November 2014 | Physician Magazine by Los Angeles County Medical Association

N AT I O N A L D I A B E T E S M O N T H : T H E I M PA C T O F D I A B E T E S O N C A L I F O R N I A H E A LT H C A R E

REPORTING ON THE ECONOMICS OF HEALTHCARE DELIVERY

A PUBLICATION OF PNN www.PhysiciansNewsNetwork.com

DEFINING

VALUE

IN HEALTHCARE NOVEMBER 2014 L I A

M A G

L I A

M A G

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NOV EM B ER 2014 | TA B LE OF CONT ENT S

Volume 145 Issue 11

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NATIONAL DIABETES MONTH 6 The Impact of Diabetes on California Healthcare 15 Communication Is Key to Improving Diabetic Patient Outcomes and Reducing Liability

COVER STORY

DEFINING VALUE IN HEALTHCARE

Healthcare delivery reform and the shift from vol-

ume-based to value-based healthcare is creating both challenges and opportunities for physicians. With the federal government, commercial health plans and other organizations increasingly using measures of healthcare spending to reward or penalize providers and healthcare systems, it is key that providers know how value-based care is being defined and how it will affect them. We will take a look at some of the new delivery models and what the implementation of these models can mean for your practice.

DEPARTMENTS FRONT OFFICE | PRACTICE MANAGEMENT 8 California’s Anti-Markup Laws on Labs and Imaging

FROM YOUR ASSOCIATION 4 President’s Letter | Pedram Salimpour, MD 16 CEO’s Letter | Rocky Delgadillo

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P RES IDEN T ’S LET T ER | P EDRAM S ALIM P OU R, M D

Dear Colleagues: Ebola is a crisis, not just for people someplace far away this time, but for us right here in Los Angeles. While we do not have any direct flights from LAX to the affected areas in West Africa from LAX, we are still at risk. And the risk can be real or it can be just panic, based on the population’s perception of it. Still, this has the potential to test the limits of our clinical systems, our communication platforms and our emergency response practices. Because of the threat, real or perceived, and because this can happen again with something else, as it did with SARS and many other threats over the past decade, we ought to use this crisis to exercise our capabilities in the management of infectious diseases in hospitals and within other healthcare setting. Most importantly, we have to exercise our duty as physicians to understand the science and to make sure cool heads prevail. It is our responsibility to be the voice of medicine and science and to have that voice guide political and public health policies. The Los Angeles County Medical Association (LACMA) has received calls from the Los Angeles Times and Los Angeles Daily News, as well as other outlets, doctors and patients, about the Ebola threat we face. We have used this opportunity to educate ourselves and the public about where we stand today and in what direction the disease spread can go. We have also used the opportunity to educate the public about threats much more real to them in the immediate future -- threats such as the simple flu and the importance of receiving a vaccine. While Ebola is far more unforgiving than the flu, it is likely that the flu will take many more lives in Los Angeles this year than Ebola ever will. We have recognized the severity of the crisis but also seize the moment to remind the public that we are going into flu season, and the way the public can help is by getting their flu vaccine. This simple act will at the very least minimize the number of worried well people who come to doctors and hospitals with the same symptoms. Once again we are reminded of the great power that united physicians at the Los Angeles County Medical Association possess to influence the daily lives of every man, woman and child in our region. United, we can conquer the most significant healthcare and public health challenges, and the political ones, too! I look forward to seeing all of you at this month’s LA Healthcare Awards event as we honor the outstanding achievements our City’s most prominent leaders. Your President, Pedram Salimpour, MD

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The Impact of Diabetes on California Healthcare A RECENT STUDY by the UCLA Center for

Health Policy Research found that since 1980, diabetes cases have more than tripled nationwide to 20.9 million. In California, diabetes cases have risen by 35% in the last 10 years, with one in three hospitalized patients (aged 35 and older) having diabetes. Hospital stays for patients with diabetes cost nearly $2,200 more than stays for non-diabetic patients. The result is an added $1.6 billion to annual hospitalization costs in our state alone. In Los Angeles County, additional hospital costs for diabetics run $491 million a year, the highest in the state. The study’s lead author, Athena Philis-Tsimikas, MD, of the Scripps Whittier Diabetes Institute, said, according to news reports, that the rising rates of diabetes are devastating to not only patients, but to the whole healthcare system. The study looked at discharge records of hospitalized California patients aged 35 and older — a group that accounts for the most hospitalizations — and found that 31% of the patients had diabetes. Although diabetes may not have been the initial reason for hospitalization, the disproportionate share 6 P H Y S I C I A N M A G A Z I N E | N OV E M B ER 2014

of patients with the disease has an impact on California’s healthcare spending, the study found. According to UCLA, diabetes is a skyrocketing problem, adding $1.6 billion to annual hospitalization costs in California. Hospital stays for patients with diabetes cost nearly $2,200 more than stays for non-diabetic patients. Three-quarters of that care is paid through Medicare and Medi-Cal, the authors found, including $254 million in costs paid by Medi-Cal alone. Treating diabetics in the hospital costs more because diabetics tend to heal slower and require additional medication, noted Dr. Philis-Tsimikas. A 30% prevalence of diabetes in hospital patients aged 35 and older is higher than in the general population, which is about 11% for that age group in California, the researchers noted. Ethnicity plays a role: 42% of hospitalized Latino patients have diabetes and 40% of African-American, Native American and Asian-American patients have diabetes vs. 27% of white patients. The study authors noted that Latinos and AfricanAmericans, who are “at a higher risk for developing diabetes in the first place,” also had higher hospitalization rates than whites. “They may also in some cases not have access to care that is as good as for white patients,” said Sue Babey, co-author and senior research scientist at the UCLA Center for Health Policy Research according to news reports. 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 also 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. Babey noted that having a healthcare team of nurses, dietitians and peer educators, such as the one at the Scripps Whittier Diabetes Institute, can help improve diabetic care for patients. “Physicians can sometimes be busy,” she said. “If you can work with the entire team, they have more time to spend with the patient, letting them know for the individual patient what they need to do,” Babey said.

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F EAT P RAC U RE T IC | DEF E M AN IN IN AG GEM VALU ENTE |IN F RONT H EALTOF H CFARE IC E

IN LAST MONTH’S COLUMN, we ad-

dressed common misconceptions regarding whether physician-owned laboratories qualify for the in-office ancillary services and shared practice “exceptions” to both the federal Stark laws and California laws. This month, we tackle another common source of confusion: When are California physicians permitted to mark up lab tests and imaging studies? (“Marking up” occurs when a physician purchases a test from an outside lab or imaging center, and then charges the payor more than the lab or imaging center would have had that entity billed the payor directly.)

California’s Anti-Markup Laws on Labs and Imaging BY HARRY NELSON AND LAURA PODOLSKY

In an era of declining reimbursement and rising costs, ancillary services, and especially laboratories, present an attractive opportunity for physicians to realize revenues from patient services. Many physicians have established in-office labs for CLIA-waived or high-complexity test. Others have looked for opportunities not only in shared labs (as we addressed last month) but also in outside lab testing. The challenge is that many of these opportunities are barred by legal restrictions. In our experience, many physicians are unaware of these prohibitions until an insurance company or government agency raises them as an issue in an effort to recoup payments. One issue that warrants attention is the disclosure requirements for mark-ups on outside laboratory testing. Since 1991, Section 655.5 of the California Business and Professions Code has limited the ability of California physicians to mark up lab tests. (In addition to lab tests, other California laws limit physicians from marking up certain anatomic pathology (Section

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655.7) and diagnostic imaging (Section 655.8) services, and federal law also limits mark-ups of diagnostic imaging services.) With respect to lab tests, Section 655.5 prohibits providers from charging for a laboratory test that they did not perform (in an in-office lab) unless the provider (a) notifies the patient of the name, address and charges of the laboratory performing the test, and (b) charges no more than what he or she was charged by the clinical laboratory that performed the test. Violation of this provision is punishable by imprisonment and/or a $10,000 fine. Section 655.5 does not prohibit the billing of all provider services associated with a laboratory test that is “purchased” from an outside lab. For example, a physician may charge a reasonable fee for the drawing and processing of the patient’s blood, or interpreting the test results, because these are examples of services performed by the physician for the patient that are separate from the performance of the test itself. However,

the need for physicians to be attentive to the antimarkup provisions with respect to outside laboratories. Physicians, for example, need to distinguish between their right to charge a reasonable drawing and processing fee for lab specimen and the marking up of the lab test itself. Physicians also should review their billers’ practices with respect to the place of testing of the CMS-1500 billing form to ensure accurate completion of the form, distinguishing between in-office and outside billing. Physicians also should verify that processes are in place to ensure that their billers make necessary disclosures. Finally, physicians who already face threats, demands or enforcement actions from insurance companies may wish to seek legal counsel to explore the legal and equitable defenses to such actions. Harry Nelson is the managing partner of Nelson Hardiman, LLP, and can be contacted at hnelson@nelsonhardiman.com. Laura Podolsky is an associate at Nelson Hardiman, LLP, and can be contacted at lpodolsky@nelsonhardiman.com.

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F RONT OF F IC E | P RAC T IC E M AN AG EM EN T

an ordering physician may not add any “additional” charge to a clinical laboratory service unless the service is “actually rendered” by the physician and itemized in the bill. While this provision does not limit charges for tests rendered by physicians in their own in-office labs, it raises a potential problem as to purchased or outsourced tests. Providers must be careful about billing for services associated with purchased tests because any errors could be viewed by the government or insurance companies as tacking on an additional charge to the purchased test in violation of Section 655.5. Although this law has been on the books for over two decades, insurance companies and law enforcement rarely if ever invoked Section 655.5 in disputing physician lab fees. Over the past several years, however, Section 655.5 has become a central issue in health plan-physician disputes over a popular test known as “ALCAT.” ALCAT, which stands for the Antigen Leukocyte Cellular Antibody Test for Chemical and Food Allergies, claims to measure adverse reactions to dietary substances. This being the era of “Gluten Free,” patients loved ALCAT. Meanwhile, insurance companies reimbursed ALCAT tests at a notably higher rate than the ordering physicians actually paid to purchase the test from the lab. Many physicians saw a “win-win”: Patients got information that they believed would improve their health, while the physician got an opportunity to profit on the difference between the purchase price and the insurance reimbursement. Inundated with ALCAT claims, the private insurers were less enamored of the test, questioning its reliability and medically necessity and also objecting that doctors had violated Section 655.5 by marking up an outside lab test. Since then, some payors have initiated recoupment actions for ALCAT testing, seeking to force physicians to repay reimbursement and leaving many physicians uncertain of their rights. In a recent San Diego case, the district attorney indicted a physician who billed for ALCAT for violation of Section 655.5 and other criminal charges. While criminal prosecution is an extreme example, physicians should not underestimate the risks of running afoul of anti-markup requirements. These enforcement activities highlight

F EAT U RE | DEF IN IN G VALU E IN H EALT H C ARE

DEFINING VALUE IN HEALTHCARE Healthcare delivery reform and the shift from volume-based to value-based healthcare is creating both challenges and opportunities for physicians. With the federal government, commercial health plans and other organizations increasingly using measures of healthcare spending to reward or penalize providers and healthcare systems, it is key that providers know how valuebased care is being defined and how it will affect them. In this article, we take examine some of the new delivery modelsâ&#x20AC;&#x201D;Accountable Care Organizations (ACOs), patient-centered medical homes, bundled payments and population-based models that aim to improve the health of entire communitiesâ&#x20AC;&#x201D;and what the implementation of these models can mean for your practice.

In the National Scorecard on Payment Reform released last March, Catalyst for Payment Reform (CPR) found that the vast majority of payments, 89%, are still being tied up in fee-for-service and other methods that are agnostic about quality of care, according to CPRâ&#x20AC;&#x2122;s executive director Suzanne Delbanco. That, however, is going to change soon given that in 2015, providers will be subjected to Medicare penalties if they do not meet up to 26 measures of value-based purchasing. These include 12 clinical process-of-care measures, eight patient-experience dimensions, five outcome measures and one efficiency measure on spending per beneficiary. Many physicians and healthcare experts are concerned that the methodology that the Centers for Medicare and Medicaid Services (CMS) adopted may lead to distorted comparisons and perverse incentives and may not achieve desired goals. In a recent report published by the Center for Healthcare Quality and Payment Reform, a Pitts1 0 P H Y S I C I A N M A G A Z I N E | N OV E M B ER 2014

burg-based not-for-profit focused on the quality and affordability of U.S. healthcare services, the author identified six areas of concern with the current value-based purchasing methodology. Harold Miller, president and CEO of the Center, wrote that patients who lack a primary-care physician can cause distortion in comparisons of spending. Physicians can easily be made accountable for services a patient received from another provider and may also be assigned spending on a preventable condition, such as a hospital-acquired infection, when treating the condition rather than the person who caused the condition. Miller noted that poorly designed measurements, attribution and accountability systems fail to provide providers with the information they need and can discourage them from making feasible changes by demanding they control services and spending beyond their range of influence. CMS responded to the report by saying that it only holds providers accountable for the patients

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DEF INING VALU E IN H EALT H C ARE | F EAT U RE

they have the greatest ability to direct and influence. amount of money. Instead, they are in the community and collaboOthers questioned whether the measures accurating with social service providers. rately reflect quality. “The future will be in serving acute care for when A report from the Rand Corp. this year also reportedly found mixed results from a broad array of it’s absolutely necessary but trying to reach commuvalue-based purchasing arrangements with govern- nity through less intensive, less expensive forms of intervention,” he said. The question of how to make ment programs and private insurers. “Even those with strong methodological designs it work financially remains. Finally, local market forces will also impact the did not lead to significant improvements,” the organization wrote, concluding that more research is success or failure of pay reform. Umbdenstock said that large national employers needed to determine the program’s impact. Either way, “the movement to value is here to can be real influences in their respective marketstay,” Richard Umbdenstock, who served as presi- places. Umbdenstock predicted that in the future, phydent and CEO of the American Hospital Association sicians will probably play either more of a consulsince 2007, told Modern Healthcare. “It’s going to take Medicare a while to move off tative role within a larger team or their services will fee-for-service, and that’s a bellwether. But there’s a be reserved for issues of clinical ambiguity that no whole lot more in Medicaid and Medicare managed other team member is as qualified to address. Doccare. The nongovernmental payers are all moving in tors may be seeing fewer patients, and their practice models will likely change. this direction.” Traditionally, many hospitals have competed Delbanco agreed with Umbdenstock’s assessment and expects that the 2014 scorecard, which based on services and level of technology, and now is expected to be released next fall, will reflect pay- they are competing more on cost, patient satisfacment models moving from volume-based to value- tion and quality outcomes, Umbdenstock told news sources. based care. Both Delbanco and Umbdenstock predicted that several variables will affect the success or failure of ACCOUNTABLE CARE ORGANIZATIONS In a recent article in Forbes magazine, business guru and various payment reform programs and strategies. Delbanco predicted that payers and purchas- best-selling author Clayton Christensen offered his ers will offer consumers incentives to seek care from views on some of the obstacles facing ACOs today “high-value” providers. This, in turn, could incentivize and how physicians may overcome some of these providers to accept new forms of payment to receive hurdles. To date, ACOs have aca greater market share. counted for measurable Secondly, she quality improvements and wrote in an article, a reported $380 million in government policies IN 2015, PROVIDERS savings, but progress recan also hinder or enWILL BE SUBJECTED mains slow and inconsishance the success of TO MEDICARE PENtent. pay reforms, such as ALTIES IF THEY DO There are an estimated state laws mandating 500 to 600 ACOs in the price transparency to NOT MEET UP TO 26 U.S., providing care for 15% complement a pay-forMEASURES OF VALUEto 17% of the population performance program. BASED PURCHASING. within three models: MediUmbdenstock told care Shared Savings ProModern Healthcare grams, Pioneer ACO Modthat states are trying els and commercial ACOs. to limit their exposure Each model is slightly as well, noting that in different, but all share comMaryland alone, 10 mon goals of coordinating rural institutions have care, reducing redundanadopted the value apcies, focusing on prevenproach of less utilization, improving clinical tion, more communioutcomes and making ty-based services and healthcare more affordable. less reliance on inNone have demonpatient care because strated consistent success, they only get a fixed

F EAT U RE | DEF IN IN G VALU E IN H EALT H C ARE

MEASURING VALUE IN HEALTHCARE While current hospital rankings by U.S. News & World Report, Leapfrog and others measure quality and popularity, there has never been a means of measuring the VALUE hospitals deliver to their patients – until now. Medical Value Partners (MVP) has developed the Medical Value Index (MVI), based on the work of veteran orthopedic surgeon William Mohlenbrock, MD. MVP uses a patented algorithm to process data provided by hospitals themselves to create a value-based index. The MVI is based on six widely recognized healthcare metrics scoring a hospital on a scale of 0-800 points. The higher the number, the greater the value delivered to healthcare consumers by the hospital. Based on MVP’s analysis, the top five hospitals in the Los Angeles area are (150+ beds): • • • • •

because moving from a fragmented, fee-for-service, paperbased healthcare system to a team-oriented, value-driven care and electronic health record system is difficult. However, National ACO LLC, a Los Angeles-based physician-owned and -operated healthcare company that was awarded participation in the Center for Medicare and Medicaid Services Shared Savings Program and Advanced Payment option in January 2013, may be the exception. In 2013, the ACO’s 20 participating physicians achieved $6.1 million in savings to the Medicare program and had shared savings of $3.05 million by improving quality of care for some 20,000 patients, said Alex Foxman, MD, who cofounded National ACO with Andre Berger in 2013. Foxman agreed with Christensen that there are major obstacles that need to be addressed, but he also pointed to opportunities, especially for private physicians, to get involved. Here are the four major obstacles that both agreed need to be addressed: 1. Perverse Payment Models For many providers who are used to increasing revenue and covering expenses by driving volume, the idea of moving toward an evidencebased reimbursement system is scary. But it comes down to what’s best for the patient is best for the bottom line, Christensen said. Doctors who convert their practices and revenue stream from fee-for-service to a prepaid model as rapidly and aggressively as possible can avoid being trapped between the past and the future. “Physicians have to start thinking differently,” Foxman agreed. “The traditional thinking is the more we bill patients, the more money we make. In the new system it’s not about how many times you see the patient, but about how well you manage the patient.”

Pacifica Hospital of the Valley in Sun Valley Citrus Valley Medical Center in Corvina Centinela Hospital Medical Center in Inglewood Community Hospital of Long Beach Los Angeles Metropolitan Medical Center..

2. Wrong-sized Medical Staff Christensen said that the typical community hospital should consider reassigning care and excluding unnecessary specialists. The solution requires improvements in care delivery and a willingness to reassess pricing based on projected increases in volume.

Dr. Mohlenbrock said that knowing which Los Angeles area hospitals deliver the greatest value empowers consumers to entrust their care to those providers. “Value is what we pay for in every area of our lives,” Dr. Mohlenbrock told Physician Magazine. “It should be the same in medicine. The challenge has always been to determine how to measure value in healthcare. With the methodology used in the Medical Value Index, we have identified the essential features for measuring healthcare value.”

3. Technology Platform Incompatibility Today, different groups of physicians use electronic health records (EHRs) in their offices that are incompatible with the hospital’s EHR system, which makes redundancy of care inevitable. The solution is for ACO providers to invest in connecting their information technologies early on, according to Christensen. Foxman agreed that ACOs are very data-driven and that the lack of interoperability of systems remains a huge issue, because doctors need information in real-time. “Information technology interoperability is not possible today,” Foxman said. “In the future, if it happens, it will be a tremendous asset to the American healthcare system.”

For more information visit www.MedicalValuePartners.com

4. Lack of Physician Leadership and Management Structure A strong physician leadership and self-gov-

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PATIENT-CENTERED MEDICAL HOMES Primary care is the foundation of healthcare reform and patient-centered medical homes. Introduced in 2007, the patient-centered medical home is a model of healthcare that stresses personal relationships, team-based care and coordination across specialties and care settings. The model ranks among the delivery systems encouraged by the Patient Protection and Affordable Care Act to improve quality and reduce costs. Yet, to date, several studies suggest that the value of creating medical homes remains to be elusive with telehealth care possibly offering viable alternatives. A CMS-funded study by RTI International researchers compared cost and quality measures, collected between July 2008 and June 2010, for 308 medical homes recognized by the National Committee for Quality Assurance and 1,906 nonrecognized practices. The study found that total Medicare payments, acute care payments and emergency department visits declined compared with the non-recognized practices. Declines were sharper among sicker patients and solo practices, according to an article in Modern Healthcare. Another study by researchers at New York’s Weill Cornell Medical College found one- to two-doctor practices had 33% fewer ambulatory care-sensitive hospital admissions than practices with 10 to 19 doctors. The study also found that physicianowned practices had fewer preventable admissions than hospital-owned practices. The researchers suggested that public policymakers and health insurance company executives consider policies that support groups that help small practices share resources. They said that these groups might “provide a viable alternative for physicians who do not want to become employed by hospitals” or don’t want to join a large medical group. Another study, by Milbank Reports, that looked at medical home programs in 17 states concluded that payer alignment is needed to foster medical home success and the corresponding payment reforms

needed for that success. “This is often because no single payer can invest enough to make transforming the entire practice cost-effective,” the Milbank researchers wrote. Proponents of telehealth believe that expanding and integrating telehealth services into medical homes would be an effective way to control costs and improve outcomes. To date, however, roadblocks such as reimbursement issues, Medicare restrictions and interoperability and compatibility issues in technology remain. The American Medical Association (AMA) also proposes integrating telemedicine into a new valueand-team-based accountable care model. “Promoting patient care coordination through medical home and accountable care models will become achievable where data portability and interoperability are promoted in the context of telemedicine,” the AMA said in a written statement. BUNDLED PAYMENTS The verdict on the value of bundled payments, when doctors, hospitals and healthcare providers share a fixed payment for a health episode under one “bundle” of services in an effort to keep costs down and improve care, is also

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DEF INING VALU E IN H EALT H C ARE | F EAT U RE

ernance is key to success in implementing clear reporting relationships and achieving individual accountability, which means that hospital administrators need to embrace physician leadership and invest in its development. Foxman agreed by saying it takes many strong physician leaders to drive success.

F EAT U RE | DEF IN IN G VALU E IN H EALT H C ARE

lenges in interoperstill out. ability among vendors Proponents say are among the top that bundled paychallenges facing the ments give healthcare national health IT infraorganizations more structure and the shift autonomy over how toward population they spend money “WHAT WE NEED IN health management, and deliver care while THIS COUNTRY IS DATA according to a recent increasing transparTHAT SHOWS VALUE ” article in HealthIT Anaency to the healthcare PAST PRESIDENT OF THE AMA , ARDIS DEE lytics. systems, as patients HOVEN, MD, IN A RECENT ARTICLE When asked about would know the costs IN THE WALL STREET JOURNAL the biggest obstacles upfront. for building a data exBut because bunchange infrastructure dles aren’t replacwith their hospital, lab, ing all fee-for-service claims, critics predict their overall effect will be small. ambulatory and community health provider partners, In a recent RAND Corp. study, funded by a $2.9 most respondents named cost as the biggest issue. Forty-seven percent also indicated that getting million federal grant, for the care of insured orthopedic patients under 65 by a handful of California consistent and timely responses from EHR and HIE hospitals and insurers, the few healthcare groups that (Health Information Exchange) product vendors was embraced bundled pay chose to process bills manu- a chief concern, while technical issues of building an ally because the custom-made software needed to interface, implementing data standards and meetprocess bundled claims cost more than $1 million, ing end-user expectations also ranked high on the list. according to an article in Kaiser Health News. At the same time, population health and the risThe prospective model also raised concerns for regulators in California, such as whether providers ing retail and consumer-minded approach are real would assume a higher insurance risk and how to and will be around for a long time, according to a blog by healthcare consultancy firm Advisory Board. apply copays and coinsurance. With more consumers looking for convenient acThe study evaluated a three-year effort coordinated by the Integrated Healthcare Association, which cess to care, demanding transparency in pricing and conducted the three-year study who said in news turning to the Internet and social media networks to reports that the results of the study should not be in- find doctors as well as read and write reviews on terpreted as a death sentence to bundled payments. providers and healthcare systems, the trend is here Rather it should be looked at as a “hard-fought to stay. The Advisory Board believes that with all the battle offering important lessons.” consolidation that has occurred, smart partnerships POPULATION HEALTH A recent report from Chil- will be vital for a hospital’s survival. “No matter the form it takes (and it’s not always mark Research said while population health is a key trend and long-term goal for healthcare organiza- M&A), a smart partnership can strengthen any orgations and vendors, the results from a recent study nization’s appeal to retail consumers,” according to an Advisory blog post. show that reimbursement creates a huge barrier. The report by Chilmark Research, a Cambridge, Mass.-based group, found that more than 100 ven- Conclusion The immediate past president of the American dors claimed to address analytics for population Medical Association, Ardis Dee Hoven, MD, recoghealth management, but few actually delivered. The potential for vendors in the EHR space is nizes the importance of healthcare value. She was particularly significant, given the ubiquity of EHRs in quoted in a recent article in the Wall Street Journal large health systems and how they impacts physi- reporting on healthcare cost data as saying, “What we need in this country is data that shows value” cians’ work. Whether dealing with ACOs, medical homes, “To leapfrog competitors, EHR vendors will acquire best-of-breed vendors that have the solutions bundled payments or population health managebest suited for their target markets,” according to an ment, defining, measuring, understanding and addressing current challenges with value-based modarticle in MedCity News. The eHealth Initiative’s 2014 survey, which in- els will be key for services and products to grow in cluded 135 respondents, also found that the financial the changing health environment and have the deburden of health information exchange and chal- sired positive effect on outcomes and costs.

1 4 P H Y S I C I A N M A G A Z I N E | N OV E M B ER 2014

BECAUSE DIABETES HAS the

potential for serious complications and requires immense involvement by patients

and

physicians

for

successful outcomes, healthcare professionals who treat diabetic patients may be at risk for malpractice lawsuits. RISK TIP

Communication Is Key to Improving Diabetic Patient Outcomes and Reducing Liability In a study of claims closed from 2007 to 2013, The Doctors Company identified four common allegations made by patients with diabetes: improper management of treatment (37%), failure or delay in diagnosis (31%), failure to treat (9%), and improper management of medication regimens (6%). Diabetic patients’ treatment is often managed by a multidisciplinary care team, which may include a primary care physician, endocrinologist, dietician, ophthalmologist, podiatrist, and dentist. When patients file claims, it’s not uncommon for them to name the entire care team in the complaint, alleging failure to properly diagnose, supervise, monitor, and/ or treat their disease. To promote patient safety, the healthcare team should engage the patient in collaborative care planning and problem solving to produce an individualized care plan as well as team support when problems are encountered. Other ways to promote patient safety and mitigate the risk of malpractice claims related to diabetes care are: • Communicate. Talking openly with diabetic patients about their condition and encouraging them to take an active role in decision making enhances patient safety. o Overcome patients’ fears about their disease by taking time to answer questions. o Discuss all associated risk factors, including weight gain. The American Medical Association and American Diabetes Association have resources available to help physicians talk to their patients about weight and diabetes. o

Provide written instructions and information

about adverse effects for prescription drugs and complex prescription drug regimens. o Communicate with the patient and prepare written information in the language and at the literacy level that the patient understands. o Ask patients to repeat the information shared, not just whether they understand what they have been told. • Educate. Educate patients about the importance of self-management to help increase their compliance and to reduce the risk of patients attributing their injuries to substandard care. Diabetic patients should be able to articulate the importance of lab tests, medication management, diet, and exercise. Barriers to self-management such as financial issues or lack of social support, healthcare literacy, and patient-caregiver relationships should be assessed. • Document. Document any and all patient interactions and discussions regarding the patient’s condition, including diagnosis, specialist referrals, and treatment options. • Manage care. Implement a program that ensures timely follow-up when a patient fails to schedule an appointment, misses an appointment, or cancels an appointment and does not reschedule. Failure to follow up and provide intensive patient management can lead to missed or delayed diagnoses, accelerated disease symptoms, morbidity, and/or mortality. Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

N OV E M B ER 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

AS S OC IAT ION H AP P ENINGS | LAC M A NEWS

CEO’s LETTER

WITH THE EBOL A cases capturing national attention, Los Angeles County physicians

are rightfully concerned about our health system’s preparedness to protect their patients and healthcare workers. Los Angeles County doctors are continually learning and practicing preparedness. To remind the public that physicians are the primary line of defense against this potentially deadly disease, LACMA’s president, Pedram Salimpour, MD, took the opportunity in recent media interviews to highlight the critical role doctors play in our public safety infrastructure. Dr. Salimpour has been quoted repeatedly in media outlets, discussing the preparedness of our LA healthcare system to handle the possibility of an Ebola outbreak. In addition, Dr. Salimpour urged the public to help the hospital system by getting flu shots. The key to prevention, Dr. Salimpour told the Los Angeles Daily News, is honesty between patients and their doctors. This serves as a reminder to all physicians, who put their lives at risk every day, of the critical role they play to serve the public good. As an organization, LACMA is proud to once again demonstrate its critical leadership in LA County and the nation overall. We are looking forward to our continued growth and strength in numbers. During this time of celebration and reflection, we want to thank our physicians for giving so much of themselves to their profession. We are excited to celebrate our outstanding physician leaders during the annual LA Healthcare Awards on Nov. 13 at the California Club. This year, we are thrilled to honor former LA mayor, Richard Riordan, as our “Healthcare Champion of the Year.” Riordan, a longtime healthcare champion, has never wavered in his public policy statements. In Riordan’s words, “Every child that comes into this world has a God-given right to a quality education and quality healthcare.” Let us hope that future generations of leaders will heed those words. While the verdict of Proposition 46 may have already been decided by the time you read this letter, LACMA remains hopeful during this time that voters will do the right thing and side with our physicians to vote “No” on Prop. 46. Happy Thanksgiving!

Rocky Delgadillo Chief Executive Officer

1 6 P H Y S I C I A N M A G A Z I N E | N OV E M B ER 2014

LACMA is commending the Los Angeles County Department of Health Services (DHS) for its aggressive approach to secure federal funding to bring more doctors to our most challenged communities. Millions of Americans have trouble accessing basic care because of the lack of primary care physicians available in their area. In Los Angeles County, 1.2 million individuals reside in areas without access to primary care. In the last two years, DHS applied to have these areas designated as a Health Professional Shortage Area (HPSA) for primary care and increased the number of areas eligible for such funding from 24 to 34 county-wide, with another thre under evaluation. “With Los Angeles County facing a growing physician shortage, LACMA recognizes the exemplary efforts by DHS to provide quality healthcare for all patients and calls on other stakeholder groups to convene and define a cohesive strategy to increase the number of physicians serving the neediest communities in the county,” said LACMA President Dr. Pedram Salimpour. HPSA is a designation that recognizes a particular geographical area, population or institutional facility that is experiencing a shortage of primary care services. Once a HPSA designation is achieved, the government infuses aid through various programs and incentives, including physician recruitment assistance and financial incentives, which may include student loan forgiveness and Medicare bonuses to providers practicing in an HPSA area. These incentives make these areas more attractive to physicians. As these professionals establish their practices within an HPSA, the shortage of primary caregivers is alleviated, government assistance is eventually withdrawn, and the physicians frequently establish permanent roots within their service area to the benefit of their careers, families and the community. “The County Health Department’s efforts generate a win-win for patients and their doctors; physicians fulfill their personal goal of serving the neediest communities while receiving a reduction in their medical school debt,” added Dr. Salimpour. “Utilizing loan repayment programs as a recruitment and retention strategy enables DHS to attract physicians to its Ambulatory Care Network and hospital-based clinics that serve our most vulnerable patients. And it helps doctors to stay connected with their patients throughout their careers.” All physicians providing services in an HPSA are eligible to receive Medicare bonus payments. Eligible providers include primary care physicians, specialists, surgeons, doctors of podiatric medicine, licensed chiropractors and optometrists. In addition, psychiatrists furnishing services in a geographic mental health HPSA are also eligible to receive bonus payments.

Los Angeles County M e d i c a l As s o c i a t i o n

Renew your dues today! 

 



By renewing your dues, you will continue to receive:

Legislative Advocacy—Continuous fight to protect the medical profession from current challenges such as Proposition 46, narrow networks in California, and CalMediConnect. Access to documentation to help you navigate through today’s changing healthcare landscape. Free Reimbursement Assistance—CMA has recovered nearly $8 million recovered since 2010 in unpaid claims for its members! Free Jury Duty Assistance—Your time is valuable! Maximize your flexibility and increase your chances for reporting for the minimum period when scheduling jury duty service. 15-27% average annual savings through LACMA’s exclusive partnership with Medline, the medical supplies company. Free and low cost access to events including CME events, mixers, training workshops, and webinars for you and your staff. For our Valued Members

FREE DUES! Renew your 2015 membership by December 31st, 2014 and be entered in a drawing to win FREE dues for 2015!

How to renew: Call: Carolina Velazquez, 213-226-0361 Renew online at www.lacmanet.org/Renew Your Medical License number will act as your login

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

N OV E M B ER 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 17

LAC M A NEWS | AS S OC IAT ION H AP P EN EIN G S

LACMA Lauds DHS Efforts to Increase Primary Care in Underserved Areas

JOB B OARD | C LAS S IF IEDS

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N OV E M B ER 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 9

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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!

TOP REASONS

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LACMA/CMA IS THE VOICE OF PHYSICIANS score

Legislative Advocacy

two

LACMA and CMA are distinguished by their successes. Dual membership provides for unparalleled legislative advocacy to end abusive practices. In addition, LACMA has sued health care plans on behalf of members to stop intimidation tactics.

• Socialize and network with members of the medical community • Find or create opportunities for your practice • Engage with legislators and policymakers

9 State-of-the-Art Communication

Tired of fighting with payors? CMA’s Economic Services experts have recovered nearly $8 million for members since 2010!

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.

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LACMA can help you: • Reschedule your date • Relocate for your convenience • Reduce number of call-in days from 5 to 1!

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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.

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.

FOR JOINING LACMA AND CMA

When you join LACMA and CMA, you hire a professional staff that serves as an extension of your practice. We are here to help you reach your goals and connect to the resources you need most. Whatever you need—be it help with a problematic payor, or details about your member discounts—just call the member helpline at (800) 786-4262 or visit www.lacmanet.org

RIGHT NOW

is the best time to join LACMA and CMA For more information on member benefits and resources, visit www.lacmanet.org/Membership LOS ANGELES COUNTY MEDICAL ASSOCIATION 707 WILSHIRE BLVD, SUITE 3800 LOS ANGELES, CA 90017 PHONE: (213) 683-9900 FAX: (213) 226-0353

radiology leaking fire $1,000,000 MRI. covered.

In a Los Angeles a

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For decades, The Doctors Company has provided the highest-quality medical malpractice insurance. Now, the professionals of The Doctors Company Insurance Services offer the expertise to protect your practice from risks beyond malpractice. From slips and falls to emerging threats in cyber security—and everything in between. We seek out all the best coverage at the most competitive prices. So talk to us today and see how helpful our experts can be in preparing your practice for the risks it faces right now—and those that may be right around the corner. Call (800) 852-8872 today for a quote or a complimentary insurance assessment. n n n n

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