December 2013

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

REPORTING ON THE ECONOMICS OF HEALTHCARE DELIVERY

A PUBLICATION OF PNN www.PhysiciansNewsNetwork.com

DECEMBER 2013

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

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

d ecem b er 2013 | TA BLE OF CONT E NT S

Volume 144 Issue 12

COVER STORY

14

the sate of healthcare in california

Health experts weigh in on how the sweeping and massive Affordable Care Act is likely going to affect physicians’ pay, operations and overall flow of running their practices moving forward.

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

12 PNN | NEWS IN REVIEW

The latest headlines impacting the economics

Year oftaking challenges, victories of healthcare delivery in Southern California Another Look at Insurance United We Stand | AT WORK FOR YOU The California Medical Association’s 2013 Legislative 8 20Wrap-Up Coverage LACMA and CMA membership at work for you

From Your Association 4

President’s Letter | marshall morgan, MD

27 LACMA News | Association Happenings 26 CEO’s Letter | Rocky Delgadillo

SPECIAL REPORT

20

year of challenges, victories

California Medical Association’s 2013 Legislative Wrap-Up reviews what turned out to be a challenging year for the CMA.

20

By Juan Carlos Torres, CMA Vice President of Government Relations

class was magnified. In addition, 2013 included 12 special his year turned out to be a challenging year for the California Medical Association (CMA). We elections that resulted from various vacancies created by knew going into the legislative session that 2013 departures and resignations. would a historic year, withInc. the(aimplementation CMA faced an unprecedented number ofatscope of Physician Magazine (ISSN 1533-9254) is published monthly bybeLACMA Services subsidiary of the Los Angeles County Medical Association) 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Periodicals ©2012 Postage Paid at Los Angeles, California, and at additionalofmailing offices.Care Volume 143, No.

by LACMA Inc. Allinrights reserved. These Reproduction in whole or in part without written permission is practice expansionServices bills introduced the Legislature. the Affordable Act (ACA) and04 theCopyright wave prohibited. POSTMASTER: Send address changes to Physician Magazine, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 9001 7.

Advertising rates and information sent upon request. of legislative freshman. It lived up to our expectations. scope bills were painted by supporters as necessary reforms to help implement the ACA. Those who wanted to expand With the beginning of each session, there are new legislators that come to Sacramento from all walks of life. scope had a key message: we need allied health professionals, including nurse practitioners, and pharmacists, CMA’s government relations team is challenged with getting d e c eoptometrists m b er 2013 | w w w. p h y s i c i a n s n e w s n e t w o r k .c o m to know them, educating them on issues of importance to to do more in order to prepare for the many Californians added to California’s health care system through the ACA the physician community and identifying the physicians with

1

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sional association representing physicians from every medical specialty and practice setting as well as medical students, interns and residents. For more

LACMA Officers President

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than 100 years, LACMA has

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strive toward a common goal– that you might spend more time treating your patients and less time worrying about the challenges of managing a practice.

Marshall Morgan, MD Pedram Salimpour, MD Peter Richman, MD Vito Imbasciani, MD Samuel I. Fink, MD LACMA BOARD OF DIRECTORS

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relations. Through its advocacy

Christina Correia 213.226.0325 | christinac@lacmanet.org Kirk Bennett 925.272.0857 | kbennett@physiciansnewsnetwork.com Dari Pebdani 858.231.1231 | dpebdani@gmail.com David H. Aizuss, MD Troy Elander, MD Thomas Horowitz, DO Robert J. Rogers, MD

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

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Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

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PRE S IDENT ’S LE T T ER | MA RS HA LL MORGA N, MD

By the time this letter is published some of us

will have recently experienced the holidays of our traditions, while others among us look forward to them. These holidays tend to cluster around the winter solstice, when the days grow short and the temperature drops. This is a time to take stock: to count our blessings and accomplishments, assess the opportunities and difficulties that lie before us and to set goals for the coming year.

With respect to “counting blessings,” it is a blessing to be a physician. We are privileged to help other human beings, our patients. We enjoy, and I believe we deserve, the respect others give us because we are physicians.

We therefore have a duty, I believe, to honor, respect, protect, and improve the profession. One of the principal ways we do so is to participate in professional organizations, which are the principal bulwark against many of the threats to the profession.

As you know, our profession does face significant threats. Professional groups with less training and less competence seek expansion of their scope of practice, which, should they succeed, would create a threat to the health of those they would treat, and a threat to the profession of medicine. Our professional organizations, in particular the CMA, are the principal force that pushes back and regularly thwarts these attempts.

The health insurance companies and health plans regularly deny reimbursement and interfere with the practice of medicine by arbitrarily determining that care provided in good faith by qualified professionals was “medically unnecessary.”

They have also inappropriately, and we believe illegally, retaliated against doctors who have referred patients, who are entitled to out-of-network care,

4 PHYSICIAN MA G A Z INE | d e c e m b er 2013

to out-of-network physicians or facilities. LACMA has filed lawsuits against companies on behalf of physicians and patients who have suffered from these practices.

The trial lawyers and their allies are mounting a determined, well-funded attack against MICRA. Should they succeed, the cost of practicing medicine will rise to levels that will surely drive many doctors out of practice, or out of state, and the cost of health care will increase, harming many patients.

We do have allies in this battle, but we physicians must do our part by raising substantial amounts of money for the MICRA PAC, communicating with our patients and the public and strongly supporting the CMA’s leadership in this effort.

We cannot effectively fight these battles and defend against these threats without a strong CMA. More than a quarter of California’s physicians live in Los Angeles County. Without a healthy LACMA, there cannot be a healthy CMA. Therefore, I submit that of all the threats faced by medicine in California, the most significant is LACMA’s membership.

The ongoing decline in LACMA membership is an existential threat not only for LACMA but for CMA as well.

It is our duty to address this problem, and we are doing so. Our efforts to improve membership are bearing fruit in that we have “bent the curve”: the rate of decline in membership has decreased perceptibly, but slowly. Our executive leadership and staff have raised the profile of LACMA among physicians, civic leaders, and the general population by filing lawsuits, increasing media exposure, and creating the very well-received LACMA Healthcare Awards program. They have developed new member benefits and reached out to local ethnic physician organizations and academic physician practices. We as individual LACMA members need to support and participate in these efforts and in addition “retail” to our colleagues the vision of a strong, vibrant, important LACMA. This is, as Joe Biden might say, “a big ******* deal,” Stay tuned. Pitch in. Help out.

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

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PR ACT ICE M A NAGEMENT | FRONT OFFICE

Risk Tip

Malpractice Case Shows Risk from Physician Not Dating and Initialing Reports Phys i cia n s must b e certain that there is a process in place to ensure that no imaging, laboratory

or consultant’s report is ever filed unless it has been dated and initialed by the physician as proof that it was reviewed. Many medical liability claims would be prevented by this simple policy.

It is also important to create a suspense file or electronic health record (EHR) follow-up list for all ordered imaging studies, laboratory tests, diagnostic procedures, and consultations—to ensure that they were completed and that the physician reviewed the reports.

The following case is an example of a “perfect storm” that led to a malpractice claim: A patient over the age of 50 was referred by the primary care physician to an orthopedist for evaluation of a two-year history of low back pain. The orthopedist ordered X-rays that showed a questionable lytic lesion measuring 6 cm in diameter in the right iliac bone just superior to the acetabulum. The orthopedist’s routine was to personally review his patients’ X-rays, which he did in this case, but he focused on the lumbar spine

6 PHYSICIAN MA G A Z INE | d e c e m b er 2013

and did not see the lytic lesion.

The radiology report was sent to the orthopedist’s office and filed without his review. No office policy existed to ensure that reports were filed only after he had initialed and dated them.

An X-ray taken eight months later again showed the large lytic lesion in the pelvis. The orthopedist reviewed the films and again missed the lytic lesion. The radiology report was not found in the orthopedist’s file.

Four months later, the orthopedist performed an L5 laminectomy. Follow-up X-rays again noted the expansile lytic lesion.

These films were reviewed by the orthopedist, who focused on the operative site in the lumbar spine and failed to see the lesion. The radiologist’s report was faxed to his office and filed; it had not been brought to his attention.

An MRI done one month later showed a lobulated, expansile lesion in the pelvis, suspicious for low-grade chondrosarcoma. The radiologist phoned the orthopedist to discuss the findings—it was the first time the orthopedist realized that an abnormality was present.

The patient was immediately referred to a major medical center, where the patient underwent partial resection of the pelvis and hip with amputation of the right leg. A claim was filed alleging failure to appreciate the presence and significance of a lesion diagnosed as chondrosarcoma more than three-and-a-half years after it was first noted in the filed radiology reports.

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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PR ACT ICE M A NAGEMENT | FRONT OFFICE

New Services and Practice Models Mean it’s Time to Take

Another Look at Insurance Coverage

By: Rick Bender, President, Bender Benefits Inc. and Jeff Brunken, President, The MGIS Companies Inc.

Phys i cia n groups in California today are incorporating a number of strategies to maintain

the viability and success of their practices. All of these changes can create new issues related to liability and risk. But with their busy schedules and multitude of responsibilities, physician leaders don’t have the time to fully understand the implications that new practice strategies may bring, or to develop effective risk management programs to address new increases in exposure and liability.

A Need to Look at the Big Picture

Medical groups today must adapt to an everchanging environment, which includes many new services that are of value and interest to patients.

However, to protect the group and minimize risks and ensure safety, there are a number of issues physician leaders should examine.

Practices are Changing

Over the next three years, more than 50% of physicians plan to make significant changes in the way they practice medicine.1 Some are selling their practices to larger health systems, merging with other groups, offering concierge or direct pay, or adopting other practice model options. Still others are looking toward offering supplements, nutritional products and dietary counseling, sports medicine and anti-aging programs.

In a survey done by a trade journal a few years ago, it was found that more than 75% of physicians and chiropractors, etc., sold supplements in their office.2 And the anti-aging market – fueled by increased physician office sales – is expected to grow to more than $290 billion in the next few years.3

8 PHYSICIAN MA G A Z INE | d e c e m b er 2013

All of these options have brought new opportunities for increased revenue, and building a strong patient base, while also increasing risk and opportunities for lawsuits.

When a physician—and by extension the medical group—recommends a product, the physician and group will take on the liability risk if a problem arises.

For example, if nutritional supplement firms promise strong sales, can they also promise little downside in terms of risk? Established nutritional supplement firms have few active claims. However, there have been some highly publicized claims against a few companies touting some nutrition and anti-aging products sold by physicians.

That’s not to say don’t explore such options, just be sure to engage in due diligence. Look closely at a company’s track record. Have there been lawsuits?

What was the outcome? If there is a problem, will the company provide legal representation? Most importantl, check with your current insurance carrier and broker to determine their opinion(s) (perhaps they are aware of related claims) and find out how your current liability program and costs may change.

Adding different services, such as sports medicine or nutrition counseling, also changes a group’s risk profile. A number of physician groups are adding nutritionists, sports medicine specialists, even aestheticians to their practices, which frequently entails bringing in new equipment and products. If those service providers are employed and see patients, the group needs to ensure they are covered under the existing group policy. If they are considered consultants or independent contractors, make sure they are covered by insurance policies offered by reputable firms and that the coverage is adequate for the service provided. Also check on the track record and insurance coverage of the equipment manufacturers used by such service providers.

How New Practice Models Impact Liability

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There needs to be a clear assignment of risks and responsibilities, and all parties need to know what is and is not covered.

This type of information is only obtained by asking a lot of questions and paying special attention to critical areas.

growing number of practices are incorporating Accountable Care Organization (ACO) or Patient Centered Medical Home (PCMH) models. These business models do hold promise for many groups; however, before moving forward, it’s important to determine who owns the ACO, and identify who holds the risk in the event of a malpractice claim. The spirit of the ACO is that physicians should run the program, but under current models most physicians, or their group, don’t have the infrastructure to fully own or manage the ACO. It is often hospital systems or very large groups that develop the model and then look to partner with local medical groups.

The insurance model currently used for ACOs and PCMH programs is similar to managed care, meaning physicians and the groups carry much broader risk and therefore need greater liability coverage. Before entering into an ACO, be very clear on the responsibilities, ownership and risk for the ACO and the group.

Insurance policies must fully cover the physician as well as all other providers. The group, the physician and every provider who comes in contact with the patient must have clearly worded and comprehensive coverage to ensure protection.

Under ACOs, patient volume will also likely increase, especially as practices continue to consolidate. To adjust, many groups will be adding physician extenders such as physician’s assistants and nurse practitioners, or bringing in other levels of caregivers for basic care such as taking patient histories.

Here’s where it can get tricky for those that haven’t checked insurance coverages recently. Because ACOs are still so new, insurers still don’t know exactly where the new types of claims may occur.

However, there are many things we do know. For example, there needs to be a clear assignment of risks and responsibilities, and all parties need to know what is and is not covered. This type of information is only obtained by asking a lot of questions and paying special attention to the following critical areas: 1. Who is running the ACO and what type of coverage do they have? The hospital group, or a physician group? That’s perhaps the most critical area to examine. You don’t want to find out after a claim is made that you as a physician had new liability you did not understand and are not covered. Similarly, you don’t want to learn that the entity managing the ACO entity did not have the right coverage.

2. Who is responsible for selecting providers – your new peers and colleagues? If the ACO management is responsible for selecting and vetting pro-

1 0 PHYSICIAN MA G A Z INE | d e c e m b er 2013

viders and if there is a subsequent claim involving improper screening or hiring, whichever party is responsible for this ACO function will be the target.

3. Who will handle contract negotiations? The ACO management will likely be charged with negotiating contracts with Medicare and Medicaid. If there is a claim citing that poor incentives led to improper care, again, the party responsible for this ACO function will likely be held liable.

4. What happens in the case of a claim involving electronic medical records and patient privacy?

There will be considerable data sharing within an ACO among other physicians, providers and hospitals. Steps must be taken at each juncture of the process to ensure medical record security. In the event of a breach, depending upon the circumstances, the ACO would likely be responsible.

Medical groups should not only address security, but also ensure that resources are in place to properly respond to a breach.

There are also issues to consider with PCMH models, beginning at what services the group now promises to deliver. PCMH programs strive to offer more patient-centric care, greater care coordination and integration. Groups are at risk when they are unable to deliver on the promises offered by a new model.

PCMH models in particular will strive to be very hightouch, creating greater demands on providers to meet standards and guidelines.

Look for Expert Guidance

Carriers, physicians and ACO administrators are discussing how to handle evolving practice models.

In some instances, established carriers and brokers are conducting analyses and making assumptions based on trends and examples from similar models, such as managed care insurance programs. In other instances, new insurance programs are being built for specific models, such as ACOs. These will be updated as data and claims information is generated.

Within today’s uncertain insurance marketplace, it is vital to ask the right questions, read contracts carefully and have a knowledgeable insurance broker by your side to serve as a resource to answer questions and advocate on behalf of the medical group and its physicians.

About the Authors: Rick Bender is president of Bender Benefits Inc., a Los Angelesbased broker specializing in services for insurers. Jeff Brunken is president and CEO of The MGIS Companies, a Salt Lake City-based company providing insurance products exclusively for physicians since 1969. More information is at www.mgis.com.

Physicians Foundation, Biannual Survey, 2012. http://www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf http://www.consumerreports.org/cro/2012/05/your-doctor-as-salesman/index.htm 3 http://www.cnn.com/2011/12/28/health/age-youth-treatment-medication/ index.html 1 2

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PNN | LOCAL • TIMELY • RELEVANT

reporting on the economics of healthcare delivery most read

State Medical Board Seeking Expert Reviewers in LA The Medical Board of California is looking for Los Angeles County physicians, in particular pain management experts, to become expert reviewers, according to the board’s program support analyst.

Experts assist the Medical Board by providing reviews and opinions on Medical Board cases and conducting professional competency exams, physical exams and psychiatric exams.

Participating physicians are reimbursed $150 per hour for conducting case reviews and oral competency exams, $200 an hour for providing expert testimony, and usual and customary fees for physical or psychiatric exams.

USC, Hoag Latest to Join Trend to Coordinate Cancer Care Major healthcare systems in both Los Angeles and Orange counties recently announced plans to affiliate their oncology programs, marking the accelerating trend of academic medical centers and health systems to join efforts to try to improve patient outcomes and cut waste under health reform.

The University of Southern California and Hoag Memorial Hospital Presbyterian announced their plans to create a new cancer and oncology services program at the Hoag Family Cancer Institute.

The new program seeks to expand patient access to care and university-based clinical trials and academic training centers.

Health Insurance Giants Send Out Cancellations in LA County Health insurers Kaiser Permanente, Blue Shield of California and Anthem Blue Cross of California have all sent out cancellations to individual policyholders in LA County and elsewhere in California, forcing many middle-class consumers to buy more expensive policies and possibly lose access to their longtime primary care physicians.

The policies have been cancelled because they fall short of the requirements put forth under the Af1 2 PHYSICIAN MA G A Z INE | d e c e m b er 2013

fordable Care Act. Individual policies must cover a higher percentage of overall medical costs and include 10 essential health benefits, such as prescription drug coverage and mental health services.

LA Malpractice Insurer Offering More Products to Larger Market The rise in mergers and acquisitions in the healthcare industry, driven by health reform, has also led to changes in what malpractice insurance carriers offer physicians in Los Angeles County and elsewhere.

Cindy Belcher, a senior VP of the Cooperative of American Physicians (CAP), a Los Angeles-based malpractice insurance company, said while CAP has traditionally offered medical professional liability coverage to solo practitioners and small to midsize group practices, it now also serves larger physician practices, hospitals and facilities.

“We have created products and services that meet the needs of physicians regardless of their practice types,” Belcher said. “We haven’t changed our focus—we have expanded our product line.”

Comparison Shopping Website Now Lists 40 LA County Providers Los Angeles-based Save on Medical, a website for consumers shopping for and scheduling affordable healthcare procedures, recently announced that consumers can now schedule appointments with some 40 radiology providers in Los Angeles.

Patients can also use the website to do comparison-shopping for pricing of radiology procedures online. With 17% of the city’s residents uninsured, patients will be looking for affordable care options, the company said in a written statement.

The idea of comparison-shopping in healthcare, while relatively new, is expected to see an upward trend in this changing healthcare environment. With healthcare costs rising and consumers being on the hook for a growing share of their medical bills, more companies are creating tools to help consumers find the best prices for medical procedures and drugs online.

UPDATE: Aetna Lawsuit Dr. Robert Bitonte, Los Angeles County Medical Association’s chairman of the Legal Affairs Committee, offered an update on the status of the pending Aetna lawsuit filed by LACMA. In the lawsuit LACMA filed against Aetna on July 3, 2012, charging that the insurer often refuses to reimburse policyholders who go out of their networks when medically necessary, even though they have purchased policies that allow them to do so, legal proceedings continue, according to Dr. Bitonte.

“We just filed a fourth amended complaint in October reiterating our fundamental allegation that physicians were interfered with in their medical decision-making process,” Dr. Bitonte told PNN. “We are still very early in litigation and nothing substantive has been decided. I would say the reality is that we are probably in a prolonged (legal battle) and that a resolution to the issue is not going to be forthcoming in the immediate future,” he said.

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LACMA Welcomes 200 New Members from USC’s Keck Medicine LACMA announced recently that 200 physicians from Keck Medicine of USC have joined the professional organization.

The addition is the largest group to join LACMA in the last 15 years.

“We’re at a pivotal point in healthcare in our country,” said Dr. Stephanie Hall, chief medical officer for Keck Hospital of USC and USC Norris Cancer Hospital, both part of Keck Medicine of USC. “From major changes such as the Affordable Care Act to challenges such as physician shortages and effective patient care, it’s important that we add our voices to organizations like LACMA that are committed to bringing effective advocacy to the front line of the healthcare debate.”

f eatu r e | healthcar e i n cali for n i a 1 4 PHYSICIAN MA G A Z INE | d e c e m b er 2013

HEA LT HCA RE IN CA LIFOR NI A | f eatu r e

BY MARION WEBB

W

ith the Affordable Care Act moving into its key implementation phase on Jan. 1, 2014, physicians can count on being af-

fected in various ways.

In this article, health experts will weigh in on how the sweeping and massive legislation is likely going to affect physicians’ pay, operations and overall flow of running their practices moving forward.

Find out what to expect in terms of Medicare and Medicaid reimbursement, learn about new regulations, how the California exchange will impact your business, what the rising consolidations in healthcare could mean for your practice and how to stay abreast of the changing doctor-patient relationship.

f eatu r e | healthcar e i n cal i for n i a

M

edicare and Medicaid Expansion

Despite a massive overhaul with an estimated 165 provisions affecting the Medicare program, doctors continue to face the threat of deep payment cuts under Medicare’s sustainable growth rate (SGR) formula, which governs the annual growth of Medicare physician payment.

The drastic provider payment cuts called for by the SGR would cut seniors’ access to care, according to an expert with the Heritage Foundation.

Congress has passed the temporary “doc fix” each year since 2003 to override the flawed pay system.

And once again, for 2014 physicians face an estimated pay cut of 25% unless Congress passes another doctor fix.

On the upside, the new law does provide some relief for physicians, according to the expert.

For instance, Medicare primary care physicians and general surgeons practicing in “shortage areas” began receiving a 10% bonus payment in 2011.

Obamacare also temporarily increases Medicaid payment for primary care doctors to no less than 100% of the Medicare payment rates for their services for 2013 and 2014, with the federal taxpayer making up the difference between Medicaid funding and the higher Medicare pay rates, according to the expert.

While this may be some consolation for Medicaid doctors, the expert noted that the pay is still significantly less compared to the private sector—in 2009, Medicare paid doctors about 80% of private-sector pay.

There is no provision for continued federal taxpayer funding beyond these two years, so taxpayers in the states will have to fund significantly higher Medicaid costs or their Medicaid physicians will face a payment cliff.

M

ore Rules

The ACA will impose more rules and regulations on physicians, including forcing physicians to an electronic filing system, which offers financial incentives if the conversion is completed and electronic files are used in a meaningful way.

However, for some smaller or solo practices, upgrading to electronic records will also be costly and complicated.

While this has been widely discussed in the media, some doctors may be less aware of the new agencies and programs that will have a direct

1 6 PHYSICIAN MA G A Z INE | d e c e m b er 2013

effect on their daily practice.

Let’s take a closer look: 1. The Patient-Centered Outcomes Research Institute: This nonprofit institute will examine clinical effectiveness of medical treatments, procedures, drugs and medical devices. While it remains to be seen how the findings and recommendations will be implemented or applied, and what financial incentives, penalties and regulatory requirements will accompany them, they could be valuable for doctors or interfere with their doctor-patient relationship.

It’s too early to say, the expert noted.

2. Independent Payment Advisory Board: The IPAB’s goal is to reduce the per capita growth rate in Medicare spending in accordance with specific targets and make recommendations for slowing growth in non-federal health programs. These recommendations would go into effect unless Congress enacts an alternative proposal of equivalent savings.

3. Physician Quality Reporting System (PQRS) and Value-based Pay: The value-based pay modifier, which will be applied to Medicare physician reimbursement starting in 2015, will adjust pay to reflect performance using quality data from the Physician Quality Reporting System (PQRS) and cost data from the Medicare feefor-service claims.

In 2015, the Centers for Medicare and Medicaid Services (CMS) will begin levying penalties based on the PQRS, in which physicians report quality measures that they select from a CMS list, according to Medscape.com.

Right now, the penalties do not exceed 1.5%, but when the PQRS and electronic medical records penalties kick in in 2015, doctors could receive a maximum total fine of 4.5%, which would rise to 6% in 2016 and 7% in 2017, Medscape.com reported in August.

The PQRS penalty follows up on a voluntary reporting program that most practices did not participate in.

While these programs are designed to improve the quality of care, some experts worry it could also create economic incentives to comply with standardized guidelines at the expense of individual patient care, encouraging doctors to achieve a high and financially beneficial score as a condition of participating in the government’s health program.

The new law removes some major impediments in insurance coverage for patients and mandates extra services that payers may not have previously covered.

Some experts believe that the Medicaid expansion and patients being covered on the exchange could be a boon for family doctors looking to grow their practices, but others see it as exacerbating the existing doctor shortage.

For newly insured patients who previously couldn’t afford to pay for medical care, the law will provide access to preventive care that is also expected to improve health outcomes.

In 2011 and 2012, the ACA required insurers to cover 63 preventive services without requiring an out-of-pocket pay from patients. They included blood pressure and mammography screenings, immunizations and childhood and autism screenings.

In 2014, individual and small group plans will have to cover specific services, including maternity care, mental health services, medications, rehabilitation services, and chronic disease management.

Primary care doctors, in particular, can expect to see more patients showing up for these services as well as annual exams; pediatricians will likely see more patients for “well-baby” visits and developmental screenings before a family member gets sick.

Insurers will need to pay doctors and other providers for these services.

will be lower than those of other commercial plans.

Many doctors reportedly refuse to join exchange plans, which would mean that exchange plans would have to offer reasonable rates to keep enough doctors in their networks.

Some exchange plans, concerned that their networks do not have enough physicians for the new enrollees, are reportedly pressuring more doctors to sign up.

While Covered California is ramping up its community outreach, doctors in private practices also need to be prepared to do a lot of education with their own patients.

A recent survey suggests that many consumers

While Covered California is ramping up its community outreach, ,doctors in private practices, also need to be prepared to do a lot of education with their own patients.

C

alifornia’s Health Insurance Exchange-Covered California

The experts say that much remains uncertain.

The rollout of healthcare.gov was mired in problems, and some experts worry about a spillover effect to Covered California.

Peter Lee, the executive director of Covered California, reportedly said that Covered California announced that 179,562 applications for insurance were started through Oct. 26, covering the first four weeks of enrollment.

Meanwhile, it remains unclear what the reimbursement rates are for doctors and whether rates

are confused about the exchange and health reform as a whole.

And a large majority of California’s eligible uninsured—seven in 10 as of late August—didn’t have enough information about the ACA to understand how it will impact them, according to a survey by the Kaiser Family Foundation.

Those who do sign up on the exchange and even covered employees will likely be faced with higher out-of-pocket charges, which will make it pertinent for practices to rethink their payment policies.

According to surveys by the Kaiser Family Foundation, the percentage of covered employees having a deductible for single coverage rose from 52% in 2006 to 72% in 2012.

In 2012, the average general annual deductible for this population was $1,097, an 88% rise since 2006, the foundation reported.

Similarly, health exchange plans will have relatively high out-of-pocket costs with the benchmark

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M

ore Covered Services

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“silver” plan on the exchange.

An enrollee with a $45,000 annual income is looking at a $2,000 deductible for medical services and co-pays of $45 to $65 for an office visit with the “silver”plan.

To make sure that doctors collect out-of-pocket charges, experts recommend collecting charges upfront.

If patients are unable to make the payment at the time of service, experts recommend setting up a pay plan or credit card payment before service is provided.

R

ating Physicians

In this new health economy, doctors need to look at patients as savvy consumers who will be shopping for the best deals and rating doctors.

H e a l t h c a re consumers can also pick physicians by going to the Physician Compare Website, which CMS rolled out in December 2010 and upgraded this summer.

In 2013, Physician Compare was supposed to add quality data gathered by PQRS, but that has been delayed until 2014. In early 2014, the site will include 2012 PQRS data from group practices and Accountable Care Organizations.

CMS reportedly has agreed to a 30-day preview period for physicians to view their information before it is posted. While some physicians may be concerned about these reviews, consumers will turn to these sites to do their comparisonshopping.

and shared networks, will likely be confusing for some time to come.

Moreover, doctors will be going through a cultural transformation where they will not only be forced to shave costs by sharing resources, but also learn how to work as part of a team and share clinical decisions with other caregivers.

The way doctors interact with patients will also change with more follow-up care outside the practice to improve outcomes and the use of more technologies, including emails and text messages, to communicate with patients.

In fact, some experts predict that the new reimbursement system will not reward doctors for face-to-face visits. More doctors are expected to be offering virtual visits and use health IT devices to run a more efficient practice.

Indeed, in 2012, CMS started imposing a penalty on physicians who didn’t meet e-prescribing levels.

In 2015, CMS will begin imposing penalties for not complying with EMR implementation standards following up on “meaningful use” incentive pay for EHRs. While many physicians are anxious about health reform, with some contemplating leaving the profession or going into early retirement, according to reports, the chances of the law being repealed are slim.

Critics of Obamacare also say the law doesn’t address such key issues as tort reform and predict it will negatively affect the patient-doctor relationship.

For others, the ACA signifies the opening of a door to provide care to patients who previously were denied insurance or didn’t have the means to afford medical care.

No matter which side you are on, one thing is for certain: Starting Jan. 1, the ACA will carry out the largest insurance coverage expansion since 1965 and make history.

LACMA is encouraging doctors in Los Angeles County to unite behind their organization to ensure that their voices are being heard.

CMS reportedly has agreed to a

30-day preview period for phy-

sicians to view their information before it is posted.

R

ising ConsolidationsWhat it Means For You

Some experts believe that the consolidation trend, with solo practitioners joining larger practices and hospitals gobbling up practices, will continue well into 2014.

The new payment methodologies, which require IT systems, a great deal of data reporting,

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HEA LT HCA RE IN CA LIFOR NI A | f eatu r e

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un i t ed w e stand | 2013 Legi slati ve wr ap- u p

Year of challenges, victories The California Medical Association’s 2013 Legislative Wrap-Up

By Juan Carlos Torres, CMA Vice President of Government Relations to be a challengingyear year for class was magnified.

In addition, 2013 included 12 special T h i s y e a r this u ryear n e turned d out out to be a challenging for the California Medical Association (CMA).

We knew would be

California Medical Association (CMA).

We care reform elections(ACA) that resulted from various vacancies created

by We a historic yearthe with the implementation of federal health and the wave of legislative freshman. knew going into the legislative 2013to educate departures and resignations. anticipated that many issues would arise session as we that helped new legislators not only about the ACA, but about would be a historic year, with the implementation CMA faced an unprecedented number of scope of the many issues important to the physician community in California. of the Affordable Care Act (ACA) and the wave

faced an unprecedented number of scope of practice exofCMA legislative freshman. It lived up to our expectations. pansion bills introduced in the Legislature. These scope of practice With the of brush each session, therereforms are newto help bills were painted beginning with a broad as necessary implement thethat ACA. Those wanted to expand scopeofhad legislators come to who Sacramento from all walks life.a key message: we need allied health professionals, including nurse practiCMA’s government relations team is challenged with getting tioners, optometrists and pharmacists, to do more in order to prepare know educating importance forto the manythem, Californians whothem wouldon beissues new toofthe health caretoinfrastructure in California.

Our message was simple: will not jeoparthe physician community and identifying thewephysicians with dize patient safety and we need to have—relationships. promote integration ofWhile allied health whom they have—or should the professionals, not fragment them as these proposals suggested.

Legislature had up effort to onebythird of its members turnoptomover We faced ahas concerted the nurse practitioners, in any year, thiswho yearjoined a majority of legislators wereagenda new etrists andgiven pharmacists together to push their collectively.

They put significant resources to mountthe a public to Sacramento.

Theinchallenging task of educating new re2 0 PHYSICIAN MA G A Z INE | d e c e m b er 2013

practice expansion bills introduced in the Legislature. These

lations campaign and were actively pursuing newspaper editorial scope bills were painted by supporters as necessary reforms boards across the state to promote their agenda. With the help of help implement the our ACA. Those whosocieties, wanted to expand ourtospecialty partners and local medical CMA won the argument in the Capitol.

We we successfully defeated the attempt by scope had a key message: need allied health professionals, nurse practitioners gain independent practiceand in California, as well including nurse to practitioners, optometrists pharmacists, as efforts by optometrists seeking to diagnose and treat diseases in to do more order to prepare for the the pharmacists’ many Californians patients.

CMA in significantly narrowed proposal to ensure that could provide in the an integrated added to they California’s healthreasonable care systemservices through ACA and safe manner thatOur promoted collaboration implementation. message was simple:with we physicians. will not CMA also tackled the incorrect perception that physicians are at patient safety and wecrisis need to promote integration thejeopardize center of the opioids overdose occurring in California.

Phyof allied healththe professionals, notensure fragment them asprescribing these sicians recognize need to help appropriate and the needsuggested. to tackle abuse and diversion of prescription drugs. proposals

uted the remainder. The funds are one time in nature and are exclusively for the upgrade of the database platform. While this funding was taken from medical board reserves, we were able to defeat attempts to have new licensing fees pay for this upgrade.

We also advanced our efforts to prioritize the need to increase Medi-Cal provider rates. There were two bills introduced in each house that called for this increase. A new coalition, We Care for California, was formed to advocate for that increase. With CMA playing a key role and under the new We Care for California banner, thousands of health care providers from across the state converged on the state capitol in the largest ever health care rally in Sacramento. The historic event, called “WE ARE MEDI-CAL,” included administrators, physicians and frontline health workers from every region of the state.

CMA sponsored legislation addressing the need to provide incentives to encourage physicians to practice in underserved communities. Addressing workforce issues, not scope expansion of allied professionals, is the long term solution to the physician distribution issues faced in California. Two CMA-sponsored bills (AB 565, AB 1288), both signed by Governor Brown, will encourage physicians to locate their practices in the Central Valley, Inland Empire and other underserved regions of our state.

There is no doubt that CMA faced a many battles this year, but thanks to the advocacy of the physician community and our government relations team, we won these battles. Bills that we opposed were either defeated or significantly amended to address our concerns. Our sponsored bills, with the exception of two, advanced to the Governor and have been signed. CMA has again demonstrated the important role it plays in shaping health policy in Sacramento.

As always, CMA will be prepared to lead our state forward.

Following are details on the major bills that CMA followed this year. CMA-Sponsored Legislation:

Moving the Physician Agenda Forward CMA didn’t just play defense. CMA made significant progress in moving our proactive agenda forward this year.

After several failed attempts in years prior, CMA partnered with local legislators to successfully secure an annual $15 million appropriation to fully fund the University of California, Riverside School of Medicine, which will be the first new four-year medical school established in California in over 40 years. The effort began this year with two CMA-sponsored bills introduced by newly elected Inland Empire legislators (SB 21 and AB27), but eventually the conversation shifted to the budget process. Following the approval of the funding in the 2013-2014 state budget, the school welcomed its first class of four-year medical students this fall.

The budget also included $3.9 million to upgrade the CURES database, $1.6 million of which was from the Medical Board of California contingent fund (licensing fees). The other professional licensing boards contrib-

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2013 Legi slati ve wr ap- u p | un i t ed w e stand

We helped craft a proposal that will ensure that our state’s prescription monitoring program, CURES, will be upgraded and funded.

CMA also secured a streamlined application process for CURES, a requirement that a stakeholders group be consulted as the upgrade and maintenance occurs, and a reduced fee impact on physicians. Most importantly, there will be no mandated participation required of physicians.

A proposal that would have given the medical board overly broad power to discipline physicians for inappropriate prescribing was soundly defeated by CMA in an overwhelming fashion on the Assembly floor. CMA was also able to garner amendments to a bill that would have required coroners to report overdose deaths due to controlled substances to the medical board, to ensure that any reports submitted by coroners would remain confidential. (This bill, SB 62, was ultimately vetoed.) In addition, an effort to shift the investigative authority from the Medical Board of California to the Department of Justice was defeated.

The trial attorneys’ campaign to eviscerate the Medical Injury Compensation Reform Act (MICRA) was also in full gear this year.

Trial attorneys invested heavily in three additional lobbyists and launched a public relations campaign titled “38 Is too Late,” and made several attempts to push a bill through the Legislature. All these efforts resulted in no action in the Capitol, not even the introduction of a bill, a major victory for CMA. While CMA is proud of our legislative victories this year, we understand that these battles will continue next year. Trial attorneys are initiating a ballot fight, allied health professionals will continue to call for inappropriate scope expansion and legislators will continue to focus on prescription drug abuses. CMA will continue to be the voice of the physician community and is prepared to take on these challenges.

Many of our fights garnered significant media attention. The Sacramento Bee outlined the five major battles facing the Legislature in the closing month of session. Of the five battles, CMA was front and center on two—each of which CMA won!

un i t ed w e stand | 2013 Legi slati ve wr ap- u p

CMA Co-Sponsored Legislation __________________________________________ SB 21 (Roth): UC Riverside Medical School This bill appropriates $15,000,000 annually from the General Fund to the Regents of the University of California for allocation to the School of Medicine at the University of California, Riverside. According to a 2010 report by the California Health Care Foundation, the Inland Empire has the lowest ratio of primary care physicians and specialists of any region in the state. The Council on Graduate Medical Education, a federally funded and authorized group that assesses the physician workforce and reports to federal policymakers, recommends a minimum of 60 to 80 primary care physicians and 85 to 105 specialists per 100,00 people.

Sadly, the physician and specialist ratio in the Inland Empire is barely half of that recommended number. The UC Riverside School of Medicine is a critical factor in addressing this need, and consistent state funding is needed for the school to maintain its accreditation. Status:

Signed by the Governor.

SB 640 (Lara): Medi-Cal: Reimbursement Provider Payments This bill seeks to restore the 10 percent Medi-Cal provider rate reductions contained in the 2011-12 state budget. CMA has built a coalition of different providers who have been impacted by the cuts or who, like CMA, are still in court over their implementation. This bill would both eliminate the retroactive portion of the cuts as well as stop them going forward. This will help provide needed stability to the Medi-Cal system as the state prepares for full federal health reform implementation on January 1, 2014. Status: Held in Senate Appropriations Com-

mittee.

AB 565 (Salas): California Physician Corps Program Ten years ago, CMA sponsored legislation to create the Steven M. Thompson Physician Corps Loan Repayment Program (STLRP) to increase access to primary care physicians in medically underserved areas. Although the STLRP has awarded more than $17 million to over 220 individuals, the high demand for this program means less than one third of applicants are awarded funding. Given the limited funds in this program, this bill will tighten the eligibility criteria of applicants to the STLRP and help identify gaps in placing physicians in the Central Valley, the Inland Empire and other underserved communities. Status:

Signed by the Governor.

AB 670 (Atkins): Therapeutic Substitutions This bill would prohibit pharmacists from receiving a financial incentive for recommending a patient receive a drug that is chemically different from the one prescribed by the physician, a practice known as therapeutic substitution.

There has been an increase in consulting contracts with pharmacists that carve out a separate fee each time a therapeutic substitution is recommended. Though the medicine may treat the same condition, the chemical ingredients are not the same. This often results in adverse side effects or ineffective treatment. Patients who are on medication to treat epilepsy or mental health conditions are particularly vulnerable. Therapeutic substitutions should be based upon the patient’s best interest, not a financial incentive. Status: Held in Assembly

Appropriations Committee.

AB 1003 (Maienschein): Employment of Physical Therapists CMA and the physical therapists had introduced competing bills this session, which were ultimately combined into one co-sponsored bill (see AB 1000). CMA’s bill would clarify existing law to explicitly authorize medical corporations to hire persons licensed under the Business and Professions Code, the Chiropractic Act or the Osteopathic Act. In November 2010, the Physical Therapy Board reversed decades-old policy that allowed physical therapy services to be provided by medical corporations. According to the California Employment Development Department, there are over 15,000 practicing physical therapists in California. Furthermore, California adds about 440 new physical therapy jobs each year. Nearly, 80 percent work in medical corporations, hospitals, home health care services and nursing care facilities. As a result, hundreds of physical therapists across California are at risk of losing their jobs. Status: Assembly Business and Professions Committee –

Hearing Postponed.

AB 1288 (V. M. Perez): Physician Workforce: Medically-Underserved Communities Assembly Bill 1288 will require the Medical 2 2 PHYSICIAN MA G A Z INE | d e c e m b er 2013

Board of California and the Osteopathic Medical Board of California to develop a process to give priority review status to the application of an applicant who can demonstrate that he or she intends to practice in a medically underserved area or serve a medically underserved population. AB 1288 will not change the vigorous standards that govern these professions but will instead focus the board’s resources on the areas and populations with the greatest need. Status: Signed by the

Governor.

CMA Co-Sponsored Legislation __________________________________________ SB 191 (Padilla): Emergency Room Funding Co-sponsored by the California American College of Emergency Physicians, this bill extends the sunset date to January 1, 2017. The bill raises approximately $50 million to augment local county emergency medical services funds in order to allow counties, hospitals and physicians to continue providing emergency services in their communities with these desperately needed funds. Emergency care in California is in crisis. In the past decade, more than 65 emergency departments (EDs) have closed; ED visits are up; wait times continue to increase, and hospital diversion is on the rise. Without this bill, the law is set to expire on January 1, 2014.

Status: Signed by the Governor.

AB 1000 (Wieckowski and Maienschein): Physical Therapists: Direct Access to Services and Medical Corporation Employees CMA and the physical therapists had introduced competing bills this session, which were ultimately combined into one co-sponsored bill (AB 1000). The joint bill clarifies an existing ambiguity in the law so that physical therapists can continue to work within the legal boundaries of medical corporations as they have for decades (as was the intention of CMA’s solo bill). The combined bill also gives health care consumers the ability to seek treatment from a physical therapist without a physicians’ consent for a limited period of time. Although CMA had previously opposed attempts to authorize such “direct access,” we believe that the final language is an acceptable compromise. The bill does not expand or modify the scope of practice for physical therapists, including the existing prohibition on a physical therapists diagnosing disease. Status: Signed by the Governor.

AB 1176 (Bocanegra): Primary Care Access: Residency Programs Co-sponsored by the California Academy of Family Physicians, this bill will follow the example of other states and create a funding source for underfunded medical residency training programs by drawing from private payers such as health insurance companies. According to the Council on Graduate Medical Education, 74 percent of California’s 58 counties have an undersupply of primary care physicians, with primary care physicians making up just 34 percent of California’s physician workforce. Status: Held in Assembly Appropriations Committee.

AB 1208 (Pan): Insurance Affordability Programs: Application Form The provisions that impacted physicians were deleted. The bill now deals with demographic data collection. Therefore we are no longer co-sponsoring this bill. Status: Vetoed by the Governor.

Opposed Legislation __________________________________________ SB 117 (Hueso): Integrative Cancer Treatment This bill would prohibit a physician and surgeon, including an osteopathic physician and surgeon, from recommending, prescribing or providing integrative cancer treatment, as defined, to cancer patients unless certain requirements are met. The bill would specify that a failure of a physician and surgeon to comply with these requirements constitutes unprofessional conduct and cause for discipline by the individual’s licensing entity. The bill would require the State Department of Public Health to investigate violations of these provisions. Status: Author pulled bill from

Senate Business and Professions Committee.

SB 266 (Lieu): Health Care Coverage: Out-of-Network Coverage This bill would prohibit a health facility or a provider group from holding itself out as being within a plan network or a provider network unless all of the individual providers providing services at the facility or with the provider group are within their network, or the provider group acknowledges to the patient in writing or verbally that individual pro-

to (1) treat and diagnose any disease, condition or disorder of the visual system, the human eye adjacent and related structures, (2) prescribe and administer drugs including controlled substances, (3) perform surgical procedures with local or topical anesthetic, (4) order laboratory and diagnostic tests, (5) administer immunizations, (6) diagnose and initiate treatment for any condition with ocular manifestations. Status:

SB 312 (Knight): Absences: Confidential Medical Services: Parent or Guardian Consent This bill would require the governing board of a school district to notify pupils in grades 9 to 12 and their parents or guardians, that school authorities may excuse a pupil from the school for confidential medical services who is 16 years of age or older without parental or guardian consent. Status: Failed in Senate

AB 591 (Fox): Hospital Emergency Room: Geriatric Physician This bill would require each general acute care hospital with an emergency department to have, at all times, a geriatric physician serving on an “on-call” basis to that department. Status: Pulled by author. AB 975 (Wieckowski): Health Facilities Community Benefits This bill would declare the necessity of establishing uniform standards for reporting the amount of charity care and community benefits a facility provides to ensure that private nonprofit hospitals and nonprofit multispecialty clinics actually meet the social obligations for which they receive favorable tax treatment. Status: Failed on Assembly Floor.

Committee.

Education Committee.

SB 430 (Wright): Pupil Health: Vision Examination: Binocular Function This bill would, before first enrollment in a California school district of a pupil at a California elementary school, and at least every third year thereafter until the pupil has completed the 8th grade, require the pupil’s vision to be examined by an optometrist or ophthalmologist and require the examination to also include a test for binocular function and refraction and eye health evaluations. The binocular function examination does not need to take effect until the pupil has reached the third grade and would require the parent or guardian of the pupil to provide results of the examination to the school district.

Status: Pulled by author in Assembly Health Committee.

SB 491 (Hernandez): Nurse Practitioners This bill gives nurse practitioners independent practice. Under this bill, nurse practitioners will no longer need to work pursuant to standardized protocols and procedures or any supervising physician and would basically give them a plenary license to practice medicine. Status: Held in Assembly Ap-

propriations Committee.

SB 492 (Hernandez): Optometric Corporations This bill allows optometrist to practice ophthalmology. Specifically, allows optometrists

Pulled by author in Assembly Business and Professions Committee.

ACA 5 (Grove): Abortion: Parental Notification This measure, which would be known as the Parental Notification, Child and Teen Safety, Stop Predators Act, would prohibit a physician and surgeon from performing an abortion on an unemancipated minor, as defined, unless the physician and surgeon or his or her agent has delivered written notice to the parent of the unemancipated minor, or until a waiver of that notice has been received from the parent or issued by a court pursuant to a prescribed process. Status: Re-referred to As-

sembly Health and Assembly Judiciary Committees.

Other Bills of Interest __________________________________________ SB 20 (Hernandez): Health Care: Workforce Training (Support) This bill would transfer all available funds left over in the Department of Managed Health Care’s Managed Care Administrative Fines and Penalties Fund to the Steve Thompson Physician Corps Loan Repayment Program, upon dissolution of the Major Risk Medical Insurance

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2013 Legi slati ve wr ap- u p | un i t ed w e stand

viders within the provider group may be outside the patient’s plan network or provider network and the provider group recommends that the patient contact his or her health care service plan or health insurer for information about providers who are within the patient’s plan network or provider network. Those provisions would not apply to emergency services and care. Status: Held in Senate Appropriations

un i t ed w e stand | 2013 Legi slati ve wr ap- u p

Program. Status: Held in Assembly Appropriations Committee.

SB 62 (Price): Coroners: Reporting Requirements: Prescription Drug Use (Neutral) This bill would expand those provisions to require a coroner to make a report when he or she receives information that indicates a death may be the result of prescription drug use and to require the coroner to additionally file the report with the Medical Board of California. Status: Vetoed by the Governor.

SB 138 (Hernandez): Confidentiality of Medical Information (Watch) The bill would define additional terms in connection with maintaining the confidentiality of this information, including an “authorization for insurance communications,” which an insured individual may submit for the purpose of specifying disclosable medical information and insurance transactions and permissible recipients.

Status: Signed by the Governor.

SB 304 (Lieu): Healing Arts: Boards (Neutral) The bill is the sunset extension bill for the Medical Board of California. Significant issues raised by CMA (expert witness, 820 evaluations) were addressed in CMA’s favor. Status: Signed by the Governor.

SB 352 (Pavley): Medical Assistants: Supervision (Support) This bill would prohibit a nurse practitioners, certified nurse-midwife or physician assistant from authorizing a medical assistant to perform any clinical laboratory test or examination for which the medical assistant is not authorized. Status: Signed by the Governor SB 439 (Steinberg): Medical Marijuana (Watch) This bill codifies the Attorney General’s “Guidelines for the Security and Non-Diversion of Marijuana Grown for Medical Use” and specifies that medical cannabis dispensaries that adhere to the guidelines will not be subject to prosecution for marijuana possession or commerce. Status: Pulled by

author in Assembly Health Committee.

SB 493 (Hernandez): Pharmacy Practice (Neutral) This bill, as introduced, would have expanded the scope of practice for pharmacists to include administering drugs and biological products that have been ordered by a prescriber and expanded other functions pharmacists are authorized to perform. These functions include, among other things, the furnishing of specified drugs including prescription smoking-cessation drugs; ordering and interpreting tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies; and to independently initiate and administer routine vaccinations. The introduced version of the bill also specified additional functions that may be performed by an advanced practice pharmacist, including performing physical assessments and certain other functions. The author has accepted numerous amendments offered

by CMA, which have the potential to improve access to vaccines for children and access to nicotine based smoking cessation products for adults seeking to end their addiction to tobacco products. The bill requires that all prescriptions be administered under a protocol with a physician. This will help improve the communication and coordination between the patient, their physician and their pharmacists.

Status: Signed by the Governor.

SB 494 (Monning): Health Care Providers: California Health Benefit Exchange (Support) This bill is sponsored by the Physician Assistants and seeks to amend statue to include physician assistants as primary care providers and to increase the number of enrollees assigned to physician assistants in Medi-Cal managed care plans. The bill maintains that physician assistants must operate under the supervision of a physician. Status: Signed by the Governor.

SB 495 (Yee): Postsecondary Education Employees: Physicians (Support) This bill would require the California State University (CSU) to increase the compensation of physicians employed at student health centers on campuses to be is comparable to the compensation earned at the University of California (UC). The bill would request the UC to increase the compensation of physicians employed at stu2 4 PHYSICIAN MA G A Z INE | d e c e m b er 2013

dent health centers on campuses of the UC if the compensation of physicians employed at a student health center on a different campus of the UC is increased. Status: Held at the Assembly Desk.

SB 598 (Hill): Biosimilars (Support) This bill would allow a pharmacist to substitute an interchangeable biosimilar medication when filling a prescription for a biologic medication. SB 598 mirrors California’s patient protections for generic pill substitution and adds a provision that requires a pharmacist to enter information about the substitution into the patient record system or notify the physician within five days after a substitution is made. Status: Vetoed by the Governor.

SB 615 (Galgiani): Prevailing Wages: California Health Facilities Financing Authority Act (Neutral) While the bill was moved out of the Assembly Appropriations Committee, the provisions of interest to CMA were removed. As a result, we are no longer co-sponsoring this legislation. Status: Vetoed by the Governor.

SB 670 (Steinberg): Physicians and Surgeons: Drug Prescribing Privileges: Investigation (Support, after significant amendments) CMA was able to secure amendments that deleted the provisions that would have expanded the Medical Board of California’s authority to limit a physician’s prescribing authority with a lower standard of evidence. With the deletion of these provisions, the bill simply made clarifying improvements to the medical board authority. Status: Signed

by the Governor.

SB 809 (Desaulnier): Controlled Substances: Reporting (Support) This bill would provide ongoing funding for the CURES database by requiring the Medical Board of California and other health professionals’ licensing boards to charge licensees who are authorized to prescribe or dispense controlled substances a fee of $6 annually. The bill also makes changes to the CURES authorizing statute to clarify that the database is a clinical tool and to simplify prescribers’ and dispensers’ enrollment into the database. Status: Signed by the Governor.

SBX1 1 (Hernandez): Medi-Cal: Eligibility (Support) This bill implements the expansion of federal Medicaid coverage in California (Medicaid is known as Medi-Cal in California) to low-income adults with incomes between 0 and 138 percent of the federal poverty level, establishes the Medi-Cal benefit package for this expansion population, and requires the existing Medi-Cal program to cover the essential health benefits contained in the Patient Protection and Affordable Care Act (ACA). This bill implements a number of the Medicaid ACA provisions to simplify the eligibility, enrollment and renewal processes for Medi-Cal. Status: Signed by the Governor.

SBX1 2 (Hernandez): Health Care Coverage (Support if Amended) This bill applies the individual insurance market reforms of the Affordable Care Act to health care service plans (health plans) regulated by the Department of Managed Health Care and updates the small group market laws for health plans to be consistent with final federal regulations. Status: Signed by the Governor.

SBX1 3 (Hernandez): Health Care Coverage: Bridge Plan (Watch) Requires Covered California (the state’s health benefit exchange) to establish a “bridge” plan product by contracting with Medi-Cal managed care plans forindividuals losing Medi-Cal coverage (for example, because of an increase in income), the parents of Medi-Cal or Healthy Families Program children, and individuals with incomes below 200 percent of the federal poverty level. Limits enrollment in bridge plan products only to eligible individuals. Status: Signed by the

Governor.

AB 154 (Atkins): Abortion (Support) Makes it a public offense, for a person to perform an abortion if the person does not have a valid license to practice as a physician and surgeon, except that it would not be a public offense for a person to perform an abortion by medication or aspiration techniques in the first trimester of pregnancy if he or she holds a license or certificate authorizing him or her to perform the functions necessary for an abortion by medication or aspiration techniques. Status: Signed by the Governor.

AB 361 (Mitchell): Medi-Cal: Health Homes for Medi-Cal En-

2013 Legi slati ve wr ap- u p | un i t ed w e stand

rollees and Section 1115 Waiver Demonstration Populations with Chronic and Complex zConditions (Support If Amended) Current federal law authorizes a state, subject to federal approval of a state plan amendment, to offer health home services to eligible individuals with chronic conditions. This bill would authorize the Department of Health Care Services, to create a health home program for enrollees with chronic conditions as authorized under federal law. Status: Signed by the Gov-

ernor.

AB 446 (Mitchell): HIV Testing (Support) After amendments taken in Senate Health Committee, this bill eliminates the requirement for written documentation of informed consent prior to administering an HIV test in non-clinical settings. Additionally, the bill requires timely delivery of the test results along with other pertinent information, tailored to whether the results are positive or negative, by the medical care provider or the person who administers the test to the patient. The bill no longer requires that every blood draw in emergency departments, public health clinics, or urgent care centers be tested for HIV. Instead, the bill now only requires primary care clinics to offer patients having a blood draw an HIV test. Lastly, the bill allows for the online posting of HIV antibody test results if the results are posted on a secure internet website, which can be accessed only with the use of personal identification number provided the patient at the time of testing. Status: Signed by the Governor.

AB 459 (Mitchell): Public Contracts: Healthy and Sustainable Food (Support) This bill would clarify and strengthen the state’s existing nutrition guidelines for food and beverages sold in vending machines on state properties. It would also increase incrementally the percentage of foods sold in vending machines that meet the nutrition guidelines from the current 35 percent to 100 percent by January 1, 2017.

Status: Held in Assembly Appropriations Committee.

AB 860 (Perea): Medical School Scholarships (Support) This bill, upon appropriation by the Legislature, would transfer $600,000 in penalty monies levied by the Department of Managed Health Care to fund the Steven M. Thompson Scholarship Program. CMA sponsored AB 589 (Perea) in 2011, which created the scholarship program, but due to state budget constraints, the bill only allowed for private donations to fund the program. Status: Held in Assembly Appropriations Committee.

AB 1139 (Lowenthal): Prescriptions: Biosimilar Products (Watch) This bill would authorize a pharmacist filling a prescription order for a biological product subject to the Federal Food, Drug, and Cosmetic Act to select a biosimilar product, provided that product is deemed by the federal Food and Drug Administration to be interchangeable with the prescribed product. Status: Assembly Business and Professions

Committee hearing postponed.

Medical Professional Liability Protection, and more!

AB 1263 (Pérez): Medi-Cal: CommuniCAL (Watch) This bill would require the Department of Health CareServices, to establish the Medi-Cal Patient-Centered Communication program (CommuniCal), to be administered by a 3rd-party administrator, to, commencing July 1, 2014, provide and reimburse for medical interpretation services to Medi-Cal beneficiaries who are limited English proficient. Status: Vetoed

by the Governor.

AB 1308 (Bonilla): Midwifery (Watch) This bill would require the Medical Board of California to, by July 1, 2015, revise and adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery and indentifying complications necessitating referral to a physician. Status: Signed by the

800-356-5672 www.caPphysicians.com San Diego

Governor.

orange

ABX1 1 (Pérez): Medi-Cal: Eligibility (Support) This bill enacts statutory changes necessary to implement the coverage expansion, eligibility, simplified enrollment and retention provisions of the Patient Protection and Affordable Care Act of 2010 as amended by the Health Care and Education Reconciliation Act of 2010 related to the Medicaid Program (Medi-Cal in California) and the California Children’s Health Insurance Program. Status: Signed by the Governor.

LoS angeLeS PaLo aLTo SacramenTo

ABX1 2 (Pan): Health Care Coverage (Support if Amended) Reforms California’s individual market in accordance with the Affordable Care Act and applies its provisions to insurers regulated by the California Department of Insurance in the individual market; requires guaranteed issue of individual market health insurance policies; prohibits the use of preexisting condition exclusions; establishes open and special enrollment periods consistent with the California health benefit exchange (Covered California); prohibits conditioning issuance or offering based on specified rating factors; prohibits specified marketing and solicitation practices consistent with small group requirements; requires guaranteed renewability of plans; and permits rating factors based on age, geographic region and family size only. Status:

Signed by the Governor.

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associ at i on ha ppeni ngs | lacm a news

ceo’s letter

I would li k e to start off by wishing all LACMA physicians and their families a happy and peaceful holiday season and a great start into the new year.

Team LACMA got a jump-start on the new year, signing up 200 new physicians from Keck Medicine of USC. Kudos to new LACMA Team members Caroline Mosessian and Michele Patzakis for capturing this opportunity. As we charge forward into the new year we will continue to “fight on” for the patients our doctors serve. This January also marks the official start of the Affordable Care Act, which will change the status quo.

Healthcare remains the No. 1 topic of public discourse. As health reform moves forward, our physicians continue to be the point of reference for existing patients and newly insured patients who will enter the marketplace.

This is a time for doctors to remind their patients that their No. 1 priority is their patients’ health.

The finest providers of healthcare are located in the United States. Many of them can be found right here in Los Angeles County, which makes it pertinent for LACMA to continue to be the chief advocate for doctors and the patients they serve. This is especially critical given the disastrous rollout of HealthCare.gov., the website created by the health reform law, that still does not measure up to expectations weeks after its initial October launch.

While the White House works to fix the problem, physicians will be called upon to do everything in their power to ensure that these glitches won’t turn into healthcare maladies for their own patients.

As we are heading into the year 2014, we need to make sure that patients will receive the care they need. Looking back, I’m pleased with all the wonderful achievements LACMA has made in 2013.

The recent LA HealthCare Awards was a huge success, not only for the significant funding we raised to benefit the Patient Care Foundation’s Medical Student Scholarship Program, but it also continues to make a statement for the NEW LACMA and the place we represent in the healthcare community in Los Angeles County and far beyond.

In 2014, we will continue to deal with the significant issues at hand, including the preservation of MICRA, the implementation of the Affordable Care Act and the delayed implementation of the dual eligible program.

I look forward to helping unite all physicians in Los Angeles County and creating an even stronger NEW LACMA for 2014.

Happy New Year!

Rocky Delgadillo

Rocky Delgadillo Chief Executive Officer

2 6 PHYSICIAN MA G A Z INE | d e c e m b er 2013

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

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.

Legal Assistance Up to date, relevant and easy to understand legal assistance that could save you thousands!

Services include contract analysis, HIPAA Compliance, ACOs, buying and selling a practice, and much more!

LACMA NEWS | A S S OCI AT I ON H A PPE NI NG S

Free Continuing Medical Education

Events

Legislative Power LACMA and CMA are distinguished by their successes. Dual membership provides for

Socialize and network with members of the medical community

legislative, legal, and regulatory advocacy on behalf of the physicians of California.

Find or create opportunities for your practice Engage with legislators and policymakers

Educational Resources

Economic Services CMA GETS YOU PAID! With over $7 Million recovered in unpaid claims since 2010, you can’t afford not to join CMA!

Medline & Enviromerica Through an exclusive partnership with these carefully selected vendors, LACMA saves you up to 45% on your medical supplies, equipment, and medical waste with compliance.

Additional Discounts & Savings LACMA offers you additional discounts and savings on Insurance, UPS services, Staples office supplies, Financial Planning, and more!

CMA develops toolkits, guides, and resources on all things related to today’s changing healthcare landscape. These resources are at your fingertips and they are FREE with membership.

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

State-of-the-Art Communication Access to exclusive information sources, including Southern California Physician Magazine, Physician News Network, Free TigerText subscription, and Find-a-Doc Phone App.

is the best time to join LACMA and CMA For more information on member benefits and resources, visit lacmanet.org/Membership or call (213) 226-0356 Los Angeles County Medical Association  707 Wilshire Blvd, Suite 3800 Los Angeles, (213) 226-0353 d e c e m b er 2013 | w w w.CA p h y s i90017 c i a n s n e wFAX: snet w o r k .c om 27

2 8 PHYSICIAN MA G A Z INE | d e c e m b er 2013

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 MICRA, Dual Eligibles, and the Health Benefits Exchange Access to documentation to help you be ready for changes in the healthcare landscape Free Reimbursement Assistance—Get your share of the over $7 million recovered since 2010 unpaid claims.

Free Jury Duty Assistance—Your time is valuable! Maximize your flexibility and reduce your changes of reporting when scheduling jury duty service.

Up to 30-40% savings through LACMA’s Group Purchasing Organization and Waste Management Company Free and low cost access to events including CME events, Mixers, Training Workshops, and Webinars for you and your staff

Summit Lending is a direct lender, which specializes in assisting physicians with all their mortgage needs. Our programs are very aggressive. Following are features of some different programs: 1. Purchases with minimal to No Down Payment 2. Offering Lowest Interest Rates in the Market 3. More Lenient on Credit 4. As a direct lender, we close loans fast and efficiently The Best Always Deliver!!!

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Mail your invoice and payment to:

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TEL: (888) 762‐0220 NMLS: 339255 CA. DRE: 01864758 As heard on KFI

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

d e c e m b er 2013 | w w w. p h y s i c i a n s n e w s n e t w o r k .c o m 2 9

LACMA NEWS | A S S OCI AT I ON H A PPE NI NG S

WE TREAT DOCTORS RIGHT!

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

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legal services

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Advertiser Index

Advanced Radiation .................................................................................................5 Athena Health...........................................................................................................7 BBVA.....................................................................................................................23 Cooperative of American Pbysicians........................................................................25 Cedars-Sanai ........................................................................................................... 9 The Doctors Company ........................................................................................ C4 Fenton Nelson ...................................................................................................... 21 Marsh.......................................................................................................................3 Medline..................................................................................................................11 NORCAL ............................................................................................................C2 Office Ally ........................................................................................................... C3 Physician Retraining & Reentry.............................................................................13 Summit Lending.....................................................................................................29 UCLA School of Public Health...............................................................................19

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b y t he nu m b er s | healthcar e i n cal i for n i a

By The Numbers Covered California

35,364 the number of people who selected a plan through Covered California from Oct. 1 to Nov. 1.

Premium Tax Credit Eligible Residents in California

79,391 people used the state exchanges to enroll, including 35,364 in California, for a total of 106,185 people enrolled from Oct. 1 to Nov. 1.

1,903,000 Prior to the implementation of the ACA, 18.45% of California residents were uninsured, an estimated 15% of those without insurance nationwide.

Just 26,794 of the 106,185 people who selected health insurance last month used the troubled federal exchange site.

80,000 California’s Uninsured

18.45%

3 2 PHYSICIAN MA G A Z INE | d e c e m b er 2013

80,000 lower-income people are eligible for expanded Medicaid coverage under another prong of the overhaul.

$xx

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company.

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. To learn more about our medical malpractice insurance program, including the Tribute Plan, call our Los Angeles office at (800) 852-8872 or visit www.thedoctors.com/tribute.

www.thedoctors.com

Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts. For additional details, see www.thedoctors.com/tribute.