December 2012

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special report:

The CMA 2012 Legislative Wrap-Up

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The California Medical Association’s 2012 Legislative Wrap-Up

y Jodi Hicks, CMA VP of Government Relations

volume 143 issue 12

December 2012

10

n years past, the California Medical Association (CMA) has defended physicians in battles waged by hospitals, health plans and mid-level practitioners, but this year we initiated a few fights of our own. CMA d what physicians do best: We fought to protect patients.

CMA fought to keep patients out of the middle of ing disputes, to educate parents about immunizations, to uire mandatory flu vaccinations for health care workers, to move sugared beverages from schools, to create a physician alth program, to expand residency programs and a last nute effort to save the Healthy Families Program.

Sponsoring legislation is the equivalent of pushing rocks up a hill… or rather big righteous boulders. The CMA Government Relations team struggled to push those rocks up the legislative hill while fighting off the enemies trying to get in the way, and at the same time stopping the many other rocks being thrown down at physicians. Sounds dramatic, but by all accounts, it was a crazy, precarious, contentious, hazardous and dramatic pathway to the finish line. We finished with some big wins and although we lost a few along the way, CMA fought for physicians and their patients until the very end.

FEATUrEs

EVErY IssUE r more information about CMA and its programs visit www.cmanet.org • Rev. 10.10.12 10 sPEcIAL rEPOrT: cMA 2012 LEGIsLATIVE WrAP-UP a detailed review of cMa sponsored and opposed legislation as we continue to battle for physician and patient rights.

18 THE FUTUrE OF HEALTHcArE In cALIFOrnIA as uncertainty looms for healthcare in l.a. county, california and the u.s., we take a look what’s next.

27 LAcPAc nEAr PErFEcT EnDOrsEMEnT rEcOrD In nOV. 6 ELEcTIOns lacMa’s political action arm was a big winner, with 41 of 42 endorsed candidates winning elections.

18

27

Page 1 of 8

6 Front Office tips, hints, advice and resources to make your practice run more smoothly.

32 Just the Facts the state of health in california by the numbers.

FrOM YOUr AssOcIATIOn 4 President’s Letter this month’s musings from samuel fink, MD. 2 cEO’s Letter an update on how your association works for you, from rocky Delgadillo.

26 Association Happenings 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.

D ec 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

O

n n OV E M B E r 2 9 T H , we held the first ever Latino Physicians Advisory Committee, which was also the first of a new planned series of advisory committees to be launched by LACMA to expand our reach to physicians and the patients we serve.

According to reported estimates, African-American and Latino physicians in Los Angeles County represent just more than 6 percent of the county’s 26,940 physicians, despite representing 48 percent of the population.

When I first came on board, we had very little representation of Latino physicians at LACMA, which made it a priority for me to reach out to the Latino community.

The idea to form a Latino Physicians Advisory Committee grew out of a dinner meeting with physicians this July.

Dr. Hector Flores, a long-time LACMA member who is passionate about organized medicine and physicians who provide care to the underserved population, agreed to lead the Latino Physicians Advisory Committee.

Dr. Flores and other committee members will tackle such key initiatives as increasing the number of Latinos enrolling into medical school while attracting Latino physicians from all over the world to practice in Los Angeles County.

About 15 to 20 physicians serving on the committee will research and implement critical issues above and others. Dr. Flores is not only a strong voice for Latino physicians, but known for addressing key regulatory and economic issues affecting physicians and patients.

When a group of CEOs representing some of the top Latino-focused healthcare organizations recently discussed the impact of the Affordable Care Act on the Latino population, Dr. Flores outlined the positives for the community.

During the Los Angeles County Medical Association panel discussion on Nov. 14, Dr. Flores noted that 30 percent of the adults nationwide will be eligible to purchase insurance through the new California run exchange or through Medi-Cal. Furthermore, he noted, that children will ‘get pretty close to universal coverage,’ which will create a better practice environment for physicians and hospitals. He vehemently supports the Affordable Care Act as benefitting all Americans, not just the underserved population in Los Angeles County.

Latino physicians who want to get involved with the Latino Physicians Advisory Committee should contact Dr. Luis Ayala, LACMA’s director of government affairs.

To reach an even more diverse population in Los Angeles County, we also plan to create a Women’s Physicians Advisory Committee, African-American Physicians Advisory Committee and an Asian Physicians Advisory Committee.

With the New Year quickly approaching, I would like to take this opportunity to thank you for your support and engagement this year.

The New Year brings many new exciting opportunities, including your support for the physicians advisory committees. We encourage you to get involved and stay involved as LACMA’s future couldn’t be brighter.

During this time of celebration, we wish you and your loved ones a wonderful and peaceful Holiday season.

rocky Delgadillo

Chief Executive Officer

2 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 | D ec e M B e r 2 0 1 2

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

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

I

HOPE THAT ALL OF YOU are enjoying your preparations for the holidays, and looking forward to spending time with your families and friends. As we face our daily struggles in the medical profession, I think we need this season to keep us grounded and to remind us which aspects of our lives are truly important.

You can be very proud of LACPAC-the Los Angeles County Political Action Committee--which is the political arm of LACMA. LACPAC endorsed candidates in 42 races, and saw 41 of our candidates elected! Of the 41, we were fortunate to have two physicians win! Raul Ruiz, MD, an emergency room physician, was elected to the House of Representatives from the 45th Congressional District, and Sandra Salazar, MD, a family physician, was elected to the Cerritos Community College District Board of Trustees. LACPAC also supported Matthew Lin, MD, an orthopedist who ran an excellent campaign in the 49th assembly district, but was, unfortunately, defeated.

The re-election of President Obama ensured the survival of the Affordable Care Act. Former House Speaker Pelosi’s quote “...We have to pass the bill so that you can find out what is in it...” has now become reality, and I think that all of us are wondering how this legislation will affect our professional lives and practices. What is clear is that all levels of organized medicine oppose the Independent Payment Advisory Board, which has the power to impose arbitrary across-the-board cuts to physicians and other providers to slow the growth in Medicare spending. As you are aware, we are doing everything possible to replace the flawed SGR formula which has physicians facing a 27% cut in Medicare reimbursement in 2013 if no congressional action is taken. Finally, the AMA is pushing Congress to expand the liability protection of California’s MICRA bill to the rest of the country.

I would advise all of you to proceed cautiously before making any significant

changes to your practice-we just don’t know enough at this point. Do not sign any contracts or agreements that are not financially sound (a frequent occurrence among physicians), and make sure that anything you do sign has been thoroughly reviewed by your attorney. As you care for your own patients, please respect as well the doctor-patient relationships established by other physicians. I have little respect for groups of doctors that try to “corner the market” within their community at the expense of their colleagues. The provision of health insurance to California’s uninsured will certainly mean that there will be more than enough patients that need our care. Our adversaries love it when we physicians forget who we are and turn on each other, and this destroys our ability to advocate for our patients or ourselves.

As I previously reported, LACMA sued Aetna Health of California in July because of Aetna’s refusal to allow patients to access their out of network benefits. Since the lawsuit was filed, Aetna has dramatically stepped up its termination of physicians who refer patients to out of network facilities for covered medical services.

The California Medical Association has asked the State Departments of Insurance and Managed Healthcare to investigate this retaliatory behavior, and we are very concerned about Aetna’s ability to provide adequate access to care for its beneficiaries in light of these widespread terminations which have diminished its physician network and disrupted physician-patient relationships. If Aetna has terminated your contract, please give us a call so that we can let you know your options, and

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 | D ECE M B ER 2 0 1 2

document what has happened!

One of my goals during my term as president is to revitalize the LACMA Districts, as well as their activities on behalf of our membership. To that end, we have hired a new district administrator who will be working with all the districts to ensure that they have functioning boards with elected leadership. We’d like to see well attended educational programs and social events in every district! Districts are also a great way for you to become involved in LACMA leadership and have a direct impact upon our organization. My own involvement in LACMA started when I became a member of the West San Fernando Valley Board of Directors in 1989. I’m not sure when the 23 years passed by, but I can tell you that I’ve enjoyed representing you and being your advocate! We always need new leaders, and if you’d like to become more involved, please contact Carol Chaker in our downtown office at 213-2260313. My best wishes to all of you for a healthy and prosperous New Year!

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

stresseD oUt DUrinG tHe HoliDaYs?

Try These Tips to Avoid Burnout sTrEss AnD FATIGUE caused by working longer hours and inadequate staffing levels can put physicians at risk of burnout and can raise the risk of negative patient outcomes. During the holiday season, physicians may face added stress as employees and colleagues have more personal commitments and practices may be short staffed.

The rate of physician burnout is significant. A recent study by the Mayo Clinic found that nearly one in two (45.8 percent) of doctors in the United States have at least one symptom of burnout.1 According to the study, being asked to see more patients, having less time with each patient, and short patient release timelines are major stressors for physicians. Physician burnout can decrease quality of care, increase risk of errors, push physicians into early retirement, and cause problems in physicians’ personal lives.

In 2010, The Doctors Company began tracking human factors as risk management issues and evaluated the influence of human factors in 862 closed liability cases. Of those cases, 114 (13%) included at least one human factor issue. Within those 114 cases, 14 percent dealt with conditions affecting the provider, including fatigue, physical or mental impairment, distractions, multitasking, or interruptions.

Stress management skills are not traditionally part of medical school curriculum. Most healthcare professionals are taught to put their heads down and persevere. At a time when medical professionals are increasingly in demand, as millions of patients become newly insured, practices should consider steps to prevent physician burnout and stress.

consider these tips to help reduce stress, especially around high-stress times such as the holidays: Ensure adequate staffing levels on holidays and night shifts.

Monitor staff schedules and curtail hours as needed to prevent undue fatigue.

Stress management skills are not traditionally part of medical school curriculum. Most healthcare professionals are taught to put their heads down and persevere. At a time when medical professionals are increasingly in demand, as millions of patients become newly insured, practices should consider steps to prevent physician burnout and stress.

Call in additional physicians and staff to combat fatigue and stress.

Provide an environment that supports staff members so that they feel comfortable expressing concerns about their stress level and ability to function effectively.

Allow staff members to express concerns to each other if they identify signs of fatigue or stress in their colleagues.

Encourage all staff members to take 20-minute meal breaks and to get fresh air to clear their minds at least once per shift.

Have regular one-on-one and group meetings with staff to learn their thoughts on how to make things run more smoothly.

Encourage physicians and staff to put their focus on things they can change, not things they have no control over.

References: 1. Shanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18):1-9.

Contributed by The Doctors Company. For more patient safety articles and practice tips, or to read more about the 2010 human risk factors evaluation, visit www.thedoctors.com/patientsafety.

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f ro n t offi c e | pr ac ti c e tips

Blue Cross Notifying Physicians of Intent to Participate in Benefit Exchange The window for healthcare plans to notify the California Health Benefit Exchange that they will participate in the state’s new digital insurance marketplace is closed, but two of the state’s major payers are making their intentions known to their contracted physicians, the California Medical Association (CMA) reported last week.

Anthem Blue Cross notified the CMA that it will create a new provider network called the “Anthem Individual/Exchange Network,” which will serve both individuals who purchase coverage through the exchange and those who purchase coverage from Anthem Blue Cross in the individual market outside of the exchange, the CMA said at its website.

The letters announced Blue Cross’ intention to roll physicians in its “Prudent Buyer Contracts” into this new network.

Included with the letter is an addendum to Blue Cross’ participating provider agreement outlining amendments and the new network’s fee schedule, according to the CMA. Apparently, both Blue Cross and Blue Shield will be bidding to be in the exchange, meaning there may be a substantial PPO presence, the CMA said. “This may come as a surprise to some exchange observers, as many believed the downward cost pressures of the exchange would deter PPO plans,” the CMA said.

This potential PPO presence also means the exchange’s 90-day grace period may become more of a concern for many California physicians.

Exchange plans will have the option to pend and deny provider claims submitted in the last 60 days of a federally subsidized enrollee’s 90-day grace period, prior to the patient being terminated for non-payment of premiums, the CMA reported.

It is presumed that the use of this option is significantly more likely under a fee-for-service payment arrangement, though plans could potentially still cap deduct under a delegated risk arrangement, the CMA said.

Neither the Blue Cross nor the Blue Shield notices and proposed contract language address the grace period issue.

Source: PNN-Physicians News Network 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 | D ECE M B ER 2 0 1 2

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“Healthcare is a special business – you can’t treat it like any other industry,” said Breck Fleming, senior vice president and team leader for healthcare with City National Bank. “We understand the complexities and challenges that healthcare providers are currently facing. Our team of healthcare bankers provides banking solutions and products that help providers to be more efficient while saving them money.”

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One Must IMagIne sIsyphus happy The California Medical Association’s 2012 Legislative Wrap-Up

By Jodi Hicks, CMA VP of Government Relations

n years past, the California Medical Association (CMA) has defended physicians in battles waged by hospitals, health plans and mid-level practitioners, but this year we initiated a few fights of our own. CMA did what physicians do best: We fought to protect patients.

CMA fought to keep patients out of the middle of billing disputes, to educate parents about immunizations, to require mandatory flu vaccinations for health care workers, to remove sugared beverages from schools, to create a physician health program, to expand residency programs and a last minute effort to save the Healthy Families Program.

Sponsoring legislation is the equivalent of pushing rocks up a hill… or rather big righteous boulders. The CMA Government Relations team struggled to push those rocks up the legislative hill while fighting off the enemies trying to get in the way, and at the same time stopping the many other rocks being thrown down at physicians. Sounds dramatic, but by all accounts, it was a crazy, precarious, contentious, hazardous and dramatic pathway to the finish line. We finished with some big wins and although we lost a few along the way, CMA fought for physicians and their patients until the very end.

1 0 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 | D ECE M B ER 2 0 1 2

For more information about CMA and its programs visit www.cmanet.org • Rev. 10.10.12

Page 1 of 8

l eg is l ative wr ap- u p | s pecial r e po rt Out of the gate in January, CMA came out swinging.

We introduced AB 1742 (Pan), which would have enabled patients to assign their benefits directly to the provider furnishing medical services. Sounds simple enough, but the bill soon came under attack from the health plans and culminated in what was described on one blog as the “juiciest” health committee hearings of the year. After much back and forth, the bill came up one vote short before reaching a legislative deadline to move the bill.

That same week, CMA battled the unions, championing a bill through both a health and labor committee that would mandate flu vaccines for health care providers in hospitals. Against all odds and much opposition, SB 1318 (Wolk) moved through the Senate in a decisive win for public health. Though CMA was able to maneuver this contentious bill all the way through the Legislature, it was subsequently vetoed by the Governor.

CMA also joined a large coalition of health care providers in a valiant attempt to create a physician health program in California. The coalition worked tirelessly to address the opposition’s concerns surrounding funding, oversight and standards, and the bill made it all the way through both committee hearings and was on its way to the floor when it stalled. Despite the coalition’s diligence, the overwhelming demands of the opposition damaged the bill beyond repair before the last legislative deadline.

Despite an end to this bill, we are confident that the conversation can continue and this will be an issue CMA will look to advance next year.

And then came Rob Schneider. CMA, along with the American Academy of Pediatricians, the Health Officers Association of California and the California Immunization Coalition, sponsored AB 2109 (Pan) in an attempt to decrease the number of parents exempting their children from being vaccinated before entering public schools.

Hundreds of anti-vaccine activists flooded the committee hearings to oppose the measure and eventually were joined

by Saturday Night Live alum Rob Schneider. Now armed with “celebrity” status, the opposition was able to secure public rallies, television time and spread of social media to oppose our efforts. Despite attempts at negative media attention by the opposition, Governor Brown signed AB 2109 into law hours before the deadline.

The year wouldn’t be complete without CMA revisiting some oldies but goodies, physical therapy and MICRA being no exceptions. Unfinished business from 2011, SB 924 (Steinberg/Price) would have fixed the ambiguity in law as to whether or not medical corporations

can legally employ physical therapists, but it would have also allowed patients to directly access physical therapy treatment for 30 business days, at which time a physician would have to sign off on a physical therapy treatment plan. CMA had an official “Oppose unless Amended” position on the bill, asking for amendments that would have required a medical diagnosis after 30 days of direct treatment. The Assembly Appropriations Committee passed the bill, adding in medical diagnosis as a requirement for direct access. The California Physical Therapy Association again amended the bill on the floor, changing the language so that instead of requiring a diagnosis it would require an examination or a diagnosis… and as the game of semantics wore on, the bill was quickly sent to Assembly Rules Committee where it stayed until its demise.

Two bills that would have weakened the protections of MICRA, SB 1528 (Steinberg) and AB 1062 (Dickenson) were amended the last week of session adding to the flurry of the chaos in the final days. The provider community strongly opposed both bills and thanks to letters and phone calls from physicians across the state, they were ultimately killed with astoundingly low vote counts.

The legislative session officially ended early Saturday morning, September 1, 2012, and CMA’s Government Relations team was at the Capitol until the very end. In the waning hours of the 2011-2012 Legislative Session, CMA successfully negotiated key amendments into the Worker’s Compensation bill and proudly fought to reinstate the Healthy Families program as part of a multi-part deal that died sometime after 1:00 am.

Despite bipartisan support for our efforts, the Healthy Families program became collateral damage to partisan politics. CMA continues to work with stakeholders on the transition of kids to Medi-Cal. More to come on this issue…

“The Myth of Sisyphus” tells us that toil is not futile, and hard work can be noble. CMA toiled throughout the year for physicians, honoring the labor physicians do for their patients every day. The struggle to push those legislative rocks up the hill was performed with pride, and as the essay reads, “The struggle itself toward the heights is enough to fill a man’s heart. One must imagine Sisyphus happy.” Of course, Sisyphus was not pushing the rock while simultaneously fighting labor lobbyists or Rob Schneider–but I still imagine him happy.

On the following pages are details on the major bills that CMA followed this year.

For more information about CMA and its programs visit www.cmanet.org • Rev. 10.10.12

Page 2 of 8

s pecial r e po rt | l eg is l ative wr ap- u p

CMA SPONSORED LEGISLATION AB 826 (Swanson/Williams/Perea): Healthy Families This CMAsponsored bill was substantially amended in August at CMA’s request to include language to both (1) extend the Managed Care Organization (MCO) tax by one year, and to use the funding for the Healthy Families program, and (2) eliminate the transition of Health Families enrollees to Medi-Cal (done through the budget this year), thereby preserving the Healthy Families program. This bill is a critical part of CMA’s ongoing push to protect the successful Healthy Families program.

Status: Failed pursuant to legislative deadline.

AB 1742 (Pan): Assignment of Benefits This bill requires Knox-Keene regulated PPO products to authorize and permit assignment of an enrollee’s or subscriber’s right to reimbursement to the provider furnishing those services. This bill provides for the direct payment of individual insurance medical benefits by a health insurer to the person who provided the hospitalization or medical or surgical aid. It limits the amount of the reimbursement to the amount of the benefit covered by the policy.

Status: Failed pursuant to legislative deadline.

AB 1746 (Williams): Sale of Sports Drinks in Schools Current California law restricts the sale of soda and most other sweetened beverages on elementary, middle, and high school campuses. However, current law does allow the sale of one type of sugar-sweetened beverage – “sports drinks” – on middle and high school campuses. There is a common misconception that sports drinks are healthy. Yet many contain high fructose corn syrup and/or other calorie-laden sweeteners that have been linked to the rise in childhood obesity, the primary cause of type-2 diabetes. Sports drinks are designed to replace fluids after intense exercise and generally contain sodium and potassium to improve fluid absorption in the body; they are not designed to be an afternoon substitute for soda. A recent study indicated that eight of the top 10 beverages sold a la carte in California’s public high schools are sports drinks, clearly becoming the drink of choice for those students wanting a substitute for soda. To close the loophole in current law that allows high-sugar sports drinks on school campuses, AB 1746 would prohibit electrolyte replacement beverages (sports drinks) from being sold to middle or high school students during school hours.

Status: Failed pursuant to legislative deadline.

AB 1848 (Atkins): Medical Expert Witnesses The goals of this legislation are twofold. It would (1) Authorize the state to discipline or deny licensure to physicians who offer deceptive or fraudulent expert witness testimony related to the practice of medicine; and (2) Require out-of-state expert witnesses to apply and become registered by the Medical Board of California to testify as a medical expert witness in California. Registration would require the completion of a written application accompanied by a fee. In the event a registered out-of-state medical expert witness deceives or commits fraud as an expert witness, the medical board could revoke his/ her registration to prevent the individual from re-offending in any other potential court cases. Status: Failed pursuant to legislative deadline.

AB 2064 (V.M. Perez): Vaccine Reimbursement This bill requires a healthcare service plan or health insurer that provides coverage for childhood and adolescent immunization to reimburse a physician or physician group in an amount not less than the actual cost of acquiring the vaccine plus the cost of administering the vaccine. It prohibits the imposition of deductibles, coinsurance or other cost sharing mechanism for the administration of childhood or adolescent immunizations or related procedures. It also prohibits provider contracts from containing a dollar limit provision for 1 2 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 | D ECE M B ER 2 0 1 2

the administration of childhood and adolescent immunizations or including the cost of those immunizations in a dollar limit provision. This bill applies the current prohibition of a physician or physician group from assuming financial risk for the acquisition costs or required immunizations to all contracts between plans and physicians and physician groups. Additionally, it prohibits a plan from requiring a physician or physician group to assume financial risk for immunizations, whether or not those immunizations are part of the current contract, and prohibits plans from including administration cost in the capitation rate of a physician who is individually capitated.

Status: Failed pursuant to legislative deadline.

AB 2109 (Pan): Childhood Immunizations California is one of 20 states that allows for the broad use of the personal belief exemption (PBEs) from immunizations that are required for children to enter school. In California, obtaining a personal belief exemption is simple–parents are only required to sign their name to a two-sentence standard exemption statement on the back of the California School Immunization Record or provide a signed written statement. Over the past decade, the number of parents choosing to exempt their children from school immunization requirements has increased significantly, leading to more school children left vulnerable to preventable diseases. Parents have the right to make choices about immunizing their children; however, these choices should not be based on misinformation or lack of information. AB 2109 requires a parent or guardian seeking a personal belief exemption for their child to obtain a document signed by themselves and a licensed healthcare practitioner. The document will state that the healthcare practitioner has informed the parent or guardian of the benefits and risks of the immunization, as well as the health risks of the diseases that a child could contract if left unvaccinated.

Status: Enrolled and sent to Governor. Signed into law 9/30/12.

SB 301 (DeSaulnier/Cannella/Pavley/Rubio/Strickland/Yee): Healthy Families This CMA-sponsored bill was substantially amended in August at CMA’s request to include language to both (1) extend the Managed Care Organization (MCO) tax by one year, and to use the funding for the Healthy Families program, and (2) eliminate the transition of Healthy Families enrollees to Medi-Cal (done through the budget this year, thereby preserving the Healthy Families program). This bill is a critical part of CMA’s ongoing push to protect the successful Healthy Families program.

Status: Failed pursuant to legislative deadline.

SB 1318 (Wolk): Influenza Vaccinations for Healthcare Providers in Health Facilities On a daily basis, healthcare workers come in contact with vulnerable populations such as seniors, young children and others with certain health conditions who may have depressed immune systems and cannot afford to catch the flu. The best way to ensure this does not happen is to have every healthcare worker vaccinated for the flu. Healthcare workers who get vaccinated reduce the transmission of influenza, staff illness and absenteeism, and influenza-related illness and death, especially among people at increased risk for severe influenza illness. Unfortunately, despite the benefits, many healthcare workers still voluntarily go unvaccinated. During the 2010-2011 influenza season, coverage for influenza vaccination among healthcare workers was estimated at 63.5 percent. However, those health facilities that had policies in place that required their healthcare workers to be vaccinated had a compliance rate at 98.1 percent. This discrepancy shows the great success of the required flu vaccination programs; programs that should be emulated. SB 1318 requires all health facilities and clinics to implement measures, including vaccine education programs, to help maximize influenza vaccination rates among their healthcare workers and medical staff. Workers who decline the vaccine will be required to declare in writing that they will adhere to the policy determined by the health facility or clinic to be the most effective measures to prevent workers from contracting or

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s pecial r e po rt | l eg is l ative wr ap- u p transmitting the virus. Any facility or clinic that fails to achieve a 90 percent or higher influenza immunization rate by January 1, 2015, will be required to adopt the model “mandatory vaccination policy” determined by the California Department of Public Health to be the most effective in achieving the 90 percent or higher goal. Status: Enrolled and sent to Governor.

Vetoed 9/30/12.

SB 1416 (Rubio): Physician Workforce This proposal would lay the groundwork to create the Graduate Medical Education Trust fund, to be administered by the Office of Statewide Health Planning and Development for the purposes of administering grants to expand the state’s residency programs. As currently drafted, funding for this bill is dependent upon private donations. Status: Failed pursuant to legislative deadline.

SB 1483 (Steinberg): Establishing a Physician Health Program in CA This bill would establish a physician health program in California to refer physicians for treatment and monitoring services when they are suffering from substance abuse, mental and behavioral health issues. California is one of only five states in the nation that do not have such a program, following the Medical Board of California’s decision to eliminate its 27-year-old Diversion Program in 2007. This program will be structured fundamentally different than its predecessor, in that instead of taking on physicians who are under disciplinary review by the board, the program will be a voluntary model, encouraging physicians to actively seek treatment before their problems progress to the level that would lead to possible complaints and patients being put at risk. The program will be run by an external, private entity that contracts with the state, as opposed to the Diversion Program, which was run by the medical board. The program will be under the purview of the state Department of Consumer Affairs, instead of the medical board.

The program will be funded by a fee charged to all new and renewed medical licenses issued in California, and will be periodically audited to ensure accountability. Status: Failed pursuant to legislative deadline.

AB 589 (Perea): Medical School Scholarships Prior CMA sponsored legislation provided $1,000,000 per year in funding for the Steve Thompson Loan Repayment Program, which gives physicians up to $105,000 in loan repayment if they agree to practice in an underserved area for at least tjree years. This bill mirrors the loan repayment program and would create the Steve Thompson Scholarship Program, which would provide scholarships to medical students who agree to practice in one of California’s medically underserved areas upon completion of residency. Status: Signed into law 9/17/12.

CMA Opposed Legislation AB 1062 (Dickinson): Elder Abuse/MICRA This bill was gutted and amended to lower the standard of evidence in elder abuse cases. It reduces proof required in elder abuse cases from clear and convincing to preponderance of the evidence. If enacted, it would encourage use of the elder abuse law to get around the MICRA cap and plaintiff attorney fee limits.

Status: Failed pursuant to legislative deadline.

SB 924 (Price): Physical Therapists–Direct Access to Services/Professional Corporations This bill addresses two significant issues pertaining to the practice of physical therapy. First, it allows physical therapists to remain employed in medical corporations, as well as create their own corporations, and requires the corporations to disclose to the patient that they are free to seek services elsewhere if they so choose. Second, it provides a framework where physical therapists may treat a patient directly without first seeing a physician, also known as “direct access.” Specifically, this bill allows physical therapists to treat patients for 30 business days, or 12 visits, without first seeing a physician. After the time limit, treatment would only 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 | D ECE M B ER 2 0 1 2

be allowed to continue if the physical therapist’s plan of care was approved by a physician, which would include a physical exam. Current law requires that no physical therapy treatment may commence without a medical diagnosis. While CMA may wish to consider allowing a certain amount of treatment prior to a diagnosis, there must still be a diagnosis requirement at some point and 30 business days is just too long. Amendments should be adopted that would limit the amount of treatment to 30 calendar days and require at the end of the 30 days, that a medical diagnosis be obtained for treatment to continue. Status: Failed pursuant to legislative deadline.

SB 1373 (Lieu): Healthcare Coverage–Out-of-Network Coverage This bill would require that prior to providing out-of-network services a healthcare provider shall in writing inform the enrollee that he or she is out of network and that the health plan may not cover some of the services, provide an estimate of the cost of the services and direct the enrollee to contact the health plan for a list of contracted providers. Additionally, it prohibits a health facility or provider group from stating that itis part of a network unless all of the providers working at the facility are contracted with the insurer. The bill also requires plans to pay out-ofnetwork providers the same rate as they pay in network providers on a non-capitated basis within the same geographic region as the contracted provider. A potential amendment would be to require disclosure language on an assignment of benefit agreement between a patient and a provider.

Status: Failed pursuant to legislative deadline.

SB 1528 (Steinberg): Damages–Medical Services This bill would overturn the Howell v. Hamilton Meats case, by allowing an injured party of medical services to be compensated based upon the reasonable value of services rather than amount actually paid. Despite the trial attorneys’ assertion that the bill doesn’t affect damages under 3333.1, it would dramatically increase economic damage awards in ALL personal injury cases in the state.

The rationale stated for the bill is flawed – that every person be treated the same regardless of how much was paid. Damages are intended to make someone whole. For medical expenses, that means giving them back in monetary damages the amount that was put out on their behalf – i.e., the amount paid. Lawsuits are not supposed to be like winning the lottery where you are put in a position more favorable than where you began. In other words, monetary damages are not supposed to go beyond recouping what was lost–for medical expenses, those are the dollars spent on medical care. Non-economic or emotional distress damages are the damages that compensate for the pain and suffering caused by the injury. This bill is going to bring up discussions about physicians billing practices and the definitions of, and differences between, billed amounts, usual and customary charges and reasonable value. Status: Failed pursuant to legislative deadline.

Bills of Interest AB 369 (Huffman): Step Therapy Reform (CMA Position: Support) This bill would limit a health plan’s or health insurer’s ability to use to step therapy or “fail first” protocols for the treatment of pain. The bill would require that the duration of any step therapy or fail first protocol be determined by the prescribing physician and would prohibit a health plan or health insurer from requiring that a patient try and fail on more than two pain medications before allowing the patient access to other pain medication prescribed by the physician. This bill would still allows step therapy to be used, but closes loopholes and puts the medical decisions back in the doctor’s hands so the patient can get the right medication in a timely fashion.

Status: Enrolled and sent to Governor. Vetoed 9/30/12.

AB 1000 (Perea) Healthcare coverage: cancer treatment (CMA Position: Support) This bill would help ensure that cancer patients

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s pecial r e po rt | l eg is l ative wr ap- u p are not denied the most appropriate and effective treatment by putting costs above care. According to the author, “there are significantly greater patient out-of-pocket costs for oral cancer therapies covered under the pharmacy benefit than IV therapies covered under the medical benefit.

These out-of-pocket costs become a de facto denial of access, which, in a study by Prime Therapeutics, resulted in 1 in 6 patients not receiving treatment solely due to cost. Therefore, patient access to potentially the only life-saving cancer therapy available to them is restricted.

Status: Enrolled and sent to Governor. Vetoed 9/30/12.

AB 1533 (Mitchell) International Medical Graduates (CMA Position: Support) This bill would allow the UCLA International Medical Graduate program to create a five-year pilot for participants to engage in a physician supervised patient care activities, as part of an approved and supervised clinical clerkship/rotation at UCLA. With this legislation, UCLA International Medical Graduates would receive valuable clinical learning opportunities and not be at risk for disciplinary action by the Medical Board of California. In light of California’s physician supply crisis, this bill would have a more immediate impact toward increasing the amount of licensed physicians that could practice in the state.

Status: Enrolled and sent to Governor. Signed into law 7/25/12.

AB 1808 (Williams) Meyers-Milias-Brown, Act Public Employees (CMA Position: Support) This bill would only impact County of Ventura employed physicians that have, since 2006, sought union recognition.

Since 2006, the county has rejected multiple legal opinions by the Public Employee Relations Board (PERB) that has sided with the physicians’ efforts for unionization. This bill simply includes the definition of “joint employer” used in the 2009 PERB decision, which would remove any doubt as to whether or not Ventura County is the employer of the physicians at the Ventura County Clinics. Status: Failed pursuant to legislative deadline.

SB 863 (De Leon): Workers’ Compensation (CMA Position: Support) This bill was substantially amended in the final weeks of session to contain a package of policy changes in the name of reforming the state’s workers’ compensation system. The bill’s text was initially developed by labor and business interests, but CMA was able to negotiate a number of significant amendments to the bill. When those amendments were adopted, CMA took a support position on the measure. SB 863 does many things, but a couple of the biggest changes for physicians are that it directs the state to adopt the Medicare fee schedule—based on the Resource-Based Relative Value Scale (RBRVS)—as well as establishing Independent Medical Review and Independent Bill Review in an effort to utilize third-party processes to adjudicate treatment and billing disputes, instead of the court system. CMA was able to secure many important changes to the bill, including medical provider network reforms, expanding categories of payment for physicians as well as increasing the entire funding allocation for physician services, and protecting physicians’ ability to own an ambulatory surgery center. Based on these changes (including mandatory and ongoing coding updates by carriers and discarding ACOEM guidelines in favor of an expanded hierarchy of evidence), CMA took a support position on the measure.

Status: Enrolled and sent to Governor. Signed into law 9/19/12.

SB 1524 (Hernandez): Nurse Practitioners (CMA Position: Watch) This bill deletes the statutory requirement that nurse practitioners complete at least six months of physician and surgeon supervised experience in the furnishing or ordering of drugs and a course in pharmacology covering the drugs that will be furnished. The author contends this statute is antiquated and was put into place before there was any significant training in pharmacology. He contends the proper training 1 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 | D ECE M B ER 2 0 1 2

and proper education now exists in and the six-month requirement only delays employment of new advanced practice registered nurses (APRN).

However, not everyone’s experience and education is equal and should be dealt with on a case-by-case basis. CMA recommended amendments, which the author accepted, that clarified that the physician may include a six-month supervised experience (or longer) requirement in the standardized protocol between the physician and the APRN. Status: Enrolled and sent to Governor. Signed into law 9/29/12.

SB 1538 (Simitian): Mammograms (CMA Position: Neutral) This bill would require physicians to notify mammography patients with highly dense breasts about the density of their breast tissue. This issue has been debated within the house of medicine for nearly two years, but physician advocates were able to secure amendments to the bill that allowed both CMA as well as ACOG District IX to take neutral positions.

Status: Enrolled and sent to Governor. Signed into law 9/22/12.

Bills Impacting Healthcare Reform AB 43 (Monning): Medi-Cal Eligibility (CMA Position: Support if Amended) This bill would require the Department of Healthcare Services to establish, by January 1, 2014, eligibility for Medi-Cal benefits for any person who meets these eligibility requirements. This bill would permit the department, to the extent permitted by federal law, to phase in coverage for those individuals. Status: Failed pursuant to legislative deadline.

AB 1453 (Monning) / SB 951 (Hernandez): Essential Health Benefits (CMA Position: Support) These two bills, which are virtually identical, would establish a set of essential health benefits (EHBs) that insurers and health plans in California’s Health Benefit Exchange will be required to cover. This pair of bills would adopt the Kaiser small group HMO as the state’s EHB benchmark. Status: Enrolled and sent to Governor. Signed into law 9/30/12.

AB 1461 (Monning) / SB 961 (Hernandez): Individual Market Reforms (CMA Position: Support) These bills conform state law to the Affordable Care Act in 2012, establishing guaranteed issue, Exchange open and special enrollment periods, rating (age, geographic region, and family size only), and same regions as PERS. Status: Enrolled and sent to Governor. Vetoed 9/30/12.

AB 1761 (John Perez): Deceptive Marketing (CMA Position: Support) This bill would prohibit deceptive marketing by outlawing “copy cats” from representing themselves as part of the California Health Benefit Exchange .

Status: Enrolled and sent to Governor. Signed into law 9/30/12.

AB 1846 (Gordon) CO-OPs (CMA Position: Watch) This bill authorizes Insurance Commissioner to issue a certificate of authority to Consumer Operated and Oriented Plans (CO-OPs). The Affordable Care Act calls for the creation of the CO-OPs, which are private, consumer-governed, non-profit health insurance plans that will be operated by its community beneficiaries (consumers, providers and employers).

Status: Enrolled and sent to Governor. Signed into law 9/30/12.

SB 970 (De Leon): CalHEERS Horizontal Integration (CMA Position: Support) This bill adds human services programs, such as CalWORKS and CalFresh, to those screened by the California Healthcare Elgibility, Enrollment and Retention System (CalHEERS), which will be used for California Health Benefit Exchange and Medi-Cal enrollment.

Status: Enrolled and sent to Governor. Vetoed 9/30/12.

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FEATURE | h e alt h car e i n cali fo r n ia

Medical care providers in Los Angeles County are wondering whether 2014 will be a “season of light or a season of darkness,” to paraphrase the famous opening paragraph from Charles Dickens’ novel “A Tale of Two Cities.” That’s when President Obama’s sweeping Affordable Care Act takes effect, promising to transform the landscape for everyone who has a stake in medical care, from the provider to the patient.

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Though January 2014 is just over the horizon, as many unknowns as knowns remain for Los Angeles County, as well as for the rest of the state, and for the nation. Many details are yet to be worked out.

The state Legislature in Sacramento, for example, has scheduled a special session this winter to hammer out necessary rules and regulations to roll out the ACA as soon as Washington releases guidelines for how care will be delivered.

To be sure, some aspects of how ACA will operate are beginning to fall into place.

The state’s new health exchange, which will negotiate rates on behalf of individual consumers with participating insurers, said in late October that more than 30 insurers have signed up to participate, including the “big four”: Anthem Blue Cross, Blue Shield of California, Health Net Inc. and Kaiser Permanente.

The exchange will take the lead in enrolling 2 million residents into the state’s Medi-Cal system, which provides care for the state’s poor, disabled and elderly, as well as helping another 2 million families earning $92,000 or less each year obtain coverage.

So far, 13 of the 33 insurers have signed on to offer bids through the exchange, which has been deftly titled “Coverage California” by officials.

Consumers can begin signing up for healthcare in January 2014, and the process will greatly expand the number of citizens who will have access to healthcare services.

Insurers can offer coverage outside of the exchange, but most are expected to participate in Coverage California because the federal and state government is subsidizing the policies.

Back in Los Angeles, the county’s Department of Health Services (DHS) is moving full steam ahead to put changes in place to accommodate an additional 550,000 residents who now don’t have coverage.

“LA is the epicenter of the uninsured,” said Shana Alex Lavarreda, director of Health Insurance Studies at the UCLA Center for Health Policy Research, who is closely monitoring efforts to deliver medical care under ACA. “The county has the largest population of the uninsured in California, and California has the largest population of the uninsured in the nation,” Lavarreda said. “The number is estimated at 2.1 million.” “That’s larger than the population of many states. Moving those people onto insurance is going to bring a big sea change to the system in Los Angeles.”

The DHS runs four hospitals and has affiliations with

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several other major hospitals in the county, including the USC School of Medicine, the UCLA School of Medicine and the Charles R. Drew University School of Medicine and Science.

For example, the department has already enrolled more than 550,000 residents from the ranks of the uninsured into the Low-Income Health Program, or LIHP, which has been marketed as Healthy Way LA for the past year.

The early signups are allowed under a waiver with financial support from Medicare, and officials hope that by getting people into the system ahead of 2014, they will remain rather than go with other providers in the future.

And a mass migration of the poor from the public to the private sector is just what county officials fear, said Dr. Marshall Morgan, chief of the medical staff at the 520-bed UCLA Medical Center and director of the Emergency Medicine Center in the School of Medicine.

“There is a big concern among the safety net hospitals that they will lose a lot of patients, that people who can’t pay at all right now will have something in the way of insurance, and a lot of these people will go elsewhere,” he said. “This happened with obstetrical care several years ago, where people received obstetrical care, and suddenly the OB wards in the public hospitals were empty.”

Third-generation physician Dr. Alexander Li, CEO of the recently created Los Angeles County Ambulatory Care Network, said his fledgling agency is restructuring to ensure that existing low-income patients who are part of his system establish relationships with doctors.

“The patients want to know who their doctor is,” he said. “That was something that’s not been a fundamental principle in the past. We want to take care of patients whom we have a long-term relationship with.”

“There are going to be many more people with a payer source,” said Dr. Li. “More than ever before. We want to be able to meet the competition with private providers through the exchange now being set up.”

Dr. Li’s agency employs more than 800 full- and part-time primary care providers and cares for more than 400,000 patients under Medi-Cal, Healthy Way LA, In-Home Supportive Services and the Healthy Families program.

The agency’s network consists of six comprehensive health centers, two multi-service ambulatory care centers, 11 health centers and more than 150 contracted community partner clinics and is adding more technology to the mix, such as using telemedicine to speed diagnosis and treatment.

The technology enables primary care doctors to

The group has installed an EMR system at four locaconsult with specialists on patient care via video confertions, which will help the practice streamline delivery at encing and related techniques without lengthy delays.

“Our specialty wait times are long,” said Dr. Li, “so the same time that it lowers costs.

“We want to make sure we’re all on the same page we’re trying to figure out how to bring down the wait and making the most efficient use of resources,” he said. times electronically.”

He said the system is also establishing ways to com- “Data drives a lot of this, such as our ability to track permunicate via email and texting, as well as video con- formance improvements.”

The system, which has been running since May, has ferencing. Adding that using new technologies allows allowed the group to automate much of the paperwork doctors to see more patients and “opens up” more appointment times for patients who need to see specialists. and to automatically interface with hospitals so that Dr. Li said the system is also using computers to pre- group doctors can better track reports of their patients.

“We want to make sure that we’re practicing eviscribe medications and to order laboratory work and to do some charting. He hopes to expand the use of com- dence-based medicine and be able to demonstrate this puters as electronic health record (EHR) systems are intro- so that insurers will look at us favorably when we negotiduced into the system. “We have a large system, and we ate contracts,” said Dr. Flores. “It’s a huge undertaking, but have to develop a systematic approach.”

Montebello family physician Dr. Hector Flores, director of a practice group with 16 doctors that “L.A. county has the largest population of the is part of a larger IPA that features 40 family care physicians and 300 specialists, said he and his col- uninsured in California, and California has the leagues are focusing on four components ahead of 2014: expanded coverage, insurance reforms, largest population of the uninsured in the nadelivery system redesign, and payment.

“As a medical group what we’re looking at is tion. The number is estimated at 2.1 million. That’s a community where a large number of residents are going to be eligible for coverage under re- larger than the population of many states. Movform, and we have to access our capacity to take on new patients,” he said, noting that the ing those people onto insurance is going to bring group has a current patient roster of 28,000, a large percentage of whom are Medi-Cal patients. a big sea change to the system in Los Angeles.”

“We want to see if the current payment rates for Medi-Cal will sustain our practice and be able to take care of the patients that we have, plus the new pa- at least we have our arms around what we’re trying to do.”

Dr. Flores noted that the group received assistance tients that we will have.”

The group continues to work with health plans on from HITEC-LA, the federally funded Health Informapayment reforms, especially those that will participate tion Technology Regional Extension Center for Los Angeles County, which helps doctors buy and install EMR in the exchange.

“Quite a few of the residents in the Latino commu- systems.

At the other end of the healthcare delivery specnity will be eligible for subsidies to purchase insurance, so we need to make sure that our patients are educated trum, large hospitals are deeply involved in preparations as far as their options are concerned by working with for reform.

“ACA is going to bring consumerism to healthcare our community-based partners in terms of outreach education and eligibility assessment so that we can help that we haven’t seen before,” said Tom Jackiewicz, seour existing patients and any new patients maximize nior vice president and chief executive officer of USC Health, who is responsible for the university’s clinical acbenefits under reform,” he said.

Dr. Flores said his practice has also started a rede- tivities, including Keck Hospital, Norris Cancer Hospital sign of the practice around a patient center “medical and the 500-physician USC Care Medical Group.

Jackiewicz said his extensive system has been busy home” that provides what healthcare reform is looking for that more closely integrates physicians on the front preparing for the advent of ACA, with lots of work still to do in the year ahead. lines with hospitals and other facilities.

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FEATURE | h e alt h car e i n cali fo r n ia

“There are three different tenets that I preach when it comes to the ACA,” he said. “It’s going to be about quality, service and cost of care.”

“They are going to be very, very important, not that they haven’t been in the past,” said Jackiewicz. “But there is going to be a lot more transparency in terms of quality and the cost of healthcare, and we’re seeing that already, with employers pushing back in terms of premiums, and Medicare reimbursement rates changing. Everybody’s got to be focused on costs,” he said. “You have to look at extra ways to squeeze out extra costs in the system.”

He noted that he already “streamlined” the management team in May in anticipation of ACA. “We looked at our organization structure,” said Jackiewicz. ‘We feel like we have too many layers, and we

installing an electronic health record-keeping system that will be up and running in the spring, and he is already anticipating the arrival of personalized medicine to healthcare delivery, including the addition of human genomic data for each patient, and how to add that to electronic patient records.

He also said that the addition of wireless technology in future years, such as being able to remotely monitor patients at home, will further enable the system to improve care at a lower cost.

“So, our No. 1 challenge is getting our information technology systems in place,” he said. “That’s going to be absolutely critical.”

Dr. Morgan said he and other providers at UCLA expect to see a wave of new patients from poorer neigh-

“[quality, service and cost of care] are going to be very, very important, not that they haven’t been in the past, But there is going to be a lot more transparency in terms of quality and the cost of healthcare, and we’re seeing that already, with employers pushing back in terms of premiums, and Medicare reimbursement rates changing.” have to tighten up our management structure, and that was a big one for us.”

Another way he is looking to cut costs while improving care is to figure out how to use the system’s 70 intensive care, or ICU, beds.

“The ICUs are huge resource issues,” he said, “and driving down costs will be key to surviving under ACA as it is implemented.”

USC is moving more surgeries, such as prostatectomies, to outpatient facilities, he said, adding, “Everyone is going to have to look at their resource usage.”

Jackiewicz also said he is looking at ways to drive down its Medicare-rated case mix index, which measures hospitals against each other when it comes to the cost of hospital stays and procedures.

“Our case mix index is 2.8 percent to 2.9 percent, when the average is 1.0 across the continuum of Medicare, so we have a ways to go,” he said.

Jackiewicz said USC is currently in the middle of 2 2 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 | D ECE M B ER 2 0 1 2

borhoods, patients who can’t access the care offered in the western reaches of Los Angeles County.

“I think what will happen here, as in most places, is that people who have health problems but who don’t have health insurance now will have insurance and will feel entitled to go and get care,” he said. “There are going to be more people with insurance but the same number of doctors, and we’re already pretty busy.”

“Private doctors have the opposite problem. They have this fear of being inundated with people who have this coverage but don’t know where to go,” said UCLA’s Lavarreda. “That’s Mitchell Katz’s worst nightmare. Katz, of course, is the director of the massive and complex Department of Health Services, who’s steering the county toward healthcare reform.

“But he’s trying to avoid that by improving the quality of care,” she added. “When you have patients who have a connection with their doctor, they’re not going to leave, even if they change insurance, or get insurance.”

NEW NAME

|

NEW FOCUS

|

IMPROVED CONTENT

|

NEW DEPARTMENTS

COMING IN JANUARY 2013 Still the official magazine of the L.A. County Medical Association, the new Physician Magazine will work hand-in-hand with PhysiciansNewsNetwork.com (PNN) to keep the Los Angeles physician community informed – in print, online, and in person – on the Economics of Healthcare Delivery with timely news, trends and issues, all with a strong local emphasis.

These changes will place Physician Magazine an invaluable resource for local physicians as they navigate through these challenging and changing times.

IMPROVED CONTENT AND NEW DEPARTMENTS! BALANCE | LIFESTYLE & WELLNESS - This exciting new department delivers news, studies, tips and opportunities that encourage physicians to maintain the healthy, balanced lifestyle that is essential to career success and longevity.

TRANSITIONS | CAREER MANAGEMENT - A look at the questions and challenges associated with various career phases of Southern California physicians, from student loans and applying for positions, to starting/buying/selling a practice, switching career focus and retirement.

UNITED WE STAND | ADVOCACY - Insight into latest news on California Medical Association news and CMA-supported and opposed legislation, as well as information on the results of healthcare related bills to keep member physicians up-to-date on the latest from the policy makers in Sacramento.

PNN | NEWS IN REVIEW - PhysiciansNewsNetwork.com <http://PhysiciansNewsNetwork. com> brings readers a look at the latest local headlines impacting the economics of healthcare delivery in Southern California.

A NEW LOOK! – sleek, modern and more reader friendly!

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D ec 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 2 3

CMA Issues Letter to Regulators Regarding Network Adequacy Concerns with Aetna The California Medical Association (CMA) has asked the California Department of Insurance (DOI) and the California Department of Managed Healthcare (DMHC) to investigate the recent rash of terminations from Aetna’s physician network

Attorneys for LACMA and the CMA are charging that Aetna Inc. is engaged in retaliatory practices against physicians in the wake of a lawsuit filed against insurer in July. In the lawsuit, the 35,000-member CMA said Aetna improperly restricts PPO and POS patients to out-of-network benefits.

CMA sent a “Letter of Concern” to both Insurance Commissioner Dave Jones and DMHC Director Brett Barnhardt, expressing serious concerns about Aetna’s ability to ensure adequate access to care for its beneficiaries in the wake of widespread physician terminations.

CMA urged the DOI and DMHC to investigate and to take appropriate action to ensure that Aetna complies with California laws that are designed to protect providers and healthcare consumers.

CMA believes the increase in terminations stems from a lawsuit filed against Aetna in July by CMA and a coalition of patients, individual physicians, ambulatory surgical centers and local county medical associations. The suit, filed in Los Angeles County Superior Court, alleges that, while Aetna is marketing and selling PPO products featuring out-of-network benefits, the insurer is

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unlawfully retaliating against patients who attempt to use their out-of-network benefits and contracted physicians who refer their patients to out-of-network providers and facilities.

Since the filing of the lawsuit, in early July 2012, rather than deny the practice being challenged, Aetna has dramatically stepped up its termination of physicians who refer PPO or POS beneficiaries to out-of-network facilities for covered medical services.

In response to the apparent increase in Aetna’s challenged practices, CMA has developed information and resources to help individual CMA members who have recently received termination notices from Aetna. The toolkit is available free to members in CMA’s online resource library.

Affected physicians are encouraged to call CMA’s legal help line for assistance.

Contact: CMA legal help line, (800) 7864262 or memberservice@cmanet.org.

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

Attempts Fail to Get New Physician Substance Abuse Diversionary Law Passed in Sacramento Efforts have failed on the part of the California Medical Association and local medical associations to establish a physician diversion program for treatment and monitoring services when suffering from substance abuse, mental and behavioral health issues.

The state’s doctors sponsored a bill, SB 1483, the so-called California Public Protection and Physician Health Act, introduced by Sen. Darrell Steinberg, D-Sacramento, that would have established a program in California to refer physicians for treatment and monitoring services when they are suffering from substance abuse, mental and behavioral health issues.

California is one of only five states in the nation that do not have such a program, following the Medical Board of California’s decision to eliminate its 27-year-old Diversion Program in 2007.

The bill was not acted upon by the Legislature before the end of the 2012 session.

Dr. Marshall Morgan, MD, chief of emer-

gency medicine at the UCLA Medical Center and president-elect of the Los Angeles County Medical Association, said that the CMA might try again in the future to get a similar bill passed.

Dr. Morgan said the CMA has been trying to get legislation passed to set up a new diversionary program since the middle of the Schwarzenegger Administration when the existing program was abandoned in favor of using tougher measures against doctors who abuse drugs and alcohol.

Dr. Morgan was one of the alternates to the recent CMA House of Delegates gathering in Sacramento that discussed this as well as other issues impacting doctors and their medical practices.

He said the original diversion program had a goal of identifying doctors with substance abuse problems and getting them into programs where they could be closely monitored and tested.

“They could continue to practice, and get the treatment they needed,” he explained.

“They could rid themselves of their substance issues and preserve their careers … [these doctors] have what is essentially a disease. It also preserves the huge investment that the state has made in their doctor instead of just throwing them away.”

Dr. Morgan said the old program had some problems and “wasn’t operating as well as it could” but didn’t think it should be thrown out.

He said Schwarzenegger’s medical board “took the approach that they are there to protect the consumer, to protect patients from doctors who might harm them because of their substance abuse.”

He said it boiled down to a law enforcement issue, and that the feeling was that doctors who abused drugs should lose their license and not practice.

Source: PNN-Physicians News Network

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

LACMA Panelists See Positive Impact on Latino Community With Coming Reform underserved population such as the Latino population in Los A group of CEOs representing some of the top Latino-focused Angeles. “This is going to have a powerful impact,” he said. healthcare organizations appearing at a recent Los Angeles County The goal of the panel discussion is to bring a CEO perspective Medical Association panel discussion agree that impact of the Afon reform. fordable Care Act on the Latino population will be positive one.

The meeting was held Nov. 14 at the City Club on Bunker Hill In addition to Flores, the panelists included in downtown Los Angeles, and included more than 120 audience members, comprised of Castulo de la Rocha, interested physician and president and CEO of the business leaders, as well as nonprofit AltaMed Health citizens interested in the Services Corp., which was topic. event co-sponsor. Alta-Med Montebello physician is one of the largest federDr. Hector Flores said, ally qualified health centers “The CEO discussed the (FQHC) in the nation opportunities, as well as Dr. Mario Molina, the challenges of healthpresident and CEO of Mocare reform.” lina Healthcare Inc. Molina “I think ACA is going Healthcare is a health plan to be a very positive for serving all sectors of the the community where purchaser community (comwe practice,” he said. He mercial and governmentnoted that 30 percent of sponsored) the adults nationwide, and Beth Zachary, president two-thirds will be eligible and CEO of White MemoLACMA CEO Rocky Delgadillo addresses the capacity croud made up of L.A. County physicians, to purchase insurance rial Medical Center, another business leaders and residents, recognizing the generous support of LACMA co-sponsors such as through the new California co-sponsor of the event.

CAP, Athena Health, NORCAL, and Mann, Urrutia, Nelson CPA’s. run exchange or through White Memorial is a private, Medi-Cal. “That gets rid of two-third of the challenge.” safety net hospital serving as a regional medical center and as a “And children will get pretty close to universal coverage,” Dr. leader in healthcare workforce training and innovation.

Flores added. “That will make for a much better practice environState Sen. Dr. Ed Hernandez, D-Los Angeles, a prominent ment for us as well as the hospitals.” leader in Sacramento and an optometrist by training, served He said that Americans everywhere will benefit, not just respondent for the event.

FO L LOW U P Beverly Hills City Council Votes: Surgery Centers Not Landlords The Beverly Hills City Council

voted 2-1 on Oct. 23 to override the Department of Finance Administration and its efforts to assess an ambulatory surgical center $5.5 million in new business taxes.

The department had earlier decided that the Specialty Surgical Center’s main purpose was to offer space for surgeries and that it should be taxed on a commercial property rather than on a professional basis.

Beverly Hills attorney Allan Cooper, representing the center at the City Council meeting, argued that city bureaucrats were using “vague code provisions to reclassify the ASC’s business to raise taxes, in violation of state law requiring voter approval for such increases.”

He said the center’s main business was

to provide patient care and had “no attributes of a landlord-tenant or other rental relationship.”

“You can’t just call its business something it’s not so you can put it into a different tax classification which has a higher tax rate,” said Cooper. “No matter how many times you try to call a camel a horse, it’s not a horse.”

He pointed out that no other city taxes surgery centers as commercial landlords.

“The law is unclear, the process has been flawed, and in the end, this surgery center does not rent space,” added Cooper.

“This was a particularly gratifying win,” Cooper later said. “To persuade a city council that its own staff has taken the wrong path is a daunting challenge, and one which

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does not often succeed. I am happy that the City Council was willing to recognize this and to put an end to the matter without the expensive litigation which otherwise would have followed.”

The center’s managing director, James Khodabakhsh MD, told a reporter for a local newspaper that the business had received tremendous support.

“The big misconception is that surgery centers owned by major corporations are big business, which is not true,” Khodabakhsh said. “The role of a surgery center is to allow physicians to have access to more advanced technology, with faster rates of surgery, as opposed to a hospital where you’d have to wait weeks to schedule a case.“ 3

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

LACPAC Achieves Near Perfect Endorsement Record in Nov. 6 Elections

T

he Los Angeles County Medical Association’s political action arm was a big winner in the Nov. 6 presidential elections.

Luis Ayala, LACMA’s director of government affairs, said that 41 of 42 local candidates endorsed by the Los Angeles County Political Action Committee, or LACPAC, won their elections.

The winning candidates will serve as U.S. representatives in Congress, as well as in the state Legislature.

Two prominent doctors backed by LACPAC were surprise winners in the election, including Raul Ruiz, MD, who beat out seventerm incumbent Mary Bono Mack to represent Palm Springs and the surrounding 45th Congressional District in Riverside County.

Ruiz, a Harvard University graduate, beat Bono by 5,000 votes.

“That was a huge upset,” said Ayala, who is also executive director of LACPAC. “He’s got a tremendous story, being the son of farmworkers, and we were very pleased to support him.”

Although Dr. Ruiz will represent Riverside County, Ayala said LACPAC supported him because he is a medical doctor and because of his compelling personal story, and his achievements in his chosen field.

Dr. Ruiz grew up in the Coachella area, and according to his website, he walked from business to business asking them to invest in the community by investing money into his education. He promised to come back to the area and practice medicine after he completed his medical studies, which he did. Dr. Ruiz was the first Latino to earn three graduate degrees from Harvard, including a master’s degree in public policy and a master’s degree in public health, as well as his medical degree, said Ayala.

He is currently an emergency physician at the Eisenhower Medical Center, which is the only nonprofit hospital in the valley.

“He’s not in Los Angeles County, but he is someone we wanted to support, because of his medical background,” said Ayala.

The other doctor to gain prominence in the election was Sandra Salazar, MD, who

won a seat on the Cerritos Community College District board of trustees.

Dr. Sandra Salazar is a family medicine physician at Alta Med Health Services providing culturally competent healthcare in Pico Rivera, while also serving the surrounding communities of Norwalk, Downey and Southeast Los Angeles, according to her website. She is the daughter of a gardener and a domestic worker who instilled in her a commitment to community, family and faith at an early age, the website says. She was the first in her family to attend college.

She earned a Bachelor of Arts degree from Wellesley College in Massachusetts and a MD from Saint Louis University in Missouri.

Ayala said that LACMA starts the endorsement process early in the campaign season, and it usually begins with a lunch with candidates who he thinks LACPAC might want to support.

Later, he’ll introduce the candidate to a

larger group in an informal setting, and then later they make an endorsement.

“We got out and meet with these candidates very early,” said Ayala. “We don’t wait till they come to us; we go to them.”

“The goal is to get to meet all of the candidates on a personal level, so that by the time we interview them, we have a pretty strong feeling one way or the other about where they stand on physician issues,” said Ayala.

It’s important to be early.

“We try to do our endorsement earlier than most other organizations,” he added.

“The first checks are the ones that the candidates remember the most – either the first ones or the largest ones.”

“The end result of all this is that we establish relationships, so we can call upon them when they need to be educated on the issues, or they call us when they want to know more about a particular issue in healthcare.”

D ECE M B ER 20 1 2 | www. s o c a l p h ys i c i a n . n e t 2 7

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

attention lacma/cma members

RENEW TODAY By now, all LACMA and CMA Members have received their 2013 dues statements.

Dues are due by December 31, 2012.

Please be sure to renew your membership to ensure continuation of your benefits.

Dues can be renewed conveniently online at www.lacmanet.org

Thank you for supporting your profession and your patients by supporting organized medicine!

Meet Your Board!

L AC M Aâ&#x20AC;&#x2122; s Board of Directors consists of a group of 30 dedicated physicians who are working hard to uphold your rights and the rights of your patients. They always welcome hearing your comments and concerns. You can contact them by emailing or calling Lisa Le, Executive Assistant, at lisa@lacmanet.org or 213-226-0304. 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

2 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 | D ECE M B ER 2 0 1 2

Pejman Salimpour, MD Councilor

Shuo Steven Wang, MD Councilor-at-Large

Erin Wilkes, MD CMA Trustee (Resident)

sadie acquah-asare, MD - student amir friedman, MD lawrence robinson, MD ryan schmidt, phD - student arsalan siddiqui, MD - resident rETInA InsTITUTE rizwan Bhatti, MD tom chang, MD anthony culotta, MD Michael Davis, MD kristie lin, MD Michael samuel, MD kevin suk, MD sami kamjoo, MD Joshua hedaya, MD

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Members may access the members only portion of the site using their California Medical License as the log in and the first initial, in capital, of the first name combined with the last name as the password. Example: If your name is Joe Smith, your password would be JSmith.

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J ust t h e fac ts | T H E STAT E O F H ealth car e

7.6 million

23%

The number of California physicians for every 100,000 residents.

100,544

$2,566

Hospital adjusted expenses per inpatient day in California vs $1,910 nationwide.

Estimated Medicaid expansion in health reform: Change in federal Medicaid spending, 2014-2019

$6,238

32 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 | D ECE M B ER 2 0 1 2

of Los Angeles County residents are Medi-Cal beneficiaries compared to 20.2% Statewide

24.5%

271

Licensed physicians in California

The total number of Medi-Cal beneficiaries in California. Los Angeles County is home to 2,418,773 of them.

Health Spending per capita in California vs. $6,815 nationwide

1 in 5 Californians are uninsured vs. one in six nationwide.

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D ECE M B ER 20 1 2 | www. s o c a l p h ys i c i a n . n e t 3 3

We do what no other medical malpractice insurer does. We reward loyalty at a level that is entirely unmatched. We honor years spent practicing good medicine with the TributeÂŽ Plan. We salute a great career with an unrivaled monetary award. We give a standing ovation.

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

We created the Tribute Plan to provide doctors with more than just a little gratitude for a career spent practicing good medicine. Now, the Tribute Plan has reached its five-year anniversary, and over 22,700 member physicians have qualified for a monetary award when they retire from the practice of medicine. More than 1,300 Tribute awards have already been distributed. So if you want an insurer thatâ&#x20AC;&#x2122;s just as committed to honoring your career as it is to relentlessly defending your reputation, request more information today. The Doctors Company is a Silver Sponsor of the Los Angeles County Medical Association (LACMA). To learn more about our benefits for LACMA members, contact us at (800) 717-5333 or visit www.thedoctors.com/tribute.

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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.