November 2012

www.socalphysician.net

November 2012

TELEMEDICINE The New deďŹ nition

SPECIAL REPORT

dual eligibles Plan goes to Legislature

HEALTHCARE CHAMPION OF THE YEAR

Los Angeles County Supervisor Mark Ridley-Thomas Honored at

L.A. County Healthcare Awards OF F IC

IAL

ZIN E M AGA he of t

G eicleals n a s d loou nt y M eio n c

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at your dental plan It’s Open Enrollment time for the Los Angeles County Medical Association sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care.

This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers).

During Open Enrollment only, members may join as an individual or as a group with your employees.

Low, calendar year deductible of $50 per person ($100 per calendar year maximum for families).

Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on January 1, 2013.

Call a Client Service Representative at 800-842-3761 for more information. Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.

Sponsored by:

Underwritten by:

Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage.

56418 ©Seabury & Smith, Inc. 2012

AR Ins. Lic. #245544 • CA Ins. Lic. #0633005 d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance@marsh.com • www.CountyCMAMemberInsurance.com

Volume 143 issue 11

november 2012

16 14

20

features

every issue

from your assoCiation

14 l.a. County healthCare aWards los angeles county supervisor Mark ridleythomas and others honored at the first annual event.

6 front office tips, hints, advice and resources to make your practice run more smoothly.

4 president’s letter this month’s musings from samuel fink, Md.

16 telemediCine redefined a look at the role of new technologies redefining telemedicine for l.a. county physicians, patients and facilities.

24 Cma the latest update on regulations.

20 speCial report: dual eligibles the potential impact for local physicians as state health care services department submits plan to legislators.

2 Ceo’s letter an update on how your association works for you from rocky delgadillo.

26 association happenings

32 Just the facts health insurance by the numbers.

28 member Benefits check out these pages to find out how your membership is working for you!

Southern California Physician (issn 1533-9254) is published monthly by research Group of companies, llc in affiliation with lacMa services inc. (a subsidiary of the los angeles county Medical association) at 707 Wilshire Boulevard, suite 3800, los angeles, ca 90017. periodicals postage paid at los angeles, california, and at additional mailing offices. Volume 143, no. 10 copyright ©2012 by lacMa services inc. all rights reserved. reproduction in whole or in part without written permission is prohibited. postmaster: send address changes to Southern California Physician, 707 Wilshire Boulevard, suite 3800, los angeles, ca 9001 7. advertising rates and information sent upon request.

Statement of ownership, Management, and Circulation Publication Title: Southern California Physician. Publication Number: 1533-9254. Filing date: 10/01/12. issue Frequency: Monthly. Number of issues Published Annually: 12. Annual Subscription Price: $39. Complete Mailing address of Known office of Publication: 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Complete Mailing Address of Headquarters or general Business office of Publisher: 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Full Names and Complete Mailing Addresses of Publisher, editor and Managing editor - Publisher: Sheri Carr, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. editor: Tom York, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Managing editor: 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017; owner: LACMA Services, inc. 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Known Bondholders, Mortgagees, and other Security Holders owning or Holding 1 Percent or more of Total Amount of Bonds, Mortgages, or other Securities: None. Tax Status: Has Not Changed during Preceding 12 Months. Publication Title: Southern California Physician. issue date for Circulation data Below: September 2012. extent and Nature of Circulation - 15a. Total Number of Copies: 6541 (avg)/4197 (actual); 15b1. 5784 (avg)/3662 (actual); 15b2. 0 (avg)/0(actual); 15b3. 0 (avg)/0(actual); 15b4. 0 (avg)/0(actual); 15c. 5784 (avg)/3462 (actual); 15d1. 0 (avg)/0(actual); 15d2. 0 (avg)/0(actual); 15d3. 0 (avg)/0 (actual); 15b4. 335 (avg)/355(actual); 15e. 355; 15f. 6119 (avg)/3797 (actual). 15g. 422(avg)/400 (actual). 15h. 6541 (avg)/4197 (actual). 15i. 94.5 (avg)/91.2 (actual). Publication of ownership: if the publication is a general publication, publication of this statement is required. Will be printed in the November 2012 issue of the Publication. Signature and Title of editor, Publisher, Business Manager or owner. , Publisher. 10/1/12.

n oV e M B e r 20 1 2 | W W W. s o c a l p h ys i c i a n . n e t 1

ceo’ s l e t t e r | rock y d e lGad i l lo

new scholarship program vital to future health of la County’s residents

o

n oCtoBer 4, we held our first los angeles health care awards, with proceeds from the formal dinner supporting the student scholarship program recently launched by lacMa’s patient care foundation of los angeles county. We plan to make these awards an annual event. the scholarships will help educate the next generation of physicians who will practice in los angeles county, many of whom will be coming from the inner city. indeed, the scholarship program will expand the efforts of the south central scholars program, which was started by longtime lacMa member dr. James london and his wife, trisha. this program takes promising students who grew up in underserved neighborhoods and puts them on a career path toward practicing medicine. at the dinner we recognized two students who have benefited from the scholarship program — current medical student roxana cortes and newly minted physician henry horton. cortes graduated from the california academy of Mathematics & science and then from pomona college. dr. horton, on staff in internal medicine at cedars sinai as of June 2012, attended the california academy of Mathematics & science. he graduated from ucla in 2005 and harvard Medical school in 2009. they could well serve as models for our new scholarship program. i met the then-future dr. horton back in 2005 while i was at ucla to give a speech to kids who were going to uc on scholarships. as i was leaving, i chatted with the kids attending, as i like to do, and one happened to be this young man who said he was the janitor, an african-american who grew up in south los angeles. he wanted to know about the scholarship program for graduate students. i was surprised when he told me he had been accepted to harvard Medical school but didn’t think he would attend for financial reasons. that night, i introduced him to trish london and dr. london, who were at the dinner, and thanks to their generosity, this smart young man was able to visit medical schools at columbia university and cornell university, as well as harvard. amazingly, he had been accepted to all three schools. cortes also spoke at the dinner, and noted that where she grew up there was little access to medical care. she said she decided to go into medicine after attending one of those free clinics where thousands of residents line up to be seen by volunteers.

Based on her own experience with the kindness of the doctors at the mass clinic, she decided she wanted to be a physician, and she’s well on that path today. the new foundation scholarship program is vital to our future. the affordable care act will give 500,000 county residents access to medical insurance in 2014. this addition of all these newly eligible patients will strain the capacity of our safety net clinics and add more of a burden to medical providers who care for underserved populations. compound patient expansion with physician attrition and we have a tremendous challenge ahead. los angeles county will face a shortage of physicians in the years ahead.

We need to open access to health care to those who need it most, and our scholarship program is one way to help accomplish that goal and bring more doctors into the system.

rocky delgadillo

Chief Executive Officer

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PHY

SO U T H E R

p u B l i c at i o n s M a n a G e r

sheri Carr

559-250-5942 | sheri@physiciansnewsnetwork.com editor

tom york

tom.york@gmail.com

contriButinG Writers

russell a. Jackson, david reynolds

advertisinG sales

d i s p l ay a d s a l e s / d i r e c t o r o f s a l e s

Christina Correia

213-226-0325 | christinac@lacmanet.org c l a s s i f i e d / d i s p l ay a d s a l e s

dari pebdani

858-231-1231 | dpebdani@gmail.com

editorial advisory Board david h. aizuss, md troy elander, md thomas horowitz, do robert J. rogers, md

los anGeles County mediCal assoCiation offiCers ceo

rocky delgadillo president

samuel i. fink, md p r e s i d e n t- e l e c t

marshall morgan, md treasurer

pedram salimpour, md s e c r e ta r y

peter richman, md i M M e d i at e pa s t p r e s i d e n t

troy elander, md

headquarters Southern California Physician los angeles county Medical association 707 Wilshire Boulevard, suite 3800 los angeles, ca 90017 tel 213-683-9900 | fax 213-226-0350 www.socalphysician.net

suBsCriptions Members of the los angeles county Medical association: Southern California Physician is a benefit of your membership. additional copies and back issues: $3 each. nonmember subscriptions: $39 per year. single copies: $5. to order or renew a subscription, make your check payable to Southern California Physician, 707 Wilshire Boulevard, suite 3800, los angeles, ca 90017. to inform us of a delivery problem, call 213683-9900. acceptance of advertising in Southern California Physician 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 Southern California Physician, lacMa services inc. or the los angeles county Medical association. Southern California Physician reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. scp is not responsible for unsolicited manuscripts.

pr e si d e n t ’ s l e t t e r | sa m u e l fi n k , M D

Medicare Reimbursement Rates Among Many Important Topics at House of Delegates

G

reetings from the California Medical Association’s House of Delegates meeting in Sacramento!

I’ve been a member of the House for over 20 years.

We are the policy-making body of the CMA ... a democratic body where all voices are heard and respected in an effort to create the best positions for CMA to advocate for on our behalf -- even pursuing legislation when needed!

First, I’d like to give you a brief legislative update, based on information provided to the House.

As you know, in the absence of legislation, Medicare reimbursement rates are projected to drop by 25-30 percent on Jan. 1, according to the SGR (Sustainable Growth Rate) index that sets Medicare payment levels.

Our best guess is that this will NOT happen. We anticipate another shortterm fix that protects current rates ... although it is difficult to know whether this fix will simply “punt” the issue to the new Congress taking office in January, or whether it will last for the entire year.

In order to eliminate the SGR issue entirely, Congress is looking for physicians to come up with new models of reimbursement that enhance patient care and are cost-effective.

These models are likely to offer many options, such as the opportunity to provide a patient-centered medical home, or participate in disease specific registries, among many choices being considered by the CMA and AMA. During the House deliberations, the CMA established a specific policy that we will advocate that physicians not be economically punished for their decision not to incorporate electronic health care records into their practice.

Medi-Cal reimbursements will increase to Medicare rates for 2013 and 2014 for primary care physicians and those in pediatric sub specialties.

Primary care physicians will also see an increase in Medicare reimbursement of approximately 5 percent -- assuming that the SGR correction is postponed or

eliminated.

Locally, the new California Health Benefits Exchange is expected to provide health insurance for 5 to 10 million state residents.

This is probably the largest change in the delivery of health care ever to occur in California.

It will certainly increase access to insurance ... but will it ensure access to care, and will reimbursement rates be high enough to get physicians to participate?

How this will subsequently impact the market for private insurance is anyone’s guess!

What about ObamaCare? If President Obama is re-elected, obviously it will continue to be federal law, although there will be significant amendments if congressional Democrats and Republicans can figure out a way to work with each other.

If Mitt Romney becomes president, and the House and Senate are Republican led, expect ObamaCare to be repealed.

If the Senate were to remain Democratic under a Romney presidency, then Romney is expected to offer waivers to states that elect not to participate in ObamaCare.

But California is expected to decline the waiver and proceed with full implementation. We do live in interesting times!

As far as the work of the House of Delegates? Let me report on a few items of major interest.

The delegates voted overwhelmingly to call on the CMA to support measures that provide same-sex households with identical rights to healthcare, health insurance and survivor benefits that are provided to opposite sex households.

The delegates also recognized that the denial of civil marriage leads to poorer health outcomes for gay and lesbian individuals, couples, and their families.

I was proud to introduce and have accepted a resolution which called on the CMA to consider legislation which would make it illegal for pharmacists to receive

4 s o u t h e r n c a l i f o r n i a p h ys i c i a n | NOV E M B ER 2 0 1 2

financial incentives to substitute a physician’s prescription.

I know that we all deal with multiple daily requests to change prescriptions for our patients against our better judgment, and in an era where we physicians cannot even receive a pen with a drug’s name inscribed, it’s important to ensure that pharmacists also have no conflict of interest when filling our prescriptions.

The delegation also opposed RAC (Recovery Audit Contractor) audits that are no more than “fishing expeditions” to take back payments, and strongly requested that both the CMA and AMA advocate for the ability of physicians to privately contract with Medicare patients when both desire to do so.

Delegates were also very concerned with the upcoming plan to transition Medi-Medi patients to managed care plans, and called on the CMA to collect data from its members on how disruptive this will be to their patients, and to promptly report these findings to the California DHS, as well as to other appropriate governmental agencies.

The New LACMA remains committed to strong, visible advocacy for you and your patients.

Please contact me at president@ lacmanet.org and let me know how we are doing or how you can become a part of this dynamic network! Until next month.

Samuel Fink, MD, is an internist in private practice in Tarzana. He is the 141st president of the Los Angeles County Medical Association.

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f ro n t o f f i c e | pr ac ti c e ti ps

What You Need to Know Before You Store Patient Credit Card Numbers

By Fran Cain, Information Technology Department, NORCAL Mutual Insurance Company

Everyone uses credit cards. Patients love to rack up points for travel and cash-back rewards. But before you store a credit card number in your practice database, be aware of the consequences if your patient records ever become compromised. Credit card companies can impose huge fines if your office system is not securing patient credit card information adequately and it becomes compromised — to the tune of up to $100,000 per data incident. After reviewing this article and weighing the risks, ask yourself, “Does my practice really need to store credit card information on file?”

I have a small practice. How does this apply to me?

All credit card companies belong to the Payment Card Industry (PCI). PCI has established a Security Standards Council to set and manage standards known as the Data Security Standard, or PCI DSS. If your practice accepts or processes payment cards, you must comply with the PCI DSS.

Patients prefer that I keep their credit card numbers on file.

What if I want to store credit card numbers electronically?

There are many rules to follow to be in compliance. You will be required to build and maintain a strong network; protect cardholder data; maintain a vulnerability management program; implement strong access control measures; regularly monitor and test networks; and maintain an information security policy.

You should assess your business systems and processes annually to ensure you are in compliance. The PCI website can help you to assess your environment. You may be able to use a Self-Assessment Questionnaire, which must be completed annually, depending on the bank card. For example, Master Card allows you to self-assess if you process less than 50,000 transactions annually, while JCB International allows you up to 1 million transactions. Check with each credit card company or look on its website to determine your merchant level and the requirements for your business.

If you are allowed to self-assess, it is not necessary to submit a report to the credit card companies or PCI, but compliance is still required at all times. There are several different self-assessment questionnaires, and it may be confusing to decide which one to use. Use the chart on the website to choose the questionnaire that most closely fits with your credit card collection practices.

If you are not allowed to self-assess, you will need to use a Qualified Security Assessor (QSA) to conduct annual assessments.

What happens if I store credit card numbers and a practice computer is lost or stolen, or some other breach of my system occurs?

You must be able to demonstrate that you have been in compliance with PCI DSS. If your practice computers, network and/or database are compromised in any way, you must notify the credit card companies. If you cannot demonstrate that the data was completely protected and that you have been in compliance with 6 s o u t h e r n c a l i f o r n i a p h ys i c i a n | NOV E M B ER 2 0 1 2

PCI DSS, you may be subject to significant fines and lawsuits. If the credit card company does not terminate the contract, you may be treated the same as a higher level merchant and be required to conduct annual on-site assessments and validation by a Qualified Security Assessor. Expect the annual on-site assessments to cost in the $10,000–$20,000 range or more. You will be required to remediate any inadequacies discovered during the annual assessments at your own expense.

Who enforces compliance of the PCI DSS? American Express, Discover Financial Services, JCB International, MasterCard Worldwide, and Visa Inc. Each of these institutions posts compliance guidance which may be slightly different from the others. Before going to each credit card company website, read, understand, and follow all guidelines provided by PCI.

What if I complete a self-assessment and uncover deficiencies?

If the self-assessment uncovers deficiencies, remediation is necessary. A remediation plan, known as an Action Plan for NonCompliant Status, should be completed. PCI allows 12 months to remediate, but progress must be demonstrable. All remediation is at the expense of the merchant. If your practice is very large and you process many transactions, you will need to work with a data security firm. PCI provides a list of qualified assessors on its website.

How do I avoid the need for assessments altogether?

If you accept credit cards for payment but don’t store credit card information, an annual assessment is required but the selfassessment questionnaire is fairly short and painless.

Now that you know some of the risks and requirements of storing credit card information, do you really need them on file?

For more information, visit the Payment Card Industry website at www.pcisecuritystandards.org. NORCAL Mutual insureds will find proprietary resources on information and network security in the DataShield™ Learning Center at www.norcalmutual.com.

Fran Cain is the Network Systems Manager for NORCAL Mutual Insurance Company. Copyright 2012 NORCAL Mutual Insurance Company.

All rights reserved.

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f ro n t o f f i C e | pr aC ti C e ti ps

iNSuRANCe TiPS: Workers’ Compensation Rates Are on the Rise By roy s. lyons, managing director, marsh

ers’ compensation insurance became a problem for Los Angeles if you haven’t heard By noW, workers’ compensation insurance County Medical Association physicians, LACMA provided a companies are losing money again in California and rates are on the rise. According to a June 2012 report by the Workers’ Comstable, long-term solution for members.

How can you get the most value from your workers’ compenpensation Insurance Rating Bureau (WCIRB), the combined loss sation policy? and expense ratio for workers’ compensaAre you one of the members who particiSince all workers’ compensation polition insurers totaled 122% in calendar pate in the LACMA/CMA sponsored workers’ cies are the same by California law, look year 2011. For every dollar in premium compensation program who: collected, $1.22 was paid out in claims, for insurance companies that offer tools • This year paid 5% less than non-members? expenses or held as reserves for future to help you promote a safer work environment and have an active return to work claims payout. This was an increase over • Enjoy consistently low, competitive rates program to assist the employee to reenter the combined loss and expense ratio of over time, providing stability year in and year out? the workplace. And don’t renew your poli117% for calendar year 2010. cy this year without getting a no-obligation The WCIRB initially recommended • Are protected from policy non-renewal simply because you had a claim? premium indication from Marsh/Seabury a 12.6% average pure premium increase & Smith Insurance Program Management. for January 1, 2013 following the July 1, • Are protected against being singled out The Los Angeles County Medical Asso2012 mid year increase of 8.3%. With the for a rate increase? ciation sponsors a workers’ compensation Governor signing SB 863 into law, the program through Marsh that offers a 5% WCIRB lowered its recommendation to premium discount, up to 15% depending upon where your group 11.5% at the time of this writing. Insurers are free to adjust their medical insurance is purchased. Call Marsh for more information rates according to their own experience. at 800-842-3761, email CMACounty.Insurance@marsh.com or At times like these, it is important to be protected by the visit www.CountyCMAMemberInsurance.com. formidable buying power of your association. The last time work-

Sorry, Mom, I am not a Doctor, I am a Provider!

Norman Lavin, M.D.,PhD. Clinical Professor UCLA Medical School; Private Practice in Endocrinology Tarzana, California

Mrs. Goldberg was being driven to the White house to witness her son becoming the first Jewish President of the United States. A reporter stopped her and commented: “You must be so proud of your son, the President.” “Yes”, Mrs. Goldberg said, “And do you know his brother is a Doctor!”

There is a new language in the field of Medicine – but not related to diseases or treatments. Patients, for example, are no longer patients, but rather ‘consumers’ or ‘customers’. We Doctors, as well as nurses, have become ‘providers’ – a term that is now widely used by insurance companies, government agencies, newspapers, medical journals, and in hospital settings.

But these descriptors are far off the target for what we do as professionals. The word patient means suffering or bearing an affliction. Doctor is derived from docere, meaning to teach and Nurse means to nurture. These century-old terms have not inhibited our profession from curing illness and prolonging life.

(NEJM 2011) Why the sudden change after 300 years? I don’t really know, but let’s explore the possibilities. We are in an economic crisis, therefore, the government and others have proposed that patient care should be industrialized and standardized. (NEJM 2010). The proposal concludes that medical facilities should run like factories, therefore

archaic terms such as Doctor, Nurse, and Patient need to be replaced to fit the ‘new order’.

Language is powerful. With the new terminology, our relationship with patients is now cast in terms of commercial transactions. Now, the consumer (patient) is the buyer and the provider(doctor) is the seller.

These terms are reductionist; they ignore the spiritual, humanistic and compassionate dimensions of the relationship, focusing only on the financial aspect as the primary impetus for Care.

Does this mean that patient care will be a ‘prepackaged’ commodity that is ‘provided’ to the consumer?

Reducing Medicine to economics makes a mockery of the bond between the healer and the patient.

Standardization in medicine has changed or eliminated other common medical terms. “Clinical judgment”, for example, has been replaced by “evidencebased medicine” –the practice of medicine based on scientific data. How insulting! Clinical judgment is clearly based on many years of studying scientific data.

Doctors constantly debate the design and results of many research studies. Clinical judgment which was the acme of professional practice evolves from these intense examinations. No more. Now, these same architects of health policy contend that clinical care should be constricted to following “guidelines” written

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by a select few people. They are stated to be scientific and objective whereas clinical judgment is subjective, unscientific, and certainly unreliable. But there is a fundamental fallacy in this new formulation. Scientific data may be objective, but their application to clinical care by the authors of guidelines is not. Subjectivity lives, as evidenced by the fact that different groups of authors write different guidelines for the same data.

Each guideline reflects the values, preferences and biases of each group of authors which are subjective – not scientific. (Groopman, “Your Medical Mind” 2011).

What is the impact of this revolutionary change in the field of Medicine? When you become ill, do you want a Provider - or a Doctor or Nurse to care for you?

Do you want someone to individualize your treatment according to guidelines and costs or to focus on humanism and caring? Clearly, there are economic issues that are of great concern in our country, but it cannot, it should not be the shibboleth of our wonderful profession of Medicine.

Well Mom, you can still call me Doctor!

Norman Lavin, M.D.PhD. is professor and Director of Education in Endocrinology at UCLA Medical School. He is Editor of “The Manual of Endocrinology and Metabolism” published by Lippincott (4th edition and translated in 6 languages). He is also Director of the Diabetes Center at Providence Tarzana Hospital where he has a private clinical practice in Endocrinology.

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f ro n t o f f i c e | pr ac ti c e ti ps

CMA Debates Resolution That Calls on Insurers to Cover E-mail Consultations As advances in technology continue to redefine health care, the California Medical Association (CMA) is taking steps to bring the physicianpatient relationship into the 21st century.

During the association’s annual House of Delegates meeting, a resolution was introduced that would ask CMA to support legislation requiring insurance providers in California to include “telephone or other electronic patient management services” in their covered services, while also allowing physicians to bill patients directly for the provision of such services.

Currently, insurance providers are not required to cover consultations that occur via telephone or email, and physicians in most instances have no legal way of billing patients or payers for such services.

Throughout a lengthy period of floor debate, several speakers noted that patients are becoming increasingly reliant upon remote interaction with their physicians, while insurers only cover services offered in a faceto-face setting, with few exceptions. If this does not change, speakers noted, physicians would be facing considerable financial losses as the trend toward remote interaction continues.

While support for the concept of requiring insurers to pay for telephone and email consults was nearly unanimous, the specific language of the resolution drew input from across the House, leading to nearly an hour of open discussion of the issue.

Ultimately, recognizing the importance of the matter and the limited time available for debate, delegates opted to refer the resolution to the CMA Board of Trustees for decision, an action which supporters claimed would allow the language to be crafted more thoughtfully.

The matter will likely be taken up during the board’s January meeting, and CMA staff will keep members updated on the resolution’s progress.

Risk Tip

Telemedicine: Creates Efficiencies, Requires Caution The adoption of telemedicine is growing as physicians seek innovative ways to provide clinical health care to patients who are at a distance, have a disability, or face other barriers that can impede access to quality care. Telemedicine can improve efficiencies, but security and confidentiality must be addressed.

The Health Resources and Services for credentialing and granting privileges Administration, an agency of the U.S. Deto practitioners who deliver care through partment of Health and Human Services, telemedicine. In addition, many payers are has identified Health Professional Shortreimbursing physicians who offer virtual age Areas (HPSAs)—geographic regions consultations. with an inadequate While the benenumber of primary Additional considerations include: fits of telemedicine care physicians. are vast, its use · Employing secure computer network Physicians who and adoption must systems with approved security codes designated under HIPAA compliance. practice in these be tempered with areas can meet the caution. Physicians · Clearly defining proper protocols for rising demand for must be aware of Webcams and Web-based portals. care from a vast the risks associated · Using mechanisms to protect the pripatient population with access, such vacy of individuals who do not want to by taking advanas patient and staff be seen on camera (including staff members, other patients, or patients’ famitage of affordable privacy, inaccuralies). technology, the cies in self-reportconvenience of ing, and symptoms · Understanding how Web-based portals send encryption keys so that hackers Webcams and that may only be can’t access the stream and decrypt the Web-based portals caught in person. conversation. like Skype, secure Additional legal · Developing a method to ensure that the Internet connecconsiderations for person you are communicating with is tions, and highonline interactions, not an impersonator. speed links via such as licensure ·

Considering the effects that telemedisatellite. Physicompliance, must cine may have on your relationship with cians who are not be addressed for your patients and developing strategies located in HPSAs the protection of to ensure they feel valued. are incorporating the physician and this technology into their practices to help the patient. According to the Federation of manage increasing patient volume.

State Medical Boards, only 10 states have The Centers for Medicare & Medicaid provided special-purpose licenses to allow Services (CMS) reimburses physicians for cross-border telemedicine, while most and hospitals that offer telemedicine to states require complete licensing if the patients in HPSAs, remote sites, and rural patient is in their jurisdiction. areas. Last year, CMS also amended the Contributed by The Doctors Company.

Medicare Conditions of Participation for For more technology safety and physician hospitals and critical access hospitals, practice tips, visit www.thedoctors.com/ patientsafety . updating the process that facilities can use

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Rep. Bass Addresses Forum on Breast Cancer Among African Americans U.S. Rep. Karen Bass, D-Los Angeles, was one of the guest speakers at a Sept. 29 forum on breast cancer in African American women sponsored

by The Charles R. Drew Medical Society and the Los Angeles Center for Women’s Health.

The forum was titled “Health Disparities Forum: Breast Cancer in African American Women.”

Bass spoke on the topic “Accelerating the End of Breast Cancer: Congressional Landscape.”

Other discussion topics included “Research Trends in Breast Cancer,” “Surgical Approaches in Treatment of Breast Cancer,” which was presented

by Dr. Dennis Holmes, and “Breast Cancer: Medical Management in the African-American Population.”

Dr. Holmes is the medical director at the women’s center, and a breast surgeon.

Dr. Holmes said the purpose of the forum was to focus attention on the difference in treating AfricanAmerican women with breast cancer, as well as the differences in outcomes and other issues involving this segment of the greater Los Angeles population.

“We want to recognize key components of quality surgical care for breast cancer in African American women, and we wanted to discuss the cultural and psychiatric barriers to early detection and timely medical management,” he said.

Dr. Holmes said that the forum also discussed the role that nutrition plays in breast cancer among African Americans. This was part of a formal talk titled “Nutrition and Cancer.” x

Credentialing by Proxy

The Opportunities and Challenges Presented by New Federal Standards for Credentialing Telehealth Providers

By John A. Mills, Esq.

Telehealth is the exchange of health and medical information between

the patient’s location and the practitioner’s location at a distant site using electronic communications such as videoconferencing and remote monitoring. The use and acceptance of telehealth is growing rapidly with technological advances. In 2011, the California Legislature enacted the Telehealth Advancement Act (AB 415), which seeks to reflect technological advances and update the definition of telehealth to reflect the broader range of services in use today, including by allowing all licensed health professionals in California to engage in telehealth services.

On a federal level, the Centers for Medicare and Medicaid (CMS) issued new regulations in 2011 that eased the requirements for hospitals to credential and grant privileges to telehealth providers located remotely. The latter development will be the subject of this article.

Prior to the 2011 federal regulations, the telehealth credentialing process was widely viewed as a major deterrent for receiving telehealth services, because of the administrative burden it imposed on hospitals and medical staffs in having to perform their own separate review and verification of licensure, training and disciplinary background of the remote practitioner. Both CMS and the Joint Commission now allow for credentialing by proxy, which means that the hospital receiving the telehealth services, or the “patient-site” hospital, can rely on a “distant-site” hospital’s credentialing of the same physician. If hospitals choose to credential by proxy, they must enter into a written agreement with a Medicare-certified hospital or telemedicine entity, i.e., the “distant-site,” where the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications.

The written agreement between the patient’s site hospital and the distant-site hospital must specify that the following conditions are met: (i) the distant site hospital is a Medicare-participating hospital; (ii) the distant-site physician is privileged at the distant-site hospital, which provides

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a current list of the distant-site physician’s privileges at the distant-site hospital; (iii) the distant-site physician holds a license issued or recognized by the state in which the hospital whose patients are receiving the telehealth services is located; and (iv) the patient-site hospital that credentials and privileges the distant-site physician also conducts an internal review of the distant-site physician’s performance of these privileges and sends the distant-site hospital such performance information, including adverse events and complaints, for use in its periodic appraisal of the distant-site physician.

Although there should be little doubt that credentialing by proxy greatly expands patient access to health care and provides greater opportunity for the advancement of telehealth delivery, it also raises new challenges for physicians and hospitals. One concern is that the patient-site hospital might be tempted to engage in lax credentialing and privileging of the distant-site physician without having adequate assurance of the thoroughness of the credentialing and privileging process used by the distant-site hospital or telemedicine entity.

This could lead to an increase in claims of negligent credentialing. There are also concerns that California hospitals will start routinely privileging out-of-state physicians who are not licensed in California. For now, however, the new federal credentialing standards do not change state-based physician licensure requirements, as the written agreement between the patient-site hospital

provide for a national licensure approach for telemedicine.

Also posing a unique challenge under the new credentialing by proxy method are the requirements that the patient-site hospital not only conduct an internal peer review of the remote practitioner’s performance of his or her privileges, but that it also send to the distant-site hospital the results Although there should be little doubt that of its peer review for use in credentialing by proxy greatly expands the distant-site’s own peripatient access to health care and provides odic appraisal of the physician. greater opportunity for the advancement This mandatory peer review of telehealth delivery, it also raises new reporting by the patient-site challenges for physicians and hospitals. hospital to the distant site hospital raises concerns about whether the confidentiality of the patient-site hospital’s peer review will be waived once the results of the provide care to patients located in Calipeer review are disclosed. The new federal fornia must be licensed in California and law does not address this issue, leaving it must provide an appropriate prior exam to be resolved under state law. However, to diagnose and/or treat the patient.” Of there can be crucial differences between the course, the flip side of this is that, for those laws of different states when it comes to the physicians who seek to practice across state confidentiality of peer review information. lines using telehealth technologies, the Thus, for example, if a California hospital new federal credentialing requirements are discloses the peer review information to frustrating precisely because they fail to and distant-site hospital must specify that the telemedicine provider holds a license issued or recognized by the state in which the hospital whose patients are receiving the telemedicine services is located. As the California Medical Board has made clear: “Physicians using telehealth technologies to

a hospital located in a different state that does not have substantially similar protections to those provided by California law, this could potentially result in a waiver of the confidentiality of the substance of the peer review, as well as an undesired disclosure of the identity of the physicians and other practitioners who participated in the peer review of the distant-site physician.

As the use of telehealth services becomes more common, the complex legal issues that arise from the credentialing of telehealth providers will need to be taken into account not only by hospitals and credentialing committees, but also by the physicians who participate in peer review as well as those who seek to provide their services via telehealth. For more information about telehealth compliance and best practices for credentialing telehealth providers, please contact John A. Mills at Fenton Nelson.

John A. Mills is an attorney with the law firm Fenton Nelson, where he regularly advises physicians on a variety of regulatory matters, including telemedicine, medical staff and peer review, reimbursement and licensure. He can be contacted through Fenton Nelson’s website: www.fentonnelson.com.

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Dinner Honors Area Leaders in Medicine The first annual LA Healthcare Awards fundraiser for the newly launched Physicians for Patients Foundation of Los Angeles County was a rousing success, said organizers.

The dinner, organized by LACMA, honored Los Angeles County Supervisor Mark Ridley-Thomas and raised monies to be used for loan repayments and scholarships to encourage newly graduated physicians to practice in underserved areas of the county.

For his tireless efforts, Ridley-Thomas was given the Healthcare Champion of the Year Award.

Ridley-Thomas is the first African-American male ever to serve on the Los Angeles County Board of Supervisors and has a long distinguished history of public service.

As county supervisor, he developed and executed a plan to re-open the MLK Medical Center and secured funding for its expansion, he reformed the 1 4 s o u t h e r n c a l i f o r n i a p h ys i c i a n | NOV E M B ER 2 0 1 2

Department of Children and Family Services and significantly increased funding for primary care health programs for uninsured residents as well as school based mental health services.

“The recently sustained Affordable Care Act will enable an estimated additional 500,000 LA County residents to qualify for medical insurance by 2014,” said Dr. Troy Elander.

“This immediate and significant expansion of newly eligible patients will strain the capacity of safety net clinics and add a burden to medical providers who care for underserved populations.

Los Angeles County will be facing a shortage of physicians.”

He added that the proceeds from the dinner would support the Foundation’s Medical Student Scholarship Program to help boost the number of doctors on the front lines.

Awards

laCma Ceo rocky delgadillo, laCma president and Chairman dr. samuel fink, md, and dr. troy elander, md, Chairman of the foundation Board, also gave out the following awards: the innovation aWard -puBliC eduCation-

Kaiser Permanente Thrive Campaign the innovation aWard -puBliC serviCe-

Los Angeles Unified’s Student & Community Health Program the independent physiCian leadership aWard

Dr. Ralph Salimpour, MD

currently a clinical professor of pediatrics at the david Geffen school of Medicine at ucla and founder of the salimpour pediatric Medical Group. he has been practicing 60 years. the hospital physiCian leadership aWard

Dr. Glenn Irani, MD

top (left to right): top (left to right): hospital physician leader Glenn irani, md; Community service innovator kimberly uyeda, md; healthcare Champion of the year la County supervisor mark ridley-thomas; independent physician leader ralph salimpour, md; Community service innovator ana lasso; and public education innovator vito imbasciani, md.

Bottom (left to right): rocky delgadillo, laCma Ceo; dr. troy elander, md, Chairman of the physicians for patients foundation of los angeles County; mark ridley-thomas; and laCma president dr. samuel fink, md.

a pediatrician and chief medical officer of pprovidence rovidence tarzana Medical center since JJanuary anuary 2009 -- the first to hold that role in tthe he hospital’s 39-year history.

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Telemedicine Redefined

BY TOM YORK

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UCLA’s Center for Inflammatory Bowel Diseases has been testing a new medical device for helping patients manage such conditions as Crohn’s disease and ulcerative colitis.

The device? The iPad. The doctors, nurses and patients are using the wildly popular wireless tablet from Apple Computer to track symptoms and care and then communicate that critical data to each other in an ongoing dialogue.

“It’s like having a doctor in your back pocket,” says Dr. Daniel Hommes, president of medicine at UCLA and director of the inflammatory center.

Hommes said such devices as the iPad can improve care while saving costs in the health care landscape of the future.

The program even goes so far as to provide near real-time traffic reports before patients head out for appointments to avoid delays.

Based on the success of its pilot, UCLA said, it is enrolling 250 patients into the program over the next few months. And Hommes says his team of experts is planning to expand to other chronic disease areas.

The UCLA pilot is but one of many similar efforts under way in Los Angeles County using new technologies to change the way medicine is practiced in the exam room and at the bedside.

While the trend can be partially attributed to the push by the federal government to digitize patient health care records and bring health care into the 21st century, it also can be directly attributed to ongoing efforts to drive down costs while bettering patient care.

It’s a trend driven by the latest generation of doctors entering the profession who favor wireless devices, such as the iPhone and the iPad, over the clipboard and pen.

Today’s 20- and 30-somethings have grown up with all of the advances in consumer technology over the past two decades and wouldn’t live without the ease and convenience of that easily accessible technology in the workplace.

To be sure, the technology-driven changes impacting medicine don’t necessarily involve “the next big thing” in gadgets and gizmos. Doctors are finding new uses for older technology, too, which is making their lives easier as well as the patients’ lives.

The Southside Coalition of Community Health Centers, for instance, is repurposing telemedicine, once used by doctors in remote clinics, for use in a densely populated urban setting.

The doctors and technicians at St. John’s Well Child and Family Center in South Los Angeles take digital images of the retinas of diabetic patients and transmit the images via the Internet to specialists in Northern California, who then determine if the eyesight of the patients are worsening.

Before the clinic installed the telemedicine equipment, patients made appointments months in advance in distant locations and, in doing so, packed already crowded waiting rooms to see the limited number of ophthalmologists available.

Southside Coalition executives say their urban adaption of telemedicine won’t replace office visits altogether, but it’s a technology that’s going to become more common with the arrival of national health care.

Indeed, the American Telemedicine Association said 10 million patients nationwide benefit from the technology today, compared to 1 million just seven years ago.

The number will double in another two years, much of the explosion to be driven by the advent of the Affordable Care Act. The ACA will greatly increase the number of citizens who will have health care coverage and, hence, access to services that are already in short supply.

The LA County Department of Health Services predicts that as many as 2 million patients will be covered under ACA alone.

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Patients as well as their doctors are rapidly adjusting to the technologies coming to health care.

Kaiser Permanente members who access their health records through the HMO’s online patient portal are 2.6 times more likely than nonusers to stay with the health care giant, according to a study published this summer in the American Journal of Managed Care.

Kaiser has more than 3.5 million members in Southern California, almost half in Los Angeles County.

The study, which looked at 394,000 members in Kaiser’s Northwest region, found that patients who used My Health Manager portal were more likely to remain members of the HMO than those who didn’t use the portal.

Members can access their health records, view lab test results, email their doctors and order prescriptions, as well as make appointments.

In fact, the HMO giant found that 63 percent of its members use the portal for various purposes, such as using email to talk to their doctors.

Members are now sending more than 1 million emails each month, the study found, and among the most popular portal functions is the ability to see lab test results online. Nearly 2.5 million results are accessed via the Internet monthly, Kaiser reported.

And speaking of the Internet, some of the biggest changes coming to the practice of medicine in Los Angeles involve the mobile Internet.

For example, Cedars-Sinai Medical Center in West Los Angeles is using a new mobile application that allows doctors to obtain realtime electrocardiographs (ECG) delivered to their iPads or iPhones to remotely monitor their patients’ conditions.

GE’s healthcare division and startup AirStrip Technologies developed the app, which is compatible with GE’s MUSE cardiology. The 1 8 s o u t h e r n c a l i f o r n i a p h ys i c i a n | NOV E M B ER 2 0 1 2

system compiles heart data for analysis, a system already in use at many hospitals.

“Among physicians, there is incredible demand for enterprise medical information on iPhones and iPads,” Darren Dworkin, the CIO at Cedars-Sinai, said in a statement. “The interactive functionality is more advanced than anything else available today and pushes the path toward a day when all clinical hospital information will be available on a mobile platform.”

Cedars-Sinai is also working with IBM Corp.’s Watson megacomputer and WellPoint Inc. to build decision-making tools for oncologists treating breast, colon and lung cancer.

In March, Memorial Sloan-Kettering Cancer Center in New York became the first provider to use Watson’s processing ability to help diagnose and treat cancer.

IBM said it is looking to use its supercomputer to reduce medical errors and boost frontline efficiency in the realm of medicine.

Built with 16 terabytes of memory, which can easily hold twice the content found in the U.S. Library of Congress, Watson can store huge amounts of data ranging from patient health records to cutting-edge treatments.

Meanwhile, neurosurgeons and other researchers at Cedars-Sinai Medical Center and the Maxine Dunitz Neurosurgical Institute are seeking to take planet-hunting technology that uses a space-age ultraviolet camera into the operating room.

The hospital said researchers are trying to determine if the camera provides sufficient visual detail for surgeons to distinguish areas of healthy brain from gliomas, which have irregular borders as they spread into normal tissue.

If the pilot proves valid, it could give surgeons real-time views of changes invisible to the naked eye and unapparent even with the high magnification levels of current medical imaging technologies.

Some of the technologies headed to area clinics and hospitals

were unthinkable just a few years ago and take advantage of the rapidly advances being made in human genomic research.

Blue Shield of California is bringing a pilot program to Saint John’s Health Center in Santa Monica that will allow doctors to obtain genomic analyses of patient cancers in less than a minute compared to the current eight weeks — at a fraction of the cost.

Dr. Patrick Soon-Shiong, a doctor-turned-entrepreneur and one of the region’s wealthiest residents, is behind the effort to help more patients survive deadly cancers.

Los Angeles-based NantHealth, a startup business that SoonShiong launched, is developing the technology to speed the delivery of crucial cancer information so that doctors can start treatment immediately.

Soon-Shiong said that reams of paperwork currently involved in cancer detection and diagnosis prevent immediate treatment.

In addition to Blue Shield, he’s working with AT&T and Verizon to perfect a system that will work on smartphones and other mobile devices.

He said his goal is to increase the accuracy of biopsies, tests and medications used to prevent deaths that are easily avoidable.

“Incorrect care that leads to loss of life is unacceptable,” Dr. Soon-Shiong said at a news conference in early October. “And from today onward, it will no longer be necessary.”

The University of Southern California’s Keck School of Medicine is a hotbed of health care-related technology R&D. At USC’s annual Body Computing Center Conference held recently on campus, presenters unveiled a number of wireless technologies in development, including one that was developed with Boston Scientific, Samsung and Verizon.

The system alerts a doctor via smartphone when a patient with a pacemaker starts to experience cardiac symptoms.

If a patient with a pacemaker experiences cardiac symptoms, he

or she usually heads for the hospital, where it can take up to seven hours to be seen and perhaps have the implanted device reprogrammed.

The system sends data to a doctor’s mobile device for evaluation and reprogramming, a process that can take five to 10 minutes without need of the patient leaving his or her home, or the physician leaving his office.

Dr. Leslie Saxon, founder of the 2-year-old body computing center, said such rapidly proliferating mobile software applications are changing the face of medicine.

Indeed, she noted that those familiar smartphone and tablet app stores now offer more than 40,000 medical apps for sale, with even hundreds more on the way.

Investors are pouring $1 billion into digital health care over the next year, she said. The number doesn’t include the 150,000 consumer health care apps available.

Saxon said one of her goals is to accelerate the introduction of wireless technology into health care delivery in Los Angeles, as well as the rest of the country.

“Every day I go to work and I ask myself, ‘How can technology bring me closer to my patients? How can I use it to make the lives of my patients better?’” Dr. Saxon told the several hundred attendees at the recent conference.

Meanwhile, Thomas Jackiewicz, CEO for USC Health, said he believes that technology is going to help Los Angeles County, as well as the rest of the country, transition into the 21st century world of health care and medicine.

“We really are at a transformational point in health care,” Jackiewicz said at the body computing conference. “Much technology on the horizon can improve clinical care, improve quality, and help us create a patient-centered environment and help us manage our costs much more effectively.”

NOV E M B ER 20 1 2 | www. s o c a l p h ys i c i a n . n e t 1 9

s pecial r e po rt | d ual e li G i B l e s

STATe HeALTH CARe SeRViCeS dePARTMeNT SuBMiTS

Dual Eligibles Plan to Legislators By toM york

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DUAL ELI G I B LES | SPECIAL REPORT On Oct. 1, the California Department of Health Care Services (DHCS) submitted the final draft of a proposal to eventually shift 1 million seniors and disabled “dual eligibles” to MediCal managed care plans. On Oct. 1, the California Department of Health Care Services (DHCS) submitted the final draft of a proposal to eventually shift 1 million seniors and disabled “dual eligible” to Medi-Cal managed care plans. The Coordinated Care Initiative would move 700,000 elderly and disabled patients living in Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara counties into a demonstration project.

The number represents close to 80 percent of the dual-eligible patients living in the state.

The proposal to lawmakers is part of an ongoing effort by Gov. Jerry Brown to cut health care costs in the wake of chronic budget deficits.

Indeed, state healthcare officials said they want to end the high degree of fragmented care that many of the state’s seniors and disabled receive under the two programs. They say that they can improve the level of care while cutting costs in the transition.

The pilot project was discussed in a series of explanatory meetings, held in Los Angeles County, which featured Herb Schultz, regional director for the federal Department of Health and Human Services (HHS) District IX, and Jane Ogle, director of DHS. The two outlined details of the proposed shift on Sept. 20 at St. Francis Medical Center in Lynwood and at St. Mary Medical Center in Long Beach.

The meetings were part of a fourhospital tour sponsored by Los Angeles County Medical Association (LACMA) and the California Medical

Association (CMA).

Ogle, who also appeared before a recent long-term care summit in Sacramento, said patients will have a choice of Medicare benefits, but if they don’t specifically choose a Medi-Cal plan or opt out of the pilot, they will be passively enrolled in a managed plan.

However, Frank Navarro, education director for CMA, said he was concerned about the switch, especially its impact on doctors and their patients.

“The impact could be significant for doctors in which so-called ‘Medi-Medi’ patients comprised 40, 50, 60 percent or more of their practice,” he said.

He noted, for example, that some specialists in Los Angeles, such as ophthalmologists, have practices that consist of more than 70 percent MediMedi patients.

“These doctors will lose their patients, and their patients will lose their doctors,” he said.

As background, Navarro explained that the state Legislature originally approved four large urban counties for a much smaller pilot program. That proposal also included Los Angeles County.

“They selected the counties with the highest Medi-Cal populations,” Navarro said, noting that that was unusual in that most demonstration projects involve much smaller populations.

Another four counties were added in the final days of the legislative budget sessions in the summer, representing about 77 percent of all dualeligibles in the state, he said.

“I have been in this business for more than 30 years, and I have never seen a pilot program that has been this massive,” he said. “Generally, pilot programs are much more focused.”

“We’re very concerned about the breadth and scope of this,” he contin-

Dual eligibles are individuals who receive both Medicare and Medicaid coverage.

There are currently approximately 9 million dual eligibles across the country.

This complex population accounts for about 15 percent of all Medicaid enrollees but 40 percent of total Medicaid spending. In the current system, care delivered to Medicare-Medicaid patients is disjointed with each program responsible for providing different parts of the patients’ care. This also results in financial misalignment which has stymied efforts to implement care coordination for this population.

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SPECIAL REPORT | DUAL ELI G I B LES

CMA Delegates Call for Increased Advocacy on Duals Transition Recognizing the challengeS that California’s planned shift of Medicare and Medi-Cal dual eligible patients to managed care plans will pose to patients and the physicians that serve them, the California Medical Association (CMA) has adopted policy to help keep physician concerns in clear view of the agencies orchestrating the transition.

The policy, which was adopted at the CMA’s annual House of Delegates meeting, calls on the association to collect data from its membership regarding difficulties with the planned duals transition and, if difficulties are found to be widespread, report them to the California Department of Health Care Services, the California Department of Managed Health Care and the federal Centers for Medicare and Medicaid Services.

During the floor debate regarding the issue, delegates noted that the state’s Coordinated Care Initiative, which includes a pilot program to passively enroll patients eligible for both Medicare and Medi-Cal in eight of California’s largest counties, would see more than 75 percent of the state’s dual eligibles transitioned to managed care plans. The shift, speakers said, would likely lead to considerable confusion among patients and almost certainly interrupt relationships that have been established with their existing physicians.

Under the pilot program, patients will be enrolled in a managed care plan unless they actively opt out.

In addition to asking that CMA monitor the transition, the newly adopted policy also requests that the association advocate that the appropriate state agencies provide “full and clear disclosure” on options and consequences facing patients affected by the pilot program.

More information regarding the dual eligible transition can be found in CMA’s online duals resource center, at www.cmanet.org/duals.

ued. “If it fails, it cannot be undone.” physicians who have tried to contract CMA had originally asked state DHS with LA Care Health Plan or Health officials to scale back the program to Net, and their subcontracting entities, one rural county and one urban county and they keep getting turned away, sayuntil it was demonstrated that the shift ing their panels are full,” he said. would work for both doctors as well as He said shutting out doctors from for their patients, he said. the managed care plans could impact Apparently that request was overthe 300,000 patients in Los Angeles looked in the plan submitted to state County, and many could end up waitlegislators for approval. ing for treatment and other services.

The “overarching concern of CMA” “This really impacts a physician’s is the approach the state is taking to bottom line,” said Navarro, in terms of move patients into the managed care missed appointments for office visits programs”, he added.

CMA, he said, fears DHS will send letters “The impact could be significant for doctors to dual-eligible patients in which so-called ‘Medi-Medi’ patients comthat note that if they prised 40, 50, 60 percent or more of their pracdon’t respond by a tice...some specialists in Los Angeles, such as preselected date, they ophthalmologists, have practices that consist will be automatically of more than 70 percent Medi-Medi patients.” enrolled into a managed program.

Many of those patients won’t understand the imporand surgeries that have been schedtance of the letter or respond as direct- uled weeks and months in advance ed, and they will be shifted without “I know my patients and know them them understanding why, explained well, and the only patients that they are Navarro. going to take away are those who are Patients who are currently enrolled unable to read the letter and underin either Medicare or Medi-Cal manstand it or don’t know how to respond,” aged programs won’t be impacted. said one concerned doctor who attendOgle told providers in Sacramento ed one of the sessions. that reimbursements will remain the “We think this is the wrong thing same during the pilot project. to do,” he said. “It’s a poorly designed Meanwhile, Navarro said that 43 attempt to save money and doesn’t percent of physicians participating in take into account the welfare of those a recent CMA survey said they weren’t patients.” enrolled in Medi-Cal or Medicare According to the American Medimanaged programs. cal Association website, 15 states are “That’s an alarming number because currently transitioning dual-eligible we thought this would be an access ispopulations to managed care plans sue, and that’s proving to be the case,” he but noted that the California effort is said. “We’re really concerned about that.” the largest.

“We’re also concerned about the inorThe transitions in California will dinate number of complaints about the begin in June 2013.

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Cm a | qu i ck list

CMA, AMA and Others Developing Alternative Medicare Payment System to Replace SGR The California Medical Association (CMA) and the American Medical Association (AMA) along with more than 100 state and specialty medical societies sent a letter to Congress on October 15, 2012, outlining the principles and core elements needed to successfully transition from the critically flawed sustainable growth rate (SGR) to a higher performing Medicare program.

The principles outlined in the letter include the notion that successful delivery reform is essential, that the Medicare program must invest and support physician infrastructure and that Medicare payment updates should not only reflect the costs of providing services but should also take into consideration efforts to improve quality and managing costs.

CMA, AMA and other health care associations are also working on an alternative payment plan to replace the SGR. In June of this year an AMA SGR Task Force began work on a payment system for physicians that would be tied to “payment points.” While the working draft is confidential, the plan would include payment for things like quality, e-prescribing, adoption of EHR, best practices, chronic disease management, patient-centered medical homes and outcomes.

The AMA, CMA, Massachusetts Medical Society, American College of Physicians and American College of Surgeons have formed a small workgroup to refine these proposals. The principles outlined in the letter to Congress were devised by the group.

CMA Delegates HELP Set Policy at Annual CMA Meeting More than 500 California physicians, including your LACMA represenatives, convened in Sacramento recently for the 2012 House of Delegates, the annual meeting of the California Medical Association (CMA). Each year, physicians from all 53 California counties, representing all modes of practice, meet to discuss issues related to health care policy, medicine and patient care and to elect CMA officers. The following are summaries of some of the resolutions that were adopted as policy.

Revised blood donor deferral criteria (Resolution 108-12) The delegates expressed support for the use of rational, scientifically-based deferral periods for blood donations, applied based on level of risk rather than on sexual orientation.

Awareness and prevention of bullying (Resolution 113-12) The delegates called on CMA to support awareness and prevention of bullying in all its forms and to support the development of family, school and community programs and referral services for victims and perpetrators of bullying.

Support for amending the Affordable Care Act (Resolution 201-12) The delegates directed CMA to support amending the Affordable Care Act to address issues of concern to the practice of medicine.

Dual eligible monitoring and reporting (Resolution 208-12) This resolution directs CMA to collect data from its membership regarding difficulties with the planned transition of dual eligibles to managed care plans and to report the findings to the California Department of Health Care Services, the California Department of Managed Health Care and the federal Centers for Medicare & Medicaid Services.

that denying civil marriage contributes to poorer health outcomes for gay and lesbian individuals, couples and their families. The resolution also calls on CMA to support measures providing same-sex households with the same rights and privileges to health care, health insurance and survivor benefits afforded to opposite sex households.

Pharmacists substitution of physician prescriptions (Resolution 507-12) The delegates asked that CMA consider legislation to make it illegal for pharmacists to receive financial incentives to substitute a physician’s prescription.

Increasing utilization of POLST orders (Resolution 512-12) The delegates approved a resolution that calls on CMA to support awareness and use of Physicians Orders for Life-Sustaining Treatment (POLST) forms by physicians in all appropriate instances where medical services are provided to patients at the end of life.

HIPAA and medical record accessibility (Resolution 606-12) The delegates asked CMA support a study on the extent to which HIPAA laws impede the timely transfer of medical information necessary for the appropriate coordination of care.

Electronic prescribing and EHR payment reductions (Resolution 214-12) The delegates voted to oppose financial penalties by any payor for physicians who do not adopt health information technology, such as electronic medical records and electronic prescribing.

Helping physicians improve their health (Resolution 610-12) The delegates voted to encourage all physicians and physiciansin-training to properly manage their own physical and mental health and to serve as exemplars of healthy behaviors.

Health care equality for same-sex household members (Resolution 505-12) The delegates unanimously voted to recognize

The complete and final actions of the 2012 House of Delegates will be posted this week at www.cmanet.org/hod under “Documents.”

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qu i ck list | cm a

ACA Topic of Heated Debate at House of Delegates Since the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, it’s been a virtual certainty that delegates at the annual House of Delegates meeting would debate to influence policy regarding the landmark reform bill.

This year’s gathering was no exception, as resolutions touching upon various aspects of the ACA were introduced, and in some cases, adopted as official California Medical Association (CMA) policy.

Of the resolutions introduced and debated over the weekend, it appears that Resolution 202-12 will produce some of the most immediate results.

The resolution, which deals with the California Health Benefits Exchange, asks that CMA support several actions that will help ease the transition of roughly 1.6 million new enrollees to the state’s Medi-Cal program, as well as lists of requirements that will help protect physicians when contracting with plans offered through the exchange’s online marketplace.

Specifically, the resolution asks that county and state funding sources that currently help provide care for medically indigent adults follow those individuals when Medi-Cal is expanded in 2014, and that the exchange takes a more active role in monitoring network adequacy of its offered plans.

The issue of network adequacy has already garnered a significant amount of attention from CMA staff, but an agreeable solution has yet to be reached with exchange leadership.

A separate resolution, 201-12, reaffirmed CMA’s position of continuing to work toward amending the ACA to “address issues of concern to the practice of medicine,” and was ad-

opted by the House.

Finally, two resolutions, 204-12 and 205-12, launched the seemingly annual debate over single payor coverage in California.

Ultimately, reference committee members recommended that delegates disapprove both resolutions, noting that CMA has “well thought out and longstanding” policy on the issue of single payor.

During the reference committee hearings, supporters and opponents of single payor in California took to the microphone to voice their opinions on

the matter, providing some of the most passionate and ideologically divided debate of the weekend.

Ultimately, reference committee members recommended that delegates disapprove both resolutions, noting that CMA has a “well thought out and longstanding” policy on the issue of single payor. (CMA’s Policy Compendium is available to members at www. cmanet.org/policies. The new policies passed this year will be added to the compendium soon.)

For more information on any of these resolutions, or general reform activities in California, please subscribe to CMA’s regular reform newsletter, CMA Reform Essentials at www.cmanet.org/reform-essentials.

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asso ciati o n happe n i n gs | N e ws & e ve n ts

LACMA Contingent Attends Annual

CMA House of Delegates Meeting

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A large contingent of 80 doctors — 40 delegates and 40 alternates — representing Los Angeles County attended the House of Delegates in Sacramento from Oct. 13 to 15, according to Dr. Paul Kirz, who led the delegation as chairman.

Dr. Kirz, an orthopedic surgeon with a practice in Whittier, said the annual gathering is an opportunity for doctors to submit resolutions that, if approved, become the official policy of the California Medical Association. Only delegates can present resolutions, he said, which gives doctors a voice in their own organization.

The work is mostly done in committees, not the full delegations, he said.

“That’s really where the main action takes place, and those committees are the place to be if you want to influence policy,” said Dr. Kirz.

He added that at the three-day meeting the delegations discussed up to 100 resolutions that came out of six different committee meetings held ahead of the full delegation deliberations.

He said the committees hear from

experts but make the final decisions themselves.

“They decide what’s best for the CMA,” he said. “That’s why they’re there.”

Dr. Kirz said one resolution drew a lot of attention and discussion — that of increasing utilization of Physicians Orders for Life-Sustaining Treatment, or POLST orders (Resolution 512-12).

“There was considerable discussion about this particular form,” said Dr. Kirz.

He said there were earlier discussions of letting nurse practitioners obtain the necessary signature for each order, but delegates adopted a resolution that calls on CMA to support awareness and use of POLST forms by physicians in appropriate instances where end-of-life medical services are provided to patients.

“The delegates felt that the doctors should be getting the forms, not nurse practitioners,” he said. “We didn’t want to give up authority and set a precedent.”

The delegates also approved a number of other resolutions, including: —Dual eligible monitoring and reporting (Resolution 208-12): The reso-

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N e ws & e ve n ts | associati o n happe n i n gs

lution directs the CMA to collect data from members regarding the difficulties with the proposed transition of dual eligible Medicare-Medi-Cal patients to managed care plans and to report the findings to the state Department of Health Care Services, the state Department of Managed Health Care and the federal Centers for Medicare & Medicaid Services.

“I don’t think there was much controversy about this issue; I think we all agreed that the patient should decide,” said Dr. Kirz. “The patients are not going to have a lot of choice if they don’t sign the form opting out of managed care. They should have a choice.”

—Revised blood donor deferral criteria (Resolution 108-12): The delegates voted to support rational, scientifically based deferral periods for blood donations based on level of risk rather than on sexual orientation.

—Support for amending the Affordable Care Act (Resolution 201-12): The delegates directed CMA to support

amending the Affordable Care Act to address issues of concern to the practice of medicine.

—Electronic prescribing and EHR payment reductions (Resolution 21412): The delegates voted to oppose financial penalties for physicians who do not adopt new technology, such as electronic medical records and electronic prescribing.

In addition, Dr. Kirz said he was impressed that CMA’s political action committee had raised more than $152,000, beating last year’s three-day fund-raising record of $110,000.

“It’s a very rewarding experience,” said Dr. Kirz, “And I would encourage more doctors to come out and participate.

This is where we have a voice.”

More than 500 doctors attended the annual meeting, the California Medical Association reported later.

The complete and final actions of the 2012 House of Delegates are posted at www.cmanet.org/hod under “Documents.”

Photos: 1. LACMA Member and Delegate Dr. Debra Judelson speaking at the house 2. LACMA Members and Delegates to the CMA, Dr. Pragnesh Patel and Dr. Nassim Moradi 3. The House of Delegates 4. LACMA Member Dr. Vito Imbasciani at the House of Delegates 5. President’s Reception & Awards Gala, which featured a cocktail reception, dinner, an inspiring awards presentation, live entertainment, and after-party

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m e mb e r b e n e fits | At Wo r k fo r yo u

Don’t Miss the New www.LacmaNet.org New Features Will Offer Members Tools to Take Action, Get Involved, and Manage Their Practice IN ADDITION, members-only portals, physician community networks, office manager online forums and physician directories will add interactive mediums for physicians to get involved. The new online marketplace showcases “best in class” vendors offering exclusive money-saving discounts on products and services geared towards efficient practice management operations. LACMA ’s website features and marketplace will be ever growing and changing, so please be sure to check regularly for updates! LAC -MA’s goal is to create a stronger online presence to improve LACMA ’s communications with doctors, patients and all healthcare constituents in Los Angeles County and throughout California.

Meet Your Board!

LAC MA’ 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. officers Samuel Fink, MD

Marshall Morgan, MD

Pedram Salimpour, MD

Peter Richman, MD

Troy Elander, MD

President

President-Elect

Treasurer

Secretary

Immediate Past President

board of directors David Aizuss, MD

Sidney Gold, MD

Lawrence Kneisley, MD

Nassim Moradi, MD

Bob Rogers, MD

CMA Trustee

Councilor

Councilor-at-Large

Councilor

Councilor

William Averill, MD

William Hale, MD

Howard Krauss, MD

Ashish Parekh, MD

Sion Roy, MD

Councilor

Councilor

Councilor

Councilor

Resident/Fellow Councilor (Alternate)

Erik Berg

Shelley Han

Gideon Lowe, MD

Jeffrey Penso, MD

Medical Student Councilor / USC Keck

Medical Student Councilor / UCLA David Geffen

Councilor

Councilor-at-Large

Stephanie Booth, MD

Vito Imbasciani, MD

Jonathan Macy, MD

Heidi Reich, MD

Councilor-at-Large

Resident/Fellow Councilor

Councilor-at-Large

Councilor

Carlos E. Martinez, MD

Susan Reynolds, MD

Councilor

Councilor

Jack Chou, MD

Paul Kirz, MD

CMA Trustee

Chair of LACMA Delegation

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Pejman Salimpour, MD Councilor

Shuo Steven Wang, MD Councilor-at-Large

Erin Wilkes, MD CMA Trustee (Resident)

ReMeMBeRed

Dr. Reinhold A. Ullrich, MD

former lacMa president, loving father, Grandfather, caring and revered physician dr. reinhold a. ullriCh, md passed away peacefully, surrounded by loving family, on thursday, october 04, 2012 in the comfort of his home in rolling hills, ca. Born in Massachusetts on June 4, 1927, reinhold lived a full and exciting life, excelling in everything he attempted. he graduated high school in pittsfield, Ma one semester early to join the u.s. army during WW ii in defense of the country he dearly loved. after the war, reinhold attended harvard university in an accelerated program, graduated in three years and went on to medical school in Buffalo, ny. there he met nora, a sweet nursing student, who became his loving wife of almost 55 years. after their marriage on June 6, 1953, reinhold and nora honeymooned by driving across the u.s. and visiting every national park they could. they arrived at los angeles harbor General hospital, where reinhold completed his medical residency. the young couple then moved to torrance, ca, where reinhold partnered with dr. lon Monk, Md at little company of Mary hospital. together they opened what would become one of the largest, most successful and respected oB/Gyn medical practices in los angeles county. reinhold dearly loved his patients and continued his practice until the final months of his life. during that 59-year career, dr ullrich was the los angeles county Medical association president from 1988-1989, delivering more than 8,000 babies and touched thousands of lives. he was revered greatly by his patients for

his sincere, gentle and caring nature, often delivering the children of patients over multiple generations: “My mom said you were wonderful when you delivered me, so i wanted you to deliver my baby as well,� was a common statement in the latter years of dr ullrich’s career. an avid outdoorsman and endurance athlete, reinhold never stopped experiencing the beauty and challenges of nature, often on foot. he conquered the highest peaks of every continent, except when inclement weather stole the peak of everest from his grasp at the age of 68. he completed marathons in every state of the u.s., every continent, including antarctica, and most major cities throughout the world. he jogged around the north pole, completed the Western states 100-miler twice and the grueling Baffin island Marathon three times. as a lover of sports, he took family members on wonderful outdoor adventures in the sierras, to Mammoth Mountain, heli-skiing in the canadian rockies, track and field events of every olympics for the last three decades and river rafting throughout the western states. in addition, he was a great lover of the arts and honored the christian spirit of philanthropy. Many charities, art venues and universities are thankful for his generosity. however, in the eyes of us, his loving family, his greatest accomplishment will always be the vast mountains of love, marathons of adventure and deep passion for life he generated in the hearts of everyone he touched.

Welcome to Our New Members district 1

district 6

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lisbeth Chang, md

francis yemofio, md

hajir dadgostar, md

thien van, md resident

norman horowitz, md

district 2 nubar Boghossian, md district 5 Bernard Weintraub, md Christine megerdichian, md resident horace mellon, md

district 10 hoori hovanessian, md matthew hwang, md district 14 timothy marcoux Medical student Cynthia Chen Medical student

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Opportunity for owner occupant/investor MEDICAL/DENTAL Office 1409 Sq. Ft. Walking distance to Centinela Hospital. Retain existing clients, has examination and records rooms, waiting area, ample parking. Call (310)9891941, angie@guaranteedrealty.net 520

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For details: ENTsocal@gmail.com MEDICAL OFFICE FOR SALE In Sunny California, just North of LA, a medical office is available for sale, all ready for the doctor to move in. Current tenant, retiring Board Certified General Surgeon will help with transition. The office is walking distance of main hospital and surrounded by multiple medical offices. May accommodate easily 2 MD’s. Current personnel will stay. It may be sold alone or together with the building it is in. Interested, please call 661-942-6565.

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J ust t h e fac ts | DUAL ELI G I B LES

1.3 million Number of people in the United States eligible for Medicare and some level of Medicaid benefits

27% Dual Eligibles as a Percent of Total California Medicare Beneficiaries

370,000 more than half live on $10,000 a year or less.

50%

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The dual eligible population is three times more likely to live with a disabling condition than the general Medicare population

Ten counties are home to about 75 percent of dually eligible beneficiaries, with Los Angeles County home to nearly

9.7 million

3x

one in three

Total number of dual eligibles in California

The number of dual eligibles in Los Angeles County

7 in 10 dual eligibles in California are age 65 and older, and the majority are women

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