, MD President Los Angeles County Medical Association

4 P H Y S I C I A N M A G A Z I N E | AUG US T 2014

and the life-changing experience you’ll find nowhere else.

THE STRENGTH TO HEAL

There are few experiences more rewarding than serving as an officer and a surgeon with the Army Reserve. You will work with professionals at the top of their fields, be exposed to new technologies and points of view, and even have the opportunity to take part in humanitarian missions that stretch and sharpen your skills. You can also receive up to $250,000 in student loan repayment and $75,000 in Special Pay. See how the time you invest with the Army Reserve can enhance everything you do from Monday through Friday — and throughout your professional career.

To learn more, call (310)216-4433 or visit Culver City Medical Recruiting Center 400 Corporate Point, STE 570 Culver City, CA 90230 Email: usarmy.knox.usarec.list.9e2c@mail.mil

SCAN THIS CODE TO WATCH A VIDEO. LTC Hustead describes what it means to him to be part of a team of professionals and to have the honor to care for our nations heroes and their families. *Certain requirements and eligibility criteria apply. ©2014. Paid for by the United States Army. All rights reserved. Information subject to change.

PR ACT I CE M A NAGEMENT | FR ONT OFFI CE

Making the Transition to EHRs

BY BRIAN O’NEILL

A KEY AREA that can greatly impact a physician’s revenue while improving both quality of care

and the patient experience is the conversion to electronic health records (EHRs). For the past few years, Medicare EHR incentives of up to $44,000 per eligible provider have been a strong motivator for physicians to convert, but now “nice to have” is quickly changing to “must have.”

That’s because the clock is ticking fast toward 2015, when financial penalties will kick in for Medicare providers who do not adopt a certified EHR. Already many large physician groups have made significant progress in implementing EHRs. Fortunately, systems now exist that make it easy and affordable for smaller groups or independent physician offices to convert from paper to EHRs as well. But in doing so, it is important to choose wisely so you can enter this new world with confidence, commitment and clarity. Here are four suggestions to make the transition easier: 1. In order to maximize performance and revenue potential, physicians need to look for an EHR vendor who has been certified for stage II of “meaningful use.” This certification means that the technology being used improves patient care coordination, reduces healthcare disparities, engages patients and their families, improves population and public health, and ensures adequate privacy and security.

2. In addition to the EHR itself, be sure to obtain the ancillary tools that are right for you, such as a tablet PC, voice recognition, handwriting recognition, etc. If, for example, you are accustomed to handwriting in your charts, then be sure to purchase a tablet PC that allows you to write your notes into the system. This will reduce the chance of failure and make the transition much easier.

3. Don’t make the mistake of processing labs, prescriptions and referrals on paper while the charts are being handled electronically. That just adds to ineffi6 P H Y S I C I A N M A G A Z I N E | AUG US T 2014

ciencies as your staff has to scan the initial order and then scan again when results come back in order to add this information to the charts. So, too, use an integrated practice management system that allows everyone to see ALL the information needed to track every aspect of office flow including calendaring, benefit information and accounting. The more you can do electronically and the more integrated your practice, the higher the likelihood of success.

4. When initially converting to electronic records, a physician’s productivity will likely drop until he or she gets “into the flow” of how to enter charts into the system. Therefore, it is best to start by adding only new patients to the electronic system. Then, as productivity and comfort improve, gradually add your existing patients until you are able to confidently move everyone into the electronic chart system.

In this era of the ACA, accountable care and population health management, there are lots of challenges that keep physicians awake at night. Conversion to EHRs need not be one of them. Through proper planning, smart decisions, patience and the right partner, conversion to a great EHR platform can be smooth, affordable and pain-free for you, your office staff and your patients.

Brian O’Neill is the chief executive officer of Office Ally, which works with more than 330,000 providers and 5,600 insurance carriers and is the only organization in the country offering healthcare providers a full suite of revenue-cycle management services. www.officeally.com.

T R A NS I T I ONS | CA R EER MA NAGEM ENT

Serving to Heal...Honored to Serve LT. COL. THOMAS R. HUSTEAD, MD

ARE YOU INTERESTED in a challenging, rewarding and exciting career that will expand your skill

set and offer you countless opportunities in all areas of medicine? Is so, Army medicine is the career for you. As an Army family physician I can tell you that, without a doubt, the Army has been the greatest experience I could have ever hoped for. Not only do I get to serve some of the finest soldiers and families, I get to work with the highest caliber of physician colleagues I could ever imagine. I work with medical professionals who are clinically excellent and are the epitome of selfless service as officers in the U.S. Army.

Opportunities in Army medicine abound. One day you can be taking care of patients in a clinic setting and the next day you can be the director of that clinic, molding and creating it to be the ideal clinic to practice in. There are opportunities to work in ambulatory clinics, community hospitals and even large tertiary medical centers. If you are interested in scholarly activity or teaching staff in graduate medical education programs, there are opportunities to do that in nearly every residency specialty and fellowship available in GME in one of the Army’s elite teaching hospitals. All the while, the opportunity to lead exists from the clinic level all the way up to directors of large medical centers. Also, there are very unique military operational positions that allow you to work with the soldiers that defend our great nation in the Army’s best units stationed around the world.

outpatient clinics, establishing the framework for the quality of care delivered there. Finally, I have also spent seven years of my career in academic medicine teaching and molding young family physician residents into well-trained family physicians, culminating in my most recent position as the chair for the Family Medicine department at Tripler Army Medical Center in Hawaii.

In my 17-year career, I have served as a flight surgeon in an aviation operational Army unit; I have worked in a community hospital caring for soldiers and their families, from birth to our elderly retiree population, practicing the full scope of my family medicine training; I have been a director of multiple

While my experience has been as a full-time physician officer, physicians can have the same rewarding experiences in the Army Reserves serving in a parttime capacity. Check us out at http://www.goarmy. com/amedd.html for your opportunity to serve. Serving to Heal…Honored to Serve.

8 P H Y S I C I A N M A G A Z I N E | AUG US T 2014

There are also opportunities to do things only the Army can offer. I have been to Thailand and Indonesia on humanitarian missions. I have jumped out of airplanes, rappelled out of helicopters and, most important of all, been deployed to both Iraq and Afghanistan and had the most professionally rewarding experience of my life caring for the men and women who are willing to put their lives on the line to protect our freedom.

CA R EER MA NAGEMENT | T R A NS I T I ONS

Expert Witness Work

BY STEVEN D. HUNT, ESQ.

All litigated cases have their surprises, twists and turns, however, as a trial lawyer, I’m most satisfied when an expert performs competently on the stand. Experts I retain must have a deep/comprehensive knowledge of their subject areas. But more important, they require a more nuanced capacity to bend but not break when protecting their testimony. I wince when an expert chooses to fight or argue with an opposing attorney.

Attorneys undermine experts by coaxing them to speculate or guess about issues outside of their area of specialization. A lawyer knows that he/she is at a disadvantage when arguing cardiological issues with a cardiologist. But rhetorical engagements over points of law or topics outside of a witness’s area of specialization present opportunities for an attorney to disassemble that opposing expert.

A combative expert who argues too much, particularly over non-material issues, can ruin a case. In some instances, this combative behavior so irritates judges and/or juries that they eventually stop listening to the expert’s testimony. Experts should objectively opine about their area of specialization and not take on the persona of an advocate. Leave that work for the attorneys.

In one trial, opposing counsel attempted to undermine my expert’s credibility by pointing out that the physician had included a list of his prior forensic cases on his CV. The attorney sought to portray the expert as a “hired gun” who attracted expert witness work by listing all of his prior trial testimony experience. The lawyer asked: “Isn’t it true that you list every case in which you’ve testified on your curriculum vitae?” My expert answered, simply: “Yes sir, I do.” This answer ruined the attorney’s attempt to pick a fight on a non-forensic issue. If the expert had responded defensively, the jury might have focused their attention on credibility issues. By sidestepping the argument, my expert denied the attorney

any opportunity of making a non-forensic issue the centerpiece of his cross-examination.

The opposing attorney’s cross-examination to discredit my expert ended. The rest of the cross-examination went smoothly.

At AG Seminars, I teach professionals how to manage their anxiety, refrain from defensiveness and deftly handle aggresExperts should sive cross-exobjectively amination. AG’s courses are an opine about outstanding retheir area of source for expespecialization rienced experts, as well as those and not take on medical specialthe persona of ists interested in successfully diveran advocate. sifying their practices.

AG Seminars was founded by working forensic experts, and its faculty has over 90 years of combined litigation experience to teach professionals how to successfully manage the challenges of forensic work, while maintaining the highest ethical and professional standards.

To learn more about AG Seminars, visit our website at AGSeminars.net.

AUG US T 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 9

F EAT U RE | H OW DO WE C OM PARE

How Do We Compare?

MARION WEBB

Healthcare reform is reshaping the economics of healthcare delivery nationwide, but not all providers will be affected equally. In this issue we will take a closer look at some of the key factors impacting healthcare delivery and how they compare in different regions and states. We will address the rapid adoption of cost-saving telehealth services nationwide and existing barriers. We will look at a preliminary analysis conducted for Kaiser Health News that shows Medicare’s penalties will hit some types of hospitals harder than others. Find out what steps hospitals and physicians are taking to avoid costly penalties. We will also compare overall healthcare costs in certain states and look at the impact skyrocketing obesity and type 2 diabetes rates are having on healthcare spending. Finally, California’s medical community continues its fight to ensure that a ballot initiative aimed at repealing the state’s landmark Medical Injury Compensation Reform Act fails. We’ll talk about the consequences if the measure were to pass.

TELEHEALTH

Studies have shown that the adoption of telehealth is accelerating in California and across the nation, and the American Telemedicine Association (ATA) and other stakeholders are working hard to remove existing barriers.

Studies show that telehealth services have wide applications and can cut hospital readmissions, improve adherence and clinical outcomes. But barriers to adoption, particularly in the areas of licensing and reimbursement, remain.

Cross-licensing remains a big concern for doctors, with state medical boards requiring that a doctor who lives in one state and virtually visits with a patient living in another state is required to be licensed by both states.

1 0 P H Y S I C I A N M A G A Z I N E | AUG US T 2014

Reimbursement is also a major sticking point in California and elsewhere.

The American Medical Association (AMA), during its recent annual meeting, gave telehealth a major boost when it voted to create guiding principles to ensure proper coverage and reimbursement for telemedicine services.

However, some telehealth advocates believe the principles didn’t go far enough.

In its eight-page list of principles, the AMA states that doctors and patients must have a “face-to-face” visit, which could be done in person or via video.

Physicians must also advise patients of “cost-sharing responsibilities and limitations in drugs that can be pre-

medicine parity insurance laws for health benefits plans to treat telemedicine-covered services comparably with in-person services and said more needs to be done.

In another positive development for telehealth advocates, the Centers for Medicare and Medicaid Services recently proposed a new physician fee schedule that would allow physicians to bill for certain telehealth services starting in 2015.

The new rule would cover such telehealth services as annual wellness visits, psychoanalysis, psychotherapy and prolonged evaluation and management services.

Telehealth advocates say studies show that telemedicine can reduce hospital admissions and cut costs, warranting wider adoption.

HOSPITAL READMISSIONS

Starting this October, a quarter of the nation’s hospitals will lose 1% of every Medicare payment for a year, according to Kaiser Health News.

In 2012, one out of every eight patients nationally suffered a potentially avoidable complication, including infections, during a hospital stay, the government estimated.

The sanctions, estimated to total $330 million a year, kick in at a time when most infections

AUG US T 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

H OW DO WE C OM PARE | F EAT U RE

scribed via telemedicine.”

The document also acknowledged that coverage for telemedicine varies widely.

The AMA applauded the efforts of private insurers, such as WellPoint, Aetna and Highmark, to cover telehealth services, but a newly released ATA study suggests that coverage by private insurers for such services still lags far behind standard in-office care.

According to the study, published in Telemedicine and e-Health, 81% of respondents were getting paid when they billed for telehealth services and 19% didn’t get paid, which led nearly half of providers who didn’t get reimbursed to cease to offer the service.

Medicare pays about $6 million a year for telehealth services, the AMA reported, but does not provide coverage for certain services.

On the Medicaid side, 46 states and the District of Columbia now offer some form of payment for telemedicine services, though only nine cover store-and-forward and 14 cover remote patient monitoring in some form, according to Healthcare IT news.

And 19 states and D.C. have mandated that private payers cover telemedicine services, though those definitions vary in each state.

“State coverage of and payment for telemedicine services are related to state laws addressing what services providers can and cannot deliver remotely and what requirements need to be met in order to do so,” the document stated.

The Federation of State Medical Boards also recently adopted a “model policy on the appropriate use of telemedicine technology in the practice of medicine.”

However, the ATA feels that this model sets the bar higher for providing telehealth than for in-person care and thus creates barriers for pay.

Meanwhile, the push for wider adoption continues in California and elsewhere.

For instance, Legislation (H.R. 3077), introduced last year, allows certain Medicare healthcare providers in one state to conduct telemedicine services to Medicare beneficiaries in another state, addressing the licensing issue that concerns many doctors.

Last month, the ATA in a letter to the National Association of Insurance Commissioners also recommended changes to the NAIC’s network adequacy model to support telehealth.

The ATA stated that only 21 states and the District of Columbia have tele-

F EAT U RE | H OW DO WE C OM PARE

measured in hospitals are on the decline but still common.

Even today, infections often are not decreasing fast enough to meet targets set by the government, and new strains of antibiotic-resistant bacteria make infections harder to cure.

Clifford McDonald, MD, a senior adviser at the federal Centers for Disease Control and Prevention, said that the worst performers “still have a lot of room to move in a positive direction.”

An analysis of the preliminary penalties that was conducted for Kaiser Health News shows that Medicare’s penalties will hit some types of hospitals harder than others.

Publicly owned hospitals that treat a large portion of low-income patients are more likely to be assessed with penalties as well as large hospitals, hospitals in cities and those in the West and Northeast.

That said, Medicare stated that it did not see a need to take the socioeconomic populations of hospitals into account in the penalties, since it had already factored in the differing health of those populations, Kaiser Health News reported.

“We routinely monitor the impact of socioeconomic status on hospitals’ results and have consistently found that hospitals that care for large proportions of patients of low socioeconomic status are capable of performing well on our measures,” the agency wrote in its rule.

The biggest impact may be on the nation’s major teaching hospitals; 54% were marked for preliminary penalties, according to news reports.

Among the 761 hospitals, 175 are most likely to be penalized because their preliminary scores are 9 or above on a scale of 1 to 10.

Preliminary penalties were assigned to more than a third of hospitals in Alaska, Colorado, Connecticut, the District of Columbia, Nevada, Oregon, Utah, Wisconsin and Wyoming, Medicare records show.

The list also includes several California hospitals.

Ventura County Medical Center and Western Medical Center Santa Ana in the Los Angeles County area and Scripps Green Hospital in La Jolla also made the list.

The Hospital-Acquired Condition Reduction Program, created by the 2010 health law, is the third of the mandatory pay-for-performance programs created under health reform. The first levies penalties against hospitals with high readmission rates; the second awards bonuses or 1 2 P H Y S I C I A N M A G A Z I N E | AUG US T 2014

penalties based on 24 quality measures.

Both programs are in their second year.

This fall, when all three programs are in place, however, hospitals risk losing up to 5.4% of their Medicare payments.

While the impact of penalties remains a major concern for hospitals everywhere, many hospitals started searching for better ways to ensure that patients don’t relapse.

Some created outreach programs to educate patients on making better lifestyle choices and adhere to medications; others have nurses check on patients in their homes. Yet other hospitals give low-income patients free medications on their way out.

Medicare does not pay for many of these efforts. But looking at overall healthcare spending in the United States, it is clear that the above recommendations are likely to have a far-reaching impact.

OVERALL COST OF HEALTHCARE

Healthcare spending in the U.S. averaged $6,815 per person in 2009, but researchers found that this figure varies significantly for each state for reasons that go beyond people living a healthier or less healthy lifestyle.

The states with the highest healthcare spending per resident are in the Northeast and are led

by Massachusetts, Connecticut and Maine.

Experts attribute the region’s higher spending to its higher cost of living, greater proportion of elderly residents and number of highprofile hospitals, according to an article in the Wall Street Journal.

Alaska and North Dakota also ranked high on spending, which representatives often attribute to their desolate location, which makes delivery of care more expensive.

Utah had the lowest spending, which experts attribute to the state’s relatively young and healthy population. The state has particularly low spending on hospital care and doctors’ services.

Florida was among the states with the highest prescription drug spending.

A recent study by the UCLA Center for Health Policy Research showed that rising diabetes rates have significantly driven up healthcare costs in the state of California, and particularly in Los Angeles County.

In California, 60% of adults and 38% of children are overweight or obese, conditions that raise the likelihood of type 2 diabetes, stroke,

MICRA

A chief concern among California’s physicians is the campaign to repeal the state’s landmark Medical Injury Compensation Reform Act (MICRA).

On May 15, an initiative aimed at repealing MICRA, which currently caps non-economic damages at $250,000, qualified for the November ballot.

If passed, Proposition 46 would quadruple the current cap on medical liability lawsuits to $1.1 million, with annual increases going forward.

The measure also seeks to require doctors to be drug tested and to check a statewide database when prescribing certain medications to clamp down on prescription drug abuse.

LACMA and other organizations say that if approved by voters, the measure would lead to significant increases in healthcare costs, less ac-

cess to care and other cost hikes.

Col. Vito Imbasciani, MD, state surgeon of the California Army National Guard and a LACMA member, told LACMA members during a fundraising event in March that he is concerned about doctors cutting back on high-risk services if the initiative were to pass.

Dr. Imbasciani recalled that when he was a medical student in New England, he considered practicing medicine as an OB-GYN but reconsidered after the dean told him that malpractice insurance rates were especially high in that area of the country.

“You will spend all night delivering babies and all day in court,” Dr. Imbasciani recalled the dean’s advice to him. “I chose urology as a result of the malpractice prices being so high in the ’80s, so I understand out-of-control premiums.”

Not much has changed since then.

Today, skyrocketing malpractice insurance premiums continue for some medical specialties in Pennsylvania, which does not have a cap on non-economic damages like California, according to Martin Ciccocioppo, VP of research at the Hospital and Healthsystem Association of Pennsylvania.

“One of the biggest drivers in a hospital’s decision to close (their obstetrics) unit is the cost of medical liability coverage,” he said, according to news reports.

He added that medical liability coverage in Pennsylvania is among the highest in the country, advocating for the state to put a cap on non-economic damages, such as “pain and suffering,” given that there is no limit to what a jury can award a plaintiff in a medical liability case.

CONCLUSION

As the reshaping of the economics of healthcare delivery continues, providers large and small will have to closely follow new developments to decide how they will survive and prosper in the new business climate. LACMA will continue to keep its members abreast of new developments and encourages all physicians to get involved.

AUG US T 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

H OW DO WE C OM PARE | F EAT U RE

heart disease and cancer.

A March 2013 report from the American Diabetes Association found that “among states, California has the largest population with diabetes and consequently the highest costs at $26.7 billion.”

UCLA’s brief found that for patients with diabetes, regardless of their primary diagnosis, hospital stays were $2,200 higher than for patients who didn’t have diabetes, adding an extra $1.6 billion a year to California’s hospitalization costs.

Ethnicity plays a role: 42% of hospitalized Latino patients have diabetes, and 40% of AfricanAmerican, Native American and Asian-American patients have diabetes vs. 27% of white patients, the researchers found.

Diabetes is a nationwide problem, according to news reports.

One in three children born today in the U.S. is expected to develop diabetes in his or her lifetime.

The researchers said that while a lifestyle change — regular physical activity, eating a healthy diet and maintaining a normal body weight — can reverse or stabilize diabetes, public policy changes are needed.

Among the authors’ recommendations are providing reimbursement for early screening for diabetes, funds to educate the public about the importance of eating a healthy diet and regular exercise, greater access to healthier foods and creating walking trails and other public places to encourage physical activity.

Annuities: On Your Road to Retirement Income?

ARTICLE WRITTEN BY: WEALTH MANAGEMENT SYSTEMS, INC., COURTESY OF: EMILIA PIRRO, FINANCIAL ADVISOR

WILL YOU HAVE enough income to fund a retirement of 20 years, 30 years or more? One way

to help ensure that you’ll meet your needs may be to invest in an annuity. Building a steady stream of retirement income is a top priority for many Americans, especially those nearing their anticipated retirement date. With life spans extending into the 80s, 90s and even into the 100s, there is even more reason for investors to ensure they’ll have a source of income that lasts a long time.

An annuity is a contract between you and an insurance company that is designed to help meet retirement and other long-range goals, under which you make a lump-sum payment or series of payments. In return, the insurer agrees to make periodic payments to you beginning right away (an immediate annuity) or at some future date (a deferred annuity).

While there are many different types of annuities, there are a number of commonalities: • There are no annual contribution limits to an annuity as there are in IRAs or 401(k)s, unless the annuity is held in a qualified account. The issuing insurance company may, however impose contribution limits.

• All contributions—and any earnings—grow taxdeferred until withdrawal. Note, however, that annuities do not provide additional tax deferral on qualified contracts.

• Annuities offer a wide range of underlying investment options, from very conservative to very aggressive.

Whether an annuity is right for you may depend on how much you anticipate receiving from traditional sources of retirement income, such as Social Security, a 401(k) or an employer pension. You have a 1 4 P H Y S I C I A N M A G A Z I N E | AUG US T 2014

choice of annuities: • A fixed annuity, which provides a fixed rate of return for a specified time period.

• A variable annuity, which provides a variable rate of return based on the underlying investments.

• An equity-indexed annuity, which offers a guaranteed rate of return that may increase depending on the index it is tied to.

FIXED ANNUITIES: As their name suggests, fixed annuities typically present a guaranteed interest rate that is locked in for an initial period (typically 1 to 15 years) and may be adjusted thereafter, often annually.

With a fixed annuity, you have no control over the investments—the issuing insurance company decides how to invest your assets, primarily in government securities and high-grade corporate bonds. There are two basic types of fixed annuities: • The Guaranteed Return Annuity (GRA) offers a guarantee that you can never receive less than 100% of your investment—no penalties or fluctuations in the interest rate market can impact your principal should you surrender.

• The Market Value Adjustment annuity (MVA) works much like the GRA, but there is no guarantee of

your principal if rates rise and you surrender your contract. MVAs often pay more than a GRA due to the increased short-term risk of rising interest rates.

Earnings accumulate tax-deferred and are not taxable until they are withdrawn, when they are taxed as ordinary income. Withdrawal options may include a lump sum or a lifetime stream of income.

VARIABLE ANNUITIES1: This type of annuity, in contrast, generates investment returns that fluctuate depending on how the underlying subaccounts are invested. Generally, you may make an investment selection that may include stock, bond, cash subaccounts or some combination of these. Available choices range from conservative—such as money market, guaranteed fixed accounts and government bond funds—to more aggressive—such as small cap, mid cap, large cap, capital appreciation, aggressive growth and emerging market investments. As with many investments, the value—and payout—of a variable annuity will change depending on the performance of the subaccounts you choose. Withdrawals are taxed as ordinary income.

In addition to offering a stream of income that cannot be outlived, many variable annuity products have “living benefits,” optional features available for an added fee that can help protect your principal investment from market declines and/or provide a minimum future income. There are three basic types: • The Guaranteed Minimum Income Benefit (GMIB) guarantees a minimum future income level regardless of how the market performs. This benefit typically requires the owner to meet certain criteria, such as owning the contract for a specified number of years before exercising the benefit, and the owner must annuitize the contract to take advantage of this benefit.

• The Guaranteed Minimum Accumulation Benefit (GMAB) ensures that you retain the value of your purchase payments regardless of investment performance. At the end of a waiting period—typically 10 years—if your contract value is worth less than your purchase payments, the insurance company will increase your contract value to equal the guaranteed amount (adjusted by any withdrawals), • The Guaranteed Lifetime Withdrawal Benefit (GLWB) guarantees a return of your purchase payments through fixed annual withdrawals. The annual withdrawals are guaranteed until your principal is returned, even if the contract value declines to zero.

Some benefits also guarantee the owner 5% annual withdrawals for life in addition to guaranteeing the principal. Withdrawals in excess of the benefit withdrawal limit may negatively impact the guarantee.

Living benefits are increasingly evolving into new hybrid benefit options, as insurance companies seek ways to differentiate their offerings in the marketplace.

This environment of expanding flexibility and functionality is helping to redefine variable – and fixed – annuities for a new generation of retirement investors.

EQUITY-INDEXED ANNUITIES (EIAS): EIAs have characteristics of both fixed and variable annuities. They frequently offer a guaranteed minimum interest rate combined with an interest rate linked to the performance of a market index. At a minimum, the guaranteed minimum is 87.5% of the premium paid at a 1% to 3% annual interest rate, but rates can fluctuate based on the issuing insurance company. The indexbased return is tied to an index, such as the S&P 500, which is a stock market index based on the common stock prices of the 500 leading American companies in leading industries.

The index-linked interest rate may be computed in a variety of ways. Some annuities present a participation rate (for example, 80%) that determines how much of the index’s gain is credited to the annuity.

There may also be an interest rate cap on how much an EIA can earn. For example, if an index linked to an annuity gained 8% and the cap rate was 6%, then the gain would be 6%. There are also a variety of indexing methods used to calculate the index-based return.

AUG US T 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 5

THE PROS AND CONS OF ANNUITIES One reason annuities are attractive is that they can help build more value over time.

Money is accumulated in an annuity through contributions and investment earnings. By providing potential growth that is tax-deferred, an annuity’s investment earnings can accumulate and compound untouched by federal, state or local income taxes until you begin making withdrawals, which is usually after retirement.

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1 6 P H Y S I C I A N M A G A Z I N E | AUG US T 2014

In addition to tax advantages, annuities also offer a choice of investment options.

These may include fixed accounts, which may help protect principal from market risk, and variable investment accounts in stock and bond portfolios, which offer the potential for higher returns. Together, these features may make annuities attractive to those who seek investments that can help supplement future retirement benefits, and to retirees who want greater control over their income and the flexibility to continue deferring taxes on investment earnings.

While annuities certainly have some advantages, there are also a number of concerns, including: • Surrender charges: While most annuities allow you to withdraw 10% to 15% of your account value without penalties, the surrender charges for pulling money out of an annuity within the first several years after you buy it can be prohibitive. Surrender charges typically run for five to ten years after first purchase and can eat up 10% or more of your account value. Most contracts will begin a new surrender period for each subsequent purchase payment.

• Taxes: Withdrawals made from an annuity are taxed as ordinary income. Withdrawals made prior to age 59½ may be subject to an additional 10% federal penalty tax.

• High annual fees: The expenses for annuities, particularly variable annuities, can be high—often 2% to 4% a year. Fees include: o Administrative expenses, which can average 0.1% to 0.3% or more. o Investment management expenses, which range anywhere from 0.25% to more than 2%. o Mortality expense, which provides a death benefit for your beneficiaries, which can range from 0.5% to 1.5%.

• Estate planning considerations: If you die with money remaining in your annuity, your beneficiary will inherit all the taxes that you have deferred. Annuities do not receive a “step up” in tax basis.

BALANCE COSTS AND BENEFITS An annuity can be an excellent retirement investment vehicle if you are able to forgo use of the money for several years. Annuities also offer unlimited contributions (subject to insurance company limitations), protection of principal in fixed accounts and/or with living benefit riders, and the potential to earn higher rates of return on your investments in variable accounts. But annuities may also entail higher fees and expenses than some other investment vehicles, in part due to the insurance feature annuities provide. Let me work with you to help determine if an annuity is right for you.

If you’d like to learn more, please contact: Emilia Pirro. Branch Name: Morgan Stanley, Beverly Hills, Phone Number: (310) 285-2691 California Insurance License #: 0C08367 Footnotes/Disclaimers: Morgan Stanley Smith Barney LLC offers insurance products in conjunction with its licensed insurance agency affiliates.

1 Variable annuities are sold by prospectus only.The prospectus contains the investment objectives, risks, fees, charges and expenses, and other information regarding the variable annuity contract and the underlying investments, which should be considered carefully before investing.

Prospectuses for both the variable annuity contract and the underlying investments are available from your financial advisor. Please read the prospectus carefully before you invest.Variable annuities are long-term investment vehicles designed for retirement. There are risks involved when investing in a variable annuity, including possible loss of principal. Withdrawal and distributions of taxable amounts are subject to ordinary income tax and, if made prior to age 59½, may be subject to an additional 10% federal income tax penalty. Early withdrawals will reduce the death benefit and cash surrender value.

All guarantees are based on the claims-paying ability of the issuing insurance company. Optional benefits, such as living benefits and enhanced death benefits, are available for an additional fee.

Article by Wealth Management Systems, Inc. and provided courtesy of Morgan Stanley Financial Advisor.

The author(s) are not employees of Morgan Stanley Smith Barney LLC (“Morgan Stanley”). The opinions expressed by the authors are solely their own and do not necessarily reflect those of Morgan Stanley. The information and data in the article or publication has been obtained from sources outside of Morgan Stanley and Morgan Stanley makes no representations or guarantees as to the accuracy or completeness of information or data from sources outside of Morgan Stanley. Neither the information provided nor any opinion expressed constitutes a solicitation by Morgan Stanley with respect to the purchase or sale of any security, investment, strategy or product that may be mentioned.

Web Address: www.morganstanleyfa.com/emilia.pirro Emilia Pirro may only transact business in states where she is registered or excluded or exempted from registration and insurance licensed www.morganstanleyfa.com/emilia.pirro, follow-up and individualized responses involving either effecting or attempting to effect transactions in securities or insurance , or the rendering of personalized investment /insurance advice for compensation, will not be made to persons in states where Emilia Pirro is not registered or excluded or exempt from registration and insurance licensed.

© 2013 Morgan Stanley Smith Barney LLC. Member SIPC.CRC 541806 [09/12]

THIS SUM M ER , L ACM A delivered on its promise to protect Los Angeles County’s most vulnerable population by filing legal action against the state of California to halt the ill-conceived Cal MediConnect demonstration project. On August 1, our legal counsel will have a hearing with the judge, and we hope that the judge and state will do the right thing for our patients.

Joining our legal challenge are three independent living centers: Communities Actively Living Independent & Free, Westside Center for Independent Living and Southern California Rehabilitation Services Inc. Dr. Manuel Puig-Llano of Chula Vista also joined the lawsuit.

In the lawsuit, filed in Sacramento Superior Court, we ask the court for a preliminary injunction to stop the passive enrollment and the implementation of the pilot project and to disenroll all duals who have been enrolled— often without their consent or knowledge—into the program.

This comes after we repeatedly expressed concerns that the passive enrollment of tens of thousands of the elderly, poor and those with permanent disabilities who qualify for both Medicare and Medi-Cal in LA County is simply too aggressive. This project threatens the care of our most vulnerable patients who may be reassigned from their trusted doctors to one of five medical groups that most likely do not understand their conditions, physical limitations and social needs.

We believe this is unacceptable and we are not alone. LACMA’s position on the issue continues to make news headlines and draw national support.

We are thrilled that the National Association for Homecare & Hospice is taking an active interest in LACMA’s pursuit to do what’s right for patients and contacted us directly to discuss an article in their publication.

Nothing is more important to a physician’s practice than a physician’s reputation. On August 5, LACMA will host a special presentation on how to manage doctors’ online reputation. With more patients turning to the Internet to research physicians and medical practices and to read and write reviews on their experiences, it is critical that doctors become aware of how to protect themselves against undeserved negative reviews, resolve issues, optimize all web and in-office patient communication, and learn how to use social media.

This event will be held at the Phoenicia Restaurant in Glendale starting at 6:30 p.m. All attendees will receive a free online practice reputation assessment, website evaluation and free consultation.

LACMA is in discussions with several large medical groups to join our organization, and we hope those efforts will come to fruition this fall. Our strength grows through collaboration, so I look forward to engaging with new partners who share our goals and priorities.

Rocky Delgadillo Chief Executive Officer

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LACM A NEWS | A S S OCI AT I ON HA PPENI NGS

CEO’s LETTER

JOB B OA R D | CLA S S I FI ED

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Psychiatrist MD or DO

Located in Vista, California, Vista Community Clinic is a private, nonprofit outpatient community clinic located in North San Diego County serving people who experience social, cultural or economic barriers to health care in a comprehensive, high quality setting.

POSITION: Full-time, Part-time and Per Diem Family Medicine Physicians.

RESPONSIBILITIES: Provides outpatient care to clinic patients and ensures quality assurance.

Malpractice coverage is provided

by Clinic.

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

CONTACT US: Visit our website at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org or fax resume to 760 414 3702.

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POSITION Part-time Psychiatry MD or DO or part-time or full-time Family Medicine/Psychiatry MD or DO. RESPONSIBILITIES Provide consultation-liaison services for patients suffering from both psychiatric and medical disorders by focusing on the evaluation and treatment of patients serving adolescents, adult, seniors and their families. Preferably able to serve children as well, but not required.

REQUIREMENTS · Graduation from a recognized school of medicine · Valid California medical license as MD or DO; Board certified or eligible · Authorized to practice psychiatry in California · Certified as a diplomat in the American Board of Psychiatry and Neurology in psychiatry · Completion of a psychiatric residency or family medicine/psychiatry residency in an ACGME approved residency program · Psychiatrist with Medicare and California Medicaid numbers prior to start of employment · Valid DEA certificate · 2 years experience working fulltime as psychiatrists and MD or DO in child and adult psychiatry CONTACT US: Visit our website at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org or fax resume to 760 414 3702.

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CLA S S I FI ED | JOB B OA R D

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Benefits & Discounts Aimed at meeting both your professional and personal needs, LACMA offers you additional discounts and savings on Auto & Home Insurance, UPS services, Staples office supplies, Financial Planning, HIPAA Compliance Kits, and more!

For Joining LACMA and CMA Working together, the Los Angeles County Medical Association and the California Medical Association are strong advocates for all physicians and for the profession of medicine. Of the many reasons for joining LACMA and CMA, 10 stand out.

FREE CME & Educational Resources CMA develops toolkits, guides, webinars, and resources on all things related to today’s changing healthcare landscape—all FREE with membership.

In addition, LACMA provides access to important and local CME-accredited events.

FREE Legal Assistance

Legislative Advocacy LACMA and CMA are distinguished by their successes. Dual membership provides for unparalleled legislative advocacy at the local, state, and federal level on behalf of our members.

FREE Reimbursement Assistance Tired of fighting with payors? CMA’s Economic Services experts recovered over $7.8 million for members since 2010.

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Save time and money by consulting with a CMA legal expert before hiring a lawyer. Services include HIPAA Compliance, ACOs, Buying and selling a practice, Upkeep of medical records, and much more!

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State-of-the-Art Communication Information is power. LACMA and CMA produce several publications full of valuable information including the award-winning Physician Magazine, Physicians’ News Network, and CMA Practice Resources, full of tips and tools for your practice.

Access to your Physician Advocate If you come across a challenge and you are not sure what to do, call 213-226-0356 to support your practice and professional needs.

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 o 707 Wilshire Blvd, Suite 3800 o Los Angeles, CA o 90017 o FAX: (213) 226-0353

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Wells Fargo Practice Finance is the preferred provider of practice financing through the AMA Member Value Program.

All financing is subject to credit approval.

The AMA name and logo are trademarks of the American Medical Association and are used with its permission. All other trademarks are the property of their respective owners. Use of the AMA trademarks in no way constitutes an endorsement, express or implied of any product or company by the AMA. © 2014 Wells Fargo Bank, N.A. All rights reserved. Wells Fargo Practice Finance is a division of Wells Fargo Bank, N.A.

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