September/October 2017

| September / October 2017 A publication of the SAN MATEO COUNTY MEDICAL ASSOCIATION

S A N M AT E O C O U N T Y

PHYSICIAN

PRACTICE INSIGHTS The Case for Organized Medicine Physician Turnover MACRA: Tips for Success

INSIDE :

Firearm Legislation | California’s New Vaccine System | Surviving MedEd

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Editorial Committee Uli Chettipally, MD, Chair; Judy Chang, MD; Russ Granich, MD; Sharon Clark, MD; D. Gurpreet Padam, MD Sue U. Malone, Executive Director Linda McLaughlin, Design/Editorial Consult

SMCMA Leadership

S A N M AT E O C O U N T Y

PHYSICIAN

Alexander Ding, MD | President Sara Whitehead, MD | President-Elect Richard Moore, MD | Secretary-Treasurer

September-October 2017 • Volume 6, Issue 8

Russ Granich, MD | Immediate Past President Janet Chaikind, MD Uli Chettipally, MD Aruna Chinnakotla, MD Mamatha Chivukula, MD

Columns President’s Message

Paul Jemelian, MD

The Case for Organized Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Alex Lakowsky, MD

Alexander Ding, MD

Joshua Parker, MD Xiushui (Mike) Ren, MD

Feature Articles

Brian Tang, MD

Firearm Violence and Protection . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Dirk Baumann, MD | AMA Alternate Delgate

Barbara Weissman, MD

Scott A. Morrow, MD | Health Officer, County of San Mateo

Guest Editorial:

Editorial/Advertising Inquiries

Paul A, Offit, MD

San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. 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.

Physician Turnover in Medical Practices . . . . . . . . . . . . . . . . . . . 10

Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

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

Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.

Who’s Cheating California’s New Vaccine System? . . . . . . . . . . . . . . . . . . . . . . 8

Debra Phairas

MACRA Is a Marathon, Not a Sprint: How to Get Started Now.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

Robin Diamond, MSN, JD, RN

Featured Blog:

MedEd: Elevators to Success? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Pamela Wible, MD

Of Interest Farewell . . . from Executive Director Sue Malone .

. . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

New SMCMA Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 In Memoriam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

© 2017 San Mateo County Medical Association

Cover image: Moss Beach, the Cypress Grove, Fitzgerald Marine Reserve

President’s MESSAGE

The Case for Organized

Medicine

Alexander Ding, MD President

The medical society should strive to be a gathering place, a place and organization that builds community.”

2 S AN M ATEO CO U NTY PH YSI CIAN

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he role of organized medicine, our medical societies and associations, across this country has changed over the past several decades due to major industry changes over this same period.

These changes include the broad explosion of medical knowledge and the resulting breadth of medical specialization, the growth of a physician employment model, and cultural and attitudinal shifts about professional duties and norms.

Organized medicine once played a central role in the professional lives of physicians. Over 75% of physicians were members of their local and state societies, in addition to the AMA. There used to be more participation because there was a sense of duty to the profession as a vital aspect of one’s career. Our local associations were also once the clearinghouse for many CME opportunities. There was an economic interest for fraternizing in the medical association, as it would drive referral patterns at a time medicine was a cottage industry. Furthermore, membership was nominally required as it was necessary for hospital credentialing and therefore local practice.

Many of these things have changed. The need for local associations in these realms is no longer as critical. Our membership penetrance at the SMCMA and CMA hover near 50% (which is considered above average). Arguably, our medical associations have not kept up with the needs of physicians.

But yet national specialty societies have been quite successful. Nearly 75% of all physicians are members of their respective specialty associations.

With the balkanization of medicine into our various specialties, our specialty societies are more relevant to our day-to-day work. It is much easier to align incentives and goals within a specialty than across the diversity of medical practice. However, aligning the broad diversity of medicine remains a worthwhile effort and is arguably more important than ever.

We need cross-specialty, broad-based medical associations to coordinate across the various tribes in medicine. When we can achieve alignment, our voices will be amplified greater than what we could do on our own, or even with just our own specialty societies. This blueprint has shown to be successful in the dismantling of the SGR. But there is still work to do as a united front, i.e MIPS, MACRA, CURES.

SEPTEMBER–OCTOBER 2017

Physicians do not owe it to us to be members when there is so much choice out there in the professional organization space. Our local and state medical societies need to rethink where our value is. We need to provide tangible benefits that provide real value. In business terms, they need to see a positive return on their investment of membership dues. In order to reach a swath of younger physicians, we will need to adapt to electronic means of engagement.

Value at the local level can mean continuing to do what we have done for decades, which includes helping our physicians navigate the challenging policy and reimbursement landscape. But that is a service that primarily helps solo and small group practices, which unfortunately, are becoming more rare. With more and more of our physicians being employed, their foundations and systems have an army of coders and administrators to manage this. For these physicians, we can help them navigate their employment contracts or advocate for them when challenges arise with their employer.

T

here is something, however, that we can provide for all physicians, across specialty, across practice modality, but very much local: community. The medical society should strive to be a gathering place, a place and organization that builds community, and provides opportunities to socialize in a professional (but non-work) setting. Physicians are so busy and isolated these days and lack the same sense of collegiality that was once present in a local community. This, I believe, is a contributing factor to the physician burnout epidemic.

Our county medical association should work to alleviate burnout, by helping us build our community, working to

help us achieve work-life balance, and provide programs and resources for wellness. It should be an organization that helps to reinvigorate you in your work. These are programs that your SMCMA is working to build so as to provide a tangible and concrete value for your membership.

Additionally, given the dysfunction in Congress, there is likely more and more to be done at the local and state level where the government still mostly functions. Therefore, our state and county medical associations, which are grassroots organizations that are in tune and connected with our community, will see an emboldened opportunity to again be the voice and advocate for our physicians.

Engaging and organizing our local physicians to advocate on these important social questions of access to care, equality, fairness of the marketplace, and the selfregulatory authority of a profession is a critical role that your SMCMA takes seriously. We encourage you to work with us to leverage the SMCMA and CMA for issues you believe are vital to the success and health of our physicians and patients. Representing the breadth of practice modes and specialties at the local level with an engaged physician community will allow us to project an amplified, united physician voice.

If you have ideas on what your SMCMA could do for you or your practice, or if you have policy or advocacy goals you would like to see us work towards, I encourage you to call or email the SMCMA office directly and give us your thoughts, ideas, feedback, and criticisms. We are always seeking to provide you more value for your membership dollars and this can best be achieved when we hear from our members about what they need and want from their local medical association.

SEPTEMBER–OCTOBER 2017 | SAN MATEO COUNTY PHYSICIAN 3

Firearm

VIOLENCE AND PREVENTION

Barbara Weissman, MD CMA Trustee for the Specialty Delegation

The paper strongly supports physicians’ rights to discuss firearm safety issues with their patients.”

4 SAN MATEO COUNTY PHYSICIAN

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t the July Board meeting of the Board of Trustees of the California Medical Association, a white paper on firearm violence prevention was submitted and approved. Physicians have expressed interest in this area for many years — there are resolutions that go back decades that shape CMA policy — but it was felt that this policy had been developed in a piecemeal manner and that a comprehensive statement was needed.

San Mateo County physicians have also been active on this issue in the past couple of years. In April 2016, the bioethics committee had a special meeting with the general membership where Stanford law professor, attorney John J. Donahue III, spoke about firearm violence. The flyer for the meeting stated that firearm violence was the third leading cause of preventable death in the United States, with more than 30,000 deaths annually (roughly two-thirds of which are suicides) and approximately 75,000 non-fatal injuries. The San Mateo Medical Association Council worked in the fall of 2016 on a resolution to address the issue.1 The CMA paper — which will be released in late November or early December as a comprehensive policy

SEPTEMBER–OCTOBER 2017

statement — declares that the United States has struggled with an epidemic of firearm violence. While acknowledging that firearm violence is primarily a human and civil rights matter, it expresses that it is also a public health and public safety matter. Physicians have a role in routine screening and assessment that allows them to educate and counsel patients about the leading causes of morbidity and mortality, and this makes them uniquely situated to assess risk, provide education and change behaviors related to gun violence. The paper strongly supports physician’s rights to discuss firearm safety issues with their patients, and is supportive of expanded education and training of physicians in the benefits and risks of firearm ownership, safety practices, and how to communicate with patients about firearm violence.

Other specific areas covered in the paper include recommendations to: Decrease the disproportionally high rates of firearm violence in low-income communities and in communities of color; Decrease the frequency of depiction of violence in the media; Oppose the suppression of firearm research that is needed for the advancement of evidence-based policies;

Address the problematic nature of the focus on people with mental illness as perpetrators of violence, as mental illness is more strongly related to suicide than violence against others, and people with mental illness are more likely to be victims than perpetrators of violence.

W

hile acknowledging that gun ownership is valued by many people, the paper suggests that there should be strong legal and regulatory protections in place including universal background checks and safety courses, requirements to report loss of a firearm within 72 hours, and restrictions on firearms designed to have rapid killing capacity. It also recommending firearm safety practices such as storing firearms unloaded and in locked positions in a separate location from ammunition. It calls for targeted public education campaigns and a public health approach directed towards firearm violence.

The full content of the statement and background material will be available late this fall at www.cmanet. org (search: Firearm Violence Prevention Committee Report). For ongoing updates on CMA’s involvement with legislative issues, go to http://www. cmanet.org/issues-and-advocacy/.

Dr. Weissman is a member of San Mateo County Medical Association.

This article is envisioned as part of a series addressing matters of interest to SMCMA that come before the CMA Board of Trustees at their quarterly meetings. If you have questions about CMA actions, or ideas for directions that CMA should be heading, please feel free to contact Dr. Weissman at barbara. yatesmd@gmail.com.

1. Access the SMCMA Gun Violence Statement (April 2016) at www.smcma.org under the Physician Resources tab.

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SEPTEMBER–OCTOBER 2017 | SAN MATEO COUNTY PHYSICIAN 5

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Farewell . . .

from Executive Director Sue Malone

I

t is with some sadness that I say farewell to the physicians and staff as I retire after serving almost 28 years as your Executive Director. It was not my first position serving as the executive of a not-for-profit organization, but certainly the longest and one of the happiest.

I actually flew out from Boston for my interview in San Mateo the day of the Loma Prieta Earthquake (yes, 1989 was 28 years ago!). I wasn’t even sure the interview would take place the following day. I was staying with a friend whose flat had no lights and limited telephone service — no iPhone then, but I finally made contact with George Koenig, a general surgeon in Redwood City and then president of SMCMA, who assured me that the interview would go on. This was an unfortunate turn of events for President Elect — Don Cheu, an ER physician at South San Francisco Kaiser who, as an aficionado of emergencies, wanted to be out with the first responders investigating the aftermath of the quake. Instead, he had to delay what he loved doing most until after the interview.

I flew home the next day with friends, who suggested that after experiencing the earthquake, surely I would not take the job! — would I? I had been away from San Francisco for eight years, as I had taken a job in Boston. But I really wanted to come “back home” to the Bay Area. Back east, I had worked with lawyers and judges, so was a little unsure what it would be like working with physicians. Now, decades later, I have found that working with physicians is exhilarating, thought-provoking, rewarding, and a great privilege: altogether enlivening.

I

t’s daunting to acknowledge how quickly the years have flown by. Societal changes through this time have dramatically altered the practice of medicine — it’s as if the earthquake had been prophetic. Working with physicians as they have adpated and modified the way they practice medicine has been a challenging and gratifying experience. I remember when Don Cheu told me that his father, who preceded him as a general surgeon at SSF Kaiser, had no love for organized medicine. Kaiser doctors were viewed as socialists, and the non-Kaiser physicians were suspicious about inviting them to join their medical societies.

You can imagine that Don’s dad, having not been invited, was less than overjoyed when he learned that his son had not only become an active member of SMCMA, but in 1990 became its president. How times were changing!

When I first arrived, physicians were increasingly finding medical insurance companies interfering in their day-to-day practices, including requiring pre-authorizations for surgery and the like. At that time it was not unusual for the insurance company to send a form letter to a patient stating that their physician had ordered a procedure that was deemed medically unnecessary. Alan Zacharia, a Daly City orthopedist, liked to tell —

in his typically feisty style — of his experience with a carrier when he ordered an epidural steroid injection for an 82-year-old patient with chronic back pain. They won their appeal, but it is hard for physicians to stand up to these insurers when it could jeopardize one’s standing with a carrier.

Dealing with HMOs then came along, causing many physicians to feel even more hassled and unappreciated. In the late 1970s, IPAs had formed to serve as the middleman, but over time they never developed the clout needed to work with the health plans and at the same time satisfactorily control the billing behavior of their physician network. By 2000 the IPAs were collapsing. After Loma Preita, the California legislature established deadlines for hospitals to meet earthquake seismic standards, which impacted almost all hospitals in the county, and occupied many in health care to fund and develop new structures to withstand another such event. It was not long before Palo Alto Medical Foundation generated plans to build a facility in San Carlos, Stanford acquired Redwood City property for an outpatient facility, and Mills-Peninsula was operating under the watchful eye of Sutter Health. Competition for patients was already intense and now would become greater.

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ll this is to say that SMCMA had to change with the times. This is just a snippet of the big picture when I first started work here. The physicians and the medical society weathered the changes — but not without pain. The one thing that is most pronounced to me over the years is loss of the independence that physicians used to enjoy. Sad indeed. We survived the earthquake, but we are still adapting to tumultuous changes in the medical landscape.

While the medical association has maintained its membership — thanks to financial support from the large groups — we are continuously seeing diminishing numbers of solo practitioners in clinical practice. Federal and state regulations make the independent practice of medicine much more difficult; this is why many practitioners now find it easier to join a group. Of course changes will continually occur, and the practice of medicine will not look the same going forward. Hopefully, younger physicans will adopt such changes with little notice.

It has been a wonderful, challenging, and fulfilling experience to serve the San Mateo County physicians during my almost 28 years with SMCMA. Life won’t be the same without you, but I do have grandchildren waiting in the wings who want attention and I will relish spending time with them in Oregon. Who knows — maybe one of them will join the ranks of physicians in the future.

Thanks to all of you for the wonderful care provided to our community.

SEPTEMBER–OCTOBER 2017 | SAN MATEO COUNTY PHYSICIAN 7

Who’s Cheating

California’s

Tough New Vaccine System?

Paul A. Offit, MD

Medical exemptions tripled once a stringent law went into effect for kindergarteners. A look at where it’s coming from suggests something sinister within anti-vaxxer strongholds.”

he numbers are in on California’s tough new vaccination law, and they reveal a disturbing phenomenon.

In June 2015, the state enacted Senate Bill 277, mandating that at the beginning of the next academic year, all students had to be vaccinated, including those in private, charter, and parochial schools. It was one of the most restrictive immunization bills in history, and a response to a measles epidemic that started in Southern California at the end of 2014 and eventually spread into 25 states and two Canadian provinces, infecting hundreds of people, mostly children.

Before SB277, California, like many states, had allowed parents to exempt themselves from vaccines. All 50 states permit medical exemptions; 47 have religious exemptions. And,

before the passage of SB277, 18 states had philosophical exemptions. SB277 eliminated California’s philosophical exemption. Because California never had a religious exemption, only medical exemptions remained. With SB277, California became the third state to allow only medical exemptions (West Virginia and Mississippi are the other two).

One year after SB277 went into effect, the results are in.

First: the good news. During the past year, kindergarten immunization rates increased to 95.6 percent from 92.8 percent. When compared to two years earlier, immunization rates were up 5.2 percent. Indeed, current immunization rates in California are the highest they’ve been since 2001.

Now: the not-so-good news.

According to an investigative report

8 SAN MATEO COUNTY PHYSICIAN | SEPTEMBER–OCTOBER 2017

by the Los Angeles Times, the number of medical exemptions during the past year tripled. The year before the bill passed, 991 kindergarteners chose a medical exemption. The year after it passed, that number increased to 2,850. Medical exemptions can only be granted with a signed letter from a doctor.

What happened?

One possibility is that parents of children with true medical exemptions had previously claimed a philosophical exemption, which was obtained by simply filling out a form—much easier than getting a doctor’s letter. With the new bill, however, these parents were forced to do something they probably should have done in the first place.

Another possibility is that more children actually did require medical

exemptions, which are given for several reasons. For example, children who are receiving chemotherapy for cancer or immune suppressive therapy for chronic diseases or steroids for asthma cannot receive live, weakened viral vaccines like the measles-mumps-rubella (MMR) or chickenpox vaccines. Also, children who are allergic to vaccine components, most notably gelatin or latex, cannot receive certain vaccines. But why the dramatic increase? Have children in California suddenly become more immune suppressed or allergic?

Unlikely.

T

he most likely explanation can be found by taking a closer look at where these medical exemptions are clustered and one unusual resource that became available after the passage of SB277.

Typically, about 0.5 percent of children require a medical exemption. Indeed, the 2,850 medical exemptions requested represent 0.5 percent of California’s kindergarten population. But according to the Los Angeles Times, in 58 schools, more than 10 percent of kindergarteners chose medical exemptions; at seven schools, more than 20 percent did.

Many of these exemptions occurred in Los Angeles, San Diego, and Orange counties: the same counties that produced the 2014-2015 measles epidemic.

The unusual resource? After SB277 passed, anti-vaccine websites appeared across the state coaching parents on how to request medical exemptions; many of these websites included a list of doctors sympathetic to parents who felt they were being unfairly coerced into vaccinating their children—doctors who, by requiring an office visit, were essentially selling a medical exemption. “It would be very unfortunate if there were physicians

who’ve shirked their professionalism, and basically are trying to monetize their professional license by putting children at risk and betraying public health,” said Richard Pan (D-Sacramento), a physician who co-authored SB277.

Given this most recent development, it would take a counsel of the gods to determine which aspect of the anti-vaccine movement is most upsetting: parents choosing to put their children in harm’s way unnecessarily; state governments, through philosophical and religious exemptions, allowing them to do it; or doctors, in some misguided sympathy for freedom of choice, writing bogus

medical exemptions for a price. At the very least, public health officials and licensing boards in California need to take a closer look at the reasons behind the dramatic increase in medical exemptions. And if they find that these exemptions have no basis in fact, doctors should be held accountable for their fraudulent behavior.

Dr. Offit is a professor of pediatrics and director of the Vaccine Education Center at the Children’s Hospital of Philadelphia.

He is the author of Pandora’s Lab: Seven Stories of Science Gone Wrong (National Geographic Press, April 2017). This article is reprinted from The Daily Beast, September 2, 201 7.

© The Daily Beast

SEPTEMBER–OCTOBER 2017 | SAN MATEO COUNTY PHYSICIAN 9

Physician Turnover

in Medical Practices Debra Phairas

Some [residents] are interested in rural programs, small independent practices and the direct or concierge model.

The tide may shift again back to private practice.“

10 SAN MATEO COUNTY PHYSICIAN

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ecruitment and retention of physicians in medical practices continues to be an issue in San Mateo County and the entire San Francisco Bay Area. The Bay Area housing prices and cost of living, as well as increased overhead expense costs for practice rent and staff make it more difficult to sustain private independent practices for some specialties. However, hospital foundation models and universities have the same problem, and find turnover of physicians costly.

An American Medical Group Association study reported an average turnover rate of 6.8%. The Bay Area should have a positive edge when recruiting according to this study, which showed that quality of life is one of the top factors in the decision to take a position. When advertising for a physician position, selling the Bay Area climate, lifestyle, recreation, cultural amenities, restaurants and local universities is imperative to bring attention to the position opportunity.

Succession planning is very important for medical groups with preparation recommended at least two years in advance. Physicians in the Bay Area should give their partners this much advance notice of retirement, due to the difficulty in recruiting new physicians to this area. Typically, in shareholder/ partner agreements we now see a minimum of 12 months’ notice requirement for retiring physicians. Failure to give the required notice often will be tied to a forfeiture of the buyout in a declining percentage. Example: 12 months’ notice = 100% of buyout formula, 11 months 90%, 10 months 80% until either are down to 0%. Some groups state anything less than 3 to 6 months’ notice results in a forfeiture of all the buyout formula.

Retiring physicians are being replaced by the millennial generation that values work/life balance and who do not wish to work 60–70 hour weeks.

Often a workaholic retiring physician in some medical groups may need to be replaced by one young physician and one Advanced Practice Clinician (NP/ PA). As older male physicians retire, they are more likely to be replaced by female physicians who may wish to work part time.

SEPTEMBER–OCTOBER 2017

concierge model. The tide may shift again back to private What many medical practices or groups may need to practice. Indeed, many consultants in the National Society consider is offering part time work, flexible schedules and of Certified Healthcare Business Consultants predict in five using triage nurses to reduce the call burden. Two physician years an exodus from hospital employment by a segment of families are becoming more prevalent so finding a position the employed physician population due to hospitals losing for both is imperative. an estimated $150,000-$250,000 per employed physiThe cost to recruit, advertise, review CVs and interview cian, the squeeze that is happening on compensation with also needs to be taken into consideration. Most physician these losses, as well as the desire to escape the control and recruitment firms charge $20–30,000 per recruitment. bureaucracy of the employment model.

According to Cejka Search, practices interview about three The Physicians Foundation survey found that 63 percent candidates per vacancy. Candidates may make more than of physicians said they do not believe the employment of one visit, and the total cost on average comes to $31,090 physicians by hospitals is a positive trend likely to enhance per position filled. That is just for interview costs. According quality of care and decrease to Echo, a HealthStream costs.2 Even a slight majority Company that offers credenof employed physicians (51 tialing and analytics, “the cost PHYSICIANS PLANNING percent) indicated they do not to train, credential, market TO PRACTICE CONCIERGE/DIRECT believe hospital employment of and onboard a physician” is PAY IN THE NEXT THREE YEARS physicians is a positive trend.3 $200,000 to $300,000.

The Association of IndepenThe 2017 Merritt Hawkins 8.8% dent Doctors (www.aid-us.org) (a national search firm) Review has formed for physicians who of Physician and Advanced wish to remain independent.

6.8% Practitioner Recruiting Incen6.2% Strategies for doctors who wish tives survey notes that Family to remain independent include: physicians are the number merging with other independent one recruitment need for the groups, outsourcing billing and eleventh consecutive year. The collections, automating schedother specialties in the top ten uling and reminders and hiring in order of requests include 2012 2014 2016 a “lean, mean fighting machine” Psychiatry, Internal Medicine, staff. Extending hours, incorpoNurse Practitioner, OB/GYN, rating diet, exercise and wellHospitalist, Emergency MediSource: 2016 Survey of America’s Physicians. ness programs and developing cine, Physician Assistant, The Physicians Foundation/Merritt Hawkins 1 ancillary revenue streams can Dermatology and Radiology. build revenues and net incomes.

New physicians are most Hiring Advanced Practice Clinicians can also expand the vulnerable to turnover. According to Lori Schutte, Cejka practice and sustain net incomes. For primary care practices, Search, physicians in the first years of practice have the the direct patient care model and partial or full concierge highest turnover rates overall. The average turnover rate practices is a growing trend (see graph). These new models for physicians in their second to third year of practice is 12.4 percent, and small groups suffer from 20.8 percent turnover are attractive for recruiting and retaining physicians. among physicians in those early years. Once physicians stay in a practice through five years, they are much less likely to leave; turnover between years five and 10 is 5.7 percent and Debra Phairas is president of Practice & Liability Consultants, LLC: dips to 4.6 percent after 10 years.2 An Orthopedic Academy www.practiceconsultants.net study many years ago that found over 50% of new physicians in practice changed jobs within two years after residency.

References: This author has taught “The Transition from Training to 1. https://www.merritthawkins.com/uploadedFiles/MerrittHawkins/ Practice” in residency programs since 1988. For the last Pdf/2017_Physician_Incentive_Review_Merritt_Hawkins.pdf two years, she has presented this program for the Kaiser 2. Five Trends to “Bend” to your Advantage, Lori Schutte, Cejka Southern California Family Practice and Internal MediSearch: www.nejmcareercenter.org/minisites/rpt/five-trendscine Residency programs. It is fascinating that while most to-bend-to-your-advantage/ will seek positions with Kaiser, some are interested in rural 3. http://www.physiciansfoundation.org/uploads/default/ programs, small independent practices and the direct or Biennial_Physician_Survey_2016.pdf SEPTEMBER–OCTOBER 2017 | SAN MATEO COUNTY PHYSICIAN 11

MACRA Is a Marathon, Not a Sprint: How to Get Started Now Robin Diamond, MSN, JD, RN

I

n September 2016 — just three months from the release of the final rule of the Centers for Medicare & Medicaid Services (CMS) Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) — half of the physicians surveyed had not heard of MACRA, which establishes a new way to pay doctors for Medicare patients. In January 2017, the beginning of the first performance reporting period, only 19 percent of physicians reported that they were very or somewhat familiar with MACRA. Physicians and practice managers may feel as if they’re being left at the starting line, but although the first quarter of 2017 is long over, there is still time to get in the MACRA race.

On your mark . . .

Assemble a team. A team is vital to tackle MACRA data collection, data analysis, and submission. Team members should come from various roles in the practice.

For example, a team might include the practice manager, a physician, a clinical staff member, and an administrative staff member. The team should brainstorm strategies to incorporate metrics into existing workflow and optimize the workflow to include data collection. The team can also then educate the rest of the organization about MACRA and its role in the process.

12 SAN MATEO COUNTY PHYSICIAN | SEPTEMBER–OCTOBER 2017

Get set . . .

Decide whether to report as a group or individual. An individual is defined as a single National Provider Identifier (NPI) tied to a single Tax Identification Number (TIN). A group is defined as a set of clinicians (identified by their NPIs) sharing a common TIN, regardless of their specialty or practice site. This is also important for the method of submission, because only clinicians reporting as individuals may use a claims submission method and the CMS Web Interface is only available to groups of 25 or more clinicians. Know the criteria, advantages, and disadvantages of reporting in each category—the Quality Payment Program (QPP) website is a helpful resource.

Pick your pace. In this transitional year of the QPP and alternative payment models, CMS solicited feedback from stakeholders about the burden of reporting under MACRA and responded by making this a learning year. Practices have four options to choose from and can participate as much, or as little, as they choose. It is points-driven: The more participation, the more points earned. The goal is to exceed 70 percent in the composite score to be considered for a bonus. The composite score is composed of Quality + Advancing Care Information + Improvement Activities.

(ACI) and will require greater participation than in the past.

Prior to 2017, measures had low thresholds and were easy to attain. As of 2017, it’s necessary to include as many patients as possible. Practices will also have base measures to report, including conducting or reviewing a security risk analysis; e-prescribing; and providing patients with access to view, download, and transmit their health information.

A new performance category for 2017 is the Improvement Activities (IA). Most groups will attest to completing four activities. Small groups with less than 15 physicians will attest to two activities. These activities focus on patient safety, care coordination, and engagement.

Understand your participation options.

For example, most clinicians will report under the Merit-Based Incentive Payment System (MIPS) versus an Alternative Payment Model (APM). There will be a small group of physicians in an APM who will only partially qualify and thus need to report under MIPS. It’s important to understand this and report correctly to avoid a negative adjustment.

Go! Start now. Reporting a single measure will avoid a nega-

Review and improve. Evaluate past performance in

tive adjustment in 2019. Don’t stop there—take advantage of this transition year. Don’t aim for the bare minimum. Instead, use this time to learn as much as possible and close as many gaps before the year’s end. This time is designed for practices to implement workflows and processes to be successful for 2018 and beyond.

Use this time to partner with your EHR vendor. Don’t wait until the third or fourth quarter to find out data is not calculating. Schedule weekly calls with your EHR account manager.

Ask for a user guide, provide it to your team, and review it often to close gaps in documentation.

If you are already reporting PQRS and MU, you’re halfway there. If you’re not reporting yet, there is still time to start before October 2, 2017—and the earlier the better. The positive or neutral adjustments are less challenging to meet in 2017, and what is done this year will reflect in the 2019 public reporting and pay-for-performance. Delaying participation may make next year more challenging.

For more information, go to the Medical Advantage Group website or contact The Doctors Company Patient Safety Department at patientsafety@thedoctors.com.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

the Physician Quality Reporting System (PQRS), which now becomes the Quality Measures and will have the greatest weight (60 percent of the composite score).

Review past performance in the Meaningful Use (MU) measures. MU now becomes Advancing Care Information

Robin Diamond is Senior Vice President of Patient Safety and Risk Management, The Doctors Company. Kim Hathaway, Healthcare Quality & Risk Consultant, The Doctors Company, contributed to this article.

Select measures and submission methods. Choose measures that best fit your practice.

Understand that not all of the measures are equal in value.

Under the quality category, one measure could earn as many as 10 points. Take time to review your options.

The measures may be reported in several ways, including through the electronic health record (EHR), a qualified registry, CMS Web Interface, and administrative claims data.

Submission methods are particularly important because they will increase points, which affects the composite score and may assist in maximizing payment or earning a bonus.

The EHR is one of the easiest ways to capture and report data. Consult your EHR vendor about functionality and creating a workflow for collecting data and reporting. EHR vendors are the primary source for ensuring the documentation of best practices data is accurately captured in the software and producing correct credits for the work provided.

Regardless of how reporting is done, now is the time to work out the process and learn how easy or difficult it is to upload and track progress prior to final submission. At least 90 consecutive days of data is required to be considered for a positive upward or neutral adjustment.

SEPTEMBER–OCTOBER 2017 | SAN MATEO COUNTY PHYSICIAN 13

Featured BLOG

Posted: September 4, 2017

S R O T ED : ELE VA

MED

to Success?

Pamela Wible, MD Excerpted from Dr. Wible’s Blog, www.idealmedicalcare.org/blog/

H

ave you ever been depressed as a physician?” I asked 220 doctors. Ninety percent stated, ”Yes,” and several stated that “about 75%” of their fellow medical school students or residents were, or had been, on psychiatric medications.

It seems the epidemic of depressed doctors begins in medical school. I wondered how best to verify this oftrepeated 75% statistic. Just then, a student called to tell me what her professor said during orientation: “Look around the room. By the end of your first year, two-thirds of your class will be on antidepressants.”

I’m appalled. Yet she’s grateful. Why? Because her school is so “progressive.” They normalize the need for antidepressants.

I must be out of touch. Do most med students require psych drugs for day-to-day survival? I turned my question over to Facebook:

“True, but most take them in secret as there are negative consequences and stigma that come with getting your mental health addressed.”

“Very true. From a practical point of view, I’d put medical students and residents at 100%.”

“The only way I’d say false is to say it’s higher. “

H

TRUE OR FALSE:

“75% of medical students and residents are taking either stimulants or antidepressants, or both.”

Here are just a few, representative responses: “It’s absolutely, horrifyingly, true. It is a symptom of a great sickness in MedEd.” “Sadly, I am guessing true, as I prescribed some for my residents every year that I worked in a residency.”

“True, but I’m sure a lot is unprescribed.”

“While working as a nurse at a major Army hospital, I was astounded by the number of medical students on Adderall or Ritalin.”

I’ve been on an antidepressant since being premed—18 years now. Little did I know it would be impossible to wean myself off, and that my entire class was using Adderall.”

14 SAN MATEO COUNTY PHYSICIAN | SEPTEMBER–OCTOBER 2017

aving received Facebook confirmation that most med students are on psych drugs, I then queried 1,800 medical students via email with the same question and encouraged respondents to share personal experiences.

To prevent professional retaliation, the following quotes are published anonymously (with permission):

“I am one of the many who are currently on BOTH antidepressants (2 types) and an amphetamine. I lost my very dear friend (also a classmate) to suicide in my third year of med school. I have been on psych treatment since then.”

“True. I’m on them, and every student I know is on them too.

I’m on both; never took them before med school. Same with all of my friends. ” “I would guess at least 50-75% of my class took stimulants and/or antidepressants.”

“I tried two types of antidepressants in medical school, lost more than 200 thousand dollars, and almost ended up homeless. All [my depression and debt] started in medical school. Yet my passion remains.”

“Students are afraid to speak about it and I know some who have even asked friends/family to get meds under their name so it isn’t on their record. I finally started talking about it with my classmates and found that many of my close friends were taking them and we had individually struggled alone, not knowing there were others going through the same thing. Also, if everyone’s doing it and it gives them an edge, then everyone else has to do it.”

“Sounds about right. I never needed antidepressants before medical school. And it definitely made me rely on higher doses of methylphenidate than I’ve needed in the past.”

“I never thought I would take study drugs. But I was near the bottom of the class in my exam results, and then found out that several who were best in our year were taking study drugs. I cut my losses and copied them. Lo and behold, my results improved drastically. I don’t like it, but for me it is better than falling behind and doing poorly.”

“True. As a med student I was on antidepressants. No different now that I am an intern. Having just finished 12 days straight and >120 hours, I can understand why people are also using stimulants.”

“True. I only have four friends in medical school that I know well enough to know which meds they take. All are on both.

I went to the university psychiatrist in my premed program for depression, and he asked me when I felt better. I said, when I take my friends’ stimulants to study. I expected him to give me a verbal wrist slap; instead, he gave me a script. “

diagnosis and talk about it openly to destigmatize it, but I have actually cut back on that because if I’m not careful, I inevitably get a lot of classmates asking if they can have some of my medication. For a future doctor to brazenly ask for illegal sharing of medicine is worrisome to me but I do understand the pressure that drives the behavior.”

I

n 1990, even I was severely depressed as a first-year med student. So my mom (a psychiatrist) mailed me a bottle of Trazodone. I thought I was the only one crying myself to sleep. Turns out that occupationally-induced depression is rampant in medical training. Now, schools dole out antidepressants like candy. Stimulants are used by med students like steroids in athletes. So where do we go from here?

Should “progressive” medical schools distribute samples of Zoloft and Adderall during orientation?

The problem is that physicians must answer mental health questions (right next to questions on felonies and DUIs) to secure a medical license, hospital privileges, and participate with insurance plans. Check the YES box and you’re forced to disclose your “confidential” medical history and defend yourself — again and again — for your entire career. Treated like a criminal for taking meds to cope with the torment of medical training (and practice).

Maybe that’s why so many future (and current) physicians sneak drugs and go off-the-grid for mental health care, as does one doctor, who says, “I’ve been in practice 20 years and have been on antidepressants and anxiolytics for all of that time. I drive 300 miles to seek care and always pay in cash. I’m forced to lie on my state relicensing every year.

There is no way I would ever disclose this to the medical board.”

What if we stop the mental health witch hunt on our doctors? Why not replace threats and punishment with safe, confidential care? What if we address the root of the problem — the great sickness in medical education — rather than shifting blame to 75% of medical students for not having enough serotonin or dopamine or norepinephrine in their brains?

As scientists, we can’t continue to approach medical education reform as a neurotransmitter deficiency in medical students. Can we?

“If everyone’s doing it and it gives them an edge, then everyone else has to do it.”

“I was on an inpatient internal medicine rotation working 12to 14-hour days 6 days a week (as a third-year med student) and would ‘keep it together’ at the hospital and fall apart on the way home, cry and sleep to cope. It was the first time in my life I felt suicidal, no plans—just wanted to fade away.

My husband was afraid to leave me alone. I put myself back on Lexapro and kept pushing on. I finally found a psychiatrist, and he put me on a trial of Adderall. I was hesitant due to the abuse potential but decided to give it a try. With the two meds I have less anxiety, way better at prioritizing, and my focus is improved. I’m studying for step 2 currently so time will tell.”

“As I’m sure you know, there is unfortunately also a great deal of illegal procurement of prescription medications as well as abuse of illegal drugs. An increase in alcohol abuse is also a major concern. People are self-medicating left and right.”

“I would not be surprised! I know 10 people from 5 different schools and at least 7 are on either.”

“I am lucky to have a great support structure and have coped quite well so far without needing any medication. I am diagnosed with ADHD and have a prescription for two medications which I don’t really use. I’m not shy about my

Dr. Wible is a family physician in Eugene, Oregon. She takes no psychiatric medication. She is author of Physician Suicide Letters—Answered. View her TEDMED talk, ”Why doctors kill themselves” at http://www.tedmed.com/talks/show?id=528918.

SEPTEMBER–OCTOBER 2017 | SAN MATEO COUNTY PHYSICIAN 15

elcom

NEW MEMBERS!

Kendall Allred, MD

Paul Bryant, MD

Kacy Church, MD

Tressia Hing, MD

Emergency Medicine Burlingame

*Psychiatry, *Child & Adolescent Psychiatry Daly City

Internal Medicine, Endocrinology Burlingame

Internal Medicine, Gastroenterology Burlingame

Rachel Intriago, MD

Erika Murphy, MD

Amir Schricker, MD

Dennis Sheehan, MD

Gregory Summerville, MD

*Obstetrics & Gynecology Daly City

*Neurology Redwood City

*Cardiovascular Disease, *Clinical Cardiac Electrophysiology Burlingame

*Cardiovascular Disease Redwood City

*Internal Medicine, Sports Medicine S. San Francisco

Marc Yonkers, MD

Alexander Zider, MD

*Ophthalmology Daly City

Pulmonary Disease, Internal Medicine Burlingame

*Board certified

In Memoriam James Dubois, MD • August 5, 2017 Francis Healy, MD • July 29, 2017 Elliot Polinger, MD • June 11, 2017

16 SAN MATEO COUNTY PHYSICIAN | SEPTEMBER–OCTOBER 2017

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