November 2016 | San Mateo County Physician

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November/ December 2016

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S A N M AT E O C O U N T Y M E D I C A L A S S O C I AT I O N

Volume 5 Issue 10

Health Plan of San Mateo Raises Reimbursements

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EDITORIAL COMMITTEE

Russ Granich, MD , Chair | Judy Chang, MD | Uli Chettipally, MD Sharon Clark, MD | Carri Allen Jones, MD | Edward Morhauser, MD Gurpreet Padam, MD

November/December 2016 - Volume 5, Issue 10

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.

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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Columns Notes from the 2016 CMA House of Delegates

2

Russ Granich, MD

Feature Articles Health Plan of San Mateo 4 What’s Next on Your Career Path? 6

MACRA 10 Of Interest Staying Connected 12

© 2016 San Mateo County Medical Association

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President’s Message

Notes from the 2016 CMA House of Delegates

I strongly urge you all to consider joining us next year at the House of Delegates in Anaheim.

I’ve gone to the CMA House of Delegates (HOD) for several years and have to say it is one of the highlights of my professional year. I find it fascinating to see how the only organization that represents all the physicians in California works. It is the forum where you can speak and contribute to the process and influence the position the CMA takes on many issues. I have managed to get my opinion heard every year, I hope in an influential and elegant fashion!

The first time I attended, it was with wide eyes. I had no idea what to expect. The format was different at that time and there were multiple “hearings” in smaller rooms focusing on specific areas of health policy or Photo by Scott Buschman organizational matters. During a session I attended, a man walked into the room, shook hands, obviously important. He was wearing the latest style, way more fashionable than any doctor I ever met. Over the course of the weekend, he wore several suits, each one impeccably tailored and obviously high quality and expensive. Turns out he was Dustin Corcoran, the CEO of CMA. Dustin has been vital in the success of the CMA and its growth as a lobbying group. He is a dynamic speaker, and he named his daughter Dylan in honor of Bob Dylan. He rocks!

This year we tackled six major topics: MACRA, ACA Changes, Maintenance of Certification, Opioids, Physician Burnout and Five-year Public Health Plan.

MACRA is probably the biggest, and I suggest you go to www.cmanet.org/macra, which is filled with many tools to make the transition as smooth as possible. In

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addition, for each of the topics, we had one or two speakers to provide information about the issue, and we will actually get some CME credit.

There were other presentations, but most remarkable were some of the award recipients. It amazes me what some of these doctors have done and accomplished. It really illustrates what we can achieve when we put our minds and hearts into our profession.

Aside from some of these issues, there is one thing that really hit home and resonated with me. What CMA really represents are the values that we as physicians espouse: to help people, to promote good health, to prevent disease, to serve the community, and at the same time, to protect physicians. Recent examples that would not have happened without the CMA: Requiring pediatric vaccines and eliminating the exceptions; promoting efforts to decrease sugary beverages for children and joining the fight against childhood obesity; strongly advocating for Proposition 56 to combat smoking. I strongly suggest you go to the CMA website, in particular www.cmanet.org/issues-and-advocacy/cmas-top-issues/.

Also remember, 2014’s Proposition 46 (Medical Malpractice Lawsuits Cap and Drug Testing of Doctors) would not have been defeated without the CMA and the help of county medical societies throughout California.

I strongly urge you all to consider joining us next year at the House of Delegates in Anaheim. It is a great experience. The SMCMA will provide some financial support, and we do have some vacancies on our delegation.

What CMA really represents are the values that we as physicians espouse: to help people, to promote good health, to prevent disease, to serve the community, and at the same time, to protect physicians.

Russ Granich, MD President

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Health Plan of San Mateo Raises Specialty Care Reimbursements to 175% of Medi-Cal Rates

By Margaret Beed, MD, Chief Medical Officer for Health Plan of San Mateo (HPSM)

AS A TRAINED PEDIATRICIAN who has referred many patients to clinical specialists over the years, I have a special appreciation for the value that clinical specialists add to our members’ quality of care.

That’s why I’m pleased to announce that Health Plan of San Mateo (HPSM) recently raised our Medi-Cal reimbursements for certain specialties to 175% of the rates set by the state, which is roughly equivalent to what Medicare pays for similar levels of service.

This is part of our new incentive program aimed at attracting and retaining the highestquality specialty providers to HPSM’s network so that our members get the specific treatment they need to be healthy.

HPSM’s 145,000 members currently have access to over 2,300 specialty physicians.

However, with a dearth of specialty practitioners in some parts of HPSM’s geographic service area, this still leaves network gaps that must be filled. This makes accessing specialty care particularly challenging for some of our members. The rate increases will help retain critical specialty providers while spurring more specialists to work with HPSM, giving more of our members access to the high-quality care they deserve from specialty practices.

Driving the initiative is HPSM’s conviction that strengthening our partnership with current specialty providers works hand-inhand with expanding the reach of HPSM’s provider network to ensure optimal care for all members. With the rate increase, we

aim to reward existing providers for their ongoing contributions while attracting new high-quality specialists. We particularly hope that our network specialists who are already contracted with us for CareAdvantage but not Medi-Cal will join our Medi-Cal program.

A central component of the incentive program has been determining which clinical specialties HPSM’s members need most. The organization is looking to fill these coverage gaps and add more specialty designations as our members’ needs evolve. As such, we are enhancing our utilization data collection efforts to identify the kinds of specialty care our members need so we can strategically target the right providers for recruitment.

HPSM has added many providers to its specialty network during the four months since the higher rates have been in place. We invite all specialists in the community who are not part of HPSM’s network to join and benefit from the increased reimbursement rates. Going forward, HPSM will continue developing new payment methods to improve access and quality of care for our members.

To learn more about how to contract with HPSM’s network as a specialty provider, please call our Provider Services department at 650616-2106 or email psinquiries@hpsm.org.

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What’s next on your

By Marion Webb

A F T E R S P E N D I N G Y E A R S I N M E D I C A L S C H O O L and completing a residency program, and for some a fellowship program in a subspecialty, doctors face the challenge of managing their careers so that they reach their full potential. Some doctors are rethinking the traditional career path altogether, while others are looking for ways to combine medicine with a special interest.

In this November issue, we provide physicians with career development inspiration and with ideas and resources to help them make the most of their current position or explore new opportunities.

Career Dissatisfaction According to a recent Physicians Foundation survey of over 17,000 physicians nationwide, doctors continue to struggle to maintain morale, adapt to changing delivery and payment models and provide patients with reasonable access to care.

The “2016 Survey of America’s Physicians: Practice Patterns and Perspectives” reports that 80% of doctors report being overextended or at capacity, with no time to see more patients.

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The level of dissatisfaction is driving nearly half of physicians surveyed to rethink their current situation, with 48% of doctors, up 5% from 2014, planning to cut back on hours, retire, take a non-clinical job, switch to “concierge” medicine or take steps to limit patient access to their practices.

Resources for Exploring New Opportunities In the book “Do You Feel Like You Wasted All That Training?,” Michael J. McLaughlin, MD, tells of his journey of leaving his plastic surgery practice after four years at the age of 36 to enter the field of medical communications.

Dr. McLaughlin wrote that while the number of physicians working as consultants in non-clinical jobs continues to rise, with companies in the pharmaceutical, communications, insurance, legal, public health, investment, publishing and creative industries having a constant need for such expertise, most physicians aren’t aware that these non-clinical options even exist.

“There is a large unmet need for cross-pollination of ideas and ideas within the non-clinical area,” he wrote. In 2004, he founded Physician Renaissance Network, a resource for doctors with non-clinical jobs and interests to explore options.

For more information, visit prnresource.com.

In another book, titled “Physicians’ Pathways to NonTraditional Careers and Leadership Opportunities,” edited by Richard D. Urman, MD, and Jesse M. Ehrenfeld, MD, more than 30 physicians tell of their careers and opportunities in areas other than traditional clinical medicine.

In the Foreword, Karen Antman, MD, provost of the Boston University Medical Campus and dean of the School of Medicine, said that the experiences of these physicians “considerably broaden career options and leadership opportunities for physicians and provide a wider framework for physicians to take leadership roles in health policy and delivery.”

In the book “Physicians in Transition: Doctors Who Successfully Reinvented Themselves,” by Richard F. Fernandez, MD, Michelle Mudge-Riley, DO, writes in that book’s Foreword that readers will be introduced to doctors who felt “lost, trapped, exhausted, sick, guilty, and frightened,” and though they may not have understood these feelings or what caused them, they faced the problem head on to overcome them.

“Most of these doctors don’t feel like they have done anything extraordinary or that they have now found their ‘perfect job,’ but each has demonstrated the courage to take the first step towards personal and professional satisfaction and fulfillment,” the author wrote.

One doctor, however, said that while Google may offer literally thousands of potential answers to alternative careers for physicians, finding one’s true passion is more of a matter of soul-searching rather than Internet surfing.

In her blog post, Evgenia Galinskaya, MD, a physician turned physician career consultant, offered these five reasons for why lists of alternative careers are actually not helpful.

1. One size doesn’t fit all, and trying to force a fit that may work for others doesn’t mean it’ll work for you.

2. Doctors may overlook what they are truly passionate about in their career choices. She cited as examples Harry Hill, Graham Chapman and other physicians who became actors.

3. Lists can be demotivating when nothing jumps out.

4. Choosing another career just to get away from medicine can have damaging effects on one’s mental and physical health if it isn’t the right career.

5. Trusting others isn’t always the answer to what works best for you.

Dr. Galinskaya finds that the real answer takes contemplation and careful evaluation, starting with self-discovery and selfassessment, exploring options and opportunities, and then narrowing down the options and implementing a plan to get there.

New Skills For doctors who are passionate about their career but feel that they lack expertise in running a successful practice, gaining new skills and certifications may be the best prescription.

Ortega said that medical school prepares doctors for becoming great practitioners but many physicians lack the business skills they need to successfully run their own practices or a group practice.

“You can be a great physician, but if you don’t manage your office effectively, you can’t make money,” Ortega said. “Even if you hire a third party to manage your office, you should have a general understanding of what to do.”

An office manager certification course, which typically runs six to eight weeks, can provide a general understanding of billing codes, managing employees, and other key skills doctors need to run a small business.

Taking courses in small business, advertising, guerrilla marketing and social media are all critical to running a successful business.

“Learning how to use the Internet and position yourself online through marketing is really key,” Ortega said. Today’s tech-savvy consumers, especially younger people with families, will turn to the Internet to find a physician of their choice.

Doctors who aren’t listed by name only but provide information about their educational background and overall philosophy and have earned positive reviews from happy patients are more competitive in the marketplace.

Online Education/ Resources Christian Fox, MD, professor of clinical emergency medicine at the University of California, Irvine, School of Medicine and a frequent speaker at medical conferences, N OV E M B ER / D E C E M B ER 2016 | S A N M AT E O C O U N T Y P H Y S I C I A N 7

feels that the Internet is the wave of the future for continuing education.

Traditionally, doctors attended medical conferences to earn their continuing medical education (CME) credits, but the Internet has gained significant market share. “We are seeing less attendance at conferences because everyone is turning to the Internet for continuing formal education,” Dr. Fox said.

The American Medical Association (AMA) also has developed several online tools to help physicians prepare for transitioning to pending Medicare payment and delivery changes under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The online MACRA tool (apps.ama-assn.org/pme/#/ education/value-based-care) is an interactive tool that offers initial assessments to physicians to determine how their practices will be impacted by MACRA. AMA President Andrew Gurman, MD, said the tool will give physicians and their staff a brief assessment and relevant educational and actionable resources. “Once physicians and medical practice administrators fill out the online questionnaire, they will receive guidance for participating in the MACRA payment model that is best for them,” he said during a conference call with healthcare industry experts on Oct. 5. He added that the tool is free. AMA plans to continually update the payment model evaluator tool to respond to regulatory changes and to keep practices up-todate throughout the new payment and care delivery reform process.

In addition, AMA launched a ReachMD podcast series titled “Inside Medicare’s New Payment System” (reachmd. com/programs/inside-medicares-new-payment-system/) featuring Andy Slavitt, CMS acting administrator, Gurman, AMA staff experts and others to help physicians be informed on upcoming Medicare changes.

Professional Degree/ Certification Courses Leah Vriesman, a professor and director of executive education programs in health policy and management at University of California, Los Angeles (UCLA), agreed with Dr. Fox, however, that some learning is still more beneficial in a classroom setting.

Professional students, including doctors, who pursue a master’s degree in public health, or MPH, at UCLA learn in a classroom setting for several reasons.

“We put an emphasis on management and policy,” Vriesman said. “You can’t do that if you’re not a good communicator and don’t build a network.”

UCLA’s 21-month-long program is geared toward the working professional, including doctors (about 25%), policymakers and lawyers. The curriculum consists of a 8 S A N M AT E O C O U N T Y P H Y S I C I A N | N OV E M B ER / D E C E M B ER 2016

three-term sequence of academic coursework, followed by a summer fieldwork placement of at least 10 weeks, and a final three terms of further academic coursework.

Classes cover topics such as biostatistics, finance, ethics and law. Vriesman said the program offers doctors a path for career advancement, ranging in classes for those requiring business skills and the regulatory know-how to start their own practice to others wanting to position themselves for leadership roles.

The contacts made within the cohorts often lead to job opportunities before students graduate, she noted.

For doctors who want to change healthcare for the better and become physician leaders, Mark Hertling, a retired three-star U.S. Army general and former tank commander, developed what some would consider a battle plan to help doctors grow as leaders.

Hertling had no experience in healthcare management until his retirement from the military in 2013 when he was hired as senior vice president at Florida Hospital in Orlando to develop better leadership skills among physicians at the hospital.

In his book “Growing Physician Leaders: Empowering Doctors to Improve Our Healthcare,” Hertling outlined how in 2014 he instituted a physician leadership development course applying military principles to the medical practice, according to a report published by Medpage Today.

His course, eight five-hour sessions, is now in its third year and as of the end of October has graduated 250 students in classes of 50 persons each. Many of the graduates have been placed in formal and informal leadership positions.

One of the course assignments focused on asking a subordinate, a peer and a supervisor about what made it challenging for each of them to deal with a doctor and to give suggestions for improvements, Medpage Today reported.

After three years, the answers were typically the same, including the doctor not delegating enough and the doctor feeling that he or she is smarter than others and never taking advice. The answers should be enlightening, Hertling was quoted as saying, because “by seeing ourselves, we could correct ourselves. The problem with healthcare today is that it doesn’t see itself for what it is doing.”

The reality today is that of 6,500 hospitals in the United States, only about 250 are run by doctors, he noted.

Continuing Medical Education For every newly minted doctor, simply getting to see more patients at the bedside is key to becoming an accurate physician, which takes time, Dr. Fox noted.

Doctors also need to focus on their CME training, which differs in every state.

In California, all general internists and family physicians who have a patient population of which more than 25% are 65 years of age or older must complete at least 20% of all mandatory continuing education hours in geriatric medicine or the care of older patients, according to the California Medical Board website. All physicians and doctors also must complete 12 credit hours in pain management, according to the report.

CME training is increasingly moving to mobile devices and smartphones.

According to a study that surveyed 971 physicians across a variety of specialties — conducted by ON24, a virtual communication vendor with headquarters in San Francisco, and MedDataGroup, an interactive content and database marketing services company in Topsfield, Mass. — 84% of the doctors surveyed currently prefer attending CME events online.

The AMA offers CME courses online arranged by topic or format and Webinars at www.ama-assn.org/ama/pub/ education-careers/continuing-medical-education.page.

Medical schools, including the University of California, Irvine, and UCLA, also offer CME coursework. UCLA’s Office of Continuing Medical Education (www.cma.ucla. edu) lists about 60 courses each year.

Social Networks and Apps Doctors are now turning increasingly to their iPads and smartphones to stay up-to-date with clinical work.

“Every specialty has their own website,” Dr. Fox said. “As an emergency room physician, I turn to www.uptodate.com and www.pubmed.com to find answers.”

Sermo (www.sermo.com) is a website that offers physicians a way to network with “highly intellectual people and a live community of doctors.” It also allows doctors to explore job opportunities, share clinical information, do case studies, and earn honoraria while having their voices heard, according to published reports.

The site is exclusive to doctors and also allows doctors to interact with drug experts, participate in forums with members of Congress and get involved in numerous other ways.

Ozmosis.org is another network for “verified U.S. physicians” only and similar to Sermo, though less established.

Dr. Fox said he’s a fan of www.sonosim.com, an online ultrasound training program he feels is remarkably lifelike.

“That kind of technology can cut down on hours one needs to spend in the classroom,” he noted.

As someone who spends a lot of time with medical students and residents, Dr. Fox observed that younger

students are attached to their iPads and embrace digital technology, including apps.

“I’m the first to admit that we have a textbook shelf in the ER that hasn’t been used in two years,” Dr. Fox noted.

One of the reasons is that several textbooks are now readily available as apps.

Apps can provide doctors with instant up-to-date information on therapies and other clinical data, which, in turn, allows doctors to make treatment decisions much quicker than ever before.

Another popular app is PubMed on Tap, an application for the iPhone, iPod Touch and iPad, which lets doctors search for PubMed and PubMed Central while on the go.

For drug information on the go, Dr. Fox recommended Micromedex and Epocrates Rx, which can be downloaded on Android phones for free.

Mentors The human connection, however, is critical for career advancement, and mentors can provide the help doctors need at the very early stages of career development and networking.

Dr. Fox said for medical students who want to do well on their exams, reaching out to their professors is key to gaining knowledge and expertise.

In addition, “It really can advance their career with letters of recommendations, providing a reference and opportunities to conduct research and publish papers,” Dr. Fox said.

Attitude A positive attitude may not be at the top of the list for future success, but Dr. Fox feels it’s a character trait that all revered doctors seem to have in common.

“When I look around the hospital and look at people, I admire those with a consistent reputation,” he said.

“Everyone trusts them, loves them; they are reasonable and honest and upbeat people who have a positive and can-do attitude.”

Organizations Finally, to advance in their careers, doctors need to shake a lot of hands said Fox. Joining organizations like SMCMA opens the door to meetings, educational events, social events and networking with top doctors in their respective fields.

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MACRA AFTER MONTHS OF CONCERN AND ANXIETY from the medical community, the Centers for Medicare and Medicaid Services (CMS) released the highly anticipated final rule for implementing the Medicare Access and CHIP Reauthorization Act (MACRA) last month.

The final rule includes more flexibility for rural and smaller practices to ease into the reporting systems with reduced requirements. Nearly a third of Medicare physicians could be exempt from Medicare’s new Merit-based Incentive Payment System (MIPS) due to changes made to the final rule.

The Pick Your Pace options for physicians to participate at their own pace, as previously covered by PNN, are still available to allow for an easier transition, particularly for smaller practices. In addition, CMS raised the low-volume threshold so that providers with less than $30,000 in Medicare payments or fewer than 100 Medicare patients are exempt from the MIPS

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reporting requirements. The earlier proposed rule exempted only physicians with less than $10,000 in Medicare payments.

The new CMS rule states, “Protection of small, independent practices is an important thematic objective for this final rule with comment. For 2017, many small practices will be excluded from new requirements due to the low-volume threshold, which has been set at less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients, representing 32.5 percent of pre-exclusion Medicare clinicians but only 5 percent of Medicare Part B spending.”

“Physicians, particularly small and rural practices, need flexible and streamlined systems to support the high-quality patient care we provide,” said California Medical Association (CMA) President Steve Larson, MD, MPH, in a statement. “From day one, CMA urged CMS to delay the MACRA reporting period and provide a longer transition timeline for small medical practices and exempt them from penalties. We applaud today’s announcement, and we appreciate that CMS will offer full participation and bonus payment eligibility to medical practices ready for MACRA on January 1, 2017.”

CMS is also offering additional support through technical assistance for practices with less IT resources to support required reporting.

“In keeping with the objectives of providing education about the program and maximizing participation, and as mandated by the MACRA, $100 million in technical assistance will be available to MIPS eligible clinicians in small practices, rural areas, and practices located in geographic health professional shortage areas (HPSAs), including IHS, tribal, and urban Indian clinics, through contracts with quality improvement organizations, regional health collaboratives, and others to offer guidance and assistance to MIPS eligible clinicians in practices of 15 or fewer MIPS eligible clinicians,” the MACRA rule states.

CMS representatives expect 25% of physicians to participate in advanced Alternative Payment Models (APMs) in 2018, an alternative payment model to MIPS. “We know that this law and regulation need to evolve,” said CMS Acting Administrator Andy Slavitt on a conference call with reporters the day the final rule was released. “We keep listening.”

The final rule is nearly 2,400 pages – the result of a CMS listening tour with nearly 100,000 attendees and 4,000 public comments.

“CMA is reviewing and assessing the impact of the complex rule,” said Dr. Larson. “We remain committed to ensuring that MACRA allows more innovative, physician-led alternative payment models and lessens the reporting burdens on everyone.”

Other key highlights of the final rule: • Restores the 0.5% payment update for 2017.

• Reduces by half the number of measures that physicians must report, from 30 to 15.

• Lets physicians pick their pace of participation and will not penalize physicians who at least attempt to report on a few measures.

• Only requires physicians to report for 90 days in 2017 to receive a bonus.

• Mostly eliminates the pass/ fail system and will provide proportional credit.

• Expands the types of alternative payment models (APMs) that can participate in MACRA, most notably Track 1 accountable care organizations. The final rule also reduces the financial risk requirements for APMs.

STAYING CONNECTED

New Stethoscope Wirelessly Captures Heart, Lung Sounds and Sends Them to EHR

A NEW STETHOSCOPE has been developed that, along with a mobile app, allows physicians to wirelessly capture heart and lung sounds that can be uploaded to a patient’s electronic health record (EHR).

The system, developed by Eko Devices Inc., works in conjunction with the drchrono EHR platform and has been tested by Direct Urgent Care, which treats about 30,000 patients through walk-in clinics in Northern California.

but it is the first to have a HIPAA-compliant smartphone app and direct integration into the EHR. Robert Harrington, MD, a cardiologist and chairman of the department of medicine at Stanford, told the New York

An audio recording of the heart and lungs in a patient’s

Times that the Eko has “the potential to improve a physician’s

EHR makes sharing information between physicians at another

diagnostic acumen” by enabling a doctor to hear and see

location or in a particular specialty much easier. For example,

the pattern of a patient’s heart rhythm in greater detail. He

this flexibility makes it possible for patients with chronic or

also sees a benefit in the ability to store the heart sounds in

complex heart and lung conditions living in rural areas to get a

a patient’s electronic record so doctors can compare sounds

second opinion from a specialist without having to travel long

from a recent visit with ones from a year or two earlier.

distances, according to Eko Chief Operating Officer Jason Bellet.

Dr. Harrington plans to use the Eko technology as a

“If we can bring the expert cardiologists from Johns Hopkins

teaching tool at the Stanford medical center with the next crop

to the patient in rural Nebraska or the rural village in India,

of physician residents, making use of the digital recording and

that opens up the opportunity to save lives,” said Bellet in an

wireless sharing capabilities. “They can hear while I listen and

interview with the Washington Post. “What we’re seeing with

describe different heart sounds,” he explained.

the age of telemedicine is now we can take a heart sound from

Eko offers a $199 attachment for analog stethoscopes for

a rural, underserved community and send that to a cardiologist

physicians hesitant to give up their existing stethoscope, as

for an instant second opinion.”

well as a $299 version that filters out ambient noise to help

Eko’s is not the only electronic stethoscope on the market,

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healthcare providers focus on the sound of the heart.

STAYING CONNECTED

What Happens

to Breached Health Data?

Cybersecurity has become one of the most daunting problems facing the healthcare industry, and the number of attacks is on the rise, as previously reported by PNN. With all the information available on the deep web market, a new report from the Institute for Critical Infrastructure Technology (ICIT) titled “Your Life, Repackaged and Resold: The Deep Web Exploitation of Health Sector Breach Victims” provides insight into what happens with all that stolen data and just how much a single medical record is worth.

Some speculate that the reason attacks are on the rise is because the value of medical records in the market is on the decline. One could sell for $75 to $100 last year, but the same kind of record would sell for only $20 to $50 today.

“The price is down,” said James Scott, senior fellow at ICIT, in an interview with Health IT News, “which means the volume of availability is exceeding demand.”

According to the study, after medical records are stolen, the information is held onto for days, weeks, months or even years, to eventually resurface and be sold. The more complete a record, the more valuable on the deep web market. Hackers can sell small bits of information at a time or create a full-ID known as a “fullz,” or identity kit. These records contain everything from the EHR as well as utility bills or insurance information, which will increase their market value.

“So, it will look like basic short-form ID theft material, but eventually the electronic health record will surface as a ‘fullz,’ the slang term on the deep web for a complete long-form document that contains all of the intricacies of a person’s health history, preferred pharmacy, literally everything,” the report states. “What happens is the

people who purchase fullz then go to another vendor on the deep web for what’s called ‘dox,’ the slang term for documentation, where they then proceed to have passports, driver’s licenses, Social Security cards, all these things that will help the counterfeit imitation of the victim.

So you have electronic health records that will typically go for $20 apiece, and you’ll spend a couple hundred dollars on ‘doxs’ to support that identity, and once it’s an identity kit, you can sell it for $1,500 to $2,000.”

The data of children and the elderly is the most desirable. According to the report, “Criminals aggressively pursue children’s health records because the data has a long lifetime and because the compromise may go unnoticed for years.”

This is supported in a separate study by Carnegie Mellon University in which researchers found that 10% of 40,000 children have had their Social Security number used by someone else at a rate 51 times higher than the rate for adults.

Scott recently was part of a panel that briefed the U.S. Senate on cyber threats and concluded that organizations must begin the effort to organize resources to quickly detect and resolve breaches. Security leaders need to take stock of where their program is and formulate next steps based on a realistic assessment of the largest unmanaged threats they currently face. If a hospital has just hired a chief information security officer, its next best step will be different from one that has a large privacy and compliance team and fully formed breach response plans.

N OV E M B ER / D E C E M B ER 2016 | S A N M AT E O C O U N T Y P H Y S I C I A N 1 3

STAYING CONNECTED

Innovative

Primary Care Service: Hybrid of Virtual, In-person Healthcare

The development of a new primary care service called Carbon Health provides two options for improving the patient experience: a web platform and app that provides telemedicine, appointment scheduling, prescription refills and more, and an actual brick and mortar private primary care office in San Francisco.

“As crazy as it may sound, we are building a healthcare

a real physician will recommend a course of treatment,

system from scratch,” said Eren Bali, cofounder of Carbon

which may include coming into Carbon Health’s clinic in

Health, at the TechCrunch Disrupt event held in San

San Francisco.

Francisco in September. “The important thing is, since

“We’ve built a seamless hybrid of virtual and in-person

you control your experience all the way from physician

care, so that when you get to the clinic, the doctor has all

application to patient application to the integration with

of the information from your virtual visit, and similarly,

third parties, we are able to design an experience that would

when you leave the clinic, you can choose to do follow-ups

be impossible for the traditional healthcare providers.”

virtually if you wish,” said Carbon Health co-founder and

Currently several major insurance plans, including

CTO Tom Berry in an interview with Mobile Health News.

UnitedHealthcare, Humana, BlueCross Blue Shield and

The clinic is considered a pilot project for Carbon Health.

Aetna, are covering Carbon Health physicians. Members

If all goes well and the network expands, they plan to open

can use the Carbon Health app to scan their insurance card,

more clinics in San Francisco and beyond. The overall

build a profile and choose a doctor.

goal is to support doctors to take on private practices to

If a patient is sick, the app will take them through an automated set of questions for the physician to review, then

1 4 S A N M AT E O C O U N T Y P H Y S I C I A N | N OV E M B ER / D E C E M B ER 2016

accommodate patients through the app and in new clinics.

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Comprehensive Ophthalmology practice with emphasis on cataract surgery and glaucoma, and an optical dispensary.

2015 revenue $1.2 million, up 6% over 2014, on 3.5 seller MD days/week. Staff includes two part-time Optometrists, a dispensing optician and loyal supporting staff. Two local surgery centers nearby. Independent appraisal available.

Photos available. Offered at only $428,000.

Revenue $1.3 million on 4 MD days/week. Five exam rooms in 2500 square feet in beautiful building close to hospital, freeway, and mass transit. Great potential for growth and expansion. Owner willing to stay PT and mentor new owner in full range of non-surgical treatment techniques. Wide referral base of physicians and satisfied patients. Third-party appraisal available. Offered at only $290,000.

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Success.

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