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Volume 143 issue 09
september 2012
16
FeatUReS 16 Raising the Bar on autism new programs, new research and new awareness are helping put the pieces of autism together.
eVeRY ISSUe 6 Front office tips, hints, advice and resources to make your practice run more smoothly. 14 CMa the latest update on regulations. 28 Just the Facts this month we focus on leukemia and lymphoma.
FRoM YoUR aSSoCIatIoN 2 Ceo’s Letter an update on how your association works for you from rocky Delgadillo. 4 president’s Letter monthly musings from samuel fink, mD. 20 Member Benefits find out how to get the absolute most from your membership. 22 association happenings making an impact in africa • house of Delegates resolutions • best of class vendor vetting • all new website coming soon • meeting with insurance commissioner Dave Jones • introducing the physicians news network • september events • Welcome to our new members!
Southern California Physician (issn 1533-9254) is published monthly by 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. 09 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.
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CeO’ s l e t t e r | rOCk Y d e lGad i l lO
Your historically progressive association
I
N L a S t M o N t h ’ S edition of Southern California Physician magazine, we introduced the new LACMA. Of all the comments I received, I found this one from Doctor Ellen Alkon, MD extremely interesting: “Readers of Southern California Physician who read the August 2012 issue focused on “The New LACMA” may be interested to know that LACMA has a long history of being a progressive organization. An excellent outline of that history is on the LACMA website. However, it does not include the fact that, in 1886, in a report from Southern California Practitioner on the Los Angeles County Medical Society—the early form of LACMA—it was noted that the society started in 1871, and that “Early in its history it took the progressive step of admitting regularly educated lady physicians to its ranks.” In the nineteenth century, including women in medical organizations was a farsighted step.” Indeed, Dr. Alkon has it right—LACMA has always been a progressive association. The “new” LACMA as described in our August edition is working hard to maintain itself as the progressive unified force for health care in Los Angeles. Our lawsuit against Aetna for the illegal practice of refusing to honor contracts with patients for out-of-network services and for threatening physicians who referred patients to out-of-network services with loss of their contract is moving along smoothly. And, in early September, right after Labor Day, we will be filing another lawsuit against a major insurer for denying payment for medically necessary services, based on their use of an illegal definition of medical necessity. (For more on this lawsuit, read Dr. Samuel Fink’s President’s Letter on the next page). In addition, we are working harder than ever to ensure that ethnic physicians have leadership roles and strong voices within LACMA. Our recent set of Latino Physician Empowerment dinners have resulted in the addition of several new members who are influential in their communities and eager to help improve the lot of physicians and patients in L.A. County. You’ll see more of these sorts of initiatives in the near future. As always, LACMA continues to forge ahead, breaking new ground to benefit you and your patients. We hope you will actively join us in these efforts and contribute your own ideas of how LACMA can continue to lead the way in health care. After all, it is you—the physician members—that make the association a forwardmoving entity. With every good wish,
PU BLISH ER /EDITOR
Cheryl England
213-226-0335 | cheryle@lacmanet.org
aRt & eDItoRIaL ART DIR EC TOR
Thomas Miller
@thruform | thruform.com CO N T R I BU TI N G WR IT E R S
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 P A 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
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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 | s e p t e m b e r 2 0 1 2
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.
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Working Tirelessly for You
I
h o p e t h at this letter finds you well, and that you’ve had a pleasant summer, hopefully pursuing some non-medical pursuits, and enjoying life! Your medical association continues to work tirelessly on your behalf. By the time you receive this magazine, we will be in the process of filing suit against a major health insurance company for illegally ignoring California’s definition of medical necessity. Don’t you just love receiving letters from insurance companies informing you that the treatment you’ve recommended to your patient is not medically necessary? California law states that in order for a health insurance company to deny a claim on the basis that a treatment or hospitalization was not medically necessary, the legal standard is that the treating physician’s judgment must be shown to be plainly unreasonable, or contrary to community medical standards. But this California health insurer has ignored this legal standard for years, and has developed its own criteria of medical necessity that ignores California law, and deprives many patients from getting the medical care they need. Thousands of health insurance claims are denied each year by several insurance carriers, based on contrived definitions of medical necessity that ignore the law. This particular insurer puts profits ahead of its responsibility to patients (where have we heard that before?), and in so doing, makes our job much harder. When patients see that we are recommending care that an insurance company deems not medically necessary, they question our judgment and concern for their well-being, when in reality the denial is just a corporate attempt by an insurer to hide its callousness and cost-cutting measures behind our white coats! This is just one example of how the new Los Angeles County Medical Association is going to bat for you. We are simply not going to put up with these kinds of abuses to our patients and practices any longer. We want to hear from you about your practice experiences. Let us know what can we help you with, and what kind of wrongs need to be corrected. The new LACMA has spent the last year visiting with physicians from all over the county, re-introducing ourselves,
and finding out what’s important to you. We recently hosted a very well attended Latino Physicians Empowerment Dinner at Tamayo’s Restaurant in East Los Angeles. I was fortunate to meet a group of passionate and dedicated physicians who care about our future, and were happy to know that LACMA was there listening to their unique needs and concerns. We told them how much we wanted and needed them to be part of our physician community. Several attendees joined LACMA on the spot, and I’m hopeful that we will be able to develop a core group of Latino physicians that will be active leaders within our organization. Your LACMA leadership also met with Fran Pavley, a state senator from the 23rd district. We spoke at length about health care issues that gravely concern us, such as the “demonstration” project that would force dual eligible Medi-Medi patients to join managed care plans against their will, and disrupt thousands of physician-patient relationships throughout Los Angeles County. LACMA is constantly meeting with our elected officials on your behalf. Political advocacy is a vital part of our mission, and you should know that our own political action committee LACPAC, as well as the California Medical Association’s CALPAC are greatly respected in Sacramento. They are deserving of your strong support.
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In October, the CMA’s House of Delegates will meet in Sacramento. This democratic body shapes the policies that will guide the direction of your medical association’s leadership during the coming year. The LACMA delegation is one of the state’s largest and most active. We have a reputation for bringing forth strong resolutions that will have an impact on our practices, and enhance the care that we provide to our patients. As an example, our delegation will be supporting a resolution that asks the CMA to consider legislation making it illegal for pharmacists to receive financial incentives for substituting a physician’s prescription. Another resolution asks that the CMA and the American Medical Association lobby Congress for the elimination of all financial penalties for solo and small group physicians who choose not to use an electronic medical record system. We are also advocating for the elimination of “Silent PPOs”, and for abolishing the sharing of confidential physician-specific fee schedules between different insurance companies. It’s a busy and exciting time at LACMA. We would love for you to become more involved! Give our member services director, Carol Chaker, a call in our downtown office at 213-226-0313 and let her know what you’d like to help us with. Or email me at president@lacmanet.org. Until next month…
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7 tips to help Prevent the coding an employment claim corner Coding for robotic assistance By rhonDa BucKholtZ, cPc co m m o n ly asked procedural terminology coding questions involve the use of robotic assistance during a procedure. the main questions are how do we bill and will we be reimbursed for it? for example, a surgeon performs a robotic-assisted repair of paraesophageal hernia with mesh. the documentation of a robotic-assisted procedure is very similar to a laparoscopic procedure; the patient’s abdomen is inflated after trocars are inserted. where the procedures differ is that during a laparoscopic procedure the surgeon would be at the operating table, and in a robotic surgery the surgeon is at the controls of the robot. the coding is assigned using the laparoscopic codes, in the example above it would be code 43282; laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed, with implantation of mesh. to report the use of the robot assist, use hcpcs code s2900—surgical techniques requiring use of robotic surgical system. the reporting of this code is purely informational and will not be reimbursed by payers. coder’s should report all appropriate codes regardless if reimbursement is attached to the codes or not. for additional information on coding, please see further articles from aapc available free to members in the california medical association’s online resource library at www.cmanet.org / resource-library. Rhonda Buckholtz, CPC, is the Vice President of ICD-10 Training and Education for the American Academy of Professional Coders.
Procedures to reduce your liability risk
I
n t h e m ay, 2012 issue of Southern California Physician, we offered tips on how to help avoid employmentrelated lawsuits. Below are seven more. If in doubt, always remember to consult a attorney that specializes in employment practices.
1
review your employment application.
Ensure that your employment application is legally sound and adequately protects your interests. Review your company’s employment application to see that it contains no improper questions (especially in light of the Americans with Disabilities Act) as well as other federal, state, and local employment discrimination laws and includes all the necessary legal protection.
2
have written training procedures or manuals in place for new hires. A
3
Perform background and reference checks on all employees. Although
4
Provide accurate written evaluations to employees on a standard basis.
written list and training on essential job functions is important for all new hires. Without such written criteria, your practice may be exposed when an employee’s performance is called into question.
background and reference checks are typically part of most job situations, it’s important that best management practices are followed when conducting them. Depending on the job responsibilities and what is discovered during the background check, you may not be able to use the information with respect to your hiring decision. For example, if you discover a prospective employee has a misdemeanor conviction from years back, depending on the nature of the offense and the type of position you are filling, you may not be able to use this information in the hiring decision.
Providing accurate written evaluations of employees on a regular basis is an important resource for demonstrating an employee’s job performance and behavior.
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By roy S. lyonS
This will help reduce your risk in “failure to promote” or “wrongful termination” situations.
5
Provide written offers of employment to prospective new hires. It’s
important to provide a written offer of employment to your prospective new hire that includes salary, title, reporting and other general job duties. Having a clearly written document alleviates any misunderstanding about the core elements of the individual’s employment.
6
Send written letters to all rejected applicants informing them of your decision not to hire them. Sending a written letter of “rejection” to all applicants that provides a simple explanation of why you hired someone else, for example, “we’ve found a more qualified candidate” helps minimize the risk of applicants suing you. It’s also a best practice to inform candidates so they are not waiting on your decision as they consider other possibilities.
7
Get employment Practices liability insurance. Employment Practices
Liability Insurance specifically protects your practice against employmentrelated lawsuits including discrimination, harassment, slander, defamation, failure to promote, among others. Most general and professional liability policies exclude employment practices from their policies. A good EPLI policy should have broad coverage, be price-competitive, include front-loaded claims handling and include risk management tools such as training, a toll-free help line staffed by employment attorneys and sample employment policies. The Los Angeles County Medical Associationsponsored EPLI policy includes all of these benefits. For more information, call 800-842-3761, e-mail CMACounty. Insurance@marsh.com, or visit www. CountyCMAMemberInsurance.com. Roy S. Lyons is the Managing Director of Marsh, www.marshaffinity.com.
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f ro n t o f fi ce | pr ac ti ce ti ps
10 tips for using Social media Good online advice from lawyers By fenton nelSon attorneyS
1
Be careful what you tweet or post. You may inadvertently disclose protected health information, especially in pictures. A number of nurses have been fired in recent years for making mistakes such as discussing patients online or posting patient x-rays online. —Aaron Lachant
2
When using social media, physicians need to keep in mind that they need not give too much detail about the patients they serve. Many want to share success stories, but they should be careful about sharing so much information that people can easily identify the patient—including the use of before and after pictures. It is always best to use general terms when describing patient cases. Some physicians want to draw in clientele by stating they have served celebrity clientele, but if the physician shares to a point where the patient is identifiable, not only will they risk losing the individual as a patient, but can easily face breach of privacy issues. —Patricia Sanchez
3
Physicians that advertise discounted services through social media such as Groupon and other similar services should take caution. Technically, this could be considered a form of paying for referrals, since Groupon makes a profit off of each item or service that is sold. —Shara Lerman
4
Physicians need to be aware of and have a protocol for responding to online reviews whether positive or negative. For example, “Dr. X is really willing to issue medical marijuana prescriptions—he barely asked any questions.” That’s not exactly a negative review but it’s also not something Dr. X would be excited to be associated with. —Laura Podolsky
5
Be careful with disclaimers regarding medical “advice.” If a physician has a blog about how he or she treats a certain condition and, relying on that blog, a patient follows that “advice” with adverse consequences, the patient can claim that he or she relied on what Dr. X wrote. —Abbie Maliniak
6
Be sure to put email communications into the patient’s medical record. —Beth Kase
7
Depending upon the use of email communications and the parties’ expectations, it might be wise to have the patient sign a consent to email communication which outlines the risks and other matters. —Beth Kase
8
A patient of one of our clients made an anonymous post about our client on a review site for surgeons. The client then posted a response about the patient, using the patient’s name, and
thereby (arguably) disclosing confidential information. The site itself made a post reprimanding our client for not being careful about patient identity. This led to our client making negative posts about the owner of the site on other websites. Ultimately this got our client sued for defamation and other torts. —John Mills
9
Making the above case even stickier was the fact that the user name of the patient who posted the negative comments contained the patient’s last name. Thus, our client didn’t even take into consideration patient privacy because he thought that the patient was identifying himself to the public. In a way he was. However, physicians should never disclose patient information in any circumstance. —Nick Jurkowitz
10
It’s unfortunate that the reputation of health care providers are subject to online attack, where anyone performing a Google search will see the negative information. Still, it’s too risky for the provider to go on the offensive. It’s better to remain quiet, or just be defensive about the negative comment without disclosing any details of the confidential relationship. —John Mills All attorneys quoted in this article work at the law firm of Fenton Nelson, www. fentonnelson.com.
physician compensation increasingly tied to Quality of care Know what key questions you should ask S u rV e yS By health care consulting firms suggest that the practices of paying employed physicians strictly a salary or paying independent physicians strictly on volume are ending, according to a news report at amednews.com. thus, the report quotes consultants as saying that physicians, both employed and self-employed, should take steps to ensure they’re receiving an appropriate share of pay-for-performance or value-based purchasing bonuses. the report said that business consultant hay Group surveyed 182 health care organizations in
By Pnn Staff
late 2011 and found that 66 percent have added incentive programs for doctors using quality measures. in a second survey released earlier this year, consultants sullivan, cotter and associates found that 72 percent of 424 health care organizations linked a portion of pay to doctors to the quality of care. the amednews.com story said physicians should ask the following key questions about performance pay in the future:
• will the practice be judged on improvement or hitting a target? • will a bonus be paid only if a full target is met, or will it be prorated for lesser achievements? • will the health system or insurer help to make sure that the metric can be achieved? • are the bonus or performance targets reasonable? health care consultants say goals should not be too easy, but within reach.
• will the assessment be based on insurance claims data or an audit of medical records?
Source: Physicians News Network at physiciansnewsnetwork.com.
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risk tip Reducing the risk of retained objects during surgery
A
r G ua B ly the most important moment of a surgery is the moment that the patient awakens from the procedure in a much-improved condition. But what happens when that patient wakes up from surgery only to find that his or her health is now impaired by a retained foreign object? According to estimates published in The New England Journal of Medicine, the incidence of retained foreign objects—which can lead to inflammation, obstruction, perforation, sepsis and even death—can be as high as 1 in 1,500 surgeries. Before a surgical procedure begins and prior to closing, a manual count of all items used, including sponges, needles, towels, and instruments, must be performed and documented. Most hospitals and surgical centers now use small metal threads embedded in sponges and towels to help them locate retained foreign objects with a portable x-ray. The surgical staff keeps diligent count of sponges and towels—a necessary best practice that can be time-consuming—but errors can
By erneSt e. allen, cSP
still occur. In fact, in a majority of cases with retained sponges, the nurse’s count appeared accurate. The subsequent surgery to remove the item increases the length of hospitalization and delays recovery. These surgeries are not reimbursable by insurance companies, Medicare, or Medicaid, as they are considered a rebuttable presumption of negligence, otherwise known as a res ipsa loquitur case. Defending these types of claims is very difficult and often results in the health care provider’s name being recorded with the National Practitioner Data Bank. But new technology is now available to prevent retained foreign objects. Medical radio frequency identification chip technology, approved by the U.S. Food and Drug Administration, automatically tracks sponges and surgical towels used during a procedure. If the count is not correct, a wand-shaped device is waved over the surgical site to identify the location of the retained item. This device saves time and does not expose the patient to unnecessary radiation, as is the
case with a portable x-ray device. The new RFI technology requires additional cost, so some hospitals reserve it for high risk cases, such as patients undergoing emergency surgery, obese patients, patients having cesarean sections, and patients having surgery on more than one area of the body. Hospitals and surgical centers that have adopted the new RFI technology report: • Improved patient outcomes • Reduced preventable claims of retained sponges and/or towels • Additional time for surgeons to complete procedures Note: RFI technology does not detect clamps or other surgical instruments. Documented counts must be performed on all items used during surgery. Ernest E. Allen, CSP, is a Patient Safety/ Risk Management Account Executive at The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com.
an operations management classic An old book, but very good, book
I
r e c e n t ly h e a r D about a classic book from the eighties that apparently was all the rage among business students and aficionados back in the day, but that somehow slipped by me. Since it was about operations management, and presented in an unusual format— a novel—I felt compelled to check it out. Now that I have, I think medical practice managers should, too. It’s called The Goal, by Eli Goldratt, and it tells the story of a plant manager named Alex Rogo who must turn around abysmal performance in his manufacturing plant. Despite achieving “efficiencies” in many steps of production, the plant’s productivity overall has deteriorated to the point where orders are backed up for weeks,
By laurie morGan
and the company’s salespeople can’t reliably forecast when orders can be delivered (and so can’t really sell any new orders, either). If Alex can’t fix the plant, it will be shut down. Alex is mentored in the book by a professor named Jonah, who guides him in the process of understanding the plant’s constraints—bottlenecks— and how to increase their throughput. By analyzing what really drives (or holds back) production in his plant, Alex learns that many of his most relied-upon assumptions aren’t correct—and develops a better way to improve his plant’s productivity. I happened to be reading this book while working with a medical practice that was having workf low problems, and the parallels were striking. This
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 | s e p t e m b e r 2 0 1 2
practice was proud of its wonderful system for triaging patients—but the system was so efficient, patients were waiting for ages in exam rooms for their providers. The practice had over-optimized in triage, creating huge bottlenecks down the line at the exam rooms—but no benefit whatsoever to patients and no improvement at all in the number of patients seen! They needed to look at their “plant” with fresh eyes, just like Alex did, to see that overall process efficiency is dependent on the performance of the slowest link in the chain. Reprinted with permission from the blog Straight Talk for Doctors, maintained by consultants Capko & Company. Visit www.capko.com/blog.
Los Angeles County Medical Association
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Safeguard against Sexual misconduct accusations by Patients Don’t be taken by surprise
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By PhylliS a. DrummonD
ccusations by patients of sexual misconduct on the part of health care professionals, both physicians and non-physicians, have become more frequent in recent years. The Medical Board of California adopted a policy on sexual misconduct in 1996. This policy defines sexual misconduct as “sexual contact occurring concurrent with the physician-patient relationship.” The California Medical Association suggests that physicians take precautions to avoid any circumstance which may be misinterpreted as sexual contact or a sexual advance toward a patient. The legal consequences of allegations of sexual misconduct are potentially severe and may even be career-ending if not handled properly. The physician or provider may face probation, suspension or revocation of his or her license, the loss of hospital privileges and the inability to obtain professional liability insurance. California has enacted a law specifically dealing with the issue of sexual misconduct allegations. The law includes the warning that “in no instance shall consent of the patient or client be a defense.” Sexual exploitation by a physician is classified as a “public offense” and can therefore be either a misdemeanor or a felony. And, sexual misconduct allegations are not limited to a female patient and a male provider. There can be accusations involving a male patient and a female provider, as well as male-male and female-female scenarios. Certain allegations may seem absurd, but are often based on the patient’s
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perception of behavior. For example, a patient felt the clinician was inappropriate when listening to the patient’s heart by placing the stethoscope on and around her breast. Not all accusations involve allegations of physical contact. Some have been made on the basis of alleged sexual innuendo during a physical exam. In one instance, a patient commented about her own weight during an exam by a male nurse practitioner. The practitioner allegedly responded with sexually explicit remarks about the patient’s shapeliness and “sexiness” that made the patient uncomfortable as she sat on the exam table wearing only a patient gown. In another, a mid-level practitioner was accused of making “flirtatious comments” to a patient and asking her for a date. A common characteristic of these accusations is that they lack a witness. Physicians are cautioned that if an accusation is made about an action taken during a physical examination, and there is no witness, it becomes a matter of the physician’s word against the patient’s. Practices that do not have a chaperone policy or do not enforce the policy are putting their providers and the practice at greater risk. To reduce the risk of allegations of sexual misconduct, consider taking the following steps:
flirtatious behavior with patients. • Ensure the policy pertains to all encounters, including working with minors and others when off-site (for example, when conducting physical exams or immunization clinics at a school). • If not already in place, develop a chaperone policy and procedure. The policy should consistently apply to any and all intimate physical exams, regardless of gender. Make it clear to your providers that the policy is for their benefit. • Advise providers not to encourage or tolerate sexual advances from a patient. • To alleviate patient concerns, educate patients prior to a physical exam about how and why the exam will be conducted. • Recognize and be sensitive to cultural values or language barriers that might affect patient or family perception of an intimate physical exam. Use translators when needed to ensure accurate communication. • Document in the medical record any flirtatious, suggestive or lewd behavior exhibited by the patient and the actions taken to halt the behavior. • Contact your medical professional liability insurance company as soon as you are aware of a potential or actual allegation of sexual misconduct.
• Implement a sexual misconduct policy and train all staff to follow the policy, being clear about what behaviors are considered acceptable and what ones are not, including unprofessional or
Phyllis Drummond is a Risk Management Specialist for NORCAL Mutual Insurance Company and the NORCAL Group. © 2012 NORCAL Mutual Insurance Company. All rights reserved.
how many of the 2.2 million uninsured people in los angeles county will gain access to health care coverage under the federal affordable care act—that’s 1,760,000 people. SOURCE: COUNTY HEALTH SERVICES DIRECTOR DR. MITCHELL KATZ
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pr ac ti ce ti ps | f ro n t o f fi ce
5 P’s
Training your staff doesn’t have to be expensive or time consuming to be effective By Daryn Keeney, CPC
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ow m u c h training does your staff have? This is a question that every practice has to consider when setting expectations for new as well as established employees. Recently at a dinner meeting with some colleagues, this became the main topic of conversation. Some interesting questions were brought up: • Is the training that the practice provides sufficient or do we need to send people out to be trained? • Is it better to bring in trainers, at the expense of the practice, to bring staff up to current standards? • With an ever-increasing need to stay current with the changes in the medical field, are our staff members keeping up?
she learns. A big fear that I hear voiced is that those employees would leave the practice for better opportunities after they gained more education. That is very true, but not everyone leaves. The benefits of having a forward-thinking staff greatly outweigh the negatives of having an under trained one. The expense of training is also a fear. Luckily, medical societies are placing information online and that has brought that expense down greatly. Now there are vast amounts of information at our fingertips for much less money. Unfortunately, that still leaves us with a question: How do we get the staff to use that information? An internal education coordinator may be a good solution for the practice. This could be a person already on staff who likes to read and stay educated but does not have the time or money. By allowing that person time
and access to materials, he or she could be feeding our offices information to stay up to date. Overall, education needs are defined by the practice. If problems continue to arise again and again, an audit of internal processes should tell you where your needs are. With proper education and good planning, it is easier to convey expectations to the staff as well as to motivate them when they are moving in a positive direction. For me, it all comes down to what my father taught me about the five Ps: “Proper planning prevents poor performance.” Daryn Keeney has been in the medical billing field since 1998 as a professional coder. Currently, he’s the billing practice manager for Anesthesia Associates PLL & Pinnacle Interventional Pain & Spine Consultants LLC.
The dinner group found that, in many practices, training and education are not requirements unless a staff member needs to keep up on CEUs or CMEs. We also found that, generally, unless a manager is approached by an employee about attending a seminar, workshop or class, training really does not come up at all. Others did not think training was part of the practice’s responsibility. I had to ponder the responses in light of my own practice. Daily, we find ourselves in situations that could be solved more efficiently and effectively if the people facing the problems had been taught how to handle them. As practice managers, we cannot just let the people that we rely on to get the job done stumble due to lack of knowledge. It is our responsibility to give our staff the opportunity to learn more so they can provide educated points of view. If we want a better job out of our staffs, shouldn’t we help them to help us? Every practice has an expectation from its staff. There is a job to do and we believe it should get done. Micromanagement is not the answer, so we need to make knowledge available for everyone to access. I know practices that pay for continuing education; this is valuable when the employee practices what he or s e p t 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 3
Cm a | qu i ck list
Regulations Quick List The latest news on medical regulations
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h e C a l i f o r n i a Medical Association’s Regulations Quick List provides a summary and current status of significant regulations followed by the CMA. This list is accurate as of the August 21, 2012 and includes only changes to regulations covered in the August edition of Southern California Physician magazine or new regulations added by the CMA since then. For the full list of regulations, visit the CMA website at www.cmanet.org. The list is only available to CMA members.
Requirements for Preceptors Physician Assistant Committee Existing regulations permit only physicians to act as preceptors for the training and education of physician assistant preceptees. This proposal would expand the type of licensed health care providers who may act as preceptors to include physicians and surgeons, PAs, registered nurses who have been certified in advanced practice, certified nurse midwives, licensed clinical social workers, marriage and family therapists, licensed educational psychologists, and licensed psychologists. The CMA submitted comments and substitute language that would maintain the requirement that PAs receive supervised clinical training from physicians, but allow other health care providers to serve as supplemental preceptors. The changes were not made at the February 6 hearing, but the CMA and the California Academy of Physician Assistants were encouraged to submit additional language changes for future consideration. The CMA and CAPA sent a joint letter with agreed upon language changes, which the PAC accepted at their May 7 meeting. The CMA submitted a letter supporting the revised language, which will be considered at the August 6 PAC meeting. Status: CMA comments submitted 7/19/12.
Chiropractic Use of Lasers Board of Chiropractic Examiners This regulation allows chiropractors to use lasers that have been approved by
By CMA Staff
the FDA and indicates that they may not use lasers for ablation or surgery. It also states that they may not treat allergies where there is a known risk of anaphylaxis. The CMA submitted comments calling for no chiropractic laser treatment of allergies under any circumstances, clarifying that cosmetic medical laser procedures, including ablative and nonablative procedures are also prohibited, and declaring that the only lasers appropriate for chiropractors use are FDA-approved devices available overthe-counter. At their March meeting, the BCE accepted the amendment that prohibits chiropractic use of lasers to treat allergies under any circumstances, but did not accept the other changes. The CMA reiterated the unaddressed issues in a letter submitted during the 15-day comment period. The BCE made no further changes before submitting the regulation to the Office of Administrative Law, where it was ultimately approved. Status: Effective 7/14/2012.
Federal Regulations Medicare and Medicaid: Reform of Hospital and Critical Access Hospital Conditions of Participation Centers for Medicare and Medicaid Services The CMS published an updated set of requirements that hospitals must meet in order to participate in the Medicare and Medicaid programs. The major changes to the requirements, known as conditions of participation, that could impact medical staffs and scope of practice within hospitals include: • Creating an option that allows a single governing body in a multi-hospital system to oversee multiple hospitals. • Allowing hospitals to broaden the definition of “medical staff” to other practitioners (for example, advanced practice registered nurses, physician assistants, pharmacists etc.) as eligible candidates for privileges required by the state to practice in a hospital.
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• Allowing for drugs and biologicals to be prepared and administered on the orders of practitioners (other than a doctor), in accordance with hospital policy and State law. The amendment also allows orders for drugs and biologicals to be documented and signed by practitioners (other than a doctor), in accordance with hospital policy and State law (which is specified to include medical staff bylaws, rules and regulations). • Eliminating the requirement for authentication of verbal orders within 48-hours and have deferred to applicable State law to establish authentications timeframes. Late last year, the CMA submitted comments objecting to several amendments in the proposed regulations. The CMA supported the elimination of the federal requirement that verbal orders be authenticated within 48 hours. With regard to authentication of verbal orders, California law still requires such authentication to take place within 48 hours, but the elimination of the federal requirement on this issue could potentially lead to changes in the California state law. The CMA will be reviewing the final rule in further detail and will take the appropriate legislative and regulatory action to ensure that state laws continue to protect patients and ensure quality of care. The CMS issued a memorandum on June 15 stating that the provision of the May 16 final rule that requires a hospital’s governing body to include a member of the medical staff was being “reconsidered”, and would not be enforced pending further action. This action is being taken in response to complaints from the American Hospital Association about the final rule. The CMA has subsequently submitted comments to the CMS urging that the directive for survey agencies not to assess compliance with this new requirement be rescinded. The CMA also urges the CMS not to revise or suspend enforcement of any other provisions of the final rule without providing
qu i ck list | cm a ample opportunity for public comment. Status: Effective 7/16/12. Additional comments submitted 7/10/2012.
Medicaid Program: Payment for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration Under the Vaccines for Children Program Centers for Medicare and Medicaid Services This proposed rule would implement Medicaid payment for primary care services furnished by certain physicians in calendar years (CYs) 2013 and 2014 at rates not less than the Medicare rates in effect in those CYs or, if greater, the payment rates that would be applicable in those CYs using the CY 2009 conversion factor. This proposed regulation would also provide for a 100 percent Federal matching rate for any increase in payment above the amounts that would be due for these services under the provisions of the State plan as of July 1, 2009. This proposed rule would also update the interim regional maximum fees that providers may charge for the administra-
tion of pediatric vaccines to federally vaccine-eligible children under the Pediatric Immunization Distribution Program, more commonly known as the Vaccines for Children program. Overall, the CMA supports the proposal but offered specific comments including urging the Administration to continue to seek opportunities to extend the rate increase beyond the two years, and ensuring f lexibility to deal with Medi-Cal’s outdated Z-codes. The CMA is also opposed to the CMS’ selection of the 2009 Medicare Physician Fee Schedule Conversion Factor as the basis for the Medicaid primary care physician rate increase, and urged the CMS to begin with the 2011 Medicare Physician Fee Schedule Conversion Factor and update it annually. Status: CMA comments submitted 6/11/12.
Medicare Program: Revisions to Payment Policies Under the Physician Fee Schedule Centers for Medicare and Medicaid Services On July 6, the CMS released a proposed
rule (to be noticed at a later date) that would include significant payment increases for primary care. For example, family medicine would receive a 7 percent rate increase, internal medicine would receive a 5 percent rate increase, and others would receive a 3 percent rate increase. Some specialists would be hit with minor reductions. The largest cut (14 percent) is to rates paid to radiation oncologists. The CMS did not propose any of the desired changes to the payment localities, but include in-depth information about how they intend to continue to study the issue and ask for public comments again in the future. At the CMA’s urging, the CMS withstood the heavy lobbying from Iowa and the Midwest state medical associations to make changes to the practice expense and work Geographic Practice Cost Indices allocations, and there are no significant changes in this area. The CMA will continue to analyze the lengthy proposed rule and intends to comment. Status: Noticed in the Federal Register 7/30/12.
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All loans subject to approval, including credit approval. Eligible properties must be located in Alabama, Arizona, California, Colorado, Central Florida, North Florida, New Mexico or Texas where BBVA Compass has a market presence. BBVA Compass is a trade name of Compass Bank, Member FDIC. s e p t 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 5
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au tism | f e at u r e
Raising the Bar on Autism New programs help lower the age for detection and effective intervention By Cheryl England
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s a Lo s A n g e l e s -based single parent of two boys with autism, Bonnie Sayers knows all about the trials and tribulations of raising a child with autism. Sayers, the author of Autism Family Adventures recently wrote a post about her 16-year-old son’s fear of dogs and the problems it has been causing. In her post she writes: My son Matthew is nonverbal and now 16 years old. He has always been afraid of dogs and sometimes the encounters are chaotic in nature with the result someone getting hurt in the process, although not from the dog, it is usually from Matthew. For years we used to walk around the lake down the street but there was a busy street on one side and the actual lake on the other side so when a dog was coming around the sidewalk there was not a lot of room to move away. Also bicyclists used to be dangerous as Matthew did not know what to do when one was getting close to us and I had to guide him to the grass area or we would stop so they could get around us. Since the lake closed down for renovations we have been walking around the park and doing trails and stairs. This presents problems when we come upon a dog or dogs that may not be on a leash or get close to Matt when on a leash. He goes on the attack towards me and digs his fingers into my skin and runs or pushes me into the woods or a ditch and one time I almost went down the stairs. I get bruises and marks on my skin from his attacks. He also runs and I have to catch up to him to get a hold of his arm or hand. Now that he is taller at 5’6 or so and weighs about 105 pounds it is not as easy as when he was younger.
As anyone who is familiar with autism spectrum disorders knows, this is not atypical behavior. But numerous studies have shown that early detection and intervention—before the age of four at the latest—are generally the most effective in providing the best long-term prognosis. “Certainly, some interventions such as social skills training or occupational therapy are only appropriate at older ages,” says Alycia Halladay, PhD, Director of Research for Environmental Sciences with Autism Speaks’ Move the Needle Initiative. “But early interventions give the child the greatest likelihood of being mainstreamed into regular school and not showing some of more disabling symptoms of autism”—symptoms such as behavioral, intellectual, social or communication problems. That’s why a number of new programs, initiatives and even new laws—many of which have been initiated in L.A. County— aim to lower the age at which children are diagnosed, educate parents, and make resources easier to find and use.
The Importance of Screening
In March, the U.S. Centers for Disease Control and Prevention greatly raised its estimate of the number of 8-year-olds with some form of autism from 1 in 150 in 2000 to 1 in 88 in 2008. The report sparked debate over whether a growing environmental threat could be at work. But autism researchers around the country said the CDC data—including striking geographic and racial variations in the rates and how they have changed—suggest that rising awareness of the disorder, better detection and improved access to services can explain much of the surge, and perhaps all of it.
In L.A. County, the statistics are even more shocking. “We have more cases of autism in this County than there are throughout the rest of the state,” says Caroline Sandberg Wilson, RN, the Executive Director of the Autism Society of Los Angeles and the parent of two adults with autism. “There are an inordinate number of cases due to our dense population. One-third of all people with ASD in California live in Los Angeles.” Yet, despite the explosion of autism cases in Los Angeles, it is still a challenge for parents to have their child diagnosed much less wind their way through state and national programs, insurance company denials and the school system for treatment. “Autism is a disability that is frequently overlooked in young children,” says Patricia Herrera, MS, Project Director of Developmental Screening for 211 LA County. “Physicians rely on clinical observation and some disabilities such as autism need more than that because they are difficult to identify.” There are a variety of reasons that autism is difficult to diagnose and can include inadequate screening practices, slow response to parental concerns, or a lack of awareness of symptoms that manifest early in life. Similarly, misdiagnosis is likely because of the similarity of some features of ASD with other conditions that show up in childhood, such as hyperactivity or repetitive behaviors. Early diagnosis of ASD also is further complicated by intellectual disability, which occurs in about half of children who have more severe symptoms and can, therefore, result in a primary diagnosis of delayed development. The American Academy of Pediatrics recommend that physicians use
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f e at u r e | au ti sm evidence-based screening tools at both 18 and 24 months of age to cast the broadest net for identification of children who possibly have or are at risk for autism. Many of these screening tools such as the Ages and Stages-3 Questionnaire, the Ages and Stages Questionnaire: Social-Emotional, Parents’Evaluation of Developmental Status, PEDS: Developmental Milestones and the Checklist for Autism in Toddlers (M-CHAT) are online. Tools like these examine specific behaviors associated with ASD in very young children such as eye contact, pointing, social-emotional behaviors and communication. Having physicians be proactive in testing for autism is critical. “The average age for a diagnosis of autism is 4 to 5 years,” says Halladay. “But most parents are concerned before their child reaches age 2. They can see something is amiss even if they don’t know it is autism but they may not know how to express their concern or even who to express it to.”
Greater Challenges
Minorities and low-income parents face even greater problems in having their child diagnosed at an early age. While the average age for all children to be diagnosed is an already-too-old 4 to 5 years of age, the average for African Americans and Hispanic children is 6 to 7 years of age. That gap is where Herrera’s pilot 211 Developmental Screening and Care Coordination Project hopes to have impact. The screening project was initially envisioned by the Early Identification and Intervention Collaborative of Los Angeles County, which is a group of more than 350 organizations across multiple sectors dedicated to improving and expanding timely identification and intervention for children with or at risk of barriers to development. 211 LA County, a 30-year-old non-profit that is
dedicated to helping low-income families in Los Angeles find help and resources and is a member of EII, averages about 500,000 calls per year with some 84,000 of those calls being related to children age 0 to 5. With all those phone calls, the group saw a prime opportunity to quickly provide immediate screening and help with navigating systems for parents. The project helps parents access free developmental assessments or diagnostic evaluations and timely and effective intervention services “It’s a powerful program,” says Herrera. “These low-income families, who have the highest risk of not receiving a diagnosis and getting treatment and who have the least resources, are already at our doorstep.” Here’s how the program works. When a parent calls in with a need, such as loss of a job, and can be identified as having a child 0 to 5 years of age, the 211 LA Information and Referral Specialist asks them at the end of the call if they would like to answer a parent questionnaire about how their child is developing for their age. Since a relationship has already been built, 80 percent of the parents say “yes.” The parent is transferred to a care coordinator who asks them several simple questions based on the PEDS or M-CHAT questionnaire, depending on the child’s age. If results are positive for autism or at high risk, the care coordinator creates an action plan for the parent right then. This includes services that a sub-5-year-old is eligible for such as the Federal Early Start program for children under 36 months, free pre-school programs for 3 and 4 year olds, and specialized services through the California Regional Center system or the local school district for children over 3 years of age with a potential diagnosis of autism or any other developmental disability. Currently, the pilot project is screening about 3,000 children per year using three care coordinators. And it has proven
effective—results from the screenings are 2.5 times the national average. Now, the goal is to make the screening project sustainable over time and scale it up. “We know the potential reach and know this is an effective way to connect kids with the most needed services,” says Herrera. “We want to be able to screen up to 20,000 kids per year and provide coordinated care so we are looking at avenues of partnership to expand the program.” Other initiatives that aim to lower the age of detection abound. Autism Speaks’ Move the Needle initiative has a goal of bringing together everything that different agencies including large national ones such as the CDC and AAP provide and ensure that the information, tools and resources are being disseminated and used across the country and the world. Because autism can now be detected in children as young as 18 months to two years, the group would like to see the average age for diagnosis and intervention lowered to two or three years of age. Still, other research is aimed at lowering the age at which autism can be reliably detected to less than 18 months. For example, Connie Kasari, PhD, of the renowned UCLA Center for Autism Research and Treatment, has researched an evidence-based communication therapy nicknamed JASPER for Joint Attention, Symbolic Play, Engagement and Regulation. The therapy has already proven effective for pre-school age children and is now being re-adapted and tested on children 12 to 21 months of age. Although still in the pilot phase, the results are looking positive so far.
A Difficult System to Navigate Even when a child is diagnosed, parents can be at a loss as to how to navigate the system. Sayers’ two boys were diagnosed with autism at ages 2 and 3 years old. “Neither one spoke,” says Sayers. “My physician gave me a referral for speech
The Lanterman Act T h e L a n t e r m a n Developmental Disabilities Services Act, or Lanterman Act, was passed in California in 1969. It essentially says that people with developmental disabilities have a right to the services and support they need to live like people without disabilities. The Act outlines the rights of the individuals and families, how the regional centers and service providers can help them, what services and support they can obtain, how to use the individualized program plan to get services, what to do when someone violates the Act, and how to improve the system. 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 | s e p t e m b e r 2 0 1 2
au tism | f e at u r e therapy and that evaluation came back with a diagnosis of autism.” Sayers was directed to one of the 21 non-profit regional centers run by the State Department of Developmental Services, which offer services for people with developmental disabilities. But the center required a referral before accepting her sons—a referral that Sayers was finding elusive to track down. Finally, the Individualized Education Program, which is mandated by the Individuals with Disabilities Education Act to meet the special educational needs of a child with a disability gave Sayers the recommendation she needed. But Sayers and her boys were still far from out of the weeds. “The school system will do some things, insurance will do some things and the regional centers will do some things but they all cut off at certain ages,” says Sayers. Sayers continues to define the problem saying, “And the regional centers didn’t hand me a list of resources—I had to find out what to do from other parents. It took me until Matthew was 9 to get him into Floortime therapy, which the regional center paid for.” Of course, parents can self-pay for help using services from Pacific Child & Family Associates, the Brain Balance Achievement Center or any other number of groups. But the cost for these services can be prohibitive for a parent that already has high ASD-related expenses. And, unless the services offer scholarships for low-income families, there is no chance they can afford them. As you might anticipate it is even harder for low-income and underserved parents to navigate the complex government resource systems than for parents from middle- or upper-incomes. “Even if a low-income parent has been given a diagnosis and a list of resources,” says Herrera, “they most likely won’t take advantage of them because the systems are very hard to navigate and these parents are the ones most likely to be stressed with other issues like getting enough food or coping with violence.” In a four-part series on “Discovering Autism,” the Los Angeles Times found a number of shocking statistics on just how wide the disparity is between expenditures on whites versus other ethnicities. Two of the more telling are: • For autistic children 3 to 6—a critical period for treating the disorder—the
state Department of Developmental Services last year spent an average of $11,723 per child on whites, compared with $11,063 on Asians, $7,634 on Latinos and $6,593 on blacks. • The divide is even starker when it comes to the most coveted service—a behavioral aide from a private company to accompany a child throughout each school day, at a cost that often reaches $60,000 a year. In the state’s largest school district, Los Angeles Unified, white elementary school students on the city’s affluent Westside have such aides at more than 10 times the rate of Latinos on the Eastside.
Who’s Got the Money?
A study released this past March showed that the lifetime cost of providing care for each person with autism affected by intellectual disability is $2.3 million. The lifetime cost of caring for individuals who are not impacted by intellectual disability are $1.4 million. More telling, the study shows that autism costs the U.S. a massive $126 billion per year for all ASD cases combined—a number that has more than tripled since 2006. The Autism Speaks-funded research was conducted by Martin Knapp, PhD, of the London School of Economics, and David Mandell, ScD, of the University of Pennsylvania. A 2006 study from Michael Ganz, Assistant Professor of Society, Human Development, and Health at Harvard School of Public Health found slightly higher costs for raising a single child with ASD—$3.2 million—and compared it to $290,000 for raising a neurotypical child. He also found a significantly lower number for caring for all people with autism over their lifetimes—$35 billion per year—which is still staggering. He also found that historically the federal autism research budget has been less than $100 million compared to research budgets of $91 billion for Alzheimer’s disease, $51 billion for mental retardation, and $57 billion for anxiety. The costs of caring for an ASD child run so high because, besides the routine child-rearing costs, there are high-priced, one-on-one speech, occupational, behavioral and communication therapies, home repairs for damage caused by the child’s meltdowns, specialized support at school, respite services and vocational training and supported employment. In many cases, at least one parent must give up a job because someone in the family
has to be able to run at a moment’s notice to pick up their child due to some autismrelated disaster. Sayers still has holes in the walls of her home where one of her sons began the habit of knocking the walls with his fist—and she’s had to leave the holes in place to prove to that her son needs more behavioral therapy. So thus the catch-22: The number of children being diagnosed with autism—a highly expensive condition for the health care community to treat—is exploding at a time when government budgets are being slashed. “The budgets for early interventions before the age of 3 were gutted in California under Gov. Schwarzenegger,” says Wilson. “And one of the most effective therapies—applied behavioral analysis—is often denied by insurers.” There is some recent good news for insured parents of children with ASD. On July 1, California Senate Bill 946— dubbed the “Autism Bill”—took effect. The bill, authored by Senate President Pro Tem Darrell Steinberg, requires insurance companies to cover behavioral treatments for from ASD patients. Some plans still may not offer the coverage, however, since companies that are self-insured—generally very large employers—are exempt from state regulations. The other wrinkle is that as federal health care reform kicks in, essential health benefits will be established nationally to determine what treatments must be covered. If those benefits do not include behavioral treatment for autism, the new California law will automatically expire and insurers will no longer be required to cover the treatments. Autism experts, however, are optimistic that those benefits will be covered under federal law.
A Gap in Understanding
Because autism is typically considered a lifelong disorder, there is a lot of stigma and fear about how a diagnosis, or even about administering a test, is communicated to parents. “Even if a physician wants to approach the topic of autism, there is still a general lack of knowledge about what autism is, what resources exist, and what to do about it,” says Halladay. “There is an even larger gap in the knowledge about autism in the underserved,” she continues. Wilson agrees. “There is a huge gap in the understanding of autism,” she says. “It’s more than a medical condition—it’s a family issue, a child issue, and a global issue.”
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m e m b e r b e n e fits | at wo r k Fo r yo u
At Work for You
LACMA offers a wide array of benefits designed to enhance your practice and protect your autonomy By CArol Chaker
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h e r e h a s n e v e r been a more important time to be a member of the Los Angeles County Medical Association and the California Medical Association. When you join LACMA and the CMA, you join a dedicated network of over 6,000 Los Angeles County physicians and over 35,000 California physicians who are working together to achieve a unified health care front and fight against unfair insurer reimbursement practices, restrictions on physician autonomy and the erosion of valuable legislation that protects physicians’ practices. LACMA and the CMA can help enhance your practice, improve your bottom line and protect your autonomy as a physician.
Your Membership, Your Benefits
Since 1871, LACMA has been at the forefront of medicine in L.A. County, ensuring that our members are represented in the areas of public policy, government
relations and community relations. Through our advocacy efforts in both L.A. County and with the California Medical Association, our physician leaders and staff strive toward a common vision—that you might spend more time treating your patients and less time navigating the obstacles that threaten your autonomy and undermine your practice of medicine. When you join LACMA and the CMA, you have access to these member-only benefits: • Legislative advocacy • Reimbursement advocacy and assistance • Free legal consulting • Jury duty assistance • Free publications • HIT resources • Free access to educational events, webinars, and CME programs • Partnerships and discounts As a member of LACMA and CMA, these benefits can:
• Provide visibility with patients and the community. • Help improve your bottom line. • Provide access to networks of peer physicians and elected officials. • Give you a powerful platform to advocate for meaningful reform of the health care system and to protect your rights as a physician. • Put valuable resources on topics ranging form practice management to legal issues at your fingertips. Most importantly, your membership works for you. As a member, you get access to a committed professional staff that stops at nothing to protect the way you practice medicine from legal, regulatory and legislative intrusions. Your membership lets you focus on what’s really important: providing exceptional care to your patients. We offer specialized memberships for physicians, residents and students. For additional information or to apply, visit www.lacmanet.org or call us at 213-226-0313.
Meet Your Board!
LAC M A’ 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
Erik Berg
President
Medical Student Councilor / USC Keck
Marshall Morgan, MD
Stephanie Booth, MD
Pedram Salimpour, MD
Jack Chou, MD
Peter Richman, MD
Sidney Gold, MD
Troy Elander, MD
William Hale, MD
President-Elect Treasurer
Secretary
Immediate Past President
Board of Directors David Aizuss, MD
Councilor-at-Large CMA Trustee Councilor Councilor
Shelley Han
CMA Trustee
Medical Student Councilor / UCLA David Geffen
William Averill, MD
Vito Imbasciani, MD
Councilor
Councilor
Paul Kirz, MD
Chair of LACMA Delegation 2 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 | s e p t e m b e r 2 0 1 2
Lawrence Kneisley, MD
Heidi Reich, MD
Councilor-at-Large
Resident/Fellow Councilor
Howard Krauss, MD
Susan Reynolds, MD
Gideon Lowe, MD
Bob Rogers, MD
Councilor Councilor
Jonathan Macy, MD Councilor-at-Large
Carlos E. Martinez, MD Councilor
Nassim Moradi, MD Councilor
Ashish Parekh, MD Councilor
Jeffrey Penso, MD Councilor-at-Large
Councilor Councilor
Sion Roy, MD
Resident/Fellow Councilor (Alternate)
Pejman Salimpour, MD Councilor
Shuo Steven Wang, MD Councilor-at-Large
Erin Wilkes, MD
CMA Trustee (Resident)
at wo r k fo r yo u | m e m b e r b e n e fit s
Benefits and Discounts
A
LAC M A a n d C M A membership offers you exclusive, time- and money-saving benefits. By taking advantage of these discounts and services, you can earn back more than the investment of your dues dollars. Products include discounts on billing and collections services, malpractice insurance, group practice insurance and HSAs, investment services, auto insurance discounts and more. Highlighted programs include: • Bank of America Affinity Card: A member-only credit card that offers reduced rates, premium service and a generous rewards program. • Marsh Insurance Services: Marsh offers members a variety of insurance programs including high deductible health plans and health savings accounts, employment practices liability insurance, workers’ compensation, term life, business owners package, long term care, long term disability, business overhead expense, dental and more.
• AAA Auto Insurance Discounts: Save hundreds annually. • CME Tracking/Credentialing: CMA’s Institute for Medical Quality, certifies CME activity for credentialing purposes to the Medical Board of California, as well as to hospitals, health plans, specialty societies, and others. • Heartland Payment Systems: Members receive exclusive discounts and a threeyear rate guarantee on Heartland Payment System’s suite of financial services, which includes credit card processing, payroll services, check management and real time health benefits eligibility verification.
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•
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Other discounted resources for you include: • Epocrates: CMA members get a discount on all Epocrates mobile and online products. Save 30 percent on subscriptions to Epocrates products such as the #1 rated Epocrates Essentials. Epocrates provides point-of-care access (via mobile devices
•
and the web) to information on drugs, diseases and diagnostics. Call 1-800-786-4262 to access this benefit. Staples: Save up to 80 percent on office supplies and equipment from Staples, Inc. Call 1-800-786-4262 to access this benefit. MedicAlert: MedicAlert is a nonprofit foundation with over 50 years of lifesaving experience identifying and providing vital medical information to emergency personnel for over 4 million members worldwide. CMA members and their patients save $10 on new adult enrollments and $2.95 on Kid Smart enrollments. Call 1-800-253-7880 to access this benefit. Magazine Subscriptions: 50 percent off subscriptions to hundreds of popular magazines, with a best price match guarantee. Call 1-800-289-6247 to access this benefit. Car Rentals: Save up to 25 percent on car rentals for business or personal travel. Members-only coupon codes are required to access this benefit. Get your code by calling the CMA’s Member Help Center 1-800-786-4262.
merage.uci.edu/go/HCEMBA
Change is on the Horizon. Now is the time to gain your competitive edge. Learn the BUSINESS of health care while earning your Executive MBA at UC Irvine: • Convenient schedule: one weekend per month • Cohort of health care professionals and practitioners • Week-long residential on Federal Policy in Health Care in Washington D.C. • Ranked among the Top 25 Health Care Executive MBA programs • Up to 50 CME units may be earned
Apply Now for Fall 2012 – merage.uci.edu/go/HCEMBA Contact us to attend an Information Session or schedule a personal consultation.
949.824.0561
HCEMBA@merage.uci.edu
Dr. Romilla Batra, HCEMBA ‘09
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asso ciati o n happe n i n gs | N e ws & e ve n ts
Pictured from left to right is Afam Onyema, GEANCO COO; Willie Roaf, newly inducted member of the NFL Hall of Fame, Class of 2012, and Alberto Tovar, COO of LACMA.
Making an Impact in Africa Nonprofit in L.A. County helps save lives in the heart of Africa
O
n J u ly 1 0 , representatives from the Los Angeles County Medical Association joined professional sports legends, entertainment celebrities, and Los Angeles’ top business, legal and medical professionals at Café Entourage in the heart of Hollywood for Impact Africa, an event benefitting The GEANCO Foundation. The GEANCO Foundation is dedicated to saving and improving lives in Africa. GEANCO leads medical missions to Nigeria and is currently developing a world-class hospital there. The Foundation has also organized African Health symposia in L.A. County. Through these symposia, GEANCO raises awareness of the health care challenges on the African continent. LACMA was a proud sponsor of Impact Africa, which was co-hosted by NFL legends Ronnie Lott and Warren Moon, ESPN television and radio host Marcellus Wiley, Arizona Cardinals’ star Calais Campbell and American Idol Finalist Syesha Mercado. Special guests included NFL Hall of Famer Willie Roaf, Shaun Robinson of Access Hollywood, Alex Ferrer of the Judge Alex show, actors Quinton Aaron (The Blind Side) and Jaleel White (Family Matters, Dancing with
the Stars), and comedian and movie/television star Cedric the Entertainer. “I live in L.A. and lead GEANCO’s efforts from this city, so it was especially heartwarming to see so many leaders and influencers in my adopted home affirm our mission,” said GEANCO’s Chief Operating Officer Afam Onyema. “We have so much urgent and important work to do, and we cannot hope to succeed unless more and more generous and broad-minded individuals in L.A. County rally to our cause.” GEANCO’s focus is Nigeria, Africa’s most populous country. Nigeria’s health care emergency is one of the worst in the world. The country’s health care system has been ranked fourth worst on the planet by the World Health Organization. Every ten minutes, at least one Nigerian woman dies in childbirth, and more pregnant women die there than anywhere else in the world except for India. Each year, approximately one million children under age 5 die in Nigeria, the majority from preventable and treatable causes. Again, more children perish in Nigeria than anywhere else except for India, which contains a billion more people. Infectious diseases like HIV/AIDS and malaria continue to ravage the country.
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Nigeria has the second largest HIV-infected population in the world and the largest number of AIDS orphans in Africa. Though malaria is easily preventable and treatable, 300,000 Nigerian children and 7,000 mothers die annually from the disease. Sixty million Nigerians experience a malaria attack at least twice in a year, and the nation’s economy loses an estimated $1.1 billion each year due to malaria-related absenteeism and treatment costs. Tragically, though malaria accounts for 63 percent of all reported diseases in Nigerian health facilities, less than 1 percent of the total population uses insecticide-treated bednets. The GEANCO Foundation seeks to bring health and hope to the sick heart of Africa. In 2005 and 2011, GEANCO led orthopedic missions to Nigeria during which incredibly rare joint replacements were performed. The Foundation has another orthopedic medical mission planned for the fall of 2013. GEANCO will also hold another special event in L.A. on October 27. For more information about the event, visit benefitnigeria.eventbrite.com. For more about The GEANCO Foundation, visit www.geanco.org or email Afam Onyema at aonyema@geanco.org.
n e ws & e ve n ts | associati o n happe n i n gs
2012 house of Delegates
Key resolutions adopted by your Association
T
h e M o s T D I r e C T way for members to get involved in current health care issues is to submit resolutions to the House of Delegates. As the California Medical Association’s legislative body, the HOD meets once a year to establish CMA policies on key issues that affect the practice of medicine, from medical ethics to critical matters of public health. With 450 delegates representing 11 geographic districts, 30 medical specialties, and all modes of practice, the delegates embody the diversity of California’s physicians. LACMA will be represented at this year’s HOD by approximately 40 physicians from across the county who are elected on an annual basis by the general membership.The delegation met this past July to review some 30 submitted resolutions. To ensure that our members’ top issues were best represented, they voted to support the following resolutions at this year’s House of Delegates on October 13 – 15 in Sacramento: • • • • • • • •
termination of physician listings on health plan rosters eliminating the fee schedule sharing clause between payers electronic prescribing and health record payment reductions abandoning the icD-10 Diagnosis coding system emergency Department full capacity protocols transparency / inappropriate incentives to pharmacy academic / counter Detailing standards opposing the expansion of retail health clinics
first vetted vendor Medical specialty law firm offers special benefits to members
W e a r e T h r I l l e D to introduce tredway, lumsdaine & Doyle, llp as the association’s first best in class Vendor. tredway, lumsdaine & Doyle, llp, a law firm that represents individuals and businesses in a full range of legal services, recently celebrated over 50 years of service to its clients and the community. tlD has a long history of working with physicians and medical practices and specializes in a variety of areas such as california and federal regulations, licensing, medicare and medi-cal issues, and formation of medical corporations. tlD represents small to mid-sized businesses and individuals in their business and corporate law issues, employment law, family law, health care law, civil litigation, personal injury, probate, estate planning, trust administration, real estate and taxation. tlD is pleased to offer members the “medical professional plan” as an exclusive benefit. this plan allows for unlimited consultations with tlD attorneys regarding any area of law under their service range. the consultations can be in person or by phone with the physician or a designated representative. in addition, members also receive a 15 percent discount off of the group’s regular legal fees. for more information, visit tlD at www.tldlaw.com or contact member services at 213-226-0313.
Once again, your Association is working hard to get key issues to the forefront of key decision makers at the state and national levels.
welcome to our new members! Please offer a warm welcome to our new members. Organized medicine is now five voices stronger thanks to them! Metropolitan District 1 said Mostafavi, MD
southwest District 9 arta lahiji, MD
sleep medicine
internal medicine
long Beach District 3 armen Choulakian, MD
allergy and immunology
Charles song, MD
neurosurgery
Beverly hills District 7 elayne Garber, MD rheumatology
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asso ciati o n happe n i n gs | n e ws & e ve n ts
september events 5 a Guide to reviewing Payor Contracts Free webinar for members and staff; $99 for nonmembers. Tips to maximize success in negotiating with a high-level review on contract terms and provisions. 1 CEU credit. 12:15 – 1:15 p.m. Contact: 800-7864262 or memberservice@cmanet.org.
19 Creating and Implementing Financial and office Policies Free webinar for members and staff; $99 for nonmembers. Creating written financial and office policies and procedures helps staff learn their jobs faster and relieves physician frustration. 1 CEU credit. 12:15 p.m. – 1:15 p.m. Contact: 800-786-4262 or memberservice@cmanet.org.
Pictured from left to right are David Lamont CEO of AICI, Mike Stephen Medical Director of St. Francis Medical Center, Commissioner Dave Jones, Dr. Thomas Horowitz and Dr. Daniel Higgins.
22-23 ethnic Physician leadership summit $25 for medical students;
Meeting with the Commissioner
$50 for physicians and members of a community-based organization; $150 for all others. This year’s theme is “How to Thrive, Not Just Survive.” Los Angeles. Contact: etrujillo@ thecmafoundation.org.
Members catch up with California Insurance Commissioner Jones o n T h u r s DaY n I G h T, August 16, a group of physician members met with California Insurance Commissioner Dave Jones at the home of Dr. Daniel Higgins. At the fundraiser, the group discussed health care reform, both in the past and future, issues surrounding the pilot dual eligibles Medi-Medi program, role of insurance commissioner with respect to health care reform, stop loss insurance, health plans and more.
building better partnerships New “best-in-class” designation brings more benefits to members T h e lo s a n G e l e s County Medical Association knows that the more members we have, the stronger our influence in the health care community will be. We feel the same way about our partnerships--the more qualified partners we have, the more we increase value to our members and the stronger our partners become due to their involvement with our members. After all, when LACMA ventures into a new partnership, we have one goal in mind: to offer the best services and products available to our ever-growing physician membership. LACMA is pleased to introduce its “bestin-class” designation for any vendor who meets the criteria outlined in our vendor
vetting process. Our goal is to build a solid list of vendors offering a wide array of practice management and administrative support services at preferred pricing to meet the demands and needs of our member physicians in managing seamless, time and money saving practice operations. The vendor list will be available in our new online marketplace when our new website at www.lacmanet.org launches this fall. Initial services to be rolled out include: • • • • •
equipment leasing equipment and practice financing n-office it services interpreter services purchasing or leasing furniture
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• revenue cycle management • automated online reputation managers/ social media assistance • staff recruitment, retention and training programs • ups discounts • Discounts on recreational activities-tickets, theme parks, etc. • career education resource • banking and financial services • medical waste disposal • legal assistance If you are interested in a specific service or would like to refer a vendor, please contact LACMA Member Services at 213-226-0313.
n e ws & e ve n ts | associati o n happe n i n gs
Brand new Website Coming soon
The new site will offer members tools to take action, get involved, and manger their practice T h e lo s a n G e l e s County Medical Association is on schedule to re-launch it’s website at www.lacmanet.org this October. New features will include members-only portals, physician community networks, office manager networks,
physician directories, and much more. LACMA will also launch its new online marketplace to showcase “best in class” vendors who are offering exclusive money-saving discounts on products and services geared towards efficient
practice management operations. Your Association’s goal is to create a stronger online presence to improve communications with doctors, patients and all health care constituents in Los Angeles County and throughout California.
easy reading on mobile devices or personal computers. sponsors make this professional service possible, and as sponsorship grows, so will the frequency and content of the pnn news bulletins. the bulletin links to a dedicated website at www.physiciansnewsnetwork.com.
to subscribe, simply go to the website and click on the advertisement for pnn to pop open a form where you can enter your email address. we are confident that you will value pnn as a companion to Southern California Physician magazine.
physicians’ news network Launches I n e a r lY J u lY, the los angeles county medical association launched the physicians’ news network, a new communications service to keep you updated on issues that impact you and your practice daily. lacma partnered with a professional news network to create pnn, which will deliver breaking local news, information, and data about the economics of health care delivery to physicians throughout los angeles county and beyond. the weekly email will contain news bulletins featuring los angeles county-based health care institutions, companies and non-profit organizations, industry suppliers, regulations, issues and best practices. pnn news bulletins are written and edited by professional health care journalists for the interests of los angeles county physicians and digitally designed and delivered for
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cL assi fi e Ds / Jo b boar D TO PLACE A CLASSIFIEDS AD, CONTACT DARI PEBDANI AT DPEBDANI@GMAIL .COM OR 858 -231-1231. 118
CONSULTING
MEDICAL SUITE AVAILABLE Inside Brookdale Medical Center. Good for specialist (Orthopedic, ENT, Cosmetic/Plastic surgery, etc.). Referrals available. Please contact jbarkodar@yahoo.com.
LANCASTER MODERN MEDICAL BUILDING Great for all multi-specialties. X-ray available. Location for Lease, Rent or Share. Plenty of free parking. Call 661-305-1539.
135
LEGAL SERVICES
TORRANCE MEDICAL OFFICE SPACE Newly renovated, available immediately 1226 sf for $1500. Three treatment rooms, fully equipped. EDA elevator, free guest parking. Also suitable for physical therapy, acupuncture, rejuvenation. Located near Little Company of Mary Hospital, Torrance Memorial Hospital. Available on full time/part time basis including weekends. Contact 310-325-4445. 240
205
OFFICE FOR LEASE/ SUBLEASE/SHARE
REDONDO BEACH ARTESIA CORRIDOR 144-2,382 sq. ft. Professional and medical offices, some views, near freeways, restaurants and shops. Parking + ADA elevator at 2512 Artesia Blvd. 310-5690384 Email: maryannejankovic@ hotmail.com or visit: http://pike. nsicorp.net. REDONDO BEACH RIVIERA VILLAGE 145 – 2,017 sq. ft. Some views, balconies, impressively near restaurants, shops and beach! Medical parking + ADA elevator, at 1611 S. Catalina Ave. 310-5690384 Email: maryannejankovic@ hotmail.com or visit us at www. plazariviera.nsicorp.net. LOS ANGELES OFFICE Office available to share in downtown LA. Reception, MD office, 3 exam rooms, with x-ray available. Across from California Medical Center. Contact: Steve Fleming 805-497-2801.
MEDICAL BUILDING FOR SALE/LEASE
GARDENA MEDICAL 7400 s.f. free standing medical building Western Ave frontage, corner lot, signage. Other medical spaces from 800-4200 s.f. (in Torrance, Gardena, Montebello, Hawthorne, Long Beach). Contact Tom Torabi 310-768-8800 or ttorabi@lee-associates.com.
520
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TRACY ZWEIG ASSOCIATES • Physicians • Nurse Practitioners • Physician Assistants LOCUM TENENS PERMANENT PLACEMENT 800-919-9141 • 805-641-9141 FAX: 805-641-9143 email: tzweig@tracyzweig.com www.tracyzweig.com
SEEKING BOARD CERTIFIED/ELIGIBLE FAMILY PRACTICE/ INTERNAL MEDICINE 27 years established Primary Care center in Hawthorne, California. Guaranteed base, bonus, benefits, buy in opportunity. Contact Dolly 310-200-5767 or doly2k@aol.com. TO PLACE A JOB BOARD AD
CONTACT DARI
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858-231-1231
MEDICAL OFFICES FOR LEASE Pacifica Medical Plaza, Huntington Beach, CA. Suite 106 – 814 sf; Suite 205 – 1,080 sf; Suite 102 – 1,351 sf; Suite 105 – 1,840 sf. For more info, contact: Todd LaPlante, CCIM; Five Points Commercial. 714-317-1090; todd@fivepointscommercial.com; DRE ID 01014322. ClassIFIeD aD
TesTIMonIal “advertising in southern California Physician magazine has had a positive impact on my Medical Professional focused practice. The readership is a great match with my client base and the services I provide.” Josh nyholt, cpa www.nyholtcpa.com
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521
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FAMILY PRACTICE Med. Group in LA County Looking for Full-Time/Part-Time NP or PA for Fam. Practice. HMO, CHDP, Fam. Pract. Exp. E-mail: miortiz@ahnmedical. com. Phone (323) 562-6182.
Jo b boar D / cm e / m ar ke t pL ace / aD i n D e X TO PLACE A CME LISTING, CONTACT DARI PEBDANI AT DPEBDANI@GMAIL .COM OR 858 -231-1231. 530
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FILM READING Carl H. Boatright, MD, DABR, 30 years’ experience, rapid turnaround. We are now accepting Teleradiographs for General X-ray and General Ultrasound examinations. 866-723-2081.
RADIOLOGIST Board certified. Have own malpractice insurance. Available for part-time position or film reading. Call 310-477-4257. 540 LOCUM TENENS AVAILABLE
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wayne gradman, mD
CMe 12TH ANNUAL CITY OF HOPE CONFERENCE ON WOMEN’S CANCERS October 25 to 27, 2012 Four Seasons Hotel Las Vegas, NV
REGISTER NOW for this exciting conference featuring prominent oncology experts who will address clinical and translational research, prevention, practical issues, current standards of care, controversies and evolving new treatment recommendations for women’s cancers. Attendees will learn new tools to optimize decision making to help improve patient outcomes. To learn more and to register, visit www.cityofhope.org/ womensconference2012
advertiser Index Athena Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 BBVA Compass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Cooperative of American Physicians . . . . . . . . . . . . . C3 Fenton Nelson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Los Angeles Center for Women’s Health . . . . . . . . . . . . 3 Los Angeles County Medical Association . . . . . . . . . . . 11 Los Angeles County Sheriff’s Department . . . . . . . . . . . 9
CoMInG soon! october: Ethnic health care: The issues facing providers in L.A. County.
Marsh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C2 NORCAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Telephone Connection . . . . . . . . . . . . . . . . . . . . . . . . . 23 The Doctors Company . . . . . . . . . . . . . . . . . . . . . . . . C4 UC Irvine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
SCP Marketplace
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#7 The 5-year survival rate for children with acute lymphocytic leukemia, which has increased greatly over time. (3)
9.3%
85%
4 minutes
Approximately how often one person in the United States is diagnosed with a blood cancer. (1)
Ranking of non-Hodgkin’s lymphoma in cancers in the United States. (2)
How many deaths are expected to be due to Leukemia, lymphoma and myeloma in 2011. (1)
10%
How much more often Leukemia is diagnosed in adults than in children. (2)
1,012,533 sources
How many people in the United States are estimated to be living with, or are in remission from, leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma or myeloma. (1)
1 The Leukemia & Lymphoma Society. 2 Leukemia Research Foundation. 3 American Cancer Society.
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How many leukemias among children and teens are acute lymphocytic leukemia. Most of the remaining cases are acute myelogenous leukemia. Chronic leukemias are rare in children. (3)
47,150
About how many people in the U.S. will be diagnosed with leukemia in 2012. Of those cases, about 19,830 will be acute leukemia, and about 21,490 will be chronic leukemia. (3)
3 out of 4
J ust t h e fac t s | L eu k e m ia & Lym ph om a
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800-252-7706 www.CAPphysicians.com San Diego orange LoS angeLeS PaLo aLTo SacramenTo
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2010, physicians faced over 9,000 alleged HIPAA violations. Make sure you’re prepared. In
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