PAST PRESENT&FUTURE OF THE SCHOLARSHIP LOAN FUND
PLUS: House of Delegates 2013 Legislative Wrap Up and 2014 New Health Law Highlights Winter 2013
at your dental plan It’s Open Enrollment time for the San Joaquin Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). During Open Enrollment only, members may join as an individual or as a group with your employees. Low, calendar year deductible of $50 per person ($100 per calendar year maximum for families). Pay no deductible on oral exams, x-rays and routine cleanings.
Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on January 1, 2014. Call a Client Service Representative at 800-842-3761 for more information. Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.
Sponsored by:
Underwritten by:
Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage.
63151 (12/13) ©Seabury & Smith, Inc. 2013
AR Ins. Lic. #245544 • CA Ins. Lic. #0633005 d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance@marsh.com • www.CountyCMAMemberInsurance.com
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VOLUME 61, NUMBER 4 • DECEMBER 2013
HOD 2013 Anaheim California
{FEATURES}
12 20 34 52
{DEPARTMENTS} 26 MICRA
HOUSE OF DELEGATES Anaheim CA 2013
NEW HEALTH LAWS 2014 Highlights
PAST, PRESENT AND FUTURE of the Scholarship Loan Fund
LEGISLATIVE WRAP UP
CMA’s 2013 Legislative Wrap Up
Trial Lawyers’ Money Grab Threatens to Overturn MICRA
28 IN THE NEWS
New Faces and Announcements
44 COVERED CALIFORNIA 48 PUBLIC HEALTH 63 TEACHING ORTHOPEADIC SURGERY In Bhutan
67 NEW MEMBERS 69 IN MEMORIAM Cover Photo by Dale Goff
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PRESIDENT Thomas McKenzie, MD PRESIDENT-ELECT Ramin Manshadi, MD PAST-PRESIDENT Raissa Hill, DO SECRETARY-TREASURER James J. Scillian, MD BOARD MEMBERS Lawrence R. Frank, MD, Moses Elam, MD, Peter Drummond, DO, Dan Vongtama, MD, Karen Furst, MD, Kwabena Adubofour, MD, Kristin M. Bennett, MD, Clyde Wong, MD, George Savage, MD, Parvinderjit Kaur, MD
MEDICAL SOCIETY STAFF EXECUTIVE DIRECTOR Lisa Richmond COMMUNITY PROJECT MANAGER Vanessa Armendariz MEMBERSHIP COORDINATOR Jessica Peluso
SAN JOAQUIN PHYSICIAN MAGAZINE EDITOR Lisa Richmond EDITORIAL COMMITTEE Thomas McKenzie, MD Lisa Richmond, Mike Steenburgh Vanessa Armendariz
COMMITTEE CHAIRPERSONS MRAC F. Karl , Gregorius, MD DECISION MEDICINE Kwabena Adubofour, MD ETHICS & PATIENT RELATIONS to be appointed
MANAGING EDITOR Mike Steenburgh CREATIVE DIRECTOR Sherry Roberts CONTRIBUTING WRITERS Vanessa Armendariz, James Noonan, Dr. Peter Salamon
LEGISLATIVE Jasbir Gill, MD COMMUNITY RELATIONS Joseph Serra, MD PUBLIC HEALTH Karen Furst, MD
THE SAN JOAQUIN PHYSICIAN MAGAZINE is produced by the San Joaquin Medical Society
SCHOLARSHIP LOAN FUND Janwyn Funamura, M.D. NORCAP COUNCIL Thomas McKenzie, MD
SUGGESTIONS, story ideas or completed stories written by current San Joaquin Medical Society
CMA HOUSE OF DELEGATES REPRESENTATIVES Robin Wong, MD, Lawrence R. Frank, MD,
members are welcome and will be reviewed by the Editorial Committee.
James R. Halderman, MD, Patricia Hatton, MD, James J. Scillian, MD, Peter Oliver, MD, Roland Hart, MD
PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO:
Kwabena Adubofour, MD,
San Joaquin Physician Magazine
Gabriel K. Tanson, MD, Ramin Manshadi, MD
3031 W. March Lane, Suite 222W Stockton, CA 95219 Phone: 209-952-5299 Fax: 209-952-5298 Email Address: lisa@sjcms.org MEDICAL SOCIETY OFFICE HOURS: Monday through Friday 9:00 AM to 5:00 PM Closed for Lunch between 12pm-1pm
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Get More Support
Craig Bobson, M.D. Hill Physicians provider since 2004. Uses Ascender preventive care reminders, RelayHealth online communication tools, Hill inSite to review eClaims and eligibility and Hill EHR for a comprehensive solution to patient care, practice management and ePrescribing.
Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large, well-integrated network of providers. Hill’s advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations. Get more for your practice and your patients by affiliating with Hill Physicians Medical Group. Get more information at www.HillPhysicians.com/Providers or contact: Bay Area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com
Hill Physicians’ 3,800 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt in.
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Letter From The Executive Director
STAFF REPORT
COMMITED TO HELPING
F
or more than 130 years, SJMS has been at the forefront of current medicine, ensuring that its members are represented in the areas of public policy, government relations and community relations. One of our many programs is the Scholarship Loan Fund, which provides interest free loans to young medical and nursing students. Today the loan fund is led by a 9 member board consisting of three SJMS physician members and six community at large members. Two of those dedicated Board Members, Dr. Eric Chapa and Royce Northcott, are featured on this issue’s beautiful cover. Through the guidance of our Chair, Dr. Janwyn Funamura the Scholarship Loan Fund Board is making positive changes! I invite you to read our feature article for all of the exciting details!
LISA RICHMOND
Covered California is here and bringing a flurry of a questions and concerns. The impact on physician practices will vary greatly depending on the mix of patients in your practice and the extent to which you contract with Covered California Plans. Millions of previously uninsured Californians will now be eligible for health insurance through Covered California and Medi-Cal. SJMS and CMA are committed to helping you navigate this new system through outreach at our popular Office Manager’s Forums scheduled in Stockton, Lodi and Tracy. Furthermore, we are happy to announce the addition of Provider Educator, Gena Welch. Gena is employed by CMA Foundation and funded by Covered California through a 1.5 million dollar grant. Her territory will include the Central Valley and the East Bay Area. She will be housed in the SJMS office and will be available as a resource for questions and education materials for you and your patients. You may reach Gena by calling our office at 952-5299. Please read more on Covered California on page 44 . Advocacy has been the name of the game this year as CMA faced an unprecedented number of scope of practice expansion bills introduced in the Legislature. Look for all of the details in the Legislative Wrap Up article towards the middle of this issue. Finally, we cannot talk about advocacy without talking about the recent attacks on MICRA. This battle is unlike anything we have seen before and the stakes are high. MICRA reform would cause malpractice insurance rates to soar and access to care for many would be decimated. Please help us protect the medical profession by becoming a member today! Finally, we hope to see all of you at our annual Holiday Party on Thursday, December 12, 2013! Please see enclosed ad for all of the details regarding this year’s festivities. Happy Holidays,
Lisa Richmond
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Param K. Gill, M.D.
Vincent P. Pennisi, M.D.
Jennifer Phung, M.D.
Jasbir S. Gill, M.D.
David L. Eibling M.D.
Patricia A. Hatton, M.D
Harjit Sud, M.D.
Thomas Streeter, M.D.
John Kim, M.D.
Maya Nambisan, M.D.
Kimberly McLaughlin, M.D.
Darrell R. Burns, M.D.
R. Afiba Arthur, M.D.
Tonja Harris-Stansil, M.D.
Catherine Mathis, M.D.
Kevin E. Rine, M.D.
Jacqualin Miller, D.O.
Linda Bouchard, M.D.
Lynette Bird, R.N., B.S.N.
Philip D. Ross, M.D.
Maria E. Escalona, M.D.
Vicki Patterson-Lambert, R.N.P.C. Denise Morgan, M.S.N. - N.P.
Convenient locations to serve you Stockton: 1617 N. California St., Ste. 2-A – Ph. (209) 466-8546 (Evening hours available) 435 E. Harding Way, Ste 1 – Ph. (209) 464-4796 • 2509 W. March Ln., Ste. 250 – Ph. (209) 957-1000 Lodi: 999 S. Fairmont Ave., Ste. 225 – Ph. (209) 334-3343 • 999 S. Fairmont Ave., Ste. 230 – Ph. (209) 334-4924 Galt: (209) 745-7473 • Manteca: 1234 E. North St., Ste. 102 – Ph. (209) 824-2202 • Tracy: 530 W. Eaton Ave,. Ste C – Ph. (209) 229-8685 We accept most health insurance, including Medi-Cal
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visit our website at www.gillobgyn.com
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YOU DON’T PROFIT FROM SICK EMPLOYEES. WHY DOES YOUR HEALTH PROVIDER? In an industry built on fee-for-service care, Kaiser Permanente succeeds because we’re built around prevention and the highest quality care. One Harvard Business Review article described our care as “untainted by any economic conflict of interest.” * And in an industry report by The Economist, Kaiser Permanente’s care was described as promoting economy and quality care with “no financial motive to order unnecessary procedures.”†
Discover a better way.
* Lew McCreary, “Kaiser Permanente’s Innovation on the Front Lines,” Harvard Business Review, September 2010. †
”Another American Way,” The Economist, May 1, 2010.
kp.org/choosebetter 8 SAN JOAQUIN PHYSICIAN
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A message from our President > Thomas McKenzie, MD
United We Stand Thank you for allowing me the privilege to lead the San Joaquin Medical Society this year.
As we approach the holiday season, the San Joaquin Medical Society wishes to extend our best wishes to you and your family to enjoy a safe holiday season, spend time to savor your families and friends, and prepare for the New Year. This is our membership renewal time. We need your active membership! That means your dues, your time to serve on Medical Society committees, your active support of making an example of service in our communities. This is not a one way street- send your money! You
receive a great value for your dues. CM A member resources include contract analysis, legal hotline and advice, legislative hotline, online resources, seminars/conferences. Local SJMS resources include insurance savings, website resources, Office Manager Forums, practice resources, patient referrals, quarterly publications and Annual Directory. So where did your membership money go last year? What has the CM A done for you lately? Well, all of the above, plus extending the political voice of the CM A trying to get Organized Medicine’s message to our lawmakers. A monumental job has been done by CM A lobbyists led by Dustin Corcoran in this last year’s legislative session.
CMA Legislation An unprecedented number of the scope of practice expansion bills were introduced in the Legislature this last
ABOUT THE AUTHOR Dr. Thomas McKenzie is President of the San Joaquin Medical Society and is an Orthopedic Surgeon practicing in Lodi.
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A message from our President > Thomas McKenzie, MD
“
with a commitment of $100 per physician. So far, in Northern California the average commitment is $1-$5 per physician. We can do better. I strongly encourage you to forward $100 for MICR A defense to the CM A. It is $100 that will be best spent in your best interest. Checks may be mailed the below address: CALPAC 1201 J. Street, Ste 275 Sacramento, CA 95814
In short, CM A lobbying efforts have served you very well over this last year. This effectiveness on a very tight budget is truly admirable. CM A effectiveness is second to none. Using facts on the issues, insuring your legislators receive unbiased information, extending commonsense explanations of the information at hand, and the obvious legislative trust that the CM A position is well thought through for the best interest of our patients and
“
year. Expansion of the scope of practice by allied health professionals to include nurse practitioners, optometrists, pharmacists were introduced. These scope of practice bills were purported by supporters as necessary reforms to help implement the Affordable Care Act to increase access. The CM A message was straightforward and clear: promotion of integration of Allied health professionals to ensure they provide reasonable services
your patients become roadkill as the result of the Covered California inequities, bureaucratic
Do not let one of
incompetence, corporate insurance greed, and governmental dictates.
in an integrated and safe manner with collaboration of physicians to promote and not jeopardize patient’s safety is paramount. The prescription monitoring program, CUR ES, will be upgraded and funded. A proposal to give the medical board overly broad powers to discipline physicians for inappropriate prescribing was overwhelmingly defeated by CM A on the Assembly f loor. An effort to shift investigative authority from the Medical Board of California to the Department of Justice was defeated. An annual $15 million appropriation to fully fund the new UC Riverside School of Medicine was approved and the school welcomed its first class of fouryear medical students this fall. Multiple efforts to increase Medi-Cal provider rates have been introduced. Two CM A sponsored bills (AB 565, AB 1288) will encourage physicians to locate their practices in the Central Valley, Inland Empire, and other underserved regions of our state.
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delivery of medicine has yielded the obvious legislative successes this year. We must maintain that trust. All of us need to continue to support the CM A. Bottom-line, that means your hard earned dollars.
MICRA MICR A remains the issue that is not going to go away. The trial attorneys campaigning to eviscerate MICR A has remained in full gear. Despite a heavy investment and public relations campaign, attempts to push a bill through this Legislature were ineffective, resulting in a bill not even being introduced. The consequent usage of an initiative ballot fight has just begun. Make no mistake; they intend to win this battle. I strongly urge you to send money to the CM A specifically to support the defense of MICR A. Southern California Medical Societies and Southern California hospitals are using the same equation they used back in 1975, asking each physician to support MICR A defense
Affordable Care Act
So how is the Affordable Care Act (ObamaCare) coming along for you? Besides the political conversations pro and con, I am receiving daily complaints by my patients who are losing healthcare coverage, receiving insurance cancellations, getting new policies quotes with 5 figure deductibles. Without a doubt, there are numerous challenges to the practice of modern day medicine. We are all trying to figure out what our roles in the new health care paradigm will be. I challenge all of you to ensure there is no loss of continuity of medical care for your patients. The Wall Street Journal opinion page 11/4/2013 article by Ms. Edie Sundby is a must read for you, your friends, your elected politicians. It potentially is an all too common story of our futures as patients, physicians, society. Do not let one of your patients become roadkill as the result of the Covered California inequities, bureaucratic incompetence, corporate insurance greed, and governmental dictates. You are better than this. Our patients are begging us and trusting us to do the right thing. Do your job!
United We Stand
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CMA > HOD 2013
CMA DELEGATES SET POLICY AT ANNUAL MEETING More than 500 California physicians convened in Anaheim October 11-13 for the 2013 House of Delegates (HOD), the annual meeting of the California Medical Association (CMA). Each year, physicians from all 53 California counties, representing all modes of practice, meet to discuss issues related to health care policy, medicine and patient care and to elect CMA officers.
HOD
2013 Over 90 resolutions were introduced and debated in reference committees on Friday, October 11. Over the next two days, the complete house met again to debate and vote on reference committee recommendations. A total of 63 resolutions were adopted. As a first step toward a “virtual� reference committee process that will enable a shorter, two-day meeting in future years, Reference Committee A (Science and Public Health) conducted all testimony online in advance of the meeting. All CMA members were invited to participate in the debate, and nearly 300 online comments were recorded. The committee members then met via web conference in advance of the meeting to develop their recommendations, which were presented to the House for f loor debate on Saturday afternoon. The House also elected a new president, Paradise internist Richard Thorp, M.D., While Humboldt surgeon Luther Cobb, M.D., was tapped as president-elect.
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CMA > HOD 2013
The following are summaries of some of the resolutions that were adopted as policy. (The full actions of the HOD are available to members at www.cmanet.org/hod, under the “documents” tab.)
Increased reporting of immunizations Resolution 104-13 The delegates approved a resolution that encourages increased reporting of patient immunizations to the California Department of Public Health for purposes of vaccination, disease control and prevention.
HIV and STDs: Consent requirements for testing Resolution 109-13 The delegates voted to support revision of HIV consent requirements to allow all health care providers to order a test for HIV when appropriate and to encourage routine HIV testing for all patients that are evaluated for other sexually transmitted diseases.
Graphic health warnings on tobacco products Resolution 115-13 Delegates called on CMA to support the use of graphic image labeling on cigarette and other tobacco packaging that warns of the health impact of smoking.
Legal blood alcohol limit for drivers Resolution 118-13 Delegates endorsed the National Transportation Safety Board’s 2013 recommendation that the legal blood alcohol limit for operating a motor vehicle be decreased from .08 percent to .05 percent or lower.
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Food insecurity screening Resolution 122-13 The delegates directed CMA to promote that providers need to identify children and adults who are food insecure to avoid detrimental development and co-morbidities and to refer them to appropriate programs and services.
Elimination of CMS outpatient observation status Resolution 211-13 The delegates directed CMA to request that the Centers for Medicare and Medicaid Services eliminate its “outpatient patient observation” status, which is placed upon patients whose anticipated hospital stay is 48 hours or less. Delegates noted that this practice places undue financial burden on patients and creates administrative hassles for physicians.
Health exchange benefit designs and tax deductibility of out-of-pocket expenses Resolution 401-13 The delegates called on CMA to support efforts to develop benefit designs in the health benefit exchange that appeal to the young and healthy to boost the risk pool; and to support legislation allowing federal and state income tax deductibility of all out-of-pocket health care expenses.
Reimbursement for telephone/electronic patient management Resolution 407-13 The delegates asked that CMA support legislation requiring health insurance companies to pay physicians for telephone or other electronic patient management services.
National health information exchange Resolution 501-13 The delegates called on CMA to support the development of a secure, interoperable, nationwide health information exchange network.
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MEET YOUR NEW CMA PRESIDENT!
Delegates push for increased reporting of immunizations The CMA House of Delegates passed a resolution directing the association to encourage and promote the reporting of immunizations to the California Department of Public Health for purposes of vaccination, disease control and prevention (Res. 104-13). “More accurate tracking of immunizations would lead to improved vaccination rates, reduce duplicative health services and improve the health of all Californians,” wrote one delegate in online testimony. Nearly one in four children sees more than one immunization provider by age two. In fact, the chart in the child’s most recent medical home is accurate only 62 percent of the time. With increased reporting, public health departments can better identify people who are at risk in the event of a disease outbreak or other emergency such as hurricanes, earthquakes, f loods or man-made disasters. They can also help locate communities with low coverage rates so that they can provide targeted interventions to increase coverage rates and protect more people from disease.
CMA supports reduced blood alcohol limit for drivers The CMA House of Delegates voted to endorse the National Transportation Safety Board’s 2013 recommendation that the legal blood alcohol limit for operating a motor vehicle be decreased from .08 percent to .05 percent or lower (Res. 118-13). According to the National Transportation Safety Board (NTSB), each year in the United States, nearly 10,000 people are killed in crashes involving alcohol-impaired drivers and more than 173,000 are injured, with 27,000 suffering incapacitating injuries. Since the mid-1990s, even as total highway fatalities have fallen, the proportion of deaths from accidents involving an alcohol-impaired
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Richard Thorp, M.D., FACP, was installed as the 146th president of the California Medical Association (CMA) at the close of the association’s 2013 House of Delegates, held October 11-13 in Anaheim. “I will not compromise the honor of this profession for the victory of the moment. I will not capitulate or surrender. I will fight to protect this profession you hold so dear,” Dr. Thorp said as he addressed the 500 physician delegates in attendance. “In this critical time, the house of medicine cannot afford to do business as usual. We cannot afford the status quo. We must come with the audacity to create a dream and a vision for the future of medicine and health care in California.” Dr. Thorp told the delegates that he hopes the physicians of California remember and are inspired by how far the profession has come as we face the new challenges of the future. “When you look at what we’re able to do today, we live in the golden age of medicine—a time when the future of medical treatments is bright and getting brighter every day,” he said. “We have serious problems today. But we have incredible opportunities,” said Dr. Thorp. “Although we are at the pinnacle of discovery in the treatment of disease, this profession is at war. More than ever. We cannot make the mistake of tempting our adversaries with complacency.” Dr. Thorp is a Paradise internist who developed an interest in health policy and health system reform while serving as president of Butte Glenn Medical Society (his local county medical society) in 1994, the year of Clinton health reform. In 1994 he was also the incorporating agent of a county wide Management Service Organization involving PPO and HMO physician groups and the area hospitals. Dr. Thorp continued a leadership role in organized medicine in 1995, serving on CMA’s Committee on Managed Care and subsequently on the Committee on Medical Services. He was the chair of the Committee on Medical Services for 10 years and
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CMA > HOD 2013
since 2008 has served as consultant to the committee. Dr. Thorp was elected to the CMA Board of Trustees in 2009 and is an Alternate Delegate to the American Medical Association House of Delegates, representing a portion of Northern California. In 2011 and 2012, Dr. Thorp was the chair of CALPAC, CMA’s political action committee. He has spent the last year serving as president-elect of CMA and as a member of CMA’s Executive Committee. Dr. Thorp is the president/CEO of Paradise Medical Group, Inc., a physician owned multi-specialty primary care group incorporated in 2001. He is also on the active medical staff of Feather River Hospital and divides his time between a private general internal medicine practice, service as a medical director of a rural health clinic and private practice administration. Dr. Thorp studied for his medical degree at Loma Linda University School of Medicine and did his residency there as well. In 2009, Dr. Thorp was recognized as a fellow by the American College of Physicians (ACP). He also serves on the Governor’s Council for the ACP’s Northern California Chapter and he has served at the national level of ACP as a committee member. He and his wife Vicki enjoy cooking together, gardening, scuba diving and their blended family of four sons: Zach Thorp, his wife, Andy, and their two grandsons, Tyler and Cody; Aaron Thorp and his partner, Michael; Cheyne Rogers; and Griffin Rogers. The delegates also named Humboldt County surgeon Luther Cobb, M.D., as president-elect. Dr. Cobb will serve as president-elect for one year, and will be installed as president following next year’s House of Delegates. Dr. Thorp’s complete address to the delegates can be watched on CMA’s YouTube channel, www.youtube.com/ cmaphysicians. Also serving on CMA’s 2013-2014 Executive Committee are: Immediate Past President Paul R. Phinney, M.D., a Sacramento pediatrician President-Elect Luther F. Cobb, M.D., a surgeon in Humboldt County Speaker of the House Theodore M. Mazer, M.D., a San Diego ear, nose and throat specialist Vice Speaker of the House Lee T. Snook, Jr., M.D., a Sacramento pain medicine specialist Chair of the Board of Trustees, Steven E. Larson, M.D., an internist infectious diseases consultant in Riverside County Vice Chair of the Board of Trustees, David H. Aizuss, M.D., a Los Angeles ophthalmologist
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driver has remained constant at around 30 percent. Research shows that although impairment begins with the first drink, by .05 percent blood alcohol content most drivers experience a decline in both cognitive and visual functions, which significantly increases the risk of a serious crash. Currently, over 100 countries on six continents have limits set at 0.05 percent or lower. The NTSB has asked all 50 states to do the same.
similar packaging for cigarettes.” CMA has been a tireless advocate for stronger restrictions on the tobacco industry for decades. In 1970, 1978 and 1980, CMA supported ballot initiatives that would have banned smoking in many public places. In 1987, CMA took on its biggest tobacco-related challenge and won, with the passage of Proposition 99, which established a 25-cents-per-pack tax on cigarettes and a tax hike for other tobaccorelated products.
CMA supports graphic image labeling on cigarettes
Delegates weigh in on exchange grace period
The CMA House of Delegates overwhelmingly voted to support graphic image warning labels on tobacco packaging that depict the very real health impact of smoking (Res. 115-13). The U.S. Centers for Disease Control and Prevention rolled out a series of graphic advertisements in 2012, which featured startling photos of the health consequences of smoking. National smoking cessation hotlines and websites saw a doubling of calls and a fivefold increase in web visits while the ads were running. The United States Food and Drug Administration has also proposed placing such images on cigarette packaging as a deterrent to smoking and a stimulus to cessation, but was stopped by legal challenges from the tobacco industry. The resolution also directs CMA to urge courts to also support such labeling. “Family physicians support the required use of graphic warnings and statements on cigarette packages and advertisements as an important step toward reducing the existing and future use of tobacco products,” wrote one delegate in online testimony. “Warnings help counter the $12.5 billion cigarette manufacturers spend marketing their products each year. More than two dozen countries already require
Members of the CMA House of Delegates took a stance on the 90-day grace period provision called for in the Affordable Care Act (ACA), an issue that has been rapidly evolving in response to CMA’s continued advocacy. The resolution (Res. 402-13) was
amended by delegates during f loor debate this weekend to ref lect recent state and federal actions regarding the grace period provision. The resolution, as adopted by the House, calls for heightened standards for information provided to physicians regarding enrollees in the state’s health benefit exchange, as well as a provision emphasizing CMA’s position that physicians should not be compelled by payors to participate in exchange products. As initially proposed, the ACA’s grace period posed considerable risk to physicians participating in exchange products, potentially exposing them to two months
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of suspended and/or denied claims if a patient is delinquent on their insurance premiums. Recently, however, California’s Department of Managed Health Care has asserted that patients falling under the grace period provision would have coverage suspended after the first 30 days, and that insurance companies could not represent this coverage as active to the participating physician. The patient would then have the second and third months to pay the premium balance and have coverage reinstated. Given that the grace period provision has been a concern to physicians across the country and California is the only state thus far to move forward on the suspension of coverage issue, the matter was also referred to the American Medical Association for national action.
Delegates say insurers should be required to pay for telephone and email consultations Voting with an overwhelming majority, the CMA House of Delegates has said that insurers should be required to reimburse physicians for telephonic and electronic patient management. The resolution (Res. 407-13) asks CMA to sponsor legislation to that effect when politically and economically feasible. The resolution received nearly universal support during testimony, with many speakers
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noting that patients are increasingly relying upon telephone calls and emails for consultations that previously were conducted during in-office appointments. Under the language adopted by the House, payment for these consultations would be similar to office visits that are similar in complexity or time required from the treating physicians. The issue of payment for telephonic or electronic patient management has come before the House in the past, with CMA previously having adopted policy to support the practice, but this latest resolution explicitly asks the association to sponsor legislation to mandate the practice in California.
Delegates support work towards EHR interoperability The CMA House of Delegates displayed a strong show of support for electronic health record (EHR) interoperability (Res. 51813) and directed the association to support the development of a secure, interoperable, nationwide health information exchange network. Supporters of the resolution noted that much work needs to be done to achieve meaningful interoperability and facilitate efficient, timely and coordinated patient care among providers in different geographical areas.
The resolution directs CMA to support efforts to harmonize standards and specifications that would enable usability and interoperability of EHR systems and facilitate the exchange of health information among health care providers.
House asks for elimination of hospital “observation” status The CMA House of Delegates has voted to take action on the Centers for Medicare and Medicaid Services’ (CMS) “outpatient patient observation” status, finding it to be a practice that places undue financial burden on patients, complicates the practice of medicine and often results in physicians receiving reduced payments for services provided. Resolution 211-13, which received strong support on the f loor of the House, was submitted as an emergency resolution and asked that CMA request that CMS eliminate its “outpatient patient observation” status, which is placed upon patients whose anticipated hospital stay is 48 hours or less. Supporters of the resolution noted that this practice places undue financial burden on patients, while also creating administrative hurdles if the patient is subsequently admitted as an inpatient to the hospital. The resolution directs CMA staff to work with CMS to address the issue.
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CMA > HOD 2013
Humboldt county surgeon named CMA president-elect The CMA House of Delegates named Luther Cobb, M.D., as the association’s new president-elect. Currently serving as the speaker of the CMA House, Dr. Cobb is a board-certified, self-employed physician practicing in general, thoracic and vascular surgery in Arcata and Eureka. In addition to his involvement in organized medicine, Dr. Cobb serves as chief of staff of the Mad River Community Hospital in Arcata, where he has been an active member of the medical staff since 1997. He had also previously served as the hospital’s chief of staff from 2000 to 2002 and vice-chief of staff from 2009 to 2011. Dr. Cobb is also on the medical staff of St. Joseph Hospital in Eureka. Previously, Dr. Cobb served as attending surgeon, director of trauma services and director of the vascular surgery clinic at Santa Clara Valley Medical Center, in San Jose, as well as clinical associate professor of surgery at Stanford University School of Medicine and the chairman of the surgery department at Mad River Community Hospital. He also served as president of the Humboldt-Del Norte County Medical Society from 2004 to 2006. A graduate of the Stanford University School of Medicine, Dr. Cobb is a current member of the school’s alumni association, as well as the American Society of Breast Disease, the Society for Surgery of the Alimentary Tract, the Sigma XI Scientific Research Society and the Pacific Coast Surgical Association. Dr. Cobb will serve as president-elect for one year, and will be installed as president following next year’s House of Delegates. Filling Dr. Cobb’s vacated position of speaker of the House is current vice speaker Theodore M. Mazer, M.D. Lee T. Snook, Jr., M.D., was also elected to serve as vice-speaker. Hoopa physician receives CMA’s annual “country doctor” award Eva Marie Smith, M.D., M.P.H., a Hoopa family physician, has received the California Medical Association’s (CMA) 2013 Frederick K.M. Plessner Memorial Award during the association’s annual House of Delegates in Anaheim. The award honors a CMA member who best exemplifies the practice and ethics of a rural practitioner. Dr. Smith provides medical care to the Hoopa Valley Tribe located in a remote section of Humboldt County where poverty, substance abuse and domestic violence are common, and resources to address these problems are slim. The Hoopa Valley is approximately 50 miles from Eureka on winding roads. On a good day it can take a patient an hour to go to a specialist or a visit the hospital. Here, where the Klamath and Trinity Rivers meet and where the Hoopa have fished the rivers for salmon since time immemorial, Dr. Smith, a Native American member of the Shinnecock nation, practices medicine at the K’ima:w Medical Center with her husband, Emmett Chase,
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M.D., a Hoopa tribal native. She is the center’s medical director. Because the reservation is remote, her practice consists of everything imaginable from managing COPD to heart attacks to gunshot wounds to pediatric care to substance abuse to helping patients manage diabetes. While there are no specialists on the reservation, she has single-handedly brought University of California, Davis telemedicine services to the medical center to give her patients access. In a throwback to another era, Dr. Smith makes frequent house calls, sometimes driving more than 60 miles a day seeing patients. “Working in Indian health means dealing with social services as well as medical services,” she says. “When you are in the home, you get the whole context” for a medical problem. You may be treating an older woman for diabetes, she said, who is not following your instructions. But, if you make a house call you realize there is a whole lot more going on. She may be a grandmother that is taking care of a lot of grandkids. “I may be frustrated that her blood sugar is out of whack,” she says. “But taking care of herself may not be her first priority.” House calls allow Dr. Smith to understand her patients. Not only does she take care of individual patients, but she also takes care of the Hoopa nation when a public health emergency emerges. Take for example the hazards of living in a forest valley. In 1999, the community spent one summer indoors trying to avoid a blanket of smoke from a forest fire that raged in the valley for three months. Because the tribal lands are considered an autonomous government, the need arose during this emergency for a public health officer to liaise with the county public health officer, the tribe and the state. Dr. Smith took on this role. She got the tribe’s air quality monitors going, took accurate particulate matter readings, looked at wind readings and the course of the fire, and determined the appropriate response overnight. She liaised with the county health department, and in the case of this fire (there have been many others), she helped the tribe and county declare a state-of-emergency – the first state declaration ever based on a threat to human life. In addition to medical care, Dr. Smith also treats her patients for substance abuse. She is certified in addiction medicine through the American Society of Addiction Medicine. Substance abuse, she says, is a regional problem, not just a problem on the reservation. Methamphetamine and opioids are the drugs of choice. She finds treating substance abuse particularly satisfying because it allows her to bring in spirituality to the treatment, she says. Her work is varied and always exciting, she says. “Medicine is a good life, if you like people,” she says smiling. “I love people.” She says she has spent the bulk of her life in small communities just like Hoopa. Dr. Smith is a graduate of the Georgetown University School of Medicine in Washington, D.C. She did her residency in family practice at Brookhaven Memorial Hospital Medical Center, Patchogue, NY, and her preventative medicine residency at the University of California, Los Angeles. She is a diplomate of the American Board of Family Physicians. The award video is available on CMA’s YouTube channel, www.youtube.com/cmaphysicians.
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Doctors Hospital
Of Manteca Tenet California
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SAN JOAQUIN PHYSICIAN
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New Laws > 2014
NEW HEALTH LAWS The California Legislature had an active year passing many new laws affecting health care. Below are highlights of the new laws likely to impact physicians next year and beyond. For more details, see “Significant New California Laws of Interest to Physicians for 2014,” in the California Medical Association’s online resource library at www.cmanet.org/resource-library.
ALLIED HEALTH PROFESSIONALS AB 1000 (Wieckowski) – PHYSICAL THERAPISTS: DIRECT ACCESS TO SERVICES (CMA Position: Support / Co-Sponsored) Allows physical therapists to treat patients for 45 days or 12 visits without first seeing a physician. Requires a physical therapist to refer a patient to a physician if the condition is beyond the therapist’s scope of practice or if the patient is not progressing, to disclose to the patient any financial interest he or she has in treating the patient, and with the patient’s authorization, notify the patient’s physician that the physical therapist is treating the patient. Specifies that professional corporations, including medical corporations, are not limited to employing those licensed professionals that are listed in Corporations Code §13401.5. AB 1308 (Bonilla) – MIDWIFERY Removes physician supervision over licensed midwives. Specifies conditions of a normal pregnancy and childbirth and requires a licensed midwife to refer
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clients who do not meet these conditions to a physician for examination. Requires Medical Board to adopt regulations specifying those certain conditions. Authorizes a licensed midwife to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing, and receive necessary reports consistent with the scope of practice. Requires disclosure to prospective clients of the specific arrangements for referral of complications to a physician and surgeon, and to obtain consent of those disclosures.
CONFIDENTIAL INFORMATION SB 46 (Corbett) – PERSONAL INFORMATION: PRIVACY Amends existing law that requires notification to individuals whose unencrypted computerized personal information was, or is reasonably believed to have been, acquired by an unauthorized person due to a breach of security of a computerized system or data. Revises certain data elements included within the definition of personal information by adding certain information that would permit access to an online account. Imposes
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New Laws > 2014
additional requirements on the disclosure of a breach of security of the system or data in situations where the breach involves personal information that would permit access to an online or email account. SB 138 (Hernandez, E.) – CONFIDENTIALITY OF MEDICAL INFORMATION Specifies the manner in which a health care service plan or health insurer would be required to maintain confidentiality of information regarding the treatment of an insured, including a requirement to accommodate requests to receive requests for confidential communication of medical information in situations involving sensitive services, including requests by dependents insured under a health insurance policy held by another person, or situations in which disclosure would endanger the individual. Authorizes a health care provider to communicate information regarding benefit cost-sharing arrangements to the health care service plan or health insurer. Prohibits health plans from conditioning enrollment in the plan or eligibility for benefits on the waiver for certain rights provided for in the bill.
DRUG PRESCRIBING AND DISPENSING AB 635 (Ammiano) – DRUG OVERDOSE TREATMENT: LIABILITY (CMA Position: Support) Authorizes a licensed health care provider, who is permitted by law to prescribe an opioid antagonist and is acting with reasonable care, to prescribe and subsequently dispense or distribute an opioid antagonist for the treatment of an opioid overdose. This is permitted to treat a person at risk of an opioid-related overdose or a specified person in a position to assist a person at risk of an opioid-related overdose. Authorizes these licensed health care providers to issue standing orders for the distribution of an opioid antagonist. SB 809 (DeSaulnier) – CONTROLLED SUBSTANCES: REPORTING (CMA Position: Support) Funds the Controlled Substance Utilization Review and Evaluation System (CURES) for the electronic monitoring of the prescribing and dispensing of controlled substances by assessing an annual fee on practitioners authorized to prescribe, order, administer, furnish or dispense controlled substances, non-governmental clinics and non-governmental pharmacies. Establishes the CURES Fund within the State Treasury. Requires the Medical Board to periodically develop and disseminate education materials relating to the assessment of a patient’s risk of abusing or diverting controlled substances and information related to CURES to physicians and general acute care hospitals. Eliminates notarization requirement for application process and requires health care practitioners and pharmacists to apply to obtain approval to access CURES after January 1, 2016. Requires the Department of Justice in conjunction with the Department of Consumer Affairs and relevant licensing boards to develop a streamlined application and approval process to access CURES and enable health care practitioners and pharmacists with access to CURES to delegate their authority to order reports from CURES. SB 28 (Hernandez, E.) – CALIFORNIA HEALTH BENEFIT EXCHANGE Requires the California Major Risk Medical Insurance Board to provide the California Health Benefit Exchange (Covered California) with specified
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information to assist in conducting outreach to subscribers to notify them that they may be eligible for coverage through the Exchange or Medi-Cal. Implements various provisions of the Affordable Care Act relating to determining eligibility for the Medi-Cal program. Requires the Department of Health Care Services (DHCS) to authorize individuals to select MediCal managed care plans via the California Healthcare, Enrollment, and Retention System. CA SBX1 3 (Hernandez, E.) – HEALTH CARE COVERAGE: BRIDGE PLAN Requires the California Health Benefit Exchange (Covered California), by means of selective contracting, to make a bridge plan product available to specified eligible individuals, as a qualified health plan (QHP). Exempts the bridge plan product from certain requirements that apply to QHPs, relating to making the product available and marketing and selling to all individuals equally (guaranteed issue) outside the Exchange and selling products at other levels of coverage. Requires the Department of Health Care Services to include provisions relating to bridge plan products in its contracts with Medi-Cal managed care plans. Requires Covered California to evaluate three years of data from the bridge plan products, as specified.
HEALTH CARE COVERAGE SB 161 (Hernandez, E.) – STOP-LOSS INSURANCE COVERAGE (CMA Position: Support) Prohibits a stop-loss insurer from excluding any employee or dependent on the basis of specified actual or expected health status-related factors. Establishes regulatory requirements for stop-loss insurance policies for small employers, including requiring a stop-loss insurer to renew all stoploss insurance policies at the option of the small employer and prohibiting setting individual attachment point of $40,000 or greater and an aggregate attachment point of the greater of $5,000 times the total number of group members, 120% of expected claims, or $40,000 for a policy year or providing coverage for an employee or his or her dependents. Exempts small employer stop-loss insurance issued prior to September 1, 2013, from these attachment point requirements. CA ABX1 2 (Pan) – HEALTH CARE COVERAGE (CMA Position: Support if Amended) Establishes health insurance market reforms contained in the Affordable Care Act specific to individual purchasers, such as open enrollment, prohibiting insurers from denying coverage based on preexisting conditions, insured claims experience as part of a single risk pool, the use of certain factors in determining individual plan rates, insurance advertising and marketing, small employer enrollment periods and coverage effective date and premium rates, a risk adjustment program, insurance data reporting, and insurer disclosure requirements; and makes conforming changes to small employer health insurance laws resulting from final federal regulations. AB 980 (Pan) – PRIMARY CARE CLINICS: ABORTION Imposes the same licensing and building standards to all primary care clinics, including those that provide abortion services. Grants the Office of Statewide Health Planning and Development emergency regulatory authority to implement these provisions and requires the Department of
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New Laws > 2014
Public Health to repeal certain regulations relating to abortion services in primary clinics by July 1, 2014. AB 1202 (Skinner) – OCCUPATIONAL SAFETY AND HEALTH STANDARDS (CMA Position: Support) Requires the Occupational Safety and Health Standards Board to adopt a standard for the handling of antineoplastic drugs, primarily cancer drugs, in health care facilities regardless of the setting. Requires the standard to be consistent with and not exceed specific recommendations adopted by the National Institute for Occupational Safety and Health for preventing occupational exposures to those drugs in health care settings. SB 191 (Padilla) – EMERGENCY MEDICAL SERVICES (CMA Position: Co-Sponsored) Extends the operative date to January 1, 2017, of existing law that establishes the Maddy Emergency Medical Services Fund, which authorizes each county to establish an emergency medical services fund for reimbursement of costs related to emergency medical services and funding for pediatric trauma centers, and authorizes county boards of supervisors to elect to levy an additional penalty upon fines, penalties and forfeitures collected for criminal offenses. Makes technical, nonsubstantive changes to the provisions.
MEDI-CAL SB 94 (Senate Budget and Fiscal Review Committee) – MEDI-CAL: MANAGED CARE: LONG-TERM SERVICES AND SUPPORTS (CMA Position: Oppose) Amends existing law regarding the Coordinated Care Initiative (CCI) and separates CCI provisions to allow the mandatory enrollment of Medi-Cal and Medicare beneficiaries (dual eligibles) into Medi-Cal managed care, the integration of long-term supports and services into managed care plans, and the commencement of the In-Home Supportive Services Statewide Public Authority, to proceed separately from the CCI Duals Demonstration Project (now called Cal MediConnect). SB 494 (Monning) – HEALTH CARE
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PROVIDERS (CMA Position: Support ) Increases the number of beneficiaries assigned to the panel of a full-time equivalent primary care physician under a Medi-Cal managed care plan. Requires a health service plan to ensure that there is at least one full-time primary care physician for every 2,000 enrollees. Authorizes the assignment of up to an additional 1,000 enrollees to the primary care physician for every full-time non-physician medical practitioner supervised by that physician. Requires the MediCal program to evaluate the location, hours, and language capabilities of practitioners and adds non-physician medical practitioners (physician assistant or a nurse practitioner) to the definition of a primary care provider.
MEDICAL EDUCATION AB 94 (Committee on Budget) – EDUCATION FINANCE: HIGHER EDUCATION Higher education budget trailer bill that allocated $15 million dollars to the Regents of the University of California, Riverside School of Medicine. AB 565 (Salas) – CALIFORNIA PHYSICIAN CORPS PROGRAM (CMA Position: Sponsor) Amends the Steven M. Thompson Physician Corps Program to require the guidelines for the selection and placement of program applicants to include criteria that would give priority consideration to program applicants with experience providing health care services to medically underserved populations or in a medically underserved area. Gives priority to applicants who agree to practice in those areas and serve a medically underserved population, and give priority consideration to applicants from rural communities who agree to practice in a physician owned and operated medical practice. Amends the definition of “practice setting” to include a physician owned and operated medical practice setting that provides primary care located in a medically underserved area.
PROFESSIONAL LICENSING AND DISCIPLINE AB 1288 (Perez, V.) – STATE MEDICAL BOARDS: LICENSING: APPLICATION PROCESSING
(CMA Position: Sponsor) Requires the State Medical Board and the Osteopathic Medical Board of California to develop a process to give priority review status to the application of an applicant who can demonstrate that he or she intends to practice in a medically underserved area or serve in a medical underserved population. SB 304 (Lieu) – HEALING ARTS: BOARDS This bill is the sunset extension bill for the Medical Board containing statutory and technical changes to provisions relating to Medical Board review by appropriate legislative committees, issuance of a license to a physician and surgeon who has acquired any part of his or her education from an unrecognized medical school who has held licensure in another state or Canada, reporting an electronic address to the Board, licensed midwives, adverse event reporting, fines for failure to provide health care records by a facility, and Medical Board investigations. SB 670 (Steinberg) – PHYSICIANS AND SURGEONS: DRUG PRESCRIBING PRIVILEGES (CMA Position: Support) Authorizes the Medical Board, in any investigation that involves the death of a patient, to inspect and copy the records of the deceased patient without authorization of the beneficiary or personal representative of the deceased patient or a court order to determine the extent to which the cause of death was the result of the physician and surgeon’s violation of the Medical Practice Act, if the board provides a written request to the physician that includes a declaration that the board was unsuccessful in locating or contacting the deceased patient’s beneficiary or personal representative after reasonable efforts. Revises definition of unprofessional conduct to include repeated failures by a licensee who is the subject of an investigation, in absence of good cause, to attend and participate in an interview by the board. Clarifies the authority of the administrative law judge to issue an interim order limiting the authority to prescribe, furnish, administer or dispense controlled substances.
PUBLIC HEALTH AB 446 (Mitchell) – HIV TESTING (CMA Position: Support)
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New Laws > 2014
Requires a medical care provider or a person administering a HIV test to provide a patient with information about risk reduction strategies and information regarding test results. Requires oral or written informed consent as specified for the HIV test except when a person independently requests an HIV test from an HIV counseling and testing site and requires the person administering the test to document the person’s independent request for the test. Exempts clinical laboratories from the informed consent requirements. Requires an HIV test to be offered to any patient having blood drawn at a primary care clinic and consents to the test. Authorizes disclosure of HIV test results by secure Internet website posting.
Screening Program patient educational information and to post that information on the department’s website. Requires the Department of Public Health to send a notice to all distributors of the patient educational information that informs them of that change and encourages obstetrician-gynecologists and midwives to discuss environmental health with their patients.
These are just a sampling of the new laws impacting health care in 2014 and beyond. For a complete list, see “Significant New California Laws of Interest to Physicians for 2014,” in the California Medical Association’s online resource library at www.cmanet.org/resource-library.
REPRODUCTIVE ISSUES AB 154 (Atkins) – ABORTION (CMA Position: Support) Allows nurse practitioners, certified nurse midwives and physician assistants to perform an abortion by medication or aspiration techniques in the first trimester of pregnancy if he or she completes training and validation of clinical competency and is working pursuant to specified standardized procedures that specify the extent of physician supervision, and procedures for transferring patients to the care of a physician or a hospital, obtaining assistance and consultation of the physician and providing emergency care until physician assistance and consultation is available. Deletes references to nonsurgical abortions. AB 460 (Ammiano) – HEALTH CARE COVERAGE: INFERTILITY (CMA Position: Support) Requires that health care service plan and health insurer coverage for the treatment of infertility be offered and, if purchased, provided without discrimination on the basis of age, ancestry, color, disability, domestic partner status, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex or sexual orientation. SB 460 (Pavley) – PRENATAL TESTING PROGRAM: EDUCATION (CMA Position: Support if Amended) Requires the Department of Public Health to include prescribed information regarding environmental health in the California Prenatal
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CDC > Antibiotic Resistance
CDC PUBLISHES NEW
ANTIBIOTIC RESISTANCE THREAT REPORT
A Threats were assessed according to seven factors associated with resistant infections: health impact, economic impact, how common the infection is, a 10-year projection of how common it could become, how easily it spreads, availability of effective antibiotics, and barriers to prevention. Infections classified as urgent threats include carbapenem-resistant Enterobacteriaceae, drug-resistant gonorrhea, and Clostridium difficile, a serious diarrheal infection usually associated with antibiotic use. C. difficile alone causes about 250,000 hospitalizations and at least 14,000 deaths every year in the United States.
“ANTIBIOTIC RESISTANCE IS RISING FOR MANY DIFFERENT PATHOGENS THAT ARE THREATS TO HEALTH,” SAID CDC DIRECTOR TOM FRIEDEN, M.D., M.P.H. “IF WE DON’T ACT NOW, OUR MEDICINE
E
very year, more than two million people in the United States become infected with bacteria that are resistant to antibiotics and at least 23,000 people die as direct a result of these infections, according to a new report issued by the Centers for Disease Control and Prevention. The report, "Antibiotic Resistance Threats in the United States, 2013," presents the first snapshot of the burden and threats posed by antibiotic-resistant germs having the most impact on human health. The threats are ranked in categories: urgent, serious, and concerning.
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CABINET WILL BE EMPTY AND WE WON’T HAVE THE ANTIBIOTICS WE NEED TO SAVE LIVES.”
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CDC > Antibiotic Resistance
Fighting Public Perception Research shows that most Americans have either missed the message about appropriate antibiotic use or they simply don’t believe it. It’s a case of mistaken popular belief winning out over fact. According to public opinion research, there is a perception that “antibiotics cure everything.” Americans believe in the power of antibiotics so much that many patients go to the doctor expecting to get a prescription. And they do. Why? Physicians often are too pressured for time to engage in lengthy explanations of why antibiotics won’t work. And, when the diagnosis is uncertain — as many symptoms for viral and bacterial infections are similar — doctors are more likely to yield to patient demands for antibiotics. To help physicians and other clinicians to educate patients about appropriate antibiotic use the California Medical Association (CMA) Foundation's Alliance Working for Antibiotic Resistance Education (AWARE) project has teamed up with the CDC and others to bring attention to this growing concern. The CMA Foundation will be getting the word out via news articles, opinion editorials and letters to the editor over the next month, leading up to "Get Smart About Antibiotics Week," Nov. 18-24, 2013. The goal of the "Get Smart" campaign is to highlight the problem of antibiotic resistance and the importance of appropriate antibiotic use.
of clinical resources and patient education materials to help reduce inappropriate antibiotic use.
• CDC 2013 Antibiotic Threat Report: http://www.cdc.gov/drugresistance/threatreport-2013
Additional Resources:
• AWARE website: http://www.aware.md Contact: CMA Foundation, (916) 779-6620 or aware@thecmafoundation.org.
• CDC "Get Smart About Antibiotics Week" web page: http://www.cdc.gov/getsmart
The "Get Smart About Antibiotics Week" campaign aims to slow the rise of antibiotic resistance by: • Promoting adherence to prescribing guidelines among providers • Decreasing demand for antibiotics for viral upper respiratory infections among healthy adults and parents of young children • Increasing adherence to prescribed antibiotics for upper respiratory infections To these ends, the CMA Foundation encourages physicians and other clinicians to download its antibiotic awareness toolkit. The toolkit, available for download at the AWARE website (www.aware.md), contains an array
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SAN JOAQUIN PHYSICIAN
25
MICRA > Defending The Law
As MICRA threat reemerges,
PHYSICIANS STAND TO DEFEND THE LAW By Richard Thorp, M.D.
When trial lawyers announced earlier this year that they were working to scrap California’s Medical Injury Compensation Reform Act (MICRA), the California Medical Association (CMA) warned that the campaign would be riddled with lies, misdirection and below-the-belt shots designed to fool the public into thinking the trial lawyers’ efforts were anything more than an outright money grab.
UNFORTUNATELY, WE DIDN’T KNOW HOW RIGHT THAT WARNING WOULD PROVE TO BE. Since its passage, MICRA has been under near-constant attack from those who place the prospect of a higher payday above the overall health and well being of California residents. While, time and time again, MICRA has weathered the storm, the law is under siege once again. This time MICRA is facing the greatest threat yet, as trial lawyers aim to put more money in their own pockets at the expense of patients across the state. Driven by greed and the promise of inflated attorney fees, California trial lawyers have renewed their fight to lift MICRA’s cap on speculative, non-economic damages, presenting ballot language that seeks to more than quadruple the maximum award for non-economic damages to roughly $1.1 million. While trial lawyers have postured and threatened major action on MICRA before, this latest effort is made credible by the nearly one million dollars the lawyers recently put into a ballot measure committee. The proposed ballot language, put forward by a trial lawyer front group inappropriately named Consumer Watchdog, was cleared by the Attorney General for MICRA opponents to begin collecting signatures to place the measure on the November 14 ballot. Trial lawyers and their allies are bankrolling the proposed initiative. With money on the table and signature gatherers on the street, it’s clear that MICRA opponents are serious about overturning the law in 2014. If successful, these efforts would be devastating to California’s health care system. More meritless lawsuits will lead to reduced patient access to our health care professionals – and fewer options for
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affordable, quality health care – especially in rural and underserved communities. With federal health care reform expanding coverage for millions of additional patients, California is already struggling to provide access to care for the neediest and most vulnerable patients. If this ballot initiative is successful, it will only make the situation worse—even longer lines in emergency rooms, extended waits for appointments with specialists and reduced access to women’s services like OB/GYNs. This measure will make health care professionals including doctors, nurses and other providers less accessible – not more accountable, as claimed by the trial lawyers. A broad-based coalition of nearly 1,000 groups and organizations led by CMA—including doctors, nurses, dentists, hospitals, Planned Parenthood and community health centers and clinics, among others— has emerged to protect access to care across the state. While the latest fight over MICRA has now taken its first steps toward the ballot box, CMA and its allies have already notched several key victories in this fight, and remain committed to defeating the initiative push in its entirety.
THE THREAT EMERGES
This latest assault on MICRA began with all the theatrics and deception that has come to be expected from California trial lawyers and their faux-grassroots front group, Consumer Watchdog. In early May, Consumer Watchdog President Jamie Court held a press conference in front of the California Capitol announcing his organization’s intent to overturn MICRA, either through legislation introduced in the final months of the 2013 legislative session, or through a ballot initiative brought before California voters. During the conference, Court nefariously painted physicians as believing they were above the law, and in some cases, completely apathetic to the pain and suffering experienced by victims of medical malpractice. Despite drawing only a small crowd and being unable to expand much upon their intentions during the May press conference, Court and his followers eventually made good on their threat of introducing a ballot measure, submitting language in early July that calls for MICRA’s cap
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MICRA > Defending The Law
on subjective non-economic damages to be raised from $250,000 to $1.1 million, with automatic annual increases every year thereafter. The ballot measure came only after Consumer Watchdog and others unsuccessfully tried to pressure the legislature to address the issue. The central intent of the proposed ballot language is nothing more than a thinly-veiled money grab by California’s trial attorneys, who stand to make hundreds of thousands of additional dollars on every malpractice case should the cap be changed. However since most voters would not support that provision, it also calls for physician drug testing and a bolstering of the state’s Controlled Substance Utilization Review and Evaluation System (CURES). Currently, MICRA protects patients involved in medical liability lawsuits by allowing unlimited economic compensation for any and all economic or out of pocket costs, including past and future lost income and earning capacity, all necessary medical care, as well as unlimited punitive damages. Under MICRA, patients can also receive up to $250,000 for non-economic pain and suffering damages. This allows legitimate medical liability cases to move forward while discouraging lawyers from filing frivolous suits. MICRA also limits how much lawyers can take as payment, ensuring more money goes to patients, not lawyers. The trial lawyers’ measure would not only nearly quadruple MICRA’s non-economic damages cap from $250,000 to $1.1 million—it would also triple the legal fees that lawyers receive. While the trial lawyers get rich, everyone else pays. More lawsuits mean higher health care costs for everyone. An analysis by California’s former independent legislative analyst found that this measure would increase health care costs for consumers and taxpayers in California by nearly $10 billion annually.
PANDERING IN THE CAPITOL
MICRA opponents also attacked the Capitol, where members of the Legislature were returning from their summer recess and preparing to begin the final legislative push for the 2013 session. Knowing that legislation attempting to scrap MICRA would never survive the vetting process typical of a full session, opponents sought to find an author willing to use the so-called “gut-and-amend” action to avoid public scrutiny provided through the regular legislative process to push an anti-MICRA bill through the Legislature in the final days, or even hours, before the Assembly and Senate adjourned for the year. In its effort to locate an author, as well as drum up opposition to MICRA, Consumer Watchdog began conducting daily mail drops featuring their “38 is too late” campaign to legislative offices. The canvassing project targeted physicians as being unsympathetic to their patients’ needs, and portrayed MICRA as a barrier to victims seeking restitution for medical malpractice. Nowhere in Consumer Watchdog’s literature did it mention that medical malpractice victims are entitled to unlimited economic damages—such as lost wages, earning capacity and medical expenses—under California law. Nor did it mention that lawyers would stand to make more money should MICRA be overturned.
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To combat this effort, CMA and a host of allies—including labor groups, public safety entities, allied health care professionals and municipal interests—inundated members of the Legislature with facts supporting MICRA’s efficacy, warning that altering the cap would adversely impact local governments, community clinics and insurance premiums for all Californians. In the end, MICRA’s supporters emerged victorious, as trial attorneys were unsuccessful in getting anti-MICRA legislation introduced during the most recent session.
CHEAP SHOTS AND SCARE TACTICS
Shortly after being defeated in the state Capitol, MICRA opponents decided it was time to start playing dirty. In late September, Consumer Watchdog distributed a mail piece featuring the names of hundreds of California physicians who it claims are afraid to “pee in a cup,” while also personally targeting CMA Past President, Paul Phinney, M.D., asking what he had to hide by opposing the trial attorneys’ greed-fueled initiative to gut MICRA. Oddly enough, the trial attorneys’ mailer makes no mention of the proposed initiative’s attempt to nearly quadruple MICRA’s cap on non-economic damages and exponentially increase their fees, and sticks to the more voterfriendly provisions regarding substance abuse in the workplace. The attack was a brazen one, illustrating that the state’s trial lawyers and their puppet organization, Consumer Watchdog, will stop at nothing to line their pockets through the inflated attorney fees that would be generated from MICRA’s cap being lifted. These cheap shots continued, however, when representatives from Consumer Watchdog crashed CMA’s annual House of Delegates conference in Anaheim, hosting a press conference outside of the conference center before circling the streets with a video truck broadcasting the message that “doctors should pee in a cup.” While these attacks may sting for those who are personally targeted, they also illustrate one fact – MICRA opponents are desperate. In the months since trial lawyers launched their latest assault against MICRA, California physicians and other allies have rallied to MICRA’s defense at a near-historic rate. Funds are being raised at record numbers, and physician engagement with the issue grows every day. As a result, Consumer Watchdog and other MICRA opponents are stooping to new lows in an attempt to intimidate those who have come to MICRA’s defense. These deceitful attacks by MICRA opponents will continue, and will get worse as the November 2014 election cycle ramps up. Physicians, however, must continue to advocate for MICRA and ensure that our patients and practices are not jeopardized by the greed of those who would like to see MICRA fall. Rest assured, CMA will win this fight, but will need all physicians in order to do so. To find out how you can help, visit www.cmanet.org/micra today. Dr. Richard Thorp is President of the California Medical Association.
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In The News
IN THE
NEWS
Providing staff, physicians and patients with relevant & up to date information
HT Family Physicians, Inc. of Stockton is proud to announce the association of Dylia Pereira Narvaez, M.D., Family Medicine, and Clyde Y. Wong, M.D., Family Medicine, to our practice. Dr. Pereira Narvaez was born and raised in South Africa. After completing Medical School at the internationally noted University of the Witwatersrand in 1992, she practiced medicine for a few years in South Africa, England and Canada. She moved to the United States after meeting her husband, then an active duty Ophthalmologist with the US Air force. She then pursued residency training in Family Practice at the UC Davis Residency Program at San Joaquin General Hospital where she was Chief Resident, completing in 2002. She is Board Certified in Family Medicine and fluent in Spanish. Dr. Wong grew up right here in the San Joaquin Valley of California. He attended the University of the Pacific, and subsequently Stanford University, School of Medicine, where he earned his medical degree. Dr. Wong completed his residency at Harbor-UCLA in Family Medicine where he was the Resident Scholar. He practices the full spectrum of Family Medicine with an emphasis on Preventive Medicine, Adolescent Medicine and Women’s Health. He is Board Certified in Family Medicine and is fluent in Chinese/Cantonese. Dr. Raissa M. Hill and Dr. San Tso want to extend a warm welcome to both new physicians. To schedule an appointment with any of HT Family Physicians’ providers, please call (209) 477-5552.
St. Joseph’s Earns “Top Performer on Key Quality Measures®” Recognition from The Joint Commission St. Joseph’s Medical Center has been named Top Performer on Key Quality Measures® by The Joint Commission, the leading accreditor of health care organizations in America. St. Joseph’s was recognized by The Joint Commission for exemplary performance in using evidence-based clinical processes that are shown to improve care for certain conditions. The clinical processes focus on care for heart attack, pneumonia, surgery, children’s asthma, stroke and venous thromboembolism, as well as inpatient psychiatric services. New this year is a category for immunization for pneumonia and influenza. St. Joseph’s is one of 1,099 hospitals in the U.S. earning the distinction of Top Performer on Key Quality Measures for attaining and sustaining excellence in accountability measure performance. St. Joseph’s was recognized for its achievement on the following measure sets: • Heart attack • Heart failure • Pneumonia • Surgical Care
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Dr. Wong
Dr. Narvaez WINTER 2013
FALL 2013
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In The News
IN THE
NEWS The ratings are based on an aggregation of accountability measure data reported to The Joint Commission during the 2012 calendar year. To be recognized as a Top Performer on Key Quality Measures , St. Joseph’s : 1) achieve cumulative performance of 95 percent or above across all reported accountability measures; 2) achieve performance of 95 percent or above on each and every reported accountability measure where there are at least 30 denominator cases; and 3) have at least one core measure set that has a composite rate of 95 percent or above, and (within that measure set) all applicable individual accountability measures have a performance rate of 95 percent or above. A 95 percent score means a hospital provided an evidence-based practice 95 times out of 100 opportunities to provide the practice. Each accountability measure represents an evidence-based practice – for example, giving aspirin at arrival for heart attack patients, giving antibiotics one hour before surgery, and providing a home management plan of care for children with asthma. “St. Joseph’s has demonstrated an exceptional commitment to quality improvement and they should be proud of their achievement,” says Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., president and chief executive officer, The Joint Commission. “This truly shows that we are approaching a tipping point in hospital quality performance that will directly contribute to better health outcomes for patients.” “St. Joseph’s is committed to positive patient outcomes through evidencebased care processes,” said St. Joseph’s President and CEO, Donald Wiley. “We are proud to receive the distinction of being a Joint Commission Top Performer on Key Quality Measures.”
National Study: St. Joseph’s Medical Center Named America’s 100 Best for Prostate Surgeries Healthgrades study of patient outcomes in approximately 4,500 hospitals finds St. Joseph’s among the best nationally
St. Joseph’s Medical Center in Stockton announced today that it has been recognized by Healthgrades as one of America’s 100 Best hospitals for Prostate Surgeries™ in 2014. Healthgrades, the leading online resource that helps consumers search, compare and connect with physicians and hospitals, evaluated nearly 4,500 hospitals nationwide for 31 of the most common inpatient procedures and conditions and identified the 100 best hospitals within each procedure. The achievement is part of findings released today in American Hospital Quality Outcomes 2014: Healthgrades Report to the Nation, which demonstrates how clinical performance differs dramatically between hospitals
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and the impact that this variation may have on health outcomes. For example, from 2010-2012, if all hospitals as a group, performed similarly to hospitals receiving 5-stars as a group, on average 234,252 lives could potentially have been saved and 157,418 complications could potentially have been avoided. A 5-star rating indicates that St. Joseph’s Medical Center’s clinical outcomes are better than expected when treating the condition or conducting the procedure being evaluated. St. Joseph’s Medical Center is also a Recipient of the Healthgrades Prostate Surgery Excellence Award™ for three years in a row (2012 – 2014); ranked among the Top 5 Percent in the Nation for Prostate Surgery for three years in a row (2012 – 2014); and a Five-Star Recipient for Transurethral Prostate Resection Surgery for three years in a row (2012 – 2014). “We are pleased to be recognized for our clinical quality achievements,” said Don Wiley, President of St. Joseph’s Medical Center. “Our physicians, nurses and staff are focused on quality care for our patients and these awards reflect the daily efforts in our hospital.”
Now is the time for a new Dental Plan! It’s Open Enrollment time for the San Joaquin Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). • During Open Enrollment only, members may join as an individual or as a group with your employees. • Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families). • Pay no deductible on oral exams, x-rays and routine cleanings. Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on January 1, 2014. Call a Client Advisor at 800-842-3761 for more information. Or visit www. CountyCMAMemberInsurance.com to download a brochure and application.
FALL 2013
In The News
IN THE
NEWS San Joaquin General is one of the top 20% of all hospitals in the U.S. earning the distinction of Top Performer on Key Quality Measures for attaining and sustaining excellence in accountability measure performance. The ratings are based on an aggregation of accountability measure data reported to The Joint Commission during the 2012 calendar year.
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San Joaquin General Hospital Top Performer on Key Quality Care Measures San Joaquin General Hospital today was named Top Performer on Key Quality Measures® by The Joint Commission, the leading accreditor of health care organizations in America. The Joint Commission recognized San Joaquin General Hospital for exemplary performance in using evidence-based clinical processes that are shown to improve care for certain conditions. The clinical processes focus on care for heart attack, pneumonia, surgery, children’s asthma, stroke and venous thromboembolism, as well as inpatient psychiatric services. New this year is a category for immunization for pneumonia and influenza. San Joaquin General is one of the top 20% of all hospitals in the U.S. earning the distinction of Top Performer on Key Quality Measures for attaining and sustaining excellence in accountability measure performance. The ratings are based on an aggregation of accountability measure data reported to The Joint Commission during the 2012 calendar year. The list of Top Performer organizations increased by 77 percent from last year and it represents 33 percent of all Joint Commission-accredited hospitals reporting accountability measure performance data for 2012. San Joaquin General Hospital and each of the hospitals that were named as a Top Performer on Key Quality Measures must: 1) achieve cumulative performance of 95 percent or above across all reported accountability measures; 2) achieve performance of 95 percent or above on each and every reported accountability measure where there are at least 30 denominator cases; and 3) have at least one core measure set that has a composite rate of 95 percent or above, and within that measure set all applicable individual accountability measures have a performance rate of 95 percent
or above. A 95 percent score means a hospital provided an evidence-based practice 95 times out of 100 opportunities. Each accountability measure represents an evidence-based practice – examples include giving aspirin at arrival for heart attack patients, giving antibiotics one hour before surgery, or providing a home management plan of care for children with asthma. San Joaquin General Hospital and all the Top Performer hospitals have demonstrated an exceptional commitment to quality improvement and they should be proud of their achievement,” says Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., president and chief executive officer, The Joint Commission. “We have much to celebrate this year. Nearly half of our accredited hospitals have attained or nearly attained the Top Performer distinction. This truly shows that we are approaching a tipping point in hospital quality performance that will directly contribute to better health outcomes for patients.” “We understand that what matters most to patients at San Joaquin General is safe, effective care. That’s why the Hospital has made a commitment to accreditation and to positive patient outcomes through evidence-based care processes. San Joaquin General Hospital is proud to receive the distinction of being a Joint Commission Top Performer on Key Quality Measures,” said David Culberson, C.E.O. San Joaquin General Hospital. In addition to being included in today’s release of The Joint Commission’s “Improving America’s Hospitals” annual report, San Joaquin General Hospital will be recognized on The Joint Commission’s Quality Check website (www. qualitycheck.org). The Top Performer program will be featured in the December issues of The Joint Commission Perspectives and The Source.
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PAST PRESENT&FUTURE
Story By: Vanessa Armendariz
OF THE SCHOLARSHIP LOAN FUND
HISTORY -
In the 1950’s and 1960’s, polio was taking its toll on the nation, killing and crippling children and adults. At the time, the Salk vaccine was used to treat the disease, but
it was in limited supply. With passion and dedication, local physicians of San Joaquin County were able to offer the vaccine to all residents of the county, free of charge. Although there were no fees associated with receiving the vaccine, patients were kindly asked to make a donation. After raising over $28,000, the physicians were tasked with deciding how to best use the money. Hoping to make a positive impact on their medical community, they decided to create a fund that would provide loans to medical students, thus the Scholarship Loan Fund was introduced.
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SJMS > Scholarship Loan Fund
BOARD OF DIRECTORS: Janwyn Funamura, M.D., Chair Gregg Jongeward, Ph.D., Chief Financial Officer
THE SAN JOAQUIN MEDICAL SOCIETY’S SCHOLARSHIP LOAN FUND WAS ESTABLISHED IN 1962
Elizabeth Grady, Secretary Eric Chapa, M.D. Royce Northcott Matthew Wetstein, Ph.D. Georgette Hunefeld
The San Joaquin Medical Society’s Scholarship Loan Fund was established in 1962 and was granted with the status of being a non-profit corporation in 1964. The original board consisted of: Bruce Nickols, MD; Clarence Luckey, MD; William Brock, MD; and Dr. Robert Burns. Although Dr. Brock referred to Dr. Luckey as being the “prime mover” of getting the fund running, they both were instrumental in being the first financial contributors. The majority of the funds commissions were paid from Intrav, a national travel agency that selected one medical society per state to arrange travel for physicians. In return, the affiliated society was paid a bonus for the trips that were sold throughout the state. Furthermore, Intrav donated additional travel tickets for the Auxilary’s raff le, which also raised more money for the fund. Over time, personal donations from Society members were also contributed. It is important to note that all of the monies donated to the fund were from the medical community. Although the loans were initially awarded only to medical students, they eventually became available to nurses and pharmacists. The loans were generous enough that loan recipients did not have to make
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GENERAL INFORMATION Eligibility: Loans are available to current residents of San Joaquin, Amador and Calaveras Counties. Persons who were born or attended school in these counties are also eligible. Application Deadline: Fall: June 20th Spring: January 1st Loans are available for academic programs for the following areas: M.D., D.O., R.N., F.N.P., and P.A. Loan Amounts: For M.D. and D.O. degrees, students can borrow $10,000 per year, totaling up to $40,000. For non-M.D. applicants, students can borrow $4,000 per year or a maximum of $8,000. Loan Terms: M.D.: Loans are to be paid in full within ten
a payment until after their first year of residency, and no interest was charged over that same period. What started out with only $28,000 has now grown to over one million dollars. As it currently stands, the fund has more money than it does applicants. Therefore, the Board of Directors is taking strides to revamp the fund by making it more appealing to medical students. In recognizing the current shortage of physicians in the San Joaquin County, the Board has new visions on how the fund can help attract graduating medical students to the area.
SJMS ENDOWED SCHOLARSHIP 2004 Dr. Robert Burns, President of UOP from 1946-1971, was one of the original board of directors. Due to his affiliation, he was interested in directing some of the loans to UOP graduates and undergraduates. The loan was first created with the intention of strictly providing loans to medical students and nurses. As time went on, the fund had excess funds. In 2004, two representatives from UOP met with the SLF Board to discuss the potential of setting up a
years of graduation. 1st year of residency: Interest free 2nd – 5th year of residency: Interestonly payments (prime + 1%) 5th year: Principal payments (prime + 3%) Non-M.D.: Interest-free during course of study. Repayment must begin the month following graduation and the loan must be paid in full in 5 years. The interest rate is prime + 3%. Loan Process: The selection of candidates is serious and thorough. After receiving the completed loan application, each student is interviewed by the Board of Directors. Upon approval, the loan funds are dispersed to the student. Each semester, the board requires a current transcript and an update of educational and personal expenses.
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SJMS > Scholarship Loan Fund
scholarship for pre-medical students. They expressed their concern for the students who wanted to stay in the area to complete their upper division pre-medical courses at UOP, but could not afford the tuition. In response, the Board decided to establish The San Joaquin County Medical Society Endowed Scholarship on their 40th anniversary. They started the endowment with $25,000, which yields $1,200 per year. Every year the scholarship supports a UOP student who is a Junior, resident of San Joaquin County for a minimum of 5 years, and/or have graduated from high school and/or a junior college within San Joaquin County. The creation of this scholarship is a great example of what the organization is doing to help local students so that they hopefully return back to the area. Now, ten years later, the Board has a new direction in mind.
ABOUT THE BOARD
FUTURE THE AVERAGE DEBT ACCUMULATED BY PHYSICIANS FROM MEDICAL SCHOOL IS $166,750.
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The Scholarship Loan Fund Board of Directors consists of nine members, three that are nominated by the San Joaquin Medical Society and six that are community members. Currently, both San Joaquin Delta College and the University of the Pacific are represented on the Board, which helps to identify qualified applicants for the loan. Having the representation from both physicians and community members allows for a diverse and unique board. The physicians are able to provide perspective on what it is like to be a premedical and medical student, which is beneficial when analyzing the needs of the applicants. The community members help in giving insight on how to recruit applicants and how to benefit the community at large. Dr. Eric Chapa and Royce Northcott offer a historical perspective because they have served on the board the longest. Royce, who is the wife of the late Eugene Northcott, MD has been a loyal board member since 1977 and is able to enlighten the board on the history and original goals of the fund. She was very active in the San Joaquin Medical Society Alliance, which helped raff le off travel tickets to raise money for the fund. Dr. Janwyn Funamura, Chair of the SLF Board, says “The SLF Board is committed to broadcasting more widely its fine program. We have made a good start with a high-energy board that is now meeting quarterly and doing committee work between meetings as well.”
THE NEED
Primary Care Physician Shortage: “Today, only 16 out of 58 California counties have enough primary care physicians. San Joaquin County has only one primary care physician for every 1,690 citizens while it ranks 47th in health factors such as incidents of adult smoking and obesity.” (The Record, May 12, 2013) Within San Joaquin County, there are seven different Medical
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STEVEN M. THOMPSON PHYSICIAN
Service Study Areas (MSSAs) that are designated as Primary Care Shortage Areas (PCSAs). The factors that are analyzed to be designated as a PCSA include: percent below 100% federal poverty level and the physician-to-population ratio. A score that is greater than or equal to 5 is considered a PCSA. The need for physicians in the valley is increasing and one way to combat this is to help our local students pursue medicine.
CORPS LOAN REPAYMENT PROGRAM The Steven M. Thompson Physician Corps Loan Repayment Program was created in 2002 via legislation sponsored by the Medical Board of California, the California
MSSA
Area
Population
% Poverty Score
Physician: Population Score
PCSA Score
164.2
Banta, Escalon, Ripon, Vernalis
48,730
1
5
6
the California Medical Association.
165
Farmington, Linden
4,805
1
5
6
Mr. Thompson was the former Vice
166
Lodi
64,311
3
4
7
President of Government Relations
167
Lockeford, North Woodridge
35,340
2
5
7
169a
Stockton North Central, Stockton Northeast
95,566
4
4
8
169b
French Camp, Stockton South, Stockton Southeast
131,836
5
0
5
169c
Stockton Northwest, Stockton West
83,061
2
3
5
Primary Care Association, the Latino Coalition for a Healthy California, and
for the California Medical Association. The program was created with the goal of providing improved access to healthcare in underserved communities. Because of the heavy debt burden associated with attaining a medical education, there is little incentive for physicians to practice in underserved areas. To incentivize, the program provides grants of up to $105,000 to physicians agreeing
Percent Below 100% Federal Poverty Level
Physician-to-Population Ratio
Score
Score
to practice in medically-underserved areas of the state for at least three years. In having a three year
5.0% or Less
0
Lower than 1:1,000
0
commitment to the area, the Board
5.1-10.0%
1
1:1000 to 1:1,500
1
hopes that the physicians would grow
10.1-15.0%
2
1:1,500 to 1:2,000
2
15.1-20.0%
3
1:2,000 to 1:2,500
3
20.1-25.0%
4
1:2,500 to 1:3,000
4
million has been awarded to more
25.1% or Greater
5
Higher than 1:3,000
5
than 220 individuals. As you may
roots in their respective communities and stay longer than their three year term. Since its inception, over $17
presume, this program is in high demand. With limited funds, less than Source: Office of Statewide Health Planning and Developing (OSHPD) “Equitable Healthcare Accessibility for California: Primary Care Shortage Areas”
one third of all applicants have been awarded funding. A current CMA bill (AB 565) will modify eligibility requirements so that applicants are
MEDICAL STUDENT DEBT:
required to have three years of experience providing
The road to becoming a physician requires determination, passion, motivation, and money. Although physician salaries generally start at six figures, physicians must begin to repay their loans during residency unless they have loan forbearance. Currently, the average cost of a four year medical school education is $207,868 for public universities and $278,455 for private universities. The average debt accumulated by physicians from medical school is $166, 750, which does not include any premedical education debt or non-education debt. The median stipend for residents is roughly $52, 571 per year. An approximate monthly income-based repayment plan would require a monthly payment of $488, which is relatively high considering the fact that residents may have other financial obligations such as living expenses, house and car payments, bills, and supporting a family. When repaying a loan, students have some options. Residents can pay it off all at once, they can choose to make income-based payments for the duration of the loan, they
health care services. The bill also gives preference
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to applicants who are committed to serving an underserved population that is located in a federally designed shortage area. CMA President, Dr. Paul Phinney, sums it up well saying, “with millions of new patients entering the health care system in the coming year, we must do all we can to incentivize providers to practice where they are most needed.”
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February 2013: Joint Commission Awards San Joaquin General Hospital Certification as a Primary Stroke Center.
August 2013: San Joaquin County Emergency Medical Services Agency Designates San Joaquin General Hospital as a Level III Trauma Center. For both Stroke and Trauma patients, San Joaquin General Hospital is prepared with physicians and surgeons at the ready 24/7. Frontline medical response teams conduct telecommunication in route with San Joaquin General’s inhouse team. This time saving technology and teamwork greatly increases the possibility for a positive outcome.
These new services result in a better community for all.
500 W. Hospital Rd. ■ French Camp, CA 95231 209.468.6000 ■ www.sjgeneralhospital .org
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SJMS > Scholarship Loan Fund
can have forbearance during residency and then make standard payments or they can undergo an extended repayment program. As with any loan, the longer the repayment plan, the more interest is incurred. The interest on a substantial loan can result in a total repayment that is more than double the initial loan amount. Alternatively, there are public loan forgiveness programs as well as advisor programs available to qualified individuals. Source: www.AAMC.org/FIRST
NEW INCENTIVES After recognizing the growing need for physicians here in the San Joaquin County, the SLF Board of Directors is planning on providing an incentive to the loan recipients to practice locally. Dr. Chapa, who has been on the board since 1983, admits that the program “hasn’t changed much. It’s finally evolving now and I think that’s a good thing because we have been rather stagnant in our approach. I think at this point that with all of the changes in medicine we need to adapt the tools we have to fit the times we live in now.” When asked for recommendations on how the SLF Program can be approved, Dr. David Lim, a 1986 SLF loan recipient, “recommend[s] that
To be considered for an award, applicants must: • Have a valid, unrestricted license to practice medicine in California • Be free of any contractual service obligations (i.e. the National Health Service Corps Federal Loan Repayment Program or other financial incentive programs) • Have outstanding educational debt from a government or commercial lending institution • Be currently employed or have accepted employment in a federally designated “health professional shortage area” in California • Commit to providing full-time direct patient care in a HPSA for a minimum of three (3) years For application, eligibility and program questions, call the Health Professions Education Foundation at (800) 773-1669 or visit http://www.healthprofessions. ca.gov.
IN TAKING THE ADVICE OF PREVIOUS SCHOLARSHIP RECIPIENTS THAT ARE CURRENTLY PRACTICING IN THE AREA, THE BOARD RECENTLY APPROVED FORGIVING THE INTEREST ON THE LOAN IF THE RECIPIENT DECIDES TO PRACTICE IN THE SAN JOAQUIN COUNTY.
San Joaquin Valley PRIME Program The UC Merced San Joaquin Valley Program in Medical Education (SJV PRIME) at UC Davis School of Medicine is collaboration between the UC Davis, UC Merced and UCSF Fresno. The program emphasizes quality of care in community-based research and educational experiences as an innovative approach to train future physicians. The overall goal of PRIME
for those students who come back and practice in the area, especially in primary care specialties where we have a shortage of physicians, that the loan be forgiven.” Dr. Richard Waters, a loan recipient from 1998, agrees in recommending to “lower interest rate or give loan forgiveness to those who return to the community to practice.” In taking the advice of previous scholarship recipients that are currently practicing in the area, the board recently approved forgiving the interest on the loan if the recipient decides to practice in the San Joaquin County. There is no minimum commitment, but the interest will only be forgiven for every full year they were practicing here. Royce Northcott feels that forgiving the interest “will be a big benefit and well worth the money” because it’s “not only helping medical students, but helping our community.” Furthermore, it is imperative that physicians connect with other local physicians and health care providers to establish a professional network of relationships. When coming back to a community after being gone for an extended period of time, it can be difficult for physicians to acclimate. To this point, the SLF has agreed to pay for the first year of membership to the San Joaquin Medical Society and the California Medical Association. Members of SJMS and CMA receive many benefits, including discounts, special resources, action alerts and workshops. More importantly, they become part of a large and diverse group that has a powerful legislative impact on the future of medicine and their ability to treat their patients as they see fit. Physician Members can build a vast network of connections throughout the medical community, which is advantageous when assimilating into the community. When asked whether or not receiving a loan through SLF had an impact on where he decided to practice, Dr. Waters says, “it did not, but could inf luence decisions if it were restructured.” The Board of Directors hopes that this added benefit will enable physicians to have stronger relationships with the medical community and their patients, which could potentially attract our locally grown physicians to stay in this area.
programs statewide is to “increase the diversity of the medical profession and remedy the uneven distribution of physicians in California.” The SJV PRIME is a tailored clinical track for medical students who are committed to ensuring high quality and diverse medical care to improve health for communities and individuals in California’s San Joaquin Valley. Students in the program receive their M.D. from UC Davis and have the option to pursue a Master’s degree at UC Merced or an alternate university. Applying a community-based approach, the medical students participate in local volunteer opportunities and they complete their clinical rotations at various valley hospitals and clinics while based out of UCSF Fresno for their entire third year of medical school. This allows the students to be more connected with the type of communities that they may serve in the future. Students who are interested in applying must meet all of the requirements of the UC Davis School of Medicine and should apply through the regular UC Davis School of Medicine admissions process. Applicants who are invited to complete the UC Davis Secondary Application will be offered an opportunity to express interest in the SJV PRIME.
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SJMS > Scholarship Loan Fund
Program Goals: • Provide an experience that leverages communityacademic collaboration to improve the health of populations. • Prepare medical students from diverse backgrounds who have a strong interest in practicing in California’s San Joaquin Valley to serve as physician leaders. • Increase the number of UC Davis School of Medicine graduates who are leaders in the provision of high quality, equitable healthcare services. Program Impact on the San Joaquin Valley
A NEW DIRECTION With a new direction in mind, the Board decided to invest a sum of money into the Community Foundation of San Joaquin and Bank of Stockton. The Community Foundation is a tax exempt public charity that enables organizations to establish charitable funds. One of the benefits of this is the fact that the SLF will now be included on the growing list of “Agency Funds,” which makes our fund visible to various charitable givers. Furthermore, the profits made from both the Community Foundation funds can be used towards funding the new incentives that the board has made available. Dr. Janwyn Funamura, current Chair of the SLF Committee, adds, “our recent decision to place some of our funds with Community Foundation of San Joaquin will raise our profile in the community, as we take advantage of CFOSJ’s marketing efforts through its contacts, website, and publications.”
• Strengthen the desire for new physicians to practice in the Valley – one of California’s most medically underserved areas • Reduce disparities and inequalities related to the
HOMEGROWN PHYSICIANS Eric Chapa, M.D. is a Family Practice Physician here in Stockton, CA. He has been a loyal member of the Board since 1983, serving as the Chair from 2009-2012. Although he joined
health care in the Valley • Improve the health status of Valley residents • Form lasting relationships with communities, hospitals, clinics and physicians to enhance health care in the region G.L. ADVISOR
“THIS IS MY HOME AND THIS IS WHERE I WANT TO BE. I NEVER REALLY CONSIDERED PRACTICING ANYWHERE ELSE. THERE WAS NO CHANCE THAT I WOULDN’T PRACTICE IN STOCKTON.”
Another program that can help residents and physicians with student debt is the GL Advisor, which was created by members of Graduate Leverage (GL). The GL Advisor provides professionals with a service that facilitates financial well-being during the time in their life that is busy and hectic. They provide resources and assistance with debt repayment, debt relief programs, personal financial matters, and more. The goal of this advisory service is to help students “fully understand their options, make better decisions regarding debt, and implement solutions to improve their financial well-being.” A common option that many medical students consider is forbearance to postpone loan payments during residency. Although forbearance offers payment relief for a few years, it will ultimately increase an already significant medical school debt burden due to the accrual of interest. Therefore, the advisors help students utilize federal student debt relief programs such as Income-Based Repayment (IBR) and Public Service Loan Forgiveness (PSLF), which help lower the monthly payments. In having professional advisors handle their educational finances, residents and medical students can save time while focusing their attention on their career in medicine. For more information, visit www.gladvisor. com.
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the Board in 1983, his association with the SLF goes back to 1975 when he received a loan for medical school. Dr. Chapa had a very close relationship with Fuad Nahas, M.D., who was on the Board of Directors. Dr. Nahas was Dr. Chapa’s major professor at the University of the Pacific and was the one who encouraged him to apply. Dr. Chapa was in the military overseas when he learned of his acceptance into medical school. He expressed that the loan gave him respite as he transitioned to medical school. He attended UC Irvine School of Medicine and completed his residency at San Joaquin General Hospital, through a program at UC Davis Medical Center. Dr. Chapa is the epitome of the type of individual that SLF seeks to help. Dr. Chapa was raised in Stockton, went to Amos Alonzo Stagg High School, completed his undergraduate studies at the University of the Pacific, received his medical degree from UC Irvine School of Medicine, and did his residency training at our local San Joaquin General Hospital. When asked why he chose to come back to Stockton, Dr. Chapa replied, “This is my home and this is where I want to be. I never really considered practicing anywhere else. There was no chance that I wouldn’t practice in Stockton.” People tend to stay connected to where they were born or raised for many reasons. Some will come back to their communities because of their family and friends, but some also want to give back to their hometown. Dr. Chapa’s role in SLF has come full circle. He went from being the loan recipient to one of the loan grantors. His personal experiences and passion towards helping serve the medical community in Stockton is truly admirable and he is a prime example of the physicians that the board hopes to serve. Jamie Funamura, M.D. is a current SLF loan recipient who is a fourth year resident physician at the University of California, Davis in the Otolaryngology-Head and Neck Surgery Department. She is from Stockton California and attended Tokay High School and Stanford University. Her father, Jack Funamura, M.D., and her mother, Janwyn Funamura, M.D., are both physicians in the San Joaquin County and they informed her about the loan. Dr. Janwyn Funamura is the current Chair of the SLF and has been very active in
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Lodi Memorial Hospital Acute Physical Rehabilitation 23 years of specialized, inpatient rehabilitation services for stroke, brain-injury, spinal-cord-injury, multiple-trauma patients and patients with other neurological conditions
The county’s only acute, inpatient physical-rehabilitation program, featuring:
Emphasis on regaining independence for safe transition home Coordinated physical, occupational, speech and recreational-therapy sessions, three hours per day State-of-the-art technology for neurologic training Dedicated 24-hour care by rehabilitation-trained, experienced nurses Daily physician visits Outdoor areas for functional activities Private rooms and room-service meals
Our 2013 outcomes Functional Independent Measurement Length of stay Discharge to community
Lodi Memorial Hospital Acute Physical Rehabilitation Ramnik Clair, MD, Medical Director 209/712-7905 Tel 209/333-3082 Fax 975 S. Fairmont Ave., Lodi, CA 95240 WINTER 2013
Lodi Memorial
Nation
32.4 12 87.1%
28.7 15.9 73.7%
www.lodihealth.org SAN JOAQUIN PHYSICIAN
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SJMS > Scholarship Loan Fund
her new executive role. As the mother of a medical community. In providing financial and dedication that our local physicians loan recipient, she has been able to provide assistance to local residents who are pursuing had for San Joaquin County. Their initial a valuable perspective on how to further medicine, SLF hopes that they can help goal of strictly providing loans to medical improve the loan fund. Although Dr. Jamie recruit students to stay and practice in the San and nursing students has now evolved to Funamura “hopes to serve the Northern California and Central Valley area after completing her training, she is looking to stay in academic medicine at a children’s hospital, THE PHYSICIAN SHORTAGE IN SAN JOAQUIN COUNTY IS which unfortunately Stockton does not yet AFFECTING NOT ONLY OUR OTHER LOCAL PHYSICIANS, BUT have.” ALSO THE COMMUNITY. Richard Waters, M.D. FACC and David Lim, M.D. FACC are both Cardiologists at the Stockton Cardiology Medical Group. They were both SLF loan recipients and have decided to practice locally. Dr. Waters went to Joaquin County. Although this will not solve providing even more incentives to helping our Stagg High School, Stanford University, and the physician shortage, it is definitely a step homegrown professionals return. The Board Vanderbilt University School of Medicine. He forward in reducing the problem. For the past of Directors is very optimistic that their new completed his internal medicine internship 52 years, SLF has assisted many physicians endeavors will make a positive impact on our and residency at Johns Hopkins Hospital and nurses to finance their education. As community. and his interventional cardiology fellowship of today, 314 people have received a loan at Duke Hospital. Although he attained his through the fund, totaling to $3,602,046. medical education and experiences across The Scholarship Loan Fund would not the country, he “came back to Stockton in have been possible without the passion order to be closer to family and to practice medicine in [his] hometown.” Dr. Lim went to Lincoln High School, UC Berkeley, and Albert Einstein College of Medicine in New York. He completed his residency at University of California San Francisco. Helping Families Cherish Life Similar to our other loan AseraCare Hospice® provides quality, compassionate care when you need it most. Our family-centered, holistic approach ensures that the needs and wishes of our recipients, Dr. Lim “felt it was a patients and their families are met when faced with life-limiting illness. great opportunity to be able to practice in the community [he] Our services include: grew up in and to be close to • Physician managed care family.”
THE FUTURE OF THE SCHOLARSHIP LOAN FUND The physician shortage in San Joaquin County is affecting not only our other local physicians, but also the community. With the new health benefit exchange, Covered California, there will be a surge of new patients and the physician shortage will have an even greater impact on the
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• Admissions 24 hours a day, seven days a week • End-of-life decision making assistance • Special veterans recognition
Rated above average by CalQualityCare.org AseraCare Hospice–Stockton 2529 W. March Lane, Ste. 101 Stockton, CA 95207 209-474-8349 www.AseraCare.com
For more information, contact us today.
This facility welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, gender, sexual orientation or source of payment. AHS-10269-13
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FREQUENTLY ASKED QUESTIONS about California’s Health Benefit Exchange for Physicians and their Staff
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CMAF > Covered California
COVERED CALIFORNIA In 2010, Congress passed historic sweeping health care legislation, the Patient Protection and Affordable Care Act (ACA), which reformed the individual and small group health insurance markets and, beginning in 2014, will provide health insurance to much of the nation’s uninsured. Under the ACA, two-thirds of California’s uninsured may be covered by private insurance through a health insurance exchange purchasing pool. California’s exchange, Covered California, began enrollment on October 1, 2013 – with coverage beginning on January 1, 2014. The following FAQ for physicians and their office staff provides answers to the most commonly asked questions about exchange eligibility and enrollment.
What is Covered California? Covered California is the new marketplace where Californians can compare and purchase health coverage. Through Covered California, many patients will be eligible for financial assistance to help pay their premiums and even co-pays. Through Covered California, individuals and small businesses can compare different health insurance companies and learn whether they qualify for premium assistance and tax credits. Californians will also be able to find out if they are eligible for low-cost or no-cost health coverage through Medi-Cal.
How will Covered California impact my practice? The impact on physician practices will vary greatly depending on the mix of patients in your practice and the extent to which you contract with Covered California plans. Millions of previously uninsured Californians will now be eligible for health insurance through Covered California and Medi-Cal. Your patients with employer-sponsored coverage are not likely to see significant changes in their coverage. Small and medium sized physician practices with 50 employees or less are also eligible to participate in the Small Business Health Options Program (SHOP). For more information, visit www.coveredCA.com.
Which patients can buy coverage through Covered California? Legal California residents, except for currently incarcerated individuals and legal minors, are eligible to buy insurance through Covered California.
Which patients are eligible for subsidies through Covered California to purchase coverage? Premium assistance is available to individuals and families who meet certain income requirements and do not have access to affordable, adequate health insurance through their employers. Eligibility for premium assistance is based on family income and the number of people in the family. The size of the premium assistance is calculated on a sliding scale, with those who make less money getting more financial assistance. Individuals with incomes up to $45,960 and a family of four with an income up to $94,200 may be eligible for premium assistance.
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EXCHANGE RESOURCES FOR PHYSICIANS The California Medical Association (CMA) has developed several resources to help educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting. Among those resources is "CMA's Got You Covered," a physician's guide to Covered California. This resource is FREE to members and provides a comprehensive overview of the Affordable Care Act and the exchange, key issues to watch and things to consider when deciding whether to contract with an exchange plan. This guide and other exchange-related resources are available at www.cmanet.org/ exchange. Additionally, CMA members and their staff have free one-on-one access to CMA's practice management experts through the CMA reimbursement helpline at (888) 401-5911 or economicservices@cmanet.org.
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CMAF > Covered California
How will patients’ federal premium subsidies work? Federal premium assistance is only available when enrolled in a health plan through Covered California, and it is paid directly to the health plan in which the patient is enrolled. Premium assistance will be adjusted at the end of the benefit year based on the patient’s actual income. A patient may be held accountable for any excess subsidies received when filing that year’s taxes. For this reason, patients should immediately report any changes in income to Covered California that may impact the amount of premium assistance, such as changing jobs, losing a job or receiving a promotion.
Will my Covered California patient be able to continue to see me? You will have to be contracted with a Covered California plan and your patient will have to select that plan. Each health insurance plan has a specific list of doctors and hospitals that are considered in-network providers for covered services. Directories of doctors and hospitals will be available at www.CoveredCA.com. Patients should be advised to verify with the individual plan that a particular doctor’s or hospital’s services will be covered under that plan. Covered California is providing a searchable online directory so that patients can see which health plan networks contain a particular doctor or hospital.
How can a patient apply for Covered California coverage or Medi-Cal? Open enrollment will continue until March 31, 2014, but patients must enroll in a plan by December 15, 2013, for coverage to begin January 1, 2014. In subsequent years, open enrollment will run from October 15 through December 7. Patients can apply for a Covered California health insurance plan online at www.CoveredCA.com or by calling (800) 300-1506. In-person assistance is also available from Certified Enrollment Counselors in many communities. Patients can be directed to their nearest Certified Enrollment Counselor by calling (800) 300-1506.
What if I have questions about how my business may be impacted by Covered California or health plan contracting under Covered California? If you have questions related to your business or contracts for providing services to Covered California patients, please refer to the California Medical Association’s (CMA) resource page, “Health Insurance Exchange Resources for Physicians,” at www. cmanet.org/exchange. For further assistance, please contact CMA’s Physician Hotline at (800) 786-4262. How much should patients expect to pay out of pocket for health care services? Patients’ co-pays and deductibles will vary based on the plan that is selected. (See chart on reverse.)
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CMAF > Covered California
Standard Benefits for Individuals KEY BENEFITS
Platinum
Gold
Silver
(Lower Cost Sharing Available on Sliding Scale)
Copays In the Yellow Sections are Not Subject to any Deductible and Count Toward the Annual Out-of-Pocket Maximum
Bronze
Benefits In Blue are Subject to Deductibles
Deductible (if any)
No Deductible
No Deductible
$2,000 Medical Deductible
$5,000 Deductible for Medical and Drugs
Preventative Care Copay
No Cost – at least 1 yearly visit
No Cost – at least 1 yearly visit
No Cost – at least 1 yearly visit
No Cost – at least 1 yearly visit
Primary Care Visit Copay
$20
$30
$45
$60 – 3 visits per year
Specialty Care Visit Copay
$40
$50
$65
$70
Urgent Care Visit Copay
$40
$90
$60
$120
Generic Medication Copay
$5
$20
$25
$25
Lab Testing Copay
$20
$30
$45
30%
X-Ray Copay
$40
$50
$65
30%
Emergency Room Copay High cost and infrequent services like Hospital Care and Outpatient Surgery
$150
$250
$250
$300
HMO Outpatient Surgery – $250 Hospital – $250/day up to 5 days
HMO Outpatient Surgery – $600 Hospital – $600/day up to 5 days
$250
30% of your plan’s negotiated rate
PPO – 10%
PPO – 20%
Imaging (MRI, CT, PET Scans)
$150
$250
$250
40%
Brand medications may be subject to Annual Drug Deductible before you pay the copay
No Deductible
No Deductible
$250 deductible then pay the copay amount
$50-$75 after meeting deductible
Preferred brand copay after Drug Deductible (if any)
$15
$50
$50
$50
MAXIMUM OUT-OF-POCKET FOR ONE
$4,000
$6,350
$6,350
$6,350
MAXIMUM OUT-OF-POCKET FOR FAMILY
$8,000
$12,700
$12,700
$12,700
Patients can learn more about their plan options and available subsidies at www.coveredca.com.
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Public Health
Update
Normalizing HIV Testing in Clinical Settings:
The benefits of early detection and treatment: Prevention and Control Background About 1150 persons are currently known to be living in San Joaquin County (SJC) with Human Immunodeficiency Virus (HIV) infection, though this figure is likely an underestimate of the true prevalence in SJC. The Centers for Disease Control and Prevention (CDC) estimates that about 20% of individuals with HIV infection are unaware of their positive status. Furthermore, 33% of newly diagnosed HIV-infected persons
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in the United States are considered ‘late-testers’, meaning they develop Acquired Immunodeficiency Syndrome (AIDS) within one year of initial HIV diagnosis. In SJC about 50% of cases are simultaneously diagnosed (within 30 days) with both HIV and AIDS. While this phenomenon is observed across all racial/ethnic groups in SJC, African Americans and Hispanics are the most likely to have an AIDS-positive status at time of HIV diagnosis. The high proportion of individuals simultaneously diagnosed indicates that SJC
SCREENING RECOMMENDATIONS The U.S Preventive Services Task Force (USPSTF) recommends providers screen for HIV infection in all adolescents and adults aged 15 to 65 years. Individuals at increased risk for HIV infection, regardless of age, should be screened at least annually. It is important that patients understand that the HIV screening test will not be positive immediately after an exposure. The window period for HIV antibodies to show up in a screening test ranges from two weeks to six months after HIV infection. HIV testing should be included in the routine panel of prenatal screening tests for all pregnant women and should be repeated in the 3rd trimester for highrisk patients. Also, all patients with either tuberculosis disease or latent TB infection should be screened for HIV infection with opt-out screening. For more detailed USPSTF screening recommendations, see http://www. uspreventiveservicestaskforce.org/uspstf/ uspshivi.htm. For more information call the San Joaquin County HIV/AIDS Program at 209-468-3820.
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providers are not routinely offering patients HIV testing, and not considering the possibility of HIV infections until patients display symptoms of AIDS. Since clinical latency of HIV can exist eight years or longer before progression to AIDS, individuals simultaneously diagnosed have been exposing others in the community for years before becoming aware of their status. Alternative explanations for the high proportion of individuals simultaneously diagnosed in SJC include poor health care access and utilization among some high-risk groups.
Benefits of Routine Screening for All Patients It is strongly recommended that health care providers adopt a policy of routine HIV screening for all patients. This reduces the stigma associated with testing and is an effective strategy for identifying unknown infections, which in the long run reduces the burden of HIV in the community. Routine screening for HIV infection empowers patients to know their status and, if HIV positive, to initiate care and treatment. Early initiation of combination antiretroviral therapy (ART) when CD4 counts are high and patients are still asymptomatic is associated with reduced progression to AIDS, and decreased AIDS-related morbidity and mortality. Evidence also shows that early initiation of ART can reduced risk for transmission of HIV to uninfected sexual partners, thereby reducing the incidence of new infections in the community. Treatment of HIV-infected pregnant women with ART dramatically reduces rates of mother-child transmission. Also identifying HIV in patients who have comorbidities with other infectious diseases (e.g. tuberculosis, hepatitis C) can decrease morbidity and mortality.
Top: Evidence also shows that early initiation of ART can reduced risk for transmission of HIV to uninfected sexual partners, thereby reducing the incidence of new infections in the community.
Opt-out HIV Screening Process In 2006, the CDC revised their HIV screening recommendations [MMWR Sept 22 2006/55(RR14)], promoting the use of opt-out screening with general medical consent for HIV testing. These recommendations are supported by the recent passage of California Assembly Bill 446. This bill allows California medical providers to legally use opt-out screening and eliminates the need for providers to obtain separate written consent for HIV testing. In opt-out screening the patients must be notified verbally that they are being tested, that they have the right to decline testing, and that testing is strongly recommended. If appropriate, also inform the patient that there are numerous treatment options
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available if the test is positive for HIV. The patient’s verbal consent or declination is to be noted by the medical provider in the chart.
Testing Options The conventional laboratory algorithm for HIV serology testing (measuring the antibody response) is the repeatedly reactive immunoassay serum test followed by confirmatory Western blot or immunofluorescent assay. Results are highly accurate and may be available within one to two days depending on the laboratory. Screening
with the rapid HIV blood or oral fluid test can provide results in less than 40 minutes and are also fairly accurate, but need to be confirmed by conventional laboratory testing. The U.S. Food and Drug Administration recently approved the OraQuick In-Home HIV screening test kit for sale in-stores and online. This rapid screening test also requires confirmatory testing with a conventional laboratory test. There is also a new HIV screening test which detects both the p24 antigen and the HIV antibodies together. Other tests include both qualitative and quantitative HIV-1 RNA antigen testing.
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practice manager Free to SJMS/CMA Members!
resources
The Office Manager’s Forum empowers physicians and their medical staff with valuable tools via expert led educational sessions from industry professionals who are committed to delivering quality health care. For more than 130 years, the San Joaquin Medical Society (SJMS) has been at the forefront of current medicine, providing its physician’s and their staff with assistance and valuable practice resources. SJMS is proud to offer the Office Manager’s Forum, a monthly educational seminar designed to enhance the healthcare environment with professional development opportunities while providing solutions to some of the challenges that come from managing a practice. Attendees gain knowledge on a broad array of topics related to the field of medical staff services, office management, billing and coding, human resources, accounting and back office support. The Office Manager’s Forum is held on the second Wednesday of each month from 11:00AM – 1:00PM at Papapavlo’s in Stockton and includes a complimentary lunch. Attendance is always FREE to our members. Non-members are welcome and may attend for one month at no cost to experience one of the quality benefits that comes with Society Membership ($35.00 thereafter). Registration required. For more information or to be added to the mailing list email Jessica Peluso, SJMS Membership coordinator, at Jessica@SJCMS. org or call (209) 952-5299.
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DECEMBER 11TH, 2013: “MEDICARE UPDATE 2014” 11:00AM to 2:00PM
Join us for our annual Medicare Update workshop for physicians and office staff. This 3 hour seminar will cover relevant information about current, future and proposed changes for the coming year. Michelle Kelly, Associate Director, CMA’s Center for Economic Services, provides one-on-one assistance to physician members and their staff on reimbursement and practice operations issues. Assistance ranges from coaching and education, to direct intervention with payors or regulators.
JANUARY 8TH, 2014:
ARE YOU READING CPR? CPR contains the latest in Practice Management Resources, Updates and Information.
“TOP THREE COMPLIANCE IMPACTS ON REVENUE” 11:00AM to 1:00PM
The Top Three Compliance Impacts on Revenue including the new CMS 1500 billing form, CMS Physician Fee Schedule and ICD-10 transition from a compliance perspective will all be discussed at this Office Managers Forum. Amy Germann, MBA, FACMPE HEALTH CARE CONSULTING MANAGER Amy has more than 20 years of experience helping physicians, hospitals and ambulatory surgery centers with performance, business development, strategic planning and effective governance.
FEBRUARY 12TH, 2014: “ENVIROMERICA” 11:00AM to 1:00PM
Hopefully you have already heard and taken advantage of the recent Member Benefit through Enviromerica. If not, then this presentation is a must-see. Save 30% or more on your regulated medical waste costs. CMA members can take advantage of this special offer right now. When you attend our next Office Managers Forum, you’ll have the opportunity to hear from Julian Goduci, CEO of Enviromerica. Julian is an expert not only of regulated medical waste but also Compliance. He’ll be joining us for our February Forum so be sure to attend and receive all the details. Julian Goduci has been a professional business and practice liability consultant in the healthcare industry for over 17 years. His expertise in practice management, regulatory compliance, accreditation, and medical waste management is well known in the industry.
MARCH 12TH, 2014:
“HOW DO PATIENTS USE THE INTERNET AND SMARTPHONES TO FIND PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS AND SERVICES” 11:00AM to 1:00PM
Over 80% of the people online use the Internet to find physicians and healthcare professionals. You will be learning tips on how to reduce staff calls and improve being found online. Basics also of having a website that can be used on smartphones. Steve Morales, Mayaco Marketing & Internet; “At MAYACO we design websites that work for YOU and your clients. Each one is completely custom with a design and functionality that fit your needs and those of your customers.”
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May 2012
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CMA Practice Resources (CPR) is a free monthly e-mail bulletin from CMA’s Center for Economic Services. This bulletin is full of tips and tools to help physicians and their office staff improve practice efficiency and viability.
SUBSCRIBE NOW Sign up now for a free subscription to our e-mail bulletin, at www.cmanet.org/news/cpr
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Legisl Wrap
lative p Up A Year of
Challenges, Victories CMA’s 2013 Legislative Wrap Up By Juan Carlos Torres, CMA VP of Government Relations
This year turned out to be a challenging year for the California Medical Association (CMA). We knew going into the legislative session
that 2013 would be a historic year, with the implementation of the Affordable Care Act (ACA) and the wave of legislative freshman. It lived up to our expectations.
With the beginning of each session, there are new legislators that come to Sacramento from all walks of life. CMA’s government relations
team is challenged with getting to know them, educating them on issues of importance to the physician community and identifying the physicians with whom they have—or should have—relationships. While the Legislature has had up to one third of its members turn over in any given year, this year a majority of legislators were new to Sacramento. The challenging task of educating the new class was magnified. In addition, 2013 included 12 special elections that resulted from various vacancies created by departures and resignations. CMA faced an unprecedented number of scope of practice expansion bills introduced in the Legislature. These scope bills were painted by supporters as necessary reforms to help implement the ACA. Those who wanted to expand scope had a key message: we need allied health professionals, including nurse practitioners, optometrists and pharmacists, to do more in order to prepare for the many Californians added to California’s health care system through the ACA implementation. Our message was simple: we will not jeopardize patient safety and we need to promote integration of allied health professionals, not fragment them as these proposals suggested. We faced a concerted effort by the nurse practitioners, optometrists and pharmacists who joined together to push their agenda collectively. They put in significant resources to mount a public relations campaign and were actively pursuing newspaper editorial boards across the state to promote their agenda. With the help of our specialty partners and our local medical societies, CMA won the argument in the Capitol. >>
CMA > Legislative Wrap Up 2013
Legisl Wrap ______________________________
Moving the Physician Agenda Forward
______________________________
We successfully defeated the attempt by nurse practitioners to gain independent practice in California, as well as efforts by optometrists seeking to diagnose and treat diseases in patients. CMA significantly narrowed the pharmacists’ proposal to ensure that they could provide reasonable services in an integrated and safe manner that promoted collaboration with physicians. CMA also tackled the incorrect perception that physicians are at the center of the opioids overdose crisis occurring in California. Physicians recognize the need to help ensure appropriate prescribing and the need to tackle abuse and diversion of prescription drugs. We helped craft a proposal that will ensure that our state’s prescription monitoring program, CURES, will be upgraded and funded. CMA also secured a streamlined application process for CURES, a requirement that a stakeholders group be consulted as the upgrade and maintenance occurs, and a reduced fee impact on physicians. Most importantly, there will be no mandated participation required of physicians. A proposal that would have given the medical board overly broad power to discipline physicians for inappropriate prescribing was soundly defeated by CMA in an overwhelming fashion on the Assembly floor. CMA was also able to garner amendments to a bill that would have required coroners to report overdose deaths due to controlled substances to the medical board, to ensure that any reports submitted by coroners
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would remain confidential. (This bill, SB 62, was ultimately vetoed.) In addition, an effort to shift the investigative authority from the Medical Board of California to the Department of Justice was defeated. The trial attorneys’ campaign to eviscerate the Medical Injury Compensation Reform Act (MICRA) was also in full gear this year. Trial attorneys invested heavily in three additional lobbyists and launched a public relations campaign titled “38 Is too Late,” and made several attempts to push a bill through the Legislature. All these efforts resulted in no action in the Capitol, not even the introduction of a bill, a major victory for CMA. While CMA is proud of our legislative victories this year, we understand that these battles will continue next year. Trial attorneys are initiating a ballot fight, allied health professionals will continue to call for inappropriate scope expansion and legislators will continue to focus on prescription drug abuses. CMA will continue to be the voice of the physician community and is prepared to take on these challenges. Many of our fights garnered significant media attention. The Sacramento Bee outlined the five major battles facing the Legislature in the closing month of session. Of the five battles, CMA was front and center on two—each of which CMA won!
xCMA didn’t just play defense. CMA made significant progress in moving our proactive agenda forward this year. After several failed attempts in years prior, CMA partnered with local legislators to successfully secure an annual $15 million appropriation to fully fund the University of California, Riverside School of Medicine, which will be the first new four-year medical school established in California in over 40 years. The effort began this year with two CMA-sponsored bills introduced by newly elected Inland Empire legislators (SB 21 and AB 27), but eventually the conversation shifted to the budget process. Following the approval of the funding in the 2013-2014 state budget, the school welcomed its first class of four-year medical students this fall. The budget also included $3.9 million to upgrade the CURES database, $1.6 million of which was from the Medical Board of California contingent fund (licensing fees). The other professional licensing boards contributed the remainder. The funds are one time in nature and are exclusively for the upgrade of the database platform. While this funding was taken from medical board reserves, we were able to defeat attempts to have new licensing fees pay for this upgrade. We also advanced our efforts to prioritize the need to increase Medi-Cal provider rates. There were two bills introduced in each house that called for this increase. A new coalition, We Care for California, was formed to advocate for that increase. With CMA playing a key role and under the new We Care for California banner, thousands of health care providers from across the state converged on the state capitol in the largest ever health care rally in Sacramento. The historic event, called “WE ARE MEDI-CAL,” included administrators, physicians and frontline health workers from every region of the state. CMA sponsored legislation addressing the need to provide incentives to encourage physicians to practice in underserved communities. Addressing workforce issues, not scope expansion of allied professionals, is the long term solution to the physician distribution issues faced in California. Two CMA-sponsored bills (AB 565, AB 1288), both signed by Governor Brown, will encourage
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lative p Up physicians to locate their practices in the Central Valley, Inland Empire and other underserved regions of our state. There is no doubt that CMA faced a many battles this year, but thanks to the advocacy of the physician community and our government relations team, we won these battles. Bills that we opposed were either defeated or significantly amended to address our concerns. Our sponsored bills, with the exception of two, advanced to the Governor and have been signed. CMA has again demonstrated the important role it plays in shaping health policy in Sacramento. As always, CMA will be prepared to lead our state forward. Below are details on the major bills that CMA followed this year. ______________________________
CMA-Sponsored Legislation
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SB 21 (Roth): UC Riverside Medical School
This bill appropriates $15,000,000 annually from the General Fund to the Regents of the University of California for allocation to the School of Medicine at the University of California, Riverside. According to a 2010 report by the California Health Care Foundation, the Inland Empire has the lowest ratio of primary care physicians and specialists of any region in the state. The Council on Graduate Medical Education, a federally funded and authorized group that assesses the physician workforce and reports to federal policymakers, recommends a minimum of 60 to 80 primary care physicians and 85 to 105 specialists per 100,00 people. Sadly, the physician and specialist ratio in the Inland Empire is barely half of that recommended number. The UC Riverside School of Medicine is a critical factor in addressing this need, and consistent state funding is needed for the school to maintain its accreditation.
Status: Signed by the Governor.
SB 640 (Lara): Medi-Cal: Reimbursement Provider Payments This bill seeks to restore the 10 percent MediCal provider rate reductions contained in the 2011-12 state budget. CMA has built a coalition of different providers who have been impacted by the cuts or who, like CMA, are still in court over their implementation. This bill would both
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eliminate the retroactive portion of the cuts as well as stop them going forward. This will help provide needed stability to the Medi-Cal system as the state prepares for full federal health reform implementation on January 1, 2014.
Status: Held in Senate Appropriations Committee. AB 565 (Salas): California Physician Corps Program
Ten years ago, CMA sponsored legislation to create the Steven M. Thompson Physician Corps Loan Repayment Program (STLRP) to increase access to primary care physicians in medically underserved areas. Although the STLRP has awarded more than $17 million to over 220 individuals, the high demand for this program means less than one third of applicants are awarded funding. Given the limited funds in this program, this bill will tighten the eligibility criteria of applicants to the STLRP and help identify gaps in placing physicians in the Central Valley, the Inland Empire and other underserved communities.
Status: Signed by the Governor. AB 670 (Atkins): Therapeutic Substitutions
This bill would prohibit pharmacists from receiving a financial incentive for recommending a patient receive a drug that is chemically different from the one prescribed by the physician, a practice known as therapeutic substitution. There has been an increase in consulting contracts with pharmacists that carve out a separate fee each time a therapeutic substitution is recommended. Though the medicine may treat the same condition, the chemical ingredients are not the same. This often results in adverse side effects or ineffective treatment. Patients who are on medication to treat epilepsy or mental health conditions are particularly vulnerable. Therapeutic substitutions should be based upon the patient’s best interest, not a financial incentive.
Status: Held in Assembly Appropriations Committee.
AB 1003 (Maienschein): Employment of Physical Therapists CMA and the physical therapists had introduced competing bills this session, which were ultimately combined into one co-sponsored bill (see AB 1000). CMA’s bill would clarify existing law to explicitly authorize medical corporations to
hire persons licensed under the Business and Professions Code, the Chiropractic Act or the Osteopathic Act. In November 2010, the Physical Therapy Board reversed decades-old policy that allowed physical therapy services to be provided by medical corporations. According to the California Employment Development Department, there are over 15,000 practicing physical therapists in California. Furthermore, California adds about 440 new physical therapy jobs each year. Nearly, 80 percent work in medical corporations, hospitals, home health care services and nursing care facilities. As a result, hundreds of physical therapists across California are at risk of losing their jobs.
Status: Assembly Business and Professions Committee – Hearing Postponed.
AB 1288 (V. M. Perez): Physician Workforce: Medically-Underserved Communities
Assembly Bill 1288 will require the Medical Board of California and the Osteopathic Medical Board of California to develop a process to give priority review status to the application of an applicant who can demonstrate that he or she intends to practice in a medically underserved area or serve a medically underserved population. AB 1288 will not change the vigorous standards that govern these professions but will instead focus the board’s resources on the areas and populations with the greatest need.
Status: Signed by the Governor.
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CMA Co-Sponsored Legislation
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SB 191 (Padilla): Emergency Room Funding
Co-sponsored by the California American College of Emergency Physicians, this bill extends the sunset date to January 1, 2017. The bill raises approximately $50 million to augment local county emergency medical services funds in order to allow counties, hospitals and physicians to continue providing emergency services in their communities with these desperately needed funds. Emergency care in California is in crisis. In the past decade, more than 65 emergency departments (EDs) have closed; ED visits are up; wait times continue
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CMA > Legislative Wrap Up 2013
Legisl Wrap to increase, and hospital diversion is on the rise. Without this bill, the law is set to expire on January 1, 2014.
Status: Signed by the Governor.
AB 1000 (Wieckowski and Maienschein): Physical Therapists: Direct Access to Services and Medical Corporation Employees
CMA and the physical therapists had introduced competing bills this session, which were ultimately combined into one co-sponsored bill (AB 1000). The joint bill clarifies an existing ambiguity in the law so that physical therapists can continue to work within the legal boundaries of medical corporations as they have for decades (as was the intention of CMA’s solo bill). The combined bill also gives health care consumers the ability to seek treatment from a physical therapist without a physicians’ consent for a limited period of time. Although CMA had previously opposed attempts to authorize such “direct access,” we believe that the final language is an acceptable compromise. The bill does not expand or modify the scope of practice for physical therapists, including the existing prohibition on a physical therapists diagnosing disease.
Status: Signed by the Governor.
AB 1176 (Bocanegra): Primary Care Access: Residency Programs
Co-sponsored by the California Academy of Family Physicians, this bill will follow the example of other states and create a funding source for underfunded medical residency training programs by drawing from private payers such as health insurance companies. According to the Council on Graduate Medical Education, 74 percent of California’s 58 counties have an undersupply of primary care physicians, with primary care physicians making up just 34 percent of California’s physician workforce.
Status: Held in Assembly
Appropriations Committee. AB 1208 (Pan): Insurance Affordability Programs: Application Form The provisions that impacted physicians were deleted. The bill now deals with demographic data collection. Therefore we are no longer cosponsoring this bill.
Status: Vetoed by Governor.
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______________________________
Opposed Legislation
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SB 117 (Hueso): Integrative Cancer Treatment
This bill would prohibit a physician and surgeon, including an osteopathic physician and surgeon, from recommending, prescribing or providing integrative cancer treatment, as defined, to cancer patients unless certain requirements are met. The bill would specify that a failure of a physician and surgeon to comply with these requirements constitutes unprofessional conduct and cause for discipline by the individual’s licensing entity. The bill would require the State Department of Public Health to investigate violations of these provisions.
Status: Author pulled bill from Senate Business and Professions Committee.
SB 266 (Lieu): Health Care Coverage: Out-of-Network Coverage
This bill would prohibit a health facility or a provider group from holding itself out as being within a plan network or a provider network unless all of the individual providers providing services at the facility or with the provider group are within their network, or the provider group acknowledges to the patient in writing or verbally that individual providers within the provider group may be outside the patient’s plan network or provider network and the provider group recommends that the patient contact his or her health care service plan or health insurer for information about providers who are within the patient’s plan network or provider network. Those provisions would not apply to emergency services and care.
Status: Held in Senate Appropriations Committee.
SB 312 (Knight): Absences: Confidential Medical Services: Parent or Guardian Consent
This bill would require the governing board of a school district to notify pupils in grades 9 to 12 and their parents or guardians, that school authorities may excuse a pupil from the school for confidential medical services who is 16 years of age or older without parental or guardian consent.
Status: Failed in Senate Education Committee.
SB 430 (Wright): Pupil Health: Vision Examination: Binocular Function
This bill would, before first enrollment in a California school district of a pupil at a California elementary school, and at least every third year thereafter until the pupil has completed the 8th grade, require the pupil’s vision to be examined by an optometrist or ophthalmologist and require the examination to also include a test for binocular function and refraction and eye health evaluations. The binocular function examination does not need to take effect until the pupil has reached the third grade and would require the parent or guardian of the pupil to provide results of the examination to the school district.
Status: Pulled by author in Assembly Health Committee.
SB 491 (Hernandez): Nurse Practitioners This bill gives nurse practitioners independent practice. Under this bill, nurse practitioners will no longer need to work pursuant to standardized protocols and procedures or any supervising physician and would basically give them a plenary license to practice medicine.
Status: Held in Assembly Appropriations Committee.
SB 492 (Hernandez): Optometric Corporations
This bill allows optometrist to practice ophthalmology. Specifically, allows optometrists to (1) treat and diagnose any disease, condition or disorder of the visual system, the human eye adjacent and related structures, (2) prescribe and administer drugs including controlled substances, (3) perform surgical procedures with local or topical anesthetic, (4) order laboratory and diagnostic tests, (5) administer immunizations, (6) diagnose and initiate treatment for any condition with ocular manifestations.
Status: Pulled by author in Assembly Business and Professions Committee. AB 591 (Fox): Hospital Emergency Room: Geriatric Physician This bill would require each general acute care hospital with an emergency department to have, at all times, a geriatric physician serving on an “oncall” basis to that department.
Status: Pulled by author.
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lative p Up AB 975 (Wieckowski): Health Facilities Community Benefits
SB 47 (Yee): Firearms: Assault Weapons (Support)
This bill would declare the necessity of establishing uniform standards for reporting the amount of charity care and community benefits a facility provides to ensure that private nonprofit hospitals and nonprofit multispecialty clinics actually meet the social obligations for which they receive favorable tax treatment.
This bill seeks to reestablish the original intent of the assault weapon ban by slowing down the process of easily reloading a firearm. For several years, gun makers have manufactured assault weapon with a magazine locking device called the “bullet button,” which requires a tool, which may include a tip of a bullet, a magnet, or a glove, to disengage the magazine yet allow for the easy reloading. Since a tool is used to disengage the ammunition feeding device, the firearm’s magazine is not classified as “detachable” and the firearm in question is legal.
Status: Failed on Assembly Floor. ACA 5 (Grove): Abortion: parental notification
This measure, which would be known as the Parental Notification, Child and Teen Safety, Stop Predators Act, would prohibit a physician and surgeon from performing an abortion on an unemancipated minor, as defined, unless the physician and surgeon or his or her agent has delivered written notice to the parent of the unemancipated minor, or until a waiver of that notice has been received from the parent or issued by a court pursuant to a prescribed process.
Status: Re-referred to Assembly Health and Assembly Judiciary Committees.
Status: Held in Assembly Appropriations Committee.
SB 138 (Hernandez): Confidentiality of Medical Information (Watch)
The bill would define additional terms in connection with maintaining the confidentiality of this information, including an “authorization for insurance communications,” which an insured individual may submit for the purpose of specifying disclosable medical information and insurance transactions and permissible recipients.
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Status: Signed by the Governor.
Other Bills of Interest
SB 304 (Lieu): Healing Arts: Boards (Neutral)
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SB 20 (Hernandez): Health Care: Workforce Training (Support)
This bill would transfer all available funds left over in the Department of Managed Health Care’s Managed Care Administrative Fines and Penalties Fund to the Steve Thompson Physician Corps Loan Repayment Program (STLRP), upon dissolution of the Major Risk Medical Insurance Program.
The bill is the sunset extension bill for the Medical Board of California. Significant issues raised by CMA (expert witness, 820 evaluations) were addressed in CMA’s favor. While the proposed transfer to the Department of Justice was rejected, the bill does transfer investigations to the Division of Investigators at the Department of Consumer Affairs.
Status: Signed by the Governor.
Marijuana Grown for Medical Use” and specifies that medical cannabis dispensaries that adhere to the guidelines will not be subject to prosecution for marijuana possession or commerce.
Status: Pulled by author in Assembly Health Committee.
SB 493 (Hernandez): Pharmacy Practice (Neutral)
This bill, as introduced, would have expanded the scope of practice for pharmacists to include administering drugs and biological products that have been ordered by a prescriber and expanded other functions pharmacists are authorized to perform. These functions include, among other things, the furnishing of specified drugs including prescription smoking-cessation drugs; ordering and interpreting tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies; and to independently initiate and administer routine vaccinations. The introduced version of the bill also specified additional functions that may be performed by an advanced practice pharmacist, including performing physical assessments and certain other functions. The author has accepted numerous amendments offered by CMA, which have the potential to improve access to vaccines for children and access to nicotine based smoking cessation products for adults seeking to end their addiction to tobacco products. The bill requires that all prescriptions be administered under a protocol with a physician. This will help improve the communication and coordination between the patient, their physician and their pharmacists.
Status: Signed by the Governor.
SB 494 (Monning): Health Care Providers: California Health Benefit Exchange (Support)
Status: Held in Assembly Appropriations Committee.
SB 352 (Pavley): Medical Assistants: Supervision (Support)
SB 62 (Price): Coroners: Reporting Requirements: Prescription Drug Use (Neutral)
This bill would prohibit a nurse practitioners, certified nurse-midwife or physician assistant from authorizing a medical assistant to perform any clinical laboratory test or examination for which the medical assistant is not authorized.
This bill is sponsored by the Physician Assistants and seeks to amend statue to include physician assistants as primary care providers and to increase the number of enrollees assigned to physician assistants in Medi-Cal managed care plans. The bill maintains that physician assistants must operate under the supervision of a physician.
Status: Signed by the Governor
Status: Signed by the Governor.
SB 439 (Steinberg): Medical Marijuana (Watch)
SB 495 (Yee): Postsecondary Education Employees: Physicians (Support)
This bill codifies the Attorney General’s “Guidelines for the Security and Non-Diversion of
This bill would require the California State University (CSU) to increase the compensation of
This bill would expand those provisions to require a coroner to make a report when he or she receives information that indicates a death may be the result of prescription drug use and to require the coroner to additionally file the report with the Medical Board of California.
Status: Vetoed by the Governor.
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CMA > Legislative Wrap Up 2013
physicians employed at student health centers on campuses to be is comparable to the compensation earned at the University of California (UC). The bill would request the UC to increase the compensation of physicians employed at student health centers on campuses of the UC if the compensation of physicians employed at a student health center on a different campus of the UC is increased.
Status: Held at the Assembly Desk. SB 598 (Hill): Biosimilars (Support)
This bill would allow a pharmacist to substitute an interchangeable biosimilar medication when filling a prescription for a biologic medication. SB 598 mirrors California’s patient protections for generic pill substitution and adds a provision that requires a pharmacist to enter information about the substitution into the patient record system or notify the physician within five days after a substitution is made.
Legislative Wrap Up Status: Vetoed by the Governor.
SB 615 (Galgiani): Public Works: Prevailing Wages: California Health Facilities Financing Authority Act (Neutral)
While the bill was moved out of the Assembly Appropriations Committee, the provisions of interest to CMA were removed. As a result, we are no longer co-sponsoring this legislation.
Status: Vetoed by the Governor.
SB 670 (Steinberg): Physicians and Surgeons: Drug Prescribing Privileges: Investigation (Support, after significant amendments)
CMA was able to secure amendments that deleted the provisions that would have expanded the Medical Board of California’s authority to limit a physician’s prescribing authority with a lower standard of evidence. With the deletion of these provisions, the bill simply made clarifying improvements to the medical board authority.
Status: Signed by the Governor.
SB 809 (Desaulnier): Controlled Substances: Reporting (Support) This bill would provide ongoing funding for the CURES database by requiring the Medical Board of California and other health professionals’ licensing boards to charge licensees who are authorized to prescribe or dispense controlled substances a
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fee of $6 annually. The bill also makes changes to the CURES authorizing statute to clarify that the database is a clinical tool and to simplify prescribers’ and dispensers’ enrollment into the database.
children, and individuals with incomes below 200 percent of the federal poverty level. Limits enrollment in bridge plan products only to eligible individuals.
SBX1 1 (Hernandez): Medi-Cal: Eligibility (Support)
AB 154 (Atkins): Abortion (Support)
Status: Signed by the Governor.
Status: Signed by the Governor.
This bill implements the expansion of federal Medicaid coverage in California (Medicaid is known as Medi-Cal in California) to low-income adults with incomes between 0 and 138 percent of the federal poverty level, establishes the Medi-Cal benefit package for this expansion population, and requires the existing Medi-Cal program to cover the essential health benefits contained in the Patient Protection and Affordable Care Act (ACA). This bill implements a number of the Medicaid ACA provisions to simplify the eligibility, enrollment and renewal processes for Medi-Cal.
This bill would make it a public offense, for a person to perform an abortion if the person does not have a valid license to practice as a physician and surgeon, except that it would not be a public offense for a person to perform an abortion by medication or aspiration techniques in the first trimester of pregnancy if he or she holds a license or certificate authorizing him or her to perform the functions necessary for an abortion by medication or aspiration techniques. With the provisions for training in the bill and the amendments that clarify physician supervision, AB 154 addresses patient safety while expanding access for these services.
SBX1 2 (Hernandez): Health Care Coverage (Support if Amended)
AB 209 (Pan): Medi-Cal: Managed Care: Quality and Accessibility (Support)
This bill applies the individual insurance market reforms of the Affordable Care Act to health care service plans (health plans) regulated by the Department of Managed Health Care and updates the small group market laws for health plans to be consistent with final federal regulations.
This bill creates the Medi-Cal Managed Care Health Care Quality and Transparency Act of 2013. The goal of the measure is to require the Department of Health Care Services to develop and implement a plan to monitor, evaluate and improve the quality and accessibility of health care and dental services provided through Medi-Cal managed care. This is meant to emulate the open government approach of the Managed Risk Medical Insurance Board/MRMIB’s operation of the Healthy Families program, which was eliminated in 2012 and all enrolled children were moved into Medi-Cal.
Status: Signed by the Governor.
Status: Signed by the Governor.
SBX1 3 (Hernandez): Health Care Coverage: Bridge Plan (Watch) Requires Covered California (the state’s health benefit exchange) to establish a “bridge” plan product by contracting with Medi-Cal managed care plans for individuals losing Medi-Cal coverage (for example, because of an increase in income), the parents of Medi-Cal or Healthy Families Program
Status: Signed by the Governor.
Status: Ordered to inactive file at the request of the author. AB 361 (Mitchell): Medi-Cal: Health
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WINTER 2013
CMA > Legislative Wrap Up 2013
Homes for Medi-Cal Enrollees and Section 1115 Waiver Demonstration Populations with Chronic and Complex Conditions (Support If Amended) Current federal law authorizes a state, subject to federal approval of a state plan amendment, to offer health home services to eligible individuals with chronic conditions. This bill would authorize the Department of Health Care Services, to create a health home program for enrollees with chronic conditions as authorized under federal law.
Status: Signed by the Governor.
the Steven M. Thompson Scholarship Program. CMA sponsored AB 589 (Perea) in 2011, which created the scholarship program, but due to state budget constraints, the bill only allowed for private donations to fund the program.
Status: Held in Assembly Appropriations Committee.
AB 880 (Gomez): Medi-Cal Program Costs (Support) This bill would require large employers of 500 or more employees to pay an “employer responsibility penalty” for each covered employee enrolled in Medi-Cal. The funding generated by the penalty could be appropriated by the Legislature for a variety of different purposes: to increase Medi-Cal provider rates, to provide a supplemental Medi-Cal payment for providers in medically underserved areas, to fund residency programs, to provide payment for the nonfederal share of Medi-Cal, to increase provider reimbursement rates, and to provide reimbursement to county hospitals, community clinics, and other safety net providers. Although the ACA requires employers pay a penalty for employees enrolled in state exchanges (a penalty based on the employers entire workforce, not just the number of individuals enrolled in the exchange), there is no such provision for employers who reduce their employees hours or wages to make them Medi-Cal eligible. Given the current beleaguered state of the Medi-Cal system, coupled with the strains that are expected as a result of the Medi-Cal expansion in 2014, the system will not be able to handle the influx of new lives resulting from large employers cutting employee wages. AB 880 incorporates portions of another CMAsponsored bill, AB 1176 (Bocanegra), which was held in the Assembly Appropriations Committee earlier this year.
AB 1263 (Pérez): Medi-Cal: CommuniCAL (Watch) This bill would require the Department of Health Care Services, to establish the Medi-Cal Patient-Centered Communication program (CommuniCal), to be administered by a 3rd-party administrator, to, commencing July 1, 2014, provide and reimburse for medical interpretation services to Medi-Cal beneficiaries who are limited English proficient.
Status: Vetoed by the Governor.
AB 1308 (Bonilla): Midwifery (Watch)
Legislative Wrap Up AB 446 (Mitchell): HIV Testing (Support)
After amendments taken in Senate Health Committee, this bill eliminates the requirement for written documentation of informed consent prior to administering an HIV test in non-clinical settings. Additionally, the bill requires timely delivery of the test results along with other pertinent information, tailored to whether the results are positive or negative, by the medical care provider or the person who administers the test to the patient. The bill no longer requires that every blood draw in emergency departments, public health clinics, or urgent care centers be tested for HIV. Instead, the bill now only requires primary care clinics to offer patients having a blood draw an HIV test. Lastly, the bill allows for the online posting of HIV antibody test results if the results are posted on a secure internet website, which can be accessed only with the use of personal identification number provided the patient at the time of testing.
Status: Signed by the Governor.
AB 459 (Mitchell): Public Contracts: Healthy and Sustainable Food (Support)
This bill would clarify and strengthen the state’s existing nutrition guidelines for food and beverages sold in vending machines on state properties. It would also increase incrementally the percentage of foods sold in vending machines that meet the nutrition guidelines from the current 35 percent to 100 percent by January 1, 2017.
Status: Held in Assembly Appropriations Committee.
AB 860 (Perea): Medical School Scholarships (Support) This bill, upon appropriation by the Legislature, would transfer $600,000 in penalty monies levied by the Department of Managed Health Care to fund
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Status: Assembly Inactive File – vote failed. AB 1139 (Lowenthal): Prescriptions: Biosimilar Products (Watch)
This bill would authorize a pharmacist filling a prescription order for a biological product subject to the Federal Food, Drug, and Cosmetic Act to select a biosimilar product, provided that product is deemed by the federal Food and Drug Administration to be interchangeable with the prescribed product.
Status: Assembly Business and Professions Committee hearing postponed.
This bill would require the Medical Board of California to, by July 1, 2015, revise and adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery and indentifying complications necessitating referral to a physician.
Status: Signed by the Governor.
ABX1 1 (Pérez): Medi-Cal: Eligibility (Support)
This bill enacts statutory changes necessary to implement the coverage expansion, eligibility, simplified enrollment and retention provisions of the Patient Protection and Affordable Care Act of 2010 as amended by the Health Care and Education Reconciliation Act of 2010 related to the Medicaid Program (Medi-Cal in California) and the California Children’s Health Insurance Program.
Status: Signed by the Governor.
ABX1 2 (Pan): Health Care Coverage (Support if Amended)
Reforms California’s individual market in accordance with the Affordable Care Act and applies its provisions to insurers regulated by the California Department of Insurance in the individual market; requires guaranteed issue of individual market health insurance policies; prohibits the use of preexisting condition exclusions; establishes open and special enrollment periods consistent with the California health benefit exchange (Covered California); prohibits conditioning issuance or offering based on specified rating factors; prohibits specified marketing and solicitation practices consistent with small group requirements; requires guaranteed renewability of plans; and permits rating factors based on age, geographic region and family size only.
Status: Signed by the Governor.
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FALL 2013
Teaching Orthopeadic Surgery In
B
hutan
The Land Of The Thunder Dragon Story and photos by Dr. Peter Salamon
B
hutan is a Buddhist monarchy that transitioned into a democracy in 2008. It is a small nation slightly larger than the state of Maryland. It is located in
the Himalayans just East of Nepal. Bhutan is surrounded on three sides by the Northeastern part of India. To the North is Tibet (People’s Republic of China). The country is extremely mountainous with essentially no flat land. The population of Bhutan is approximately 700,000 people. The capitol city is Thimphu with about 25,000 people. By comparison, Nepal is three times larger in area than Bhutan and has a population of 19,000,000 (nineteen million). Bhutan’s economy is largely a Agrarin with more than 90% of the work force employed in subsistence farming and animal husbandry. Although Bhutan has a population of 700,000 many parts of Bhutan are very remote and quite difficult to access. There are 4 orthopaedic surgeons for the entire country of Bhutan. Three of these surgeons are located at the National Hospital in Thimphu. The fourth is in Eastern Bhutan, in the town of Mongar. >>
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There are 24 districts in Bhutan, each of which has some type of hospital or clinic. None of these district clinics are staffed by orthopaedic surgeons; they are staffed by orthopaedic technicians. Since there are no orthopaedic surgeons in the various district clinics, the orthopaedic care is provided by these orthopaedic technicians. Patients requiring the care of an orthopaedic surgeon are sent to Thimphu. Travel to Thimphu can be difficult and take many days. The orthopaedic surgeons in Bhutan are very well trained. Most have done residencies in either Thailand or India. The major limitation in orthopaedic surgical care is not the skills or training of the surgeons, but the equipment they have and patient’s access to care. My role while in Bhutan was to teach the orthopaedic technicians. The orthopaedic technician training takes place in Thimphu at the National Hospital. There are 2 orthopaedic student technicians at any given time and I spent considerable time teaching them and trying to bring them up to speed in orthopaedic surgery so that when they are assigned to the district hospitals, they can function independently. I also spent time working with the orthopaedic surgeons, helping them treat often complex problems. It is a long way to travel to reach Bhutan. The trip takes almost 2 days and about the same amount of time to get home. The only airline that flies to Bhutan is Druk Air which is the national airline of the country. During my month in Bhutan, I had time to travel and see the country. The scenery is spectacular. The walking and hiking are outstanding. The capitol city of Thimphu is at 7,500 feet above sea-level; most of the hikes go up higher from this level. The people are extremely friendly and outgoing and English is spoken everywhere. I would urge every person who has the opportunity to visit Bhutan to take advantage of it. Volunteering with Health Volunteers Overseas is an excellent way not only to see Bhutan, but to get to know many of the local physicians and technicians, and not feel completely like a tourist. I hope to return to Bhutan at some point in time to renew the acquaintances I made while I was there. For further information, please see Health Volunteers Overseas website: www. hvousa.org.
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In Memoriam
In Memoriam William E. Latham M.D.
Bill loved his tennis and skiing groups and also enjoyed scuba diving, gardening, wine and food. Bill was a true adventurer and felt fortunate to travel extensively.
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WILLIAM E. LATHAM M.D. Sept. 1, 1924 - Oct. 29, 2013 Dr. Latham was a true Stocktonian having been born and raised in Stockton. He graduated from UC Berkeley and UCSF Medical School. He returned after medical school and military service in Korea to become an active member of the community. Dr. Latham was Chairman of The Sierra Traumatological Society, President of San Joaquin Academy of General Practice and Honorary Medical Consultant, University of the Pacific. He received an award recognizing aid rendered to the children of the Star of the Sea Orphanage in Inchon, Korea from George Drake, Chairman, Jane Russell, actress and Buzz Addrin, astronaut. He was a charter member of the American Academy of Family Practice and was a board member of the California Academy of Family Practice. Dr. Latham practiced medicine well into his eighties and loved his patients who often became lifelong friends. Bill loved his tennis and skiing groups and also enjoyed scuba diving, gardening, wine and food. Bill was a true adventurer and felt fortunate to travel extensively. As a board member of Stockton’s Haggin Museum he organized and escorted trips to Europe as a philanthropic support for the museum. Bill’s military service was of great pride to him and included a call to duty October 1950 by the Navy, attached to the U.S. Marines as Battalion Surgeon, George Co., 3rd. Bn., 1st Reg., 1st Marine Division. He was a member of the U.S. Navy League and over the years spoke to various service organizations about his experiences as a MASH Doctor in Korea. He is survived and beloved by his wife of 61 years, Carol Latham and his daughters Linda Knight of Arizona, and Leslie Kelly of Pebble Beach. Bill also loved his sons-inlaw Scott Kelly and George Knight. His grandchildren Kristen Kelly, Megan Kelly and Andrew Knight were a source of great joy and pride. He was preceded in death by his son Stephen Elliott Latham. Memorial contributions in Dr. Latham’s memory may be made to Hospice of San Joaquin or a charity of your choice.
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