June2013smcp by SMCMA

S a n M at e o C o u n t y

Physician

June 2013 | Volume 2, Issue 6

A publication of the San Mateo County Medical Association

The Perils of Prescribing

also in this issue What PhysicianEmployers Need to Know about Health Care Reform

The Physician Payment Sunshine Act Is Here

Retaining Independence While Embracing Accountability

A ﬁnancial safety net for you—

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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 * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 90 days’ advance written notice. The County Medical Associations and Societies/NORCAP/CMA receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.

Editorial Committee Russ Granich, MD, Chair; Sharon Clark, MD; Edward Morhauser, MD; Gurpreet Padam, MD; Sue U. Malone, SMCMA Executive Director; Shannon Goecke, Managing Editor

SMCMA Leadership Gregory C. Lukaszewicz, MD, President Amita Saxena, MD, President-Elect Vincent Mason, MD, Secretary-Treasurer John D. Hoff, MD, Immediate Past President Raymond Gaeta, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Michael Norris, MD; Michael O’Holleran, MD; Irwin Shelub, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Editorial and Advertising Inquiries

S a n M at e o C o u n t y

Physician

June 2013

Introduction | Russ Granich, MD Abuse of prescription drugs has been classified as an epidemic by the CDC. Our cover story this month comes from Sacramento-based doctor/lawyer Bruce Barnett, who emphasizes the importance of following approved guidelines to properly prescribe controlled substances and avoid promoting illicit and dangerous drug use. On the same topic, we are also including the executive summary of a new CMA report on the use of opioid analgesics in California, as well as information about the California Department of Justice’s CURES program (Controlled Substance Utilization Review and Evaluation System, which allows physicians and others to access information about a patient’s controlled substance prescription history.

San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Members are encouraged to submit articles, commentary and letters to the editor. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

Some Final Thoughts.. ................................................................................. 5

Advertising in San Mateo County Physician is a great way to reach out to the San Mateo County medical community. Classified ads begin at $40 (for up to five lines) for members. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

Prescription Drug Usage. . ......................................................................... 11

For more information, contact managing editor Shannon Goecke at (650) 312-1663 or sgoecke@smcma.org.

Retaining Independence While Embracing Accountability: Care Coordination and Integration Strategies for Small Physician Practices (Part 3 of 3)..................................................... 15

Gregory Lukaszewicz, MD 2013 National Health Insurer Report Card................................................ 7 Sue U. Malone Careless Narcotic Prescribing Kills Patients.............................................. 8 Bruce Barnett, MD, JD Physicians Urged to Utilize Database that Monitors CMA Staff Opioid Analgesics in California: Relieving Pain, Preventing Misuse, Finding Balance ....................................................... 12 CMA Staff The Physician Payment Sunshine Act Is Here—Are You Ready?............. 14 Jeremy Lazarus, MD

AMA Staff Upcoming Educational Programs. . ........................................................... 16 Member Updates, Classified Ads, Index of Advertisers.......................... 18

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Presidentâ&#x20AC;&#x2122;s Message | Gregory Lukaszewicz, MD

Some Final Reflections

s my term as president of the San Mateo County Medical Association comes to an end, I find myself reflecting on the role the medical society plays in the life and work of the 21st century physician. Medicine in general continues to go through a period of incredible transformation, though perhaps it is more accurate to look at the current period as being simply part of the overall pattern of continuous growth over the last century or more. If we look at the larger historical context, then we see many of the recent advances in imaging studies, minimally invasive surgery, preventative medicine, information technology and cancer treatment as a continuation of such basic but still incredible advances as x-rays, antibiotics, anesthesia, and vaccinations, then we can see that change and growth is the norm in modern medicine, not some aberration. By looking at modern medicine within a wider historical context, we can also see that we should not fear the future but embrace its possibilities. Within this context, I often ask myself, is there a role for our local, state and national medical societies? After all, most physicians tend to relate more closely and feel that their interests are in many ways better represented by their

Only through broad general associations representing all physicians, from general internists to neurosurgeons, from solo practitioners to members of large groups, and from urban academics to rural physicians, can we address the many problems that we face as physicians today.

specialty societies. The question of relevancy is indeed an existential challenge to our medical association and one that we must face. My own answer is that only through broad general associations representing all physicians, from general internists to neurosurgeons, from solo practitioners to members of large groups, and from urban academics to rural physicians, can we address the many problems that we face as physicians today. If we simply throw all our support behind our specialty organizations, we will only end up fighting with each other for the increasingly scarce resources, where every political or budgetary fight will come down to a conflict between one group or specialty against another. If we are to meet all the challenges that the 21st century holds for medicine, then our general physician associations, where we can represent ourselves with a united voice, must continue to thrive and play a role in molding that future. However, balancing the many voices and needs of our members can be a real challenge. In many ways, as president of the SMCMA, I had it easy, representing a single group of professionals in a relatively small and comparatively uniform county. When I extrapolate my own experience to the much larger field of our political leaders, particularly at the national level, it is much easier to see how difficult their jobs really are. I came into this position with my own set of ideas, political biases and agenda. I quickly realized that I needed to put these aside in order to best represent all the members of the SMCMA, many of whom may not share my viewpoint. This is one of the conflicts of being in a position of leadership: Does one lead by attempting to push through oneâ&#x20AC;&#x2122;s own agenda, or by promoting the needs and desires of the majority of oneâ&#x20AC;&#x2122;s constituents? A career politician must balance multiple competing agendas, accommodate continued on next page

june 2013 | SAN MATEO COUNTY PHYSICIAN 5

President’s Message | Gregory Lukaszewicz, MD

Some Final Thoughts continued multiple and often powerful interests, represent their particular community, and work toward the betterment of the country while also worrying constantly about reelection. This is not to excuse our current political gridlock or frustration with our political leadership, but rather to help understand where part of the problem lies. It has been a great privilege and honor to serve the SMCMA and its members. I am extremely proud of our profession, what we stand for and what we do. After the Boston Marathon Bombing, I contacted a close friend from medical school

It has been a great privilege and honor to serve the SMCMA and its members. I am extremely proud of our profession, what we stand for and what we do.

and residency who now works at the Massachusetts General Hospital about two miles from the finish line and where many wounded were brought. He remarked that, despite the despair one feels at such a terrible tragedy, the actions of the first responders, medical students, residents, attending physicians, nurses and support staff should remind us that there is still reason to be hopeful and believe that not all is chaos and destruction. This is what we attempt to do every day as physicians caring for the sick and dying. Finally, the Medical Association could not function without its dedicated staff: our Executive Director Sue Malone, our Director of Communications Shannon Goecke, our Membership, Development and Programs Director Karen Stone, our Controller James Richie and our Administrative Assistant Gina Cromosini. To each of them, as well as the members of the Board and Executive Committee and all those who participate at the Board Meetings in offering their guidance and wisdom, I am grateful. ■

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Executive Report | Sue U. Malone

2013 National Health Insurer Report Card

he AMA’s sixth annual National Health Insurer Report Card (NHIRC) for physicians and the general public is a reliable source of critical metrics concerning the timeliness, transparency and accuracy of claims processing by health insurance companies. This year it also studied for the first time patient responsibility via co-pays, deductibles and co-insurance. The AMA initiated a “Heal the Claims Process” in 2008, which aims to streamline claims processing through the use of electronic health care transactions and reduce the administrative cost of claims processing from 14 percent of gross revenue to just one percent of collections. In February and March 2013, patients on average paid 23.6 percent of the amount of reimbursement that insurers set for physicians. The report card is based on 2.6 million electronic claims for 4.7 million medical services submitted in February and March to eight insurers: Aetna, Anthem Blue Cross, Blue Shield, Cigna, UnitedHealthcare, Humana, Health Care Service Corp. (the parent company of Blue Cross and Blue Shield in Illinois, Texas, and New Mexico), Regence, and Medicare. The claims came from 450 physician practices covering 80 specialties in 41 states. The findings of the analysis of the claims data found: • Insurers are getting more accurate in payments, with an average error rate of nearly 20 percent in 2010 falling to 7.1 percent now. Medicare had the highest accuracy rate, with 98.1 percent. Unitedhealthcare led studied commercial payers with a 97.52 percent accuracy rate. • After a big increase in 2012, claim denial rates fell 47 percent in 2013, from 3.49 percent to 1.82 percent. Cigna recorded the lowest denial rate of .54 percent; Medicare’s rate was nine times higher at 4.92 percent. • Humana had the fastest median commercial claims turnaround time at six days; Aetna had the longest at 14 days. Medicare has been at 14 days since 2008. • Between 2008 an 2013, studied insurers have improved transparency of rules to edit claims by 37 percent, reducing provider administrative costs of reconciling claims.

2013 Administrative Burden Index As part of the 2013 NHIRC, the first-ever Administration Burden Index (ABI) was created to encourage increased physician and payer engagement. This index identifies the practice cost of performing rework with the NHIRC payers, including phone calls, investigative work and claim appeals associated with a specific pay-based on the NHIRC metric results for payment timeliness, accuracy, application of undisclosed and payor— specific edits, prior authorization and denial. In utilizing the ABI index, physician practices will be assisted when determining their practice automation priorities with contracting. It will also allow physician practices to score the payers with which they do business, review their internal workflows to identify areas to increase practice efficiency, identify the associated cost of rework with a payer prior to contracting, and take advantage of automated options from payers to potentially lower claims processing costs, and more. To enable all physician practices to achieve results similar to those reported in the ABI, all health insurers must be fully transparent and compliant with the electronic data interchange standards. Listed below are the names of payers and the percent of claims requiring rework: Aetna 7.13% Anthem 14.30% Cigna 5.45% Humana 7.57% Health Care Service Corp. 14.85% UnitedHealthcare 5.36% Regence 20.49% For complete detail on the 2013 National Health Insurer Report Card, visit www.ama-asn.org/go/reportcard. Keep in mind that these results may not be typical across all practices. The practices profiled have adopted best practices for electronic data interchange and contract compliance. For the full results of the 2013 Administrative Burden Index, go to www.ama-assn.org/ resources/doc/psa/2013-abi.pdf. ■

june 2013 | SAN MATEO COUNTY PHYSICIAN 7

Careless Narcotic Prescribing Kills Patients by

B ruce B arnet t , MD, JD

At their February 2013 conference at the South San Francisco Conference Center, the California Medical Board and Pharmacy Board enlisted local and federal authorities to warn nearly 600 physicians and pharmacists that they risk suspension and prison sentences when improperly prescribing narcotics and other drugs. This message has been delivered before. The duties of physicians to perform good faith examinations and of pharmacists to dispense drugs only upon receipt of legitimate/legal prescriptions are the foundations of their respective professional canons. However, on this occasion, new data was presented with particular urgency. There is no mistaking that the patterns of controlled substance prescribing in the United States greatly alarm state and federal enforcement agencies. The first two speakers in this meeting came from Washington, DC, with the latest reports about the impact of prescribed opiates. Michael Boticelli, Deputy Director of the White House Office of National Drug Control Policy, announced that the abuse of prescribed drugs has been classified as an epidemic by the Centers for Disease Control. He referred attendees to the website whitehouse. gov/ondcp for further information. Joseph Rannazzisi, from the Drug Enforcement Agency (DEA), held the audience’s total attention for a remarkable two-hour talk that provided the following information: 1. Deaths in 2010 caused by accidental overdose of prescription opiates exceeded the combined rate from all other drug deaths, including heroin and cocaine combined. 2. Deaths from accidental drug overdoses exceeded all other causes of accidental deaths, including vehicle accidents. 3. Physicians and pharmacists may not be aware of how illicit users achieve the desired effects from prescriptions. The “Holy Trinity” sought on the street is a combination of opiate such as hydrocodone, muscle relaxant such as carisopodol, and tranquilizer like alprazolam. Physicians will prescribe any of these individually not realizing the intent is to put them together into a cocktail. 8 San Mateo county physician | June 2013

4. Methadone is particularly dangerous, accounting for the bulk of opiate deaths, and should not be prescribed by physicians unfamiliar with its use. 5. Fentanyl is a very popular street drug. Fentanyl patches are highly sought after, as they are widely abused. 6. Websites that educate abusers include Erowid and Bluelight. All physicians should access these websites for an education in the real world of drug users. 7. The Controlled Substances Act provides details of the law that should be followed by all physicians and pharmacists, 21 U.SC. 822. An important case and regulation are U.S. v. Moore, 423 U.S. 122 (1975) and 21 C.F.R. 1306.04. They propose that pharmacists should not fill prescriptions for controlled substances presented by customers who do not seem to have a legitimate medical need for the prescription requested. For example, patients who will pay thousands of dollars in cash for large amounts of opiates at each pharmacy visit are not likely buying them for their own use. Laura Meyers, Assistant District Attorney in San Francisco, and Ruth Moretz, Manager for Special Investigations, are both experts in fraud in the worker’s compensation arena. Their observations are relevant among all illicit drug users. They described some of the motives for fraud in prescription procurement: 1. Need to sell drugs or use them as a medium for transactions. 2. Examples of transactions are to use drugs to pay off debts, to exchange for other drugs, or to gain favors. Ms. Meyer and Ms. Moretz recommended physicians adhere to standard best practices for treating patients

with opiates to reduce the risk of prescribing to patients who intend to abuse or sell the drugs: 1. Obtain a thorough history, including any history of prior drug abuse. 2. Document a focused examination. 3. Have the patient sign a pain contract that makes clear the expectations for compliance. 4. Regularly review effectiveness of the prescribed medications and reconsider the need for drugs. 5. Report suspected fraud to the local district attorney or California Department of Insurance. On day two of this conference, the attendees heard compelling data and insights from Dr. Cesar A. Aristeiguieta, an emergency physician and longstanding member of the Medical Board. Dr. Aristeiguieta also served as a police officer prior to becoming a physician. Speaking from the perspective of medicine and enforcement, he made the following points: 1. Many patients seeking opiates and other controlled substances are actors playing a role to gain the drugs. 2. United States has 4.6 percent of the worldâ&#x20AC;&#x2122;s population, but consumes 80 percent of the worldâ&#x20AC;&#x2122;s opiates and 99 percent of the entire world production of hydrocodone. 3. For every death by opiate, there are 130 individuals abusing the drug chronically. 4. The person at highest risk for opiate abuse is doctor shopping, misuses all drugs (not just opiates), has low income, has a history of substance abuse in the past and has other mental health issues. 5. Pain in the rest of the world is managed with far fewer opiates than in the U.S. Alternatives include NSAIDs, acetaminophen, physical therapy, herbal remedies and supportive care. 6. Except for sickle cell disease, most conditions for which opiates are prescribed do not benefit from opiates, including kidney stones, chronic low back pain, and most causes of chronic pain. 7. Physicians eager to please patients mistakenly administer opiates to satisfy demands despite the lack of efficacy from these drugs and the dangers in their use. Dr. David G. Greenberg, addiction specialist working with the Arizona Medical Board, described how commercial interests in promoting opiate medications have created a huge demand for these drugs, with

misleading claims that underestimate the danger in their use and overstate opiate effectiveness. In particular, Dr. Greenberg reported that there is a paucity of evidence to support the following myths: 1. No substantial risks exist for overdose or respiratory suppression. This is not only false, but it is especially misleading because narcotics are often combined with other drugs, such as muscle relaxants, which together, have extremely potent respiratory suppressant effects. 2. There is no maximum opiate dose that will be dangerous; patients can take as much as they need to treat pain and not be at risk of toxic effects. This is incorrect, as the adverse side effects of opiate use increase with increasing doses, just like any other drug. 3. The risk of addiction to opiates is minimal. This has been shown to be false. All package inserts approved by the FDA make the risk of addiction clear. 4. It is safe to drive while taking doses of opiates for which the body has acclimated. This is false. Reaction times, judgment and intellectual functions are significantly impacted by opiates. 5. Physicians will be sued for not prescribing opiates. This fear is exaggerated. Except for the inmate population that files frequent habeas and civil rights petitions on multiple accounts including reduction in their opiate prescriptions, there are very few suits filed for failure to prescribe an opiate, as little or no harm comes from not being prescribed an opiate. On the other hand, there is a substantial risk of being sued for prescribing too many opiates, as an opiate overdose can lead to death. 6. Any licensed physician can prescribe large amounts of opiates to control pain without specialized training. This is not true. The treatment of patients who are seeking unusually large amounts of opiates, or claim to need opiates chronically requires expertise and experience not necessarily possessed by physicians without additional training in these matters. Drug diversion is rare, and thus testing to assure drug use is unnecessary. This has not turned out to be the case. Drug diversion is, in fact, relatively common. Random drug testing is appropriate and necessary for many patients on chronic opiate therapy. continued on next page

june 2013 | SAN MATEO COUNTY PHYSICIAN 9

Careless Narcotic Prescribing Kills Patients {continued}

7. Opiate therapy will permit patients otherwise severely impaired by pain to resume normal function. This has not been the case. There are no studies to support this notion. In fact, patients who have needed opiates to treat substantial disease are not able to resume normal activities merely with the use of opiates. 8. Addiction to opiates and accidental overdose is relatively rare. This is the most false of all presumptions promoted by drug manufacturers. Many causes of overdose related to opiates are not reported, such as deaths from illicit drugs like heroin used only after prescription opiates provided the gateway, vehicle accidents while under the influence, accidents at work reported through the workerâ&#x20AC;&#x2122;s compensation system, and deaths in hospitals/SNF/prisons from opiate overdoses. The real number of deaths due to prescribed opiates likely exceeds 30,000 individuals each year. Additional lectures by physicians, pharmacists, attorneys and enforcement agencies during the two-day conference emphasized the importance of following approved guidelines (most recently updated by the California Medical Board in 2007) to properly prescribe controlled substances and avoid promoting illicit and dangerous drug use. The investigative arms of the Pharmacy Board and the Medical Board reiterated that professionals suspected of overprescribing will be rigorously reviewed and prosecuted if wrongdoing is established. However, investigators and prosecutors have no interest in physicians adhering to the following process, which is recommended by the Medical Board: 1. Document appropriate history and physical examination. 2. Establish a diagnosis and an objective measure of pain that justifies use of opiate. 3. Obtain informed consent from patient for opiate use, such as an opiate contract.

7. Perform annual review of the patient at a minimum. 8. Provide adequate and appropriate documentation of NP/PA supervision. This joint medical and pharmacy conference provided much food for thought. The admonitions were obviously intended for pain and addiction specialists and pharmacists who are filling large amounts of opiate prescriptions. The main message delivered to attendees was: It is time for the pendulum of liberal prescriptions to swing back to the more conservative days. Providing opiates on demand is not working very well. In fact, the increase in opiate prescribing has directly caused a substantial increase in opiate-related deaths. However, a significant problem encountered in controlling use of opiates was only touched upon. That is the stress associated with denying patients drugs they have been accustomed to for many years when prescribing was more liberal. A few of the presenters acknowledged that physicians have been prescribing opiates to please their patients, and that physicians often lack the skills and temperament to deal with patients misusing or abusing drugs. But none of the presenters provided any direct answers to the question as to how we will deal with the onslaught of complaints to medical boards from patients denied their usual opiate dose. The conference speakers did not propose means to reduce the number of complaints by patients denied their favored drugs. But physicians are on firm and safe ground denying long-term prescriptions for opiates to patients who have no objective evidence of anatomic or physiologic dysfunction that justifies the substantial risks associated with the use of chronic opiates. For more information, and to see Power Point presentations and the entire conference on video, go to the California Medical Board website www.mbc.ca.gov/ pain_forum_february_2013.html.

4. Perform periodic review of patient condition and effectiveness of the therapy.

About the Author

5. Obtain further consultations from col-leagues and/or appropriate specialists if pain is difficult to control.

Bruce Barnett, MD, JD, is Chief Medical Officer with California Correctional Health Care Services and President of the CA/NV Chapter for the American Correctional Health Service Association.

6. Maintain accurate records.

This article was originally published in the May/June 2013 issue of Sierra Sacramento Valley Medicine. 10 San Mateo county physician | June 2013

Physicians urged to utilize database that monitors prescription drug usage by

CMA S taff

he California Medical Association (CMA) encourages physicians who prescribe controlled substances to use the California Department of Justice (DOJ) prescription drug monitoring program, known as CURES (Controlled Substance Utilization Review and Evaluation System). CURES allows authorized users, including physicians, pharmacists, law enforcement and regulatory boards, to access information about a patient’s controlled substance prescription history. The mission of CURES is to prevent pharmaceuticals from falling into the wrong hands, while promoting legitimate medical practice and quality patient care. If prescribers and dispensaries have access to controlled substance history information at the point of care, it helps them identify and assist patients who may be abusing controlled substances, make appropriate prescribing decisions and cut down on prescription drug abuse in California. Registered users can access CURES to verify a patient’s controlled substances history before prescribing and the information can be used to help identify a patient who may be “doctor shopping.” The system entrusts that well-informed prescribers and pharmacists can and will use their professional expertise to evaluate their patients’ care, prevent inappropriate use of drugs and assist those patients who may be abusing controlled substances. Registration is only required to access the database. No action is necessary to have your prescribing data added to the database. That will happen automatically when the drug is dispensed. A common misconception is that if a physician does not register for CURES, then their prescribing information will not be included in the database. Pharmacies and other dispensers of controlled substances are, however, required to report all prescriptions for controlled

substances regardless of whether the prescriber has registered for CURES. In order to access to the CURES system, prescribers and pharmacists must complete the following: 1. Pre-register online. Complete the registration application at https://pmp.doj.ca.gov/pmpreg. 2. Print and notarize the registration confirmation. Upon completion of the online registration, immediately print your registration confirmation. The confirmation page is the user application form, which must be signed, notarized and submitted to the DOJ with copies of supporting documents (see below.) 3. Gather supporting documents. a. Copy of medical license or pharmacy license; b. Copy of Drug Enforcement Administration registration; and c. Copy of government issued identification. 4. Mail completed application packages to the DOJ. California Department of Justice PDMP/CURES P.O. Box 160447 Sacramento, CA 95816 5. Verify your email. Applicants will receive an email requesting verification of their email address. This notification is automatically generated once the online registration has been submitted to DOJ. E-mail verification must be completed within 72 hours.

For assistance with the registration process, please contact the CURES Help Desk at pmp_registration@doj.ca.gov or (916) 227-3843. Please note that a response may be delayed due to insufficient staffing as a result of DOJ budget cuts. If you need additional assistance, please contact CMA’s Scott Clark at sclark@cmanet.org. CMA is working with other stakeholders to secure funding for this important public health tool. We are also working with DOJ to create a new version of CURES that is more user-friendly for physicians. For more information on the CURES program, please visit http://oag.ca.gov/cures-pdmp. june 2013 | SAN MATEO COUNTY PHYSICIAN 11

Opioid Analgesics in California: Relieving Pain, Preventing Misuse, Finding Balance ExEcutivE SuMMaRy June 2013 Like the nation as a whole, California is faced with a serious health care dilemma: how to use opioid medications to relieve pain safely and effectively while simultaneously reducing the risk of prescription medication misuse, addiction and overdose. All parties involved in this complex issue can, and must, work together to advance pain care while minimizing risks to patients and society. The California Medical Association (CMA) believes that opioids have a legitimate role in medical practice and can be safe and effective when prescribed responsibly. The pendulum of opinion about the safety, efficacy and proper use of opioid pain medications has swung markedly in recent years. Concerns about the documented under-treatment of pain in the 1990s were so serious that California enacted laws to promote and protect pain management-related care. Two decades later, growing concerns about prescription medication misuse and opioid misuse in particular, has brought nationwide calls for instituting prescriber and dispenser limitations, as well as for an expansion of law enforcement investigations of physicians. Although some proposed legislative and regulatory actions could potentially address current inadequacies (such as properly funding and improving a prescription drug monitoring program) other actions being considered could erode the progress in pain management practices that have been made over the course of decades. Opioids are not the only tool, nor necessarily the best tool, for every patient, but for some, opioids can improve function, ease suffering and improve overall quality of life. The goal is to bring the swinging pendulum of opinion to rest at a stable,

chronic pain is estimated to affect roughly 100 million americans and to cost about $635 billion annually in treatment and lost productivity. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, Institute of Medicine, 2011

healthy point of balance between minimizing misuse of prescription opioids and ensuring access for their legitimate use.

Finding SOlutiOnS Physicians, patients, law enforcement, and the general public need accurate information about appropriate opioid use and better data on the factors involved in misuse. Progress in making effective change requires all stakeholders to work together to define and implement rational approaches for the safe and effective use of opioids. However, public discussion can be limited by the presentation of misleading and inaccurate information and a lack of familiarity with the issue. In order to have a productive discussion, developing a shared understanding of what pain is, how opioids are used as one tool to manage pain, and how existing regulatory controls impact prescribing practices is essential. CMAâ&#x20AC;&#x2122;s full length report, â&#x20AC;&#x153;Opioid Analgesics in California: Relieving Pain, Preventing Misuse, Finding Balance,â&#x20AC;? summarizes these fundamentals. No single effort, law, policy change or initiative will solve the complex issues related to prescription drug-related deaths and injuries, including those involving opioids. Physicians are not the only players in the issue of prescription drug misuse. Patient expectations are influenced by pharmaceutical company marketing. Dentists, veterinarians and others also prescribe controlled substances. Pharmacists have corresponding responsibility to ensure prescriptions are legitimate. Insurance policies impact what types of treatment will be covered. All of the licensing boards must provide consumer protection. Opioids can be illegally obtained for non-medical use throughout the manufacturing and distribution process. For these reasons, and more, there is a need for a comprehensive approach to address the many facets of the problem. The disadvantages posed by the use of opioid medications must be weighed against the disadvantages of untreated or inappropriately treated pain. Pain remains the most common reason people seek health care, and has been considered an epidemic by the Institute of Medicine. Physicians have a professional, ethical and legal obligaCOnTInueD...

12 San Mateo county physician | June 2013

70.8 percent of those who reported using pain relievers non-medically, obtained the drugs from a friend or relative. National Survey on Drug Use and Health, for persons aged 12 or older in 2010-2011, Substance Abuse and Mental Health Services Administration 2011

tion to mitigate the effects of illness, and pain is no exception. However, opioids are not panaceas. They seldom, by themselves, adequately address the complex issues that a patient with chronic pain faces and have a wide range of potential adverse effects. Nonetheless, opioids remain important tools for alleviating suffering, promoting healing and restoring function.

CMA RECOMMENDATIONS Encourage the education of prescribers, policymakers and the public. CMA has invested in and promoted physician education regarding pain management, and will continue to do so along with other medical professional groups. The state can help by taking steps to create opportunities for physicians to increase their knowledge related to opioid analgesics. Medical education must be augmented by education in all sectors of society including patients, policy makers and the public at large. California agencies can work with the physician community when developing materials for events, such as drug take back days, to build in accurate and educational messages. Obtain additional data on opioid misuse speciﬁc to California. A great deal remains unknown about the risks of opioid pain medications, underlying causes of opioid misuse, as well as the degree of misuse that can be attributed to direct prescribing. In particular, access to data speciﬁc to opioid misuse in California is limited. Gathering additional information, evaluating it and sharing it with others are all critical for building effective strategies. Establish and fund a range of tools to improve patient safety. California’s prescription drug monitoring program, CURES, is an important public health tool that needs to be funded and upgraded with an emphasis on improving patient safety. Yet, even if improved, the system would not be able to address many aspects

of prescription drug misuse, such as the pills taken out of the medicine cabinet by a family member, or a legitimate patient who mixes their drugs with contraindicated substances. Non-medical strategies to help stem opioid abuse need funding as well. Providing drug take-back opportunities and drug storage and disposal education programs are key. In addition, providing increased access to quality substance abuse treatment programs is another critical component of a comprehensive approach. Maintain the physician role in evaluating appropriate pain management and use of opioids analgesics. The Medical Board of California should have the resources for a strong and effective process for investigating and prosecuting physicians who do not practice the accepted standard of care. Medical Board Contingency Fund “loans” to the General Fund and restrictions on ﬁling vacant positions stymie enforcement efforts. Ensuring due process is critical, requiring a system that uses physicians with the appropriate expertise to review complaints and medical records during the investigation process in order to determine whether there has been a departure from the standard of care. It is also critical that the physician role in evaluating appropriate pain management is ﬂexible enough to treat the unique needs of a given patient. Providing a wide range of treatment options maximizes the potential of pain management and recognizes the individualized needs of the patient.

To view the full report, visit http://www.cmanet.org/resourcelibrary/detail/?item=opioid-analgesics-in-california-relieving-pain.

For more information about CMA and it’s programs, visit www.cmanet.org or call (800) 786-4262 (4CMA).

The majority of people with pain use their prescription drugs properly, are not a source of misuse, and should not be stigmatized or denied access because of the misdeeds or carelessness of others. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research , Institute of Medicine, 2011

june 2013 | SAN MATEO COUNTY PHYSICIAN 13

The Physician Payment Sunshine Act is here—Are you ready?

he new Physician Payment Sunshine Act (Sunshine Act) was created by Congress to ensure transparency in physicians’ interactions with the pharmaceutical, biologic and medical device industries as well as group purchasing organizations. Physicians elected to our House of Delegates have developed strong ethical standards and made clear that physicians’ relationships with these industries should be transparent and focused on benefits to patients. Many interactions between physicians and the pharmaceutical, biologic and medical device industries occur to advance clinical research that is essential to discovering treatments and improving patient care. The Sunshine Act is not meant to stifle these important interactions. The AMA has provided input to the Centers for Medicare and Medicaid Services (CMS) on how to present a meaningful picture of physicianindustry interactions and give physicians an easy way to correct any inaccuracies. Our efforts were aimed at ensuring the benefits of transparency and avoiding the burden of incorrect information. Research shows that physicians are not yet aware of many of the changes coming from the Sunshine Act. Here is what you need to know right now: Beginning in August, pharmaceutical and medical device companies must begin tracking information on their interactions with physicians, which they will report to CMS from that point forward. CMS is creating a public database on its website that will display the information reported by the pharmaceutical, biologic and medical device companies. This database will go live in September of 2014. CMS incorporated a number of our comments in the final rule governing the Sunshine Act. We are pleased that they will not require the reporting of pharmaceutical industry funding to CME providers as long as the CME complies with existing requirements for certification and accreditation. There are other exclusions as well, including product samples and inkind donations for charity care.

14 San Mateo county physician | June 2013

by Jeremy Lazarus, MD AMA President

Accuracy is just as important as transparency, so we are also pleased that physicians will have a minimum of 45 days to challenge any information before it is public and can dispute inaccurate reports and seek corrections during a two-year period. Physicians can, and absolutely should, review information submitted about them before it becomes public so they can correct any inaccuracies. This can be done by asking manufacturers and their representatives to provide the information they intend to report, or by registering with CMS (beginning January 1, 2014) to receive a consolidated report on your activities each June for the prior reporting year. Now is the time to get up to speed on this major change, and the AMA is offering resources to help. An easy way to get started is by viewing a webinar I recently hosted. This resource provides information on what is happening and when, and what you need to do to be ready. Because this information is critical for all physicians to have, the AMA is providing this webinar free of charge. I hope you will tune in and encourage your colleagues to do so as well. We are also developing tools to aid physicians in talking with their patients about the transactions included in the new Sunshine Act database. These and other resources—including answers to frequently asked questions, important dates to remember and information on how to challenge incorrect reports— are available at www.ama-assn.org/go/sunshine. We will continue to update this page and offer the latest information and tools to help you prepare for the changes coming from the Sunshine Act.

Retaining independence while embracing accountability: Care coordination and integration strategies for small physician practices

hysicians throughout the country are trying to figure out how to best achieve their professional goals in the changing healthcare delivery environment. Physician payments are increasingly being structured in a way that incentivizes quality and cost effectiveness over volume, and many place physicians at financial risk. In addition, public reporting of physicians’ performance will now be the norm, rather than the exception, with Medicare’s expansion of its Physician Compare website in 2013. Will physicians need to be employed by a hospital or a large medical group or health system in order to provide the quality and manage the costs that these payment and reporting systems require and take advantage of the emerging opportunities resulting from health system reform? Not necessarily. While some physicians may ultimately decide that formal alignment with a large medical group or hospital system is their best option, others are actively working to integrate new care coordination and accountability capabilities into their smaller practices. Indeed, there are a number of avenues that physicians in smaller practices can take that will allow them to retain their independence while also achieving the new capabilities they will need to succeed in this new environment. Funding transformation AMA has published a new resource to assist physicians in small and solo practices in taking advantage of the opportunities presented by the changing health care delivery environment, entitled “Retaining Independence While Embracing Accountability: Care Coordination and Integration Strategies for Small Physician Practices.” This article will summarize the final section of that resource, which focuses on options to obtain financing for practice enhancement. Capitalization For any change to be successful, there must be adequate funding. First, you need to determine how much money you will need. An attorney and/or an experienced practice consultant will be needed to help you estimate what it will cost to implement the care coordination infrastructure you will need for

your practice or to develop and operate your new organization. These individuals also often have good relationships with lenders that can be a fertile source of funding. Second, you have to find the funding you need. Fortunately, many of the services physicians need to start integrating and acquire capabilities required for coordination (such as information systems, scheduling and billing and collections) can be arranged through a contract for a percentage of collections, and therefore do not need an initial source of capital for funding purposes. There are a variety of additional sources for funding that physicians may wish to consider, including commercial lenders, physician participants (upfront cash contribution, loans, salary withholds, and/or their accounts receivables), hospitals, vendors (e.g. electronic health care equipment vendors will often arrange financing of the acquisition of computer systems), payers including Medicare and private health insurers, and grant-making foundations. Conclusion The fundamental goal of a more coordinated and integrated health care delivery system is being driven on multiple fronts and will continue in the future. Many options are available for physicians in small and solo practices to survive, and indeed, thrive in the future. Physicians must decide individually which option is best for them and whether they will be able to implement those changes needed to succeed with that option in the future. While the level of change in the current environment may seem daunting, there are many resources available to assist physicians attempting to navigate in the evolving marketplace. ■

Editor’s note: This article is the third in a series summarizing Chapter 8, “Retaining Independence While Embracing Accountability: Care Coordination and Integration Strategies for Small Physician Practices,” of the AMA publication ACOs and Other Options: A “How To” Manual for Physicians Navigating a Post-Health Reform World. The entire publication is available at www.ama-assn.org/go/ACO. june 2013 | SAN MATEO COUNTY PHYSICIAN 15

~ SMCMA Webinar ~

~ Upcoming CMA Webinars ~

A Vendor’s Perspective: Best Practices for Successful EHR Implementation

Protect and Preserve Your Patient Relationships Wednesday, July 24, 2013 • 12:15 – 1:15 p.m.

Transitioning to a new EHR can be daunting— whether you’re moving from paper charts to an EHR or converting from an existing EHR to another. By choosing the right EHR for your practice style and identifying and addressing the potential pain points up front, you can complete your EHR implementation with no downtime.

Presented by the Department of Health Care Services (DHCS), this webinar will help you increase understanding and awareness of the impact of fraud, waste and abuse on patient care, and discuss methods to prevent abuse and preserve the integrity of the physician/patient relationship.

ElationEMR has spent a great deal of time listening to its customers, learning where the pain points were in their prior EHR implementations in order to avoid problems while still keeping costs low. At this informative free webinar, representatives from ElationEMR will share a set of best practices for selecting and implementing the right EHR system for your practice.

Wednesday, July 31, 2013 • 12:15 – 1:15 p.m.

Wednesday, July 17, 2013 12:30-1:45 p.m. Free to SMCMA Members/$50 All Others

Enforcement Provisions of the Medical Practice Act

Presented by the Medical Board of California, this webinar will describe basic facts about physicians licensed by the Board. Additionally, learn about laws regarding the Medical Board’s enforcement program, including factors that can get a physician into trouble, the process from complaint receipt to adjudication; and why there is a physician interview and the benefits to fully responding. The webinar will also cover the sunset review process and the issues that are being discussed at the legislative level to enhance the law for consumer protection.

Please RSVP to Shannon Goecke at (650) 312-1663 or shannon@smcma.org. Upon registration, you will receive an email with your webinar login credentials.

These webinars are free to CMA members and their staff, $99 for all others. To register, visit www.cmanet.org/events or contact the CMA Member Help Center at (800) 786-4262 or memberservice@cmanet.org. Please register at least one hour before the webinar.

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16 San Mateo county physician | June 2013

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Walk with a Doc! Walk with a Doc is a community service program that encourages healthy physical activity for county residents of all ages. Walkers enjoy one-hour walks with physician volunteers and can ask questions about general health topics along the way. We are looking for physicians to walk with participants at designated public parks in San Mateo County on one or more Saturdays. Walks commence with a 3-minute talk by the physician on the importance of regular physical activity, followed by a free blood pressure check for those walkers who desire it Sign up at www.smcma.org/walkwithadoc, or contact Karen Stone at (650) 312-1663 or kstone@smcma.org. Saturday, July 6, 2013 Red Morton Community Park, Redwood City

Saturday, August 17, 2013 Red Morton Community Park, Redwood City

Saturday, July 20, 2013 Orange Memorial Park, S. San Francisco

Saturday, September 7, 2013 Central Park, San Mateo

Saturday, August 3, 2013 Leo J. Ryan Memorial Park, Foster City

Saturday, September 21, 2013 Leo J. Ryan Memorial Park, Foster City

Top Left: Physician volunteers from our June 8 kick-off walk in South San Francisco included, Venkateshwar Kapur, MD; Aileen Shieu, MD; Michael Norris, MD; and Sharon Ou, MD; not pictured: Eva Liu, MD. Bottom Left: Dr. Kapur, a family doctor at Kaiser Permanente, leads our walkers in some gentle stretches at our June 8 walk. Bottom Right: One of our Walk with a Doc billboards, this one in South San Francisco.

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june 2013 | SAN MATEO COUNTY PHYSICIAN 17

NEW SMCMA MEMBERS

Marci Bowers, MD OBG*/San Mateo

Erin Gills, MD EM*/Burlingame

Kesook Lee, MD PD*/SSF

D eceased M embers

Don Park, MD ORS/San Mateo

Ann Thai, MD GE, IM*/San Mateo

CLASSIFIED ADS BARGAIN-PRICED SUB-LEASE IN SAN MATEO

Gordon Binder, MD May 5, 2013

Thomas McGeoy, MD April 8, 2013

James Hansen, MD May 8, 2013

Barry Oberstein, MD April 16, 2013

Danny Lesnick, MD January 27, 2013

Thomas Parker, MD April 7, 2013

Ruben Mallari, MD May 8, 2013

Leo van der Reis, MD May 1, 2013

SMCMA MEMBERSHIP DIRECTORY UPDATE Please note that the phone number for Subha Y. Aahlad, MD, was listed incorrectly in the 2013 SMCMA Membership Directory. The correct phone number is (650) 574-2774.

PULMONARY ASSOCIATES IS PLEASED TO ANNOUNCE THAT

Charles K. Everett, MD HAS JOINED THE PRACTICE OF LUNG DISEASE AND CRITICAL CARE MEDICINE

1720 El Camino Real, Suite 150 • Burlingame, CA 94010 (650) 697-5367, option 2 18 San Mateo county physician | June 2013

Ob/Gyn/Urogynecologist on San Mateo Drive like to sub-lease his brand new, furnished 3-room medical office space for up to 5 days/week. $75 dollars/day or $1500/ month—a price lower than what leaseholder is paying the landlord. Bargain and a great opportunity for part- or full-time practitioner. For more information, please email paulsurinder1@yahoo.com.

PHYSICIAN VOLUNTEERS NEEDED IN RWC Samaritan House Free Clinic provides free medical and dental services to low-income and uninsured adults in San Mateo County. Please consider volunteering as little as four hours a month directly at the clinic or in your office by referral. For more information, please contact Jason Wong, MD at (650) 839-1447 or jason@samaritanhouse.com.

COALITION OF CONCERNED MEDICAL PROFESSIONALS (CCMP) NEEDS PHYSICIAN VOLUNTEERS CCMP is an all-volunteer. unincorporated membership association of medical professionals and others who provide free preventive medical care for low-income workers and advocate for access to health care. For more information, please call (510) 436-8020.

Index of Advertisers Bayside Realty Partners........................................................................... 16 Dementia Therapeutics........................................Inside Back Cover The Doctors Company...............................................................................6 The Magnolia of Millbrae..........................................................................4 Marsh............................................................................. Inside Front Cover NORCAL......................................................................Outside Back Cover Pulmonary Associates.............................................................................. 18 Tracy Zweig Associates........................................................................... 16 For information about advertising in San Mateo County Physician, please contact Shannon Goecke at (650) 312-1663 or sgoecke@smcma.org.

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