January 2017 | San Mateo County Physician

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EDITOR

Sheri Carr 858.226.7647 | sheri@physiciansnewsnetwork.com DESIGN

Rob Davis 916.709.2007 | sherlockmedia@gmail.com ADVERTISING SALES

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JANUARY 2017 - VOLUME 6, ISSUE 1

www.PhysiciansNewsNetwork.com EDITORIAL COMMITTEE

Russ Granich, MD , Chair | Judy Chang, MD | Uli Chettipally, MD Sharon Clark, MD | Carri Allen Jones, MD | Gurpreet Padam, MD Sue U. Malone | Executive Director SMCMA LEADERSHIP

Russ Granich, MD | President Alexander Ding, MD | President-Elect Sara Whitehead, MD | Secretary- Treasurer Michael Norris, MD | Immediate Past President Janet Chaikind, MD Uli Chettipally, MD Mamatha Chivukula, MD Paul Jemelian, MD Alex Lakowsky, MD Richard Moore, MD Joshua Parker, MD Xiushui (Mike) Ren, MD Brian Tang, MD Dirk Baumann, MD | AMA Alternate Delgate Scott A. Morrow, MD | Health Officer, County of San Mateo www.SMCMA.org facebook.com/smcma | twitter.com/SMCMedAssoc.

On The Inside 2................President’s Letter | Russ Granich, MD The Symbol of Medicine

3................The Opioid Crisis in San Mateo County 4................County’s Only Hospice House Opens

6................New Healthcare Laws

EDITORIAL

San Mateo County Physician is published ten times per year by Physicians News Network (PNN) and the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of PNN or SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

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J A N UA RY 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 1

PRESIDENT’S MESSAGE

THE SYMBOL OF

MEDICINE

BY RUSS GRANICH, MD

I recently was at a talk given by a medical officer for the California Medical Association.

THE CADUCEUS Great presentation but on the slide with is the traditional her name she had symbol of Hermes. the wrong symbol It is often mistakenly of medicine: the used as a symbol of caduceus. What? you medicine, especially say. Of course this is in the United States. the proper symbol!

Hate to burst your bubble, but it is time for some education. The caduceus is a rod with wings and two snakes entwined around it. It is actually the symbol of the Greek god Hermes (Mercury was his Roman name). Who does Hermes represent? He is the guide for the dead and the protector of merchants and shepherds, but let’s not forget thieves, liars and gamblers. Nowhere does it say medicine or healing.

Somewhere around the seventh century, Hermes became associated with alchemy and, thus, medicine. Alchemists were often referred to as Hermetists. They developed a secret method of making a container airtight, what we still refer to as “hermetically sealed.” When you see the symbol in modern times, it often is associated with a commercial or military medical enterprise. Maybe it is an appropriate symbol for a government doctor?

The actual symbol is the Rod of Asclepius. Asclepius is a Greek demigod and son of Apollo. He was the god of healing and medicinal arts. He is PHOTO BY SCOTT BUSCHMAN often portrayed as a bearded man wearing a robe; his chest is bare and he is carrying a gnarled staff with a snake wrapped around it. Interestingly, Asclepius was taught his healing skills by a centaur (who knew centaurs had this knowledge?) and The actual became so adept that he could raise the dead. Zeus felt this threatened the immortal nature of gods symbol is and killed Asclepius with a thunderbolt (i.e., struck by lightning). There were temples built to him for the Rod of the purpose of healing. It was not uncommon to find snakes slithering about the floor. The snakes were appropriately named Aesculapian snakes and are fairly long and non-venomous. They are mainly Asclepius. found in Southern Europe and still retain that name. How the snake and staff came to be associated Asclepius with healing and how they became a combined symbol is not known but has existed for over 3,000 years. An ancient Greek philosopher, Cornutus, felt the snake renews itself after shedding its skin, just is a Greek as patients renew themselves by shedding off their disease. However, my favorite explanation of the demigod rod and snake is from ancient times when doctors would treat a specific parasite that basically was worm-like and would burrow under the skin (a and son of giant Loa loa perhaps?). The physician would Apollo make a small incision, and the worm, which THE ROD OF ASCLEPIUS represents Asclepius, obviously had the IQ of a worm, would just the god of healing. The pop its little head out, and the doctor would Asclepiadae were a large put a rod there. Naturally the worm would order of priest physicians continue to crawl, and the doctor would who controlled the sacred slowly twirl the rod, and voila!, you had a rod secrets of healing. with a serpentine creature curled around it!

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BY SUNIL BHOPALE, MD, FACEP CHIEF, EMERGENCY DEPARTMENT KAISER FOUNDATION HOSPITAL, REDWOOD CITY

in San Mateo County — The Time for Action Is Now! MY FIRST PATIENT recently was a 36-year-old man who walked into the Emergency Department, and he had had 10/10 low back pain for months. The patient had tried to contact his primary physician, but because his physician was out of town and the patient had needed more Percocet than usual for a recent flare, he had run out of medications.

When I checked the CURES database, I discovered that he had 80 prescriptions for controlled substances, including multiple prescriptions for Norco, Percocet and lorazepam from several different providers.

His exam was unremarkable, and despite his pain, he was pleasant. After I confirmed that he had no acute neurological deficit, I prepared myself for the challenge — how to address the patient’s concerns without giving him medications that were not indicated.

After discussing the lack of any worrisome findings, I informed him that I would not give him any opioids. I explained to him the risks of opioids, offered non-opioid alternatives, and listened to his plight (again). When I told him that the ED was not the place to obtain medication refills, he said that he had heard the same statement from other ED physicians. He ended up leaving with prescriptions for naproxen and baclofen.

This case illustrates how our approach to opioids has evolved over the past few decades. At the beginning of this millennium, physicians were told that pain was the “fifth vital sign” and that we undertreated pain. We were required to take mandatory CME on pain management, and thus the number of opioid prescriptions exploded. As of 2014, 1.5 times as many people have died from opioids when compared to car accidents. According to the Centers for Disease Control and Prevention (CDC), 78 patients die from opioid overdoses daily, although opioid overdose deaths are much less common in San Mateo County. Now that the “opioid epidemic” has even become a campaign issue, the time has come for us to confront this crisis.

We must remember that opioids not only are powerful and effective medications but also carry significant risks — delirium, dependence and even death. Few other drug classes have as high a mortality as opioids. As physicians, we are morally obliged to alleviate pain, but we must do so in keeping with three principles: safety, consistency and respect.

Safety comes with prescribing these medications for appropriate indications at appropriate dosages and frequency, along with regular reassessments. With consistent messaging, where a patient’s primary physician (or a specific specialist) is the only person prescribing these medications, we can start to address the challenges If you are interested in joining me on that come with getting medications from various sources — physicians, how we can address opioid management online or illegally. in San Mateo County, please contact me There is a tendency among us to label patients as “drug-seeking,” at sunil.bhopale@kp.org.

I am looking but these patients need our respect. The CDC and other organizations to develop local agreements regarding have proposed guidelines that can help us create a consistent plan on safe opioid prescribing.

Together we can how to treat these patients, and we can manage patient expectations provide the best care that our patients in a respectful manner so that patients are treated safely. Although deserve — all while making you practice the opioid crisis may have arisen from overprescribing of opioids, as medicine safely and responsibly. physicians, we must assume the mantle of responsibility to fix this problem. If not us, who will?

J A N UA RY 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 3

&

Mission Hospice

Home Care

Opens County’s Only Hospice House

BY STEPHEN WELLER, MD

IMPROVEMENTS IN MEDICAL CARE FOR CALIFORNIANS include a recent emphasis on physical and emotional support for patients with incurable medical conditions.

Palliative care, focused on relieving symptoms and stress, is increasingly used as a component of care to enhance the quality of life for these patients in our community.

In their last weeks of life, many hospice patients are cared for in the comfort of their own homes or in the homes of loved ones. Patients suffering with severe symptoms or emotional stress may require hospital admission or transfer to a skilled nursing facility — neither of which is specifically designed or staffed for intensive hospice care.

Mission Hospice & Home Care, a local and independent nonprofit hospice established in 1979, last year fulfilled a longstanding dream to open San Mateo County’s only inpatient hospice house. Mission House is a peaceful, homelike environment for patients in the final weeks of life who need intensive, round-the-clock symptom management that cannot be provided at home.

The 10-bedroom house also offers a safety net for patients whose caregivers need a few days of respite.

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Comprehensive physical and emotional support is provided by trained palliative care physicians, nurses, aides, social workers, spiritual and grief counselors, and volunteers. This full-time care allows loved ones to spend quality time with the patient while professional hospice staff attend to the patient’s physical needs.

As with all of our hospice care, the focus at Mission House is on family support and patient comfort. The hospice house is designed not only for patients but also for their family and friends, who are always welcome and encouraged to visit. It includes common areas and peaceful gardens for families to gather, as well as room for overnight guests.

In the past year, Mission House has become an integral part of the services offered by Mission Hospice & Home Care. We are honored to have already cared for

more than 100 people and their families — families like Maureen’s: “From the minute Mom was admitted to Mission House, I knew she was in capable, loving hands. Knowing that she was so well cared for allowed our family to be truly present with her in those final weeks — time we treasured. We are so grateful that Mission House was there for us. Thank you from the bottom of my heart.”

To fund the opening of Mission House, Mission Hospice & Home Care launched a $6 million fundraising campaign. Local leaders and community partners have already invested more than $4.3 million for needed renovations to the house and to help cover the cost of care for patients who are underinsured.

More information about Mission House is available online at www.missionhospice.org/services/missionhouse/. To arrange a tour, please call Dwight Wilson, CEO, at (650) 554-1000.

— Maureen, Belmont —

— Eddie —

— Barry —

At 95, Eddie was suffering from end-stage cancer and bouts of delirium. After his final hospitalization, it became too difficult for his wife, Jean, to care for him at home, and they could not afford round-the-clock caregivers.

Once Eddie was at Mission House, our professional staff monitored his medications carefully to be sure that he was safe, comfortable and present for his wife and family. They visited frequently; Jean often slept in a rollaway bed beside him.

On the couple’s 49th wedding anniversary, the Mission House team gathered with cake and cider. Eddie sang love songs to his wife, and the staff created a photograph album for Jean to keep. Weeks after his admission to Mission House, Eddie passed away, peacefully, his wife at his side.

A lifelong bachelor, Barry, 60, lived alone in Belmont. His older siblings cared for him until the symptoms of his end-stage cancer became too much for them to manage. Once he was admitted to Mission House, his family gathered at the house every day to be with their baby brother.

On St. Patrick’s Day, the family brought in corned beef and all the trimmings; the Mission House cook prepared the meal, which Barry and his family shared with staff and volunteers.

When Barry needed rest, he would send his family out of his room so he could sleep. They spent time together as a family in the living room, dining room, and garden of the house, knowing that Barry was in good hands.

After Barry’s death, his family expressed their enormous gratitude — not only for the compassion and care Barry received, but also for the welcoming, warm environment of the house, which allowed them to retain their sense of family.

J A N UA RY 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 5

2017

New Healthcare Laws

What They Mean for You, Your Practice & Your Patients

BY MARION WEBB PNN STAFF WRITER

T H I S Y E A R , A N U M B E R O F C A L I F O R N I A B I L L S will take effect that could have a significant impact on you, your practice and your patients. Below, we have listed the ones we think will warrant your attention and generate some discussion with other healthcare providers and with your patients.

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New Healthcare Laws

YOU

AB 1668 | Investigational Drugs, Biological Products and Devices

AB 38 | Mental Health: Early Diagnosis and Preventive Treatment Program

AB 1668 addresses the national “right to try” movement, which seeks to expand access to not-yet-approved treatments for people who fail to get into clinical trials. AB 1668 authorizes the manufacturer of an investigational drug, biological product, or device not yet approved by the U.S. Food and Drug Administration (FDA) to make the investigational product available to an eligible patient with a serious or immediately life-threatening disease or condition, as specified, when that patient has considered all other treatment options currently approved by the FDA, has been unable to participate in a relevant clinical trial, and for whom the investigational drug has been recommended by the patient’s primary physician and a consulting physician.

AB 38 establishes the Early Diagnosis and Preventive Treatment (EDAPT) Program Fund in the state Treasury to provide funding to the Regents of the University of California for the purpose of providing reimbursement to an EDAPT program using an integrated system of care for early intervention, assessment, diagnosis, treatment plan and necessary services for individuals with severe mental illness and children with emotional disturbances.

SB 1177 | Physician and Surgeon Health and Wellness Program This California Medical Association (CMA)-sponsored bill authorizes the Medical Board of California (MBC) to establish a Physician and Surgeon Health and Wellness Program for early identification and appropriate interventions to support a physician or surgeon in his or her rehabilitation from substance abuse. It requires the Board to contract for the program’s administration.

Program participants are required to pay for services, including expenses related to treatment, monitoring and laboratory tests, as provided. It creates an account to support the program and prohibits funds in the account from being used to cover costs of participation.

SB 1261 | Physicians and Surgeons: Residency Fee Exemption SB 1261 amends the Medical Practice Act that provides for the licensure and regulation of physicians and removes the requirement that a physician and surgeon reside in California in order to receive a license fee waiver when the license is for the sole purpose of providing voluntary and unpaid services.

AB 2024 | Critical Access Hospitals: Employment AB 2024 lifts a century-old ban on direct physician employment. It allows California’s smallest and most remote hospitals to directly employ physicians rather than hire them as independent contractors. AB 2024 will apply only to critical access hospitals, small hospitals with 25 or fewer beds that are typically located in remote areas of the state, and has been in effect since Jan. 1.

YOUR PRACTICE AB 1676 | Employers: Wage Discrimination Existing law prohibits an employer from paying an employee at wage rates less than the rates paid to employees of the opposite sex in the same establishment for equal work and establishes exceptions to the prohibition based on any bona fide factor other than sex. This bill specifies that prior salary cannot, by itself, justify any disparity in compensation under the bona fide exception to the above prohibition.

SB 482 | Controlled Substances: CURES Database SB 482 requires a prescriber to consult the Controlled Substance Utilization Review and Evaluation System (CURES) no earlier than 24 hours or the previous business day prior to prescribing a Schedule II, III and Schedule IV controlled substance to the patient for the first time and at least once every four months thereafter, if the substance remains part of the patient’s treatment. This bill would exempt a veterinarian and a pharmacist from this requirement. It would also exempt healthcare practitioners from this requirement under specified circumstances including if prescribing, ordering, administering or furnishing a controlled substance to a patient receiving hospice care, to a patient admitted to a specified facility for use while on facility premises, or to a patient as part of a treatment for a surgical procedure in a specified facility if the quantity of the controlled substance does not exceed a non-refillable fiveday supply of the controlled substance.

The measure seeks to crack down on a practice called “doctorshopping” in which addicts use multiple providers to obtain prescriptions for narcotic painkillers.

J A N UA RY 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 7

New Healthcare Laws

SB 482, sponsored by Sen. Ricardo Lara (D-Bell Gardens), seeks to prevent opioid overdose deaths, which, according to state officials, have increased by 200% since 2000. California is the first of 49 states that currently have prescription drug monitoring programs.

AB 72 | Healthcare Coverage: Out-of-network Coverage AB 72 requires a healthcare service plan contract or health insurance policy issued, amended or renewed on or after July 1, 2017, to provide that if an enrollee or insured receives covered services from a contracting health facility and covered services by a non-contracting health provider, the enrollee would be required to pay the non-contracting provider only the “in-network cost-sharing amount.” The bill would prohibit the insured from owing the non-contracting health provider anything more than the in-network cost-sharing amount.

The bill makes an exception from this prohibition if the insured provides written consent that satisfies specified criteria.

The bill would require a non-contracting health provider who collects more than the in-network cost-sharing amount from the insured to refund any overpayment to the enrollee or insured, as specified, and would provide that interest on any payment not refunded to the enrollee or insured accrue at 15% per annum, as specified.

Shortly after Gov. Jerry Brown signed the law in October 2016, the Association of American Physicians and Surgeons (AAPS) filed a lawsuit in the U.S. District Court requesting the court to block the new law.

According to court documents, the complaint by AAPS names the governor and the head of the state Department of Managed Health Care as defendants and states that the law violates the U.S. and California constitutions in at least three ways.

PNN reported the Act violates the Due Process Clauses of the U.S. and California constitutions by delegating rate-setting authority to private insurance companies with respect to physicians who are not under any contract with the insurance companies. It also says the Act is unconstitutional under the Due Process Clauses by requiring arbitration for the out-ofnetwork physicians for their reimbursements, thereby denying them their due process rights in court for their claims.

Furthermore, PNN reported, the Act violates the Takings Clause of both the U.S. and California constitutions because the Act empowers private insurance companies to deprive outof-network physicians of the market value of their services, and arbitrarily denies them just compensation for their labor.

The Act also reportedly violates the Equal Protection Clause of both the U.S. and California constitutions by having a disparate impact on minority patients for whom the availability of medical care will sharply decline as out-of-network physicians are coerced by the Act to withdraw services from predominantly minority communities.

Others see the Act as protecting patients and their well-being.

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AB 1671 | Confidential Communications: Disclosure Distributing secret recordings involving healthcare conversations will become a crime in California in 2017.

Introduced by Los Angeles Assemblyman Jimmy Gomez in the wake of an undercover Planned Parenthood investigation, AB 1671 makes it a crime for a person who unlawfully eavesdrops upon or records a confidential communication with a healthcare provider to intentionally disclose or distribute the contents of the confidential communication in any manner, in any forum, including on Internet websites and social media, or for any purpose without the consent of all parties to the confidential communication unless specified conditions are met.

AB 2828 | Personal Information: Privacy: Breach Data breach notification will now be required for instances when encrypted personal information of California residents has been breached and certain conditions are met, according to this newly amended law. Previously, California’s data breach notification law required organizations to notify individuals only if unencrypted personal information was reasonably believed to have been acquired by an unauthorized third party.

AB 2745 | Healing Arts: Licensing and Certification AB 2745 specifies that a physician or surgeon licensee who is otherwise eligible for a license but is unable to practice some aspects of medicine safely due to a disability is authorized to receive the limited license if specified described conditions are met, including payment of the appropriate fee. The bill clarifies the Medical Board of California’s authority to revoke, suspend or deny a license for licensees and applicants who are guilty of unprofessional conduct, expands the Board’s authority to request medical records of deceased patients, and authorizes specified disciplinary actions for licensed midwives, research psychoanalysts and certified polysomnographic technologists.

SB 1478 | Committee on Business, Professions and Economic Development. Healing Arts.

Existing law requires the Medical Board of California to keep a copy of a complaint it receives regarding the poor quality of care rendered by a licensee for 10 years from the date the board receives the complaint, as provided. This bill deletes that requirement. Existing law requires a CURES fee of $6 to be assessed annually, at the time of license renewal, on specified licensees to pay the reasonable costs associated with operating and maintaining CURES for the purpose of

SB 482 requires a prescriber to consult the Controlled Substance Utilization Review and Evaluation System (CURES) no earlier than 24 hours or the previous business day prior to prescribing a Schedule II, III and Schedule IV controlled substance to the patient for the first time and at least once every four months thereafter, if the substance remains part of the patient’s treatment.

regulating those licensees. This bill, beginning July 1, 2017, except as specified, exempts licensees issued a license placed in a retired or inactive status from the CURES fee requirement.

The bill also creates changes to statutes related to dentists, podiatrists, opticians, licensed marriage and family therapists, licensed professional clinical counselors and clinical social workers. It also deletes obsolete provisions, makes conforming changes and other non-substantive changes.

AB 2503 | Workers’ Compensation: Utilization Review AB 2503, backed by CMA, requires a physician providing treatment to an injured worker to send any requests for authorization for medical treatment, with supporting documentation, to the claims administrator for the employer, insurer or other entity, according to rules adopted by the Administrative Director of the Division of Workers’ Compensation.

SB 1175 | Workers’ Compensation: Requests for Payment.

SB 1175 requires that, for treatment provided on or after January 1, 2017, the medical provider must submit the request for payment within 12 months of the date of service or 12 months of the date of discharge for inpatient facility services.

The bill also requires that for medical-legal services or expenses, to submit the request for payment to the employer within 12 months of the date of service. Unless otherwise allowed, any request for payment and bills for medical-legal charges are barred unless timely submitted.

YOUR PATIENTS AB 1823 | California Cancer Clinical Trials Program

J A N UA RY 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 9

New Healthcare Laws

AB 1823 establishes the California Cancer Clinical Trials Program to increase access to cancer clinical trials for patients, especially women and under-represented communities. This makes the state the first in the country to legally recognize the financial burdens afflicting cancer patients seeking treatment in clinical trials.

The new law distinguishes between inducement and reimbursement. It recognizes ancillary costs as a barrier to clinical trial participation, encourages industry support of these costs, and identifies the allowable expenses that can be reimbursed to patients.

The California Cancer Clinical Trials Program will be administered by the University of California, which will raise funds and distribute privately funded grants aimed at reducing barriers to trial participation. The funds will be used to help connect patients with appropriate clinical trials and to cover expenses stemming from participation in those trials. It will authorize industry, public and private foundations, individuals and other stakeholders to donate to the program directed by UC, as well as to other nonprofit corporations and public charities that specialize in the enrollment, retention and increased participation of patients in cancer clinical trials.

“The California Cancer Clinical Trials Program will transform how we connect patients with cancer trials in California and engage with industry and businesses in the oncology field,” said Assemblywoman Susan Bonilla (D-Concord), the author of the bill. “Research and clinical trials are keys to treatment success, but just as important is the access and participation to those trials by a diverse population.”

8 Key Changes to the 2017 Medicare Fee Schedule In November, CMS released its final 2017 Medicare physician fee schedule aimed to improve Medicare payments for services provided by primary care doctors with a focus on chronic care management and behavioral health. Bakers Hospital Review published eight key changes that doctors need to be aware of.

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1. Data on post-operative visits: Starting July 1, 2017, doctors in practices with 10 or more physicians must report data on post-operative visits for high-volume/high-cost procedures.

2. Screening: Providers and suppliers must be screened and enrolled in Medicare to contract with a Medicare Advantage organization to provide items and services to those enrolled in Medicare Advantage health plans. This provision will start two years after publication of the final rule and will be effective on the first day of the plan year.

3. Telehealth services: Additional codes include those for end-stage renal disease-related dialysis, advanced care planning and critical care consultations. The critical care consultations provided via telehealth will use the new Medicare G-codes.

4. Improve data transparency: Medicare Advantage organizations use a bidding process to apply to participate in the Medicare Advantage program. The bids reflect the organization’s estimated costs to provide benefits to enrollees. Under the final rule, Medicare Advantage organizations are required to release data associated with these bids every year. CMS also requires Medicare Advantage organizations and Part D sponsors to release medical loss ratio data on a yearly basis to help beneficiaries make enrollment decisions.

5. Geographic practice cost indices: CMS adjusts payments under the physician fee schedule to reflect local differences in practice costs using geographic practice cost indices, which will also overhaul California’s outdated geographic payment localities. This reform will raise payment levels for 14 urban California counties classified as rural while holding the remaining rural counties permanently harmless from cuts (the hold harmless provisions will take place in 2018).

6. Expansion of Medicare Diabetes Prevention Program (MDPP): The MDPP expanded model seeks to help prevent onset of type 2 diabetes among Medicare beneficiaries diagnosed with pre-diabetes, CMS said. Payment for MDPP services will begin in 2018.

7. Billing codes: Among the changes are new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions.

8. Pay increase: Physician payment rates will increase by 0.24% in 2017 compared to 2016, accounting for a 0.5% increase required by the Medicare Access and CHIP Reauthorization Act and mandated budget neutrality cuts, according to the American Hospital Association.

For more information, visit the CMS.gov page at: https://goo.gl/D2xu7l

New Healthcare Laws

MACRA What You Need to Know

With the Centers for Medicare and Medicaid Services’ (CMS) finalized rule last year for the Medicare Access and CHIP Reauthorization Act (MACRA), the landmark payment system for Medicare physician fees, qualifying physicians need to become familiar with its new rules and initialisms and make important decisions.

MACRA, which replaces the sustainable growth formula, will pertain to healthcare providers who bill more than $30,000 a year for Medicare Part B services or provide care for at least 100 Medicare patients. For providers new to Medicare in 2017, participation is not required. Under the new rule, there will be some leniency for 2017 with “pick your pace options” to take part in the new MACRA Quality Payment program. The final rule includes two pathways for provider participation: the Merit-based Incentive Payment System, or MIPS, and the Advanced Alternative Payment Model, or APM. MIPS aims to align three currently independent programs — quality reporting (what physicians know now as PQRS), Advancing Care Information (now known as EHR Meaningful Use), and cost (now known as the value-based modifier) and adds a fourth component, Improvement Activities, aimed at promoting practice improvement and innovation.

APMs typically offer shared savings, flexible payment bundles and other desirable features. There are two APM participation classifications — Advanced APMs, which have their own reporting requirements and are exempt from MIPS reporting, and MIPS APMs. CMS reportedly signaled it plans to create additional pathways for participating in the APM track, including a new accountable care organization Track 1+ model, Comprehensive Care for Joint Replacement and the Medicare Diabetes Prevention Program. CMS plans to add these programs in 2017 or 2018.

CMS made adjustments to help small, independent practices participate. Besides the exemption for providers who fall below the $30,000 Medicare Part B charges or 100 Medicare patients to participate this year, CMS offers small practices and solo physicians the opportunity to join together in virtual groups and submit combined MIPS data.

Except for those qualifying for the low-volume threshold, physicians who don’t report any performance data in 2017 will be subject to a -4% payment adjustment when the new adjustments take effect in 2019. Those who provide partial or full reporting may be eligible for positive payment adjustments.

The final rule also allots $20 million a year for five years for training and educating physicians in practices of 15 or fewer and those who work in underserved areas.

For more information on MACRA, visit the American Medical Association page at:

https://goo.gl/CycoZt

J A N UA RY 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 11

SMCMA New Members

Daniel Holtzman, MD

Erick Ducut, MD

Jennie Lee, MD

Jimmy Kakkanad, MD

Kristine Girard, MD

Mariya Pelvitski, MD

Lada Alexeenko, MD

Meredith Brady, MD

Michael Tang, MD

Miguel Cazares, MD

Patracia Lee, MD

Rachel Berkowitz, MD

Seema Nair, MD

Sonia Chen, MD

(no photo)

Thaw Thiha, MD

Varun Saxena, MD

Veronica Li, MD

William Johnston, MD

Retirements: Michael Goldfield, MD James Rumack, MD Nell Stinson, MD Wilma Arguelles-Gaviola, MD Frederick Becker Jr., MD

Ross Dykstra, MD

Ivy Fisher, MD

Alan Marx, MD

Laura Prager, MD

Beverly Sarver, MD

Elliot Shubin, MD

Nina Schwartz, MD

Carol Tabak, MD

Sudhakar Tumuluri, MD

(no photo)

Rosalia Mendoza, MD

In Memoriam: August 1, 2016 July 1, 2016 August 5, 2016 August 1, 2016 April 4, 2016 June 29, 2016 February 12, 2016 June 30, 2016 November 30, 2016 December 31, 2016 November 1, 2016 September 16, 2016 August 1, 2016

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Edward Morhauser, MD Saburo Nagumo, MD Dwight Wesley Fitterer Jr., MD

October 16, 2016 September 15, 2016 July 13, 2016

Edward G. Morhauser, MD

Ed Morhauser, dedicated psychiatrist and dear friend, died on Oct. 16, 2016, surrounded by family. He had dedicated his long career to helping others in private practice in San Mateo. Born in Camden, N.J., he was a graduate of Villanova University and Temple Medical School. He came to California as a Navy doctor stationed at the Oakland Navy Hospital, and after serving at the Chelsea Naval Hospital and McLean Hospital, both in Boston, he returned to make the Bay Area his home. He was twice chairman of psychiatry at MillsPeninsula Hospital, a Distinguished Life Fellow of the American Psychiatric Association, a valued member of the editorial board of the San Mateo County Medical Association, a mentor and supervisor of psychiatric residents, and for a long time and until recently head of continuing education at Mills-Peninsula. In the community, he was an active volunteer, offering to talk at schools and organizations. He was also an avid sports fan. He had been scouted for pro baseball before he decided on a medical career, and he coached Little League as well as his granddaughter’s softball and soccer teams. He will be greatly missed.

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