April 2013 by SMCMA

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

Physician

April 2013 | Volume 2, Issue 4

A publication of the San Mateo County Medical Association

Nursing Homes The Mystery Unraveled

Antidepressant Usage in Pregnancy and Breastfeeding

Online Reputation Tips for Physicians

CMA Webinars AMA Practice Tips

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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

Contributing Authors Michael Fertik, JD; Shannon Goecke; Russ Granich, MD; Gregory Lukaszewicz, MD; Thomas Lupton, MD; Sue U. Malone

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 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. 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.

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

Physician

April 2013

Introduction | Russ Granich, MD As our healthcare community tries to shorten hospital stays, patients with increasing needs are ending up in nursing homes to continue their care. But many physicians don’t fully understand what nursing homes and skilled nursing facilities can (and cannot) do for patients. In this issue of San Mateo County Physician, I’ve explained the different levels of care, some of the costs involved, and touched on what is covered by Medicare. Next, my Kaiser colleague Thomas Lupton, MD, has provided clear guidelines on an issue that affects physicians in primary care, obstetrics, and psychiatry: antidepressant usage during pregnancy and nursing. We’re also including some articles to help you manage your practice, whether it’s managing your social media presence, getting involved with quality reporting and e-health incentive programs, or integrating new care coordination and accountability capabilities.

President’s Message | The Long Hours of Residency: The “Trial by Fire” that Transforms Us........................................................ 5 Gregory Lukaszewicz, MD Executive Report | Covered California: The Impact of the ACA on California’s Individual Health Insurance. . ..................................... 7 Sue U. Malone Nursing Homes: The Mystery Unraveled. . .................................................. 8 Russ Granich, MD Antidepressant Usage in Pregnancy and Breastfeeding . . ....................... 10 Thomas Lupton, MD Online Reputation for Physicians. . ........................................................... 13 Michael Fertik, MD

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

Act NOW to Avoid Medicare Penalties in 2015........................................ 14 CMA Staff

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

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President’s Message | Gregory Lukaszewicz, MD The Long Hours of Residency: The “Trial by Fire” that Transforms Us

What matters most is how well you walk through the fire. — Charles Bukowski A few months ago, I had the opportunity to work with some residents from UCSF and was amazed to learn of the changes which have taken place in residency training, particularly the limits on the number of hours a resident is permitted to work. This issue first came to the public’s notice following the tragic death in 1984 of Libby Zion, an 18-year-old college student admitted to a New York teaching hospital with fevers and jerking movements. She died a few hours after being admitted to the hospital with uncontrolled fevers and a cardiac arrest. Though the exact cause was never determined, her death was thought to be caused by an interaction between Meperidine, administered to her in the hospital to control her jerking movements, and the Phenelzine she had been taking as an outpatient for depression prior to her admission. Her father, Sidney Zion, a former lawyer and a writer for The New York Times, ultimately blamed his daughter’s death on the long hours that residents work and the lack of adequate supervision those residents receive. He began a public campaign that eventually led to regulations adopted in New York State in 1989, limiting resident hours to 80 per week. In 2003 the Accreditation Council for Graduate Medical Education adopted similar guidelines for all accredited training institutions. In 2011 the rules became even stricter, limiting first-year residents to no more than 16 continuous hours of work. In order to meet these increasingly strict rules and regulations, residents are now essentially performing “shift work.” For example, one resident may come in early in the morning, make rounds, perform the daily tasks of caring for inpatients and then sign out to the next resident, who is coming in at six o’clock at night for the next shift. As part of the “old guard” who trained in the era of every other and every third night call, this new approach required a major shift in my thinking. On the one hand, my residency was at times absolutely brutal and I certainly do not miss that level of exhaustion or stress. I am certainly not of the mind that what was good for previous generations of physicians is the way it should always be. Studies show (and common sense dictates) that adequate rest is vital for making good decisions. Whenever new health care policy is initiated, patient safety must always be the very first priority, whether it relates to residency training hours, nurse-patient ratios, electronic prescribing, or any of the various initiatives we

undertake. Interestingly, though, a study published online in JAMA Internal Medicine provides some early data that suggests that residents working more limited shifts may be making more mistakes, not fewer. The cause is not clear, but some postulate that the increased number of handoffs between residents leads to a greater number of errors. Clearly more research will need to be done before any final conclusions can be drawn. Like many, I have concerns that residents’ education will suffer if they lose out on the opportunity to operate on or admit a patient and then follow that patient and learn firsthand about the issues that can unfold after that operation or admission. From the patient’s perspective, coming into a teaching hospital can be an absolutely bewildering experience. Constantly changing physicians only makes the experience more difficult for the patient. The new model of residency training raises other questions in my mind. This model of a team working together to care for patients is admirable, but does it carry forward into the way we care for our patients after residency? If a resident never really has to work under stress or fatigue, and has several other members of a team around to provide guidance and support, what will he or she do alone in practice, when faced with life-or-death decisions? Our transformation into physicians begins in medical school. We spend long hours studying, surrounded by the spirits of physicians who changed the course of medical and surgical care. We spend long hours caring for patients and working under amazing mentors who embody the ideals of our profession and inspire us with their skills and dedication. It is this “trial by fire” that transforms us, initiating us into the noble profession of medicine. Whether the changes in residency training, with its emphasis on shorter work hours and shift work, will allow this vital transformation to occur remains to be seen. While change is inevitable and patient safety must always come first, we should guard against losing the vital experience that transforms us from someone simply doing a job to someone who has answered a calling to care for others, despite the sometimes very grueling demands of the profession. ■

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Executive Report | Sue U. Malone Covered California: The Impact of the ACA on California’s Individual Health Insurance

Covered California, formerly known as the California Health Care Exchange, contracted with Milliman, employee benefits consultants, who recently released their report on the financial impact of the Affordable Care Act (ACA) for most Californians in 2014. While tax credits and cost sharing subsidy provisions of the ACA will sharply reduce costs for millions of Californians who purchase health insurance on the individual market in 2014, the study also concludes that those earning above 400 percent of the federal poverty level may see an average cost increase of 20 percent, though the cost would be partially offset by reduced out-of-pocket costs. The Milliman report focused on the roughly 600,000 people currently enrolled in individual health care plans who are eligible for premium tax credits through Covered California. Californians who will qualify for the highest premium tax credits due to their income will see a drop on average of 85 percent in what they pay for health coverage. Depending on the individual’s choice of health plan, this premium tax credit could cover a higher percentage of premium. Individuals who are uninsured but earn too much to qualify for the federal tax credit will likely face premiums similar to what they would have faced in the absence of the ACA, but they cannot be denied coverage. The report does not look at the 85 percent of Californians who receive their health insurance through their employers. Generally, the ACA does not affect the rates of these individuals. There is some optimism that in future years, these Californians will benefit from improvements in how care is delivered and see deceases in their health care cost as they no longer pay for the millions of uninsured. The report highlights the potential impacts of changes to health plan rates based on the age of consumers, showing that adults under the age of 25 may experience the highest rate increases (approximately 25 percent higher than the average increase for all ages), while older adults may see rates 15 percent lower than the average increase. If appears that Californians under 30 years old will be led toward a reducedcost “catastrophic plan”. The Act allows adults under the age of 26 to remain covered under their parents’ health plan. A significant factor in the potential premium rate increases is the enrollment of Californians who can no longer be charged higher premiums or excluded based on their health

status. “Guaranteed Issue,” a key component of the ACA, will likely add to a less healthy mix of insureds than is currently part of the individual markets with the inclusion of highrisk participants with pre-existing conditions. Also, while insurance companies today may charge five times as much for the premium of an older person compared to the youngest adult they cover, they will now only be able to charge three times as much. For those who have insurance through their employer, the potential increases projected do not apply; however, rates in California are expected to rise by 9 percent in 2014; even in the absence of the ACA; due to underlying medical cost and utilization trends. Expanded enrollment of a sicker population is estimated to cause rates to increase on average 26 percent for individual plans. This increase is offset by other factors, such as an estimated 9 percent premium reduction due to the ACA’s temporary reinsurance program that reimburses carriers 80% of claims exceeding $60,000 (capped at $250,000), and a projected reduction of costs of 6 percent due to better competition and more effective contracting. Premiums are also likely to increase due to the corresponding increase in improved coverage provided under the ACA. The ACA requires that health plans or insurers change some of their practices. For example, an insurance company is required to spend 80 percent of premium dollars on quality health care, not administrative costs, and health insurers are not allowed to set a maximum dollar amount they will pay for key health benefits during a patient’s lifetime. All new plans must also cover preventive care and medical screenings, as well as women’s services. Insurers cannot charge copayments, coinsurance or deductibles for such services. Based on Milliman’s estimates, the effect of provider contracting changes assumes that 20 percent of the ACA population will be low income members that enroll in a Qualified Health Plan sponsored by a Medi-Cal carrier that will reimburse provider somewhere between Medi-Cal and commercial levels. At a recent Health Conference carriers stated they were expecting to offer narrow network plans with hospital contracts that are 10-15 percent lower than current commercial rates. Milliman states that they do not have independent knowledge of the likelihood of this type of hospital contracting, or whether similar results will apply to physician contracts. Some believe that providers will take continued on page 18... april 2013 | SAN MATEO COUNTY PHYSICIAN 7

Nursing Homes: The Mystery Unraveled Russ Granich, MD

When people think about nursing homes, they often conjure up images from movies and TV. Many physicians don’t know what nursing homes are really like or fully understand what they can (and cannot) do for patients. Primary care doctors typically hand off their patients to nursing home doctors without ever setting foot inside the facility. As our healthcare community tries to shorten hospital stays, patients with increasing needs are ending up in nursing homes to continue their care. Let’s see what really goes on behind those doors! The first concept is called “level of care”(LOC). We are familiar with this in the hospital setting—the medical ward, step down units, and ICU are all examples of different LOCs. Home is the lowest LOC, followed by facilities such as independent living, assisted living, and board and care, which all provide higher levels of care. Nursing homes provide two levels of care. The first is custodial, which basically means that the patient lives there full-time due to physical or cognitive impairments that require 24-hour care. MediCal will pay for this type of care if a patient (who financially qualifies) is dependent in three or more activities of daily living (ADLs), such as ambulating, dressing, feeding, and so on. The next LOC is called skilled or acute nursing home care. This is why we often refer to nursing homes as Skilled Nursing Facilities (SNFs) although technically that is only part of their clientele. To qualify for skilled care, the patient must require the expertise of a skilled professional, not just a caregiver. Some of the most common reasons for choosing

8 San Mateo county physician | april 2013

skilled care are the availability of rehabilitative services, wound care, IVs and tube feeding. Medicare provides for 100 days of skilled care. It resets when the patient is no longer receiving skilled services for 60 days. Patients who have Medicare as their primary insurance are required to have a “qualified” three-day stay in the acute inpatient setting before they can get skilled services paid for by Medicare. For example, if a patient falls and sustains a pelvic fracture, if he or she is sent directly to a SNF for therapy, Medicare will not pay. However, most HMOs and other insurers do not require the three-day hospital stay. How long can a patient stay and have insurance pick up the bill? This is a good question and not easy to answer. For some skilled services, such as IVs, it is pretty clear cut. For therapy, however, the rules state that as long as a patient is improving and not yet at a safe level for discharge, he or she can remain at a SNF. There are two elements at work here: improvement and level of functioning. Medicare considers a fourday period of time when considering improvement. A safe discharge is less defined: most practitioners consider someone safe for discharge when he or she can mobilize with less than 25% of the effort required provided by a caregiver. If the patient or family disagree with the discharge, they can appeal it to the Quality improvement Organization for California, Health Services Advisory group (HSAG). The appeal process is very simple. An independent physician will review the chart and make a determination. This is available to all patients who have Medicare primary or

secondary and are being discharged from the hospital, SNF, home health or hospice. For non-Medicare patients, insurers contract with independent review organizations to decide appeals. What does this mean in practical terms? Let’s take a few examples. Mrs. R is hospitalized with endocarditis. She is stabilized but still needs to be on two antibiotics for another four weeks. She goes to the SNF, where she receives therapy to bring her back from her weakened state. When her antibiotics are finished, she is ambulatory, feels great, and goes back home. Sometimes it doesn’t work out as well. Mr. A has a stroke with hemiparesis and dysphagia. He has a PEG placed and is sent to a SNF for rehab. After three weeks, he still can’t walk and is not showing any significant improvement. Skilled therapy (with the goal of improvement) stops, and he is put on a restorative program to maintain his levels. After four weeks, he is now eating. He no longer has any skilled needs and is discharged from skilled care. Back at home, his elderly wife is unable to provide the care he needs. His children work and have families of their own, so there is no one to care for him at home. His options now are to remain at the SNF as a custodial patient, at his own expense, or to be discharged home or to a board and care facility, all caregiving at his own expense. (If he were still tube fed, and dependent on the feedings for 26% or more of his nutrition, his benefit would expire at 100 days.) This is a difficult situation for the patient, his family, and his providers.

the consequences of any particular decision. How often do we include nursing home care as part of that consent? Mrs. S falls and breaks her femur. The orthopedist sees her and offers a surgical or non-surgical option. She really doesn’t want surgery, so she goes to the SNF in her cast, non-weight bearing. She learns to get out of bed to the wheelchair, but is not able to ambulate without using her leg. After a two-week stay, with no further gains expected, she is discharged to custodial care at the nursing home since there is no one at home to care for her. Now she has to pay her own way, anwhere from $6,000-10,000 per month, until she becomes weight-bearing. At that time, she can be reassessed and may resume skilled therapy if appropriate.

Informed consent is not limited to the immediate events, but should take into consideration the consequences of any particular decision. How often do we include nursing home care as part of that consent?

Results can also be mixed, with sometimes unexpected outcomes. For example, Mr. G, who lives independently at 88 years of age, decides to have his hip replaced. He responds well to therapy, although at a slow pace. After a few weeks, he is able to ambulate short distances with support. There is no way he can go back home safely, so he goes to a board and care facility, where home health visits him and continues his therapy. He has to pay for the board and care and hopes one day to return home. Informed consent is not just limited to the immediate events, but should take into consideration

What’s the bottom line? Skilled nursing facilities can provide excellent care and get our patients back home. They can help shorten hospital stays. However, they only bridge the gap between the acute illness and the time the patient has improved enough to safely return home with help. And some patients will never improve enough to return home. We have to be aware of the whole patient, the environment and the resources available, in order to make sure we don’t put them into a situation they didn’t expect.

About the Author Russ Granich, MD, is Chief of the Home Care Department at Kaiser Permanente Medical Group in South San Francisco. He is also medical director of Hospice and Home Health. Board-certified in internal medicine and hospice & palliative care, he completed his education at Boston University School of Medicine and his residency at California Pacific Medical Center. He has participated on the SMCMA’s Editorial Committee for many years and currently serves as chair.

april 2013 | SAN MATEO COUNTY PHYSICIAN 9

Antidepressant Usage During Pregnancy and Breastfeeding Thomas Lupton, MD One issue that many of my colleagues in primary care, obstetrics, and psychiatry find difficult is treating depression and insomnia in women who are pregnant or breastfeeding. Therefore, I wanted to show how I simplify this issue with my pregnant and breastfeeding patients. Background: Women with recurrent depression are at high risk of relapse if medication is discontinued. The majority (68%) of women with recurrent major depression, who stop antidepressants near conception, relapse during pregnancy.Pregnant women with severe depression or a history of severe depression, especially if a history of suicide attempts, psychiatric hospitalizations for depression, psychotic depression, or recurrent severe disabling depression (functional incapacitation) should often be encouraged to remain on psychiatric medication. If you choose a medication during pregnancy or breastfeeding, it is best to use the lowest effective dosage, and the starting and maximum dosage recommendations may be lower than the recommendations for the general population. I divide my discussion with these patients into two categories: I. Taking antidepressant during pregnancy: A)

Any selected serotonin reuptake inhibitor (SSRI) (i.e. Sertraline, Fluoxetine, Citalopram, Escitalopram, and Paroxetine) can be used during pregnancy. Sertraline and Citalopram appear to probably be less transmitted into cord blood and breast milk than many of the other SSRIs during pregnancy and lactation, but some is still transferred.

B) However, there are risks:

Possible increased risk of persistent pulmonary hypertension (PPHN) in the newborn (baseline rate is 1-2 per 1000 live births). However, untreated depression during pregnancy has also

10 San Mateo county physician | april 2013

been linked to reduced length of gestation, and the risk of PPHN is increased fourfold in babies born at 34â&#x20AC;&#x201C;36 weeksâ&#x20AC;&#x2122; gestation. Obesity and smoking, established risk factors for PPHN, are more common in depressed women. Lastly, Cesarean section, a known risk factor for PPHN, is more common among women with depression.

Self-limited poor neonatal adaptation (tachypnea, jitteriness, poor feeding) occur in 10 to 30% of neonates with SSRIs near-term.

Some studies link fetal malformations, cardiac defects, and reduced birth weight to antidepressant use during pregnancy.

There has been some possible linkage to Autism Spectrum Disorders among children exposed to SSRIs during pregnancy (possibly a twofold increase).

There has been limited data regarding the risks of congenital malformations (particularly ventricular septal defects) with Paroxetine. Therefore, Paroxetine is not recommended as first line

6) Other possible risks/side effects.

7) C)

choice of treatment for new start patients during pregnancy. Contrary to the above risks, some limited long-term studies to date demonstrate normal childhood development in children born to women taking SSRIs.

Sertraline is often the medication of choice for new start during pregnancy or just before conception. If Paroxetine is the only antidepressant that the patient has tried, substitution may be reasonable; however, substitution always carries the risk of relapse. If Paroxetine has been found to be the medication that is efficacious for the patient (especially if there is a history of severe depression), it is recommended to keep the patient on Paroxetine (after discussing the relative risks).

II. Not taking antidepressant during pregnancy: A) There is risk of decompensation if history of depression. B) Some risks of depression during pregnancy include: 1.

Depression and its symptoms are associated with the possibility of pregnancy complications such as early delivery (premature birth) due to shorter gestation periods. Also, there is a risk of nausea, vomiting, and preeclampsia, as these appear to occur at higher rate in depressed than non-depressed women.

Infants born to mothers with untreated depression have increased risk for irritability, less activity, less attentiveness, and fewer facial expressions compared with those born to mothers without depression.

3. Depression and its symptoms appear to be associated with poor fetal growth and poor development. 4. Depressed women are more likely to have poor prenatal care and more likely to use drugs, alcohol, and nicotine.

For breastfeeding, I also divide my discussion into two categories: 1. Taking antidepressants during breastfeeding: Any SSRI is compatible with breastfeeding. The benefits of breastfeeding while taking SSRIs probably outweighs the risks to the nursing infant. Sertraline and Paroxetine (and possibly Citalopram) appear to possibly be less transmitted than many of the other SSRIs during lactation; therefore Sertraline and Paroxetine appear to have the lowest infant serum concentrations in breast-milk and are considered the best choices for new start patients in the postpartum period. Fluoxetine should typically be avoided as a new start during breastfeeding. If the mother took a SSRI that is efficacious during pregnancy, then it is usually recommended to maintain the same medication through the first post-partum year. 2. Not taking antidepressant during breastfeeding: There is a risk of depression returning postpartum if not taking medication. Untreated postpartum depression can result in poor bonding with the infant with subsequent learning disabilities, and so on. Also, untreated postpartum depression can lead to family alienation from the mother. Sleep Medication During Pregnancy and Breastfeeding If needed, I would recommend Diphenhydramine 12.5 to 50 mg at bedtime as needed or Trazodone 12.5 to 50 mg at bedtime. However, these are also transferred into cord blood. Lastly, I provide these instructions to my pregnant patients using an antidepressant: 1. Minimize or taper off caffeine. 2. Follow-up with your OB/GYN and primary care provider regularly. Your OB/GYN will monitor you and your fetus during pregnancy. 3. Psychotherapy can be very important in treatment for depression and anxiety. I recommend that you follow-up with your therapist. 4. Abstain from drugs and alcohol completely. 5. Please consider a class or group for depression. 6. Please speak with a genetics counselor to answer questions regarding medication use in pregnancy (and for another opinion about medication use in continued on next page...

april 2013 | SAN MATEO COUNTY PHYSICIAN 11

Antidepressant Usage During Pregnancy and Breastfeeding pregnancy). Also, please discuss this decision as soon as possible with your OB/GYN and primary care to get their input. This way you can get multiple opinions about use of medication during pregnancy and breastfeeding, as this is an important decision. 7. Lastly, please notify your baby’s pediatrician that you took medication during pregnancy and ask about the risks of medication during breastfeeding. In summary, the benefits to both pregnant patient and fetus of treating severe depression most likely outweigh the risks associated with untreated depression. ■

About the Author Thomas Lupton, MD, is a board certified psychiatrist at Kaiser South San Francisco. He completing his residency at Emory in 2003. He is known for championing technology, quality, preventative health care, and helping his fellow physicians. Dr. Lupton is currently Assistant Chief and Quality Chief for the Department of Psychiatry.

Interested in health care that values compassion, respect, and dignity for all? We are looking for physicians to JOIN US! Clinic by the Bay is a volunteer-powered, free health clinic for low-income working uninsured adults living in San Francisco and Daly City. As part of the national Volunteers in Medicine (VIM) network, the clinic engages retired and practicing healthcare professionals and community volunteers to provide free, high quality care. The clinic is located in the Excelsior neighborhood of San Francisco and became the 82nd VIM clinic in the country on November 9, 2010. The clinic currently provides primary care on Tuesdays from noon to 8 p.m. and Thursdays from 10 a.m. to 6 p.m. Beginning in April the clinic will also be open Saturdays from 9 a.m. to noon. Unlike many community clinics, Clinic by the Bay does not rely on government funding and does not accept insurance. The clinic is 100% privately funded. Clinic by the Bay truly is a neighborhood solution to the health care crisis where healthcare providers get to practice the art of medicine instead of the business of health care. For more information, please contact David Goldschmid, MD, Medical Director, at david@clinicbythebay.org or 650-888-2163. www.clinicbythebay.org.

12 San Mateo county physician | april 2013

SMCMA’s 108th Annual Meeting of Members Thursday Evening June 27, 2013 Peninsula Golf & Country Club

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Online Reputation for Physicians: 6 Tips from Reputation.com CEO Michael Fertik Technophile or technophobe, your online presence is becoming increasingly important. Four out of five internet users now look online when they need healthcare information, and searches for specific providers make up a sizable portion of their requests, according to recent data from the Pew Research Center. You’ve likely heard a fair amount about the threats this can pose, yet what’s important to keep in mind is that it’s also a powerful opportunity. Below are six key ideas you can use on your own. Prevention is more effective than treatment: From both a financial and time-saving perspective, preventive reputation building is much more efficient than reacting after a problem appears. Setting up a public profile on healthcare-focused social network Doximity can be a good start—you control what information you share, from practice address to published works. You can also set up an About.me page or a www.YourNameMD.com site, listing any professional information you want to emphasize. In addition, update your practice information on physician review sites. Search engines prioritize websites that have been up for a long time, so there’s no time like the present to get started. Own your presence: If you fail to publish some of your own information, your online reputation will consist entirely of what other people have written about you. Patients often search by condition or procedure, so even if you don’t have any negative reviews, you might, for example, find yourself with a lot of content that—while positive—doesn’t represent the full scope of your practice or interests. Diversity is your friend: Once you start putting information online, try to hit as many bases as possible. Search engines penalize duplicate content, and they give priority to different types of results: websites, blogs, new articles, journal publications, photos, videos, social media and so on. Make sure you have a presence on several types of sites. Rebuttals usually backfire: If someone attacks you online, avoid the temptation to post a rebuke in the comments. Your feedback tells search engines that this is an important website that people will want to see— the opposite of the message you want to send. For this reason, your best approach is almost always to keep your cool and just move on.

Remember there are positives to patient reviews: For many consumers these days, reviews are almost as trusted as word-of-mouth endorsements. And there are plenty of positives to this. Don’t be shy, for example, about encouraging satisfied patients to leave their opinions on review sites. Also, consider linking to positive reviews on your website; they’re an added reminder to potential patients of just what you’re capable of. If you’d like professional help managing reviews, consider Reputation.com’s online medical review monitoring service. Lastly, be sure to establish a patient wrap-up protocol with your staff that encourages unhappy patients to vent in your office instead of online. With social media, it’s okay to stick to your comfort zone: You need a basic presence in social media to prevent “brandjacking” (antagonistic impersonations of yourself ), so go ahead and set up a Facebook page and Twitter handle for your practice. If you enjoy social media, use those accounts, taking care to respect HIPAA regulations and other ethical considerations. However, if you don’t enjoy it, or feel you have too much on your plate, that’s fine. Social media is a good way to build your online reputation, but there are plenty of other paths you can take. The bottom line: Regardless of the situation, ceo reputation, teacher reputation, doctor reputation, the more types of material you publish, the more you yourself can own your online presence. ■ About the Author Michael Fertik, JD, is the founder and CEO of Reputation. com, a Redwood City-based online reputation management (ORM) company. Considered the world’s leading cyberthinker in digital privacy and reputation, Fertik received his JD from Harvard Law School. Learn more at reputation.com, facebook.com/reputation.com, and twitter.com/reputation_com. San Mateo County Physician thanks Reputation.com for permission to reprint this article.

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Act NOW to Avoid Medicare Penalties in 2015 On-Demand CMA Webinar Can Help Over the past six years, the Centers for Medicare and Medicaid Services (CMS) has launched a number of initiatives that offer physicians the opportunity to increase their net revenue by participating in quality reporting programs. Until now, these programs have been voluntary and physicians have received bonuses for participating. That’s about to change. Failure to participate now means physicians could face significant penalties.

Bonuses: For the Medicare EHR incentive program, your cumulative payment amount depends on the first year of participation. Physicians who start participating in 2013 can receive up to $39,000; physicians who start in 2014, up to $24,000. The last year to begin participation in the Medicare EHR incentive program is 2014. For the Medicaid (Medi-Cal) incentive program, physicians can receive up to $63,750.

The American Academy of Family Physicians estimates that participating in these initiatives in 2013, rather than waiting until 2014, could save a physician $19,000 in avoided penalties.

Penalties: Physicians who do not demonstrate meaningful use by 2015 will be subject to Medicare payment penalties. These reductions increase from 1-2 percent of total Medicare charges in 2015, to 2 percent in 2016 and 3-5 percent in 2017 and beyond. Medicaid rates will not be adjusted for failure to achieve meaningful use.

To help physicians understand the bonuses and penalties associated with key Medicare initiatives, the California Medical Association (CMA) recently hosted a webinar for members, “Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties.” The webinar is now available for on-demand viewing in the CMA resource library at www.cmanet.org/webinars. During the webinar, CMS Region 9 Chief Medical Officer, Betsy L. Thompson, M.D., discusses about the major quality reporting and e-health incentive programs currently underway for eligible professionals. The session covers the basics of the Physician Quality Reporting System, the Medicare and Medicaid Electronic Health Records Incentive Programs, the Medicare E-Prescribing Incentive Program and the new value-based payment modifier. The content is geared toward physicians, nurse practitioners and physician assistants and what they need to know, although other health care professionals and medical office may find the information useful as well. If you are not already familiar with each of these programs, the time to learn about them is now. Below is a brief summary of the programs and key dates that were discussed in the CMA webinar. Meaningful Use Meaningful use is the set of criteria on which physicians must report in order to receive federal incentive payments for EHR adoption under the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs. Meaningful use is also the necessary foundation for all impending payment changes involving patient-centered medical homes, accountable care organizations, bundled payments and value-based purchasing.

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Electronic Prescribing Medicare’s e-prescribing program provides incentive payments for physicians who e-prescribe and payment penalties for physicians who do not. Bonuses: This year is the last year to receive a bonus for e-prescribing.To qualify for the 0.5 percent bonus in 2013, you must have successfully reported e-prescribing activity for at least 25 patient visits between January 1 and December 31, 2012. Penalties: Starting in 2012, physicians who did not electronically transmit their prescriptions became subject to payment penalties on all Medicare allowed charges. The penalty in 2013 is 1.5 percent, and in 2014, 2 percent. Physician Quality Reporting System The Physician Quality Reporting System (PQRS) is a voluntary quality reporting program that provides incentive payments to eligible professionals who report data on quality measures for services provided to Medicare beneficiaries. Bonuses: Physicians must report on three individual measures or one measures group to receive a 0.5 percent bonus. Physicians participating in a maintenance-ofcertification program are eligible for an extra 0.5 percent bonus, for a total bonus of 1 percent. Penalties: The Affordable Care Act calls for PQRS payment penalties starting in 2015. In the 2012 Medicare Physician Fee Schedule, CMS announced that 2015 program penalties will be based on 2013 performance. Therefore, physicians who do not successfully report on at least one individual measure in 2013 or elect to participate

in the administrative claims reporting option will receive a 1.5 percent payment penalty in 2015. The penalty goes up to 2 percent in 2016 and beyond. Value-Based Payment Modifier Program The value-based payment modifier was mandated by Congress under the Affordable Care Act. It will adjust physician payment based on the quality and cost of the care they provide. It will take effect in 2015 using 2013 data for groups of 100 or more physicians. By 2017, this modifier will be implemented for all physicians. Bonuses: Participating physicians may receive bonuses based on their quality and cost scores.

Each of these programs has specific deadlines and reporting requirements, some of which are overlapping, and are not always simple to understand. CMA’s webinar will give physicians the information they need to successfully participate in each program. During the webinar, Dr. Thompson will help participants understand which programs they are eligible for, the associated incentives and penalties for each program, and the deadlines and requirements for participation. The on-demand webinar is available free to CMA members at www.cmanet.org/webinars. Nonmembers can purchase the webinar for $99. For more information, please contact CMA’s member service center at (800) 786-4262 or memberservice@cmanet.org. ■

Penalties: Participating physicians may be penalized up to 1 percent based on their quality and cost scores. Physicians who choose not to participate will be docked 1 percent.

U p c o m i n g CMA W e b i n a r s Wednesday, May 1, 2013 12:15 - 1:15 p.m.

The Power of the Pen: The Physician’s Responsibility in Prescribing and Referring for Medi-Cal Patients Presented by the Department of Health Care Services (DHCS), this webinar will help you understand the importance of documentation, understand the physician’s role in prescribing/ordering/referring, and increase awareness of fraud and abuse in prescribing and referring.

Wednesday, May 8, 2013 12:15 - 1:15 p.m.

Time Management: How to Quickly Make Decisions on What Matters Most Learn how to value what matters most and achieve your goals by understanding what you are giving away and practicing simple tools to find solutions (not excuses) to get what matters most checked off the list. This interactive webinar will provide live one-on-one coaching to illustrate the techniques taught in the session.

Wednesday, May 15, 2013 12:15 - 1:15 p.m.

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, including residence, age and specialties. Additionally, learn about laws regarding the Medical Board’s enforcement program, the sunset review process, and issues being discussed at the legislative level to enhance the law for consumer protection.

Most webinars are FREE for CMA members, $99 for non-members. Please note: this calendar is subject to change. Visit www.cmanet.org/events for updates. Questions? Please contact the CMA Member Help Center at (800) 786-4262. april 2013 | SAN MATEO COUNTY PHYSICIAN 15

Retaining Independence While Embracing Accountability: Part 2: Care Coordination and Integration Strategies for Small Physician Practices Physicians 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?

An independent physician practice can build stronger connections with other independent practices through a number of organizational forms. But an organization should not be created just for the purpose of “organizing” physicians. The success of a new physician-owned and controlled integrated organization will depend largely on the organization’s ability to demonstrate that it can provide value to those individuals and organizations that will be purchasing its services. As the organization’s payment will ultimately be based on its performance with respect to quality and costeffectiveness measures, a sincere commitment to quality improvement and reducing health care resource utilization will be required.

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.

Establishing an Initial Planning Team

Strength in Numbers: Options for Physicians to Maintain Autonomy while Collaborating with Others 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,” available at www. ama-assn.org/go/ACO. This article will summarize the second section of that resource which focuses on potential options small practices may have to collaborate with other physicians. Considerations for Physicians Interested in Virtual Integration There are plenty of reasons for small practices to be optimistic about their ability to succeed in the future. Many believe that to survive, however, smaller practices may need stronger connections to at least other small practices, so they can use their combined efforts to: (1) reduce overhead through economies of scale; (2) depending upon the degree of integration, improve their negotiating position with thirdparty payers1; and (3) if collaborating with other specialists, increase revenues through ancillary services and retaining referrals within the group. Further, such connections help move away from fragmented care to a coordinated care delivery system.

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An initial leadership planning team, in consultation with advisors such as an attorney and/or practice consultant, will be needed to: • Perform strategic planning; • Conduct an environmental scan; • Assess potential organizational structures and create a strategic plan that meets the organizers’ mission, vision, and values; and • Identify and communicate those mission, vision, and values to additional participants. A planning tool for organizing a physician collaboration is included in Appendix I to the resource to help physicians in this effort. The first part of the process is identifying compatible partners to lead the initial effort for change. It is essential that the physicians on this team trust each other, on both a personal and clinical level, and share the same level of commitment to their patients and community and the success of the new organization. Once this initial team is assembled, it may be advisable to include other professionals in the process, such as office managers, an attorney, and a practice consultant. Doing so will help avoid costly mistakes by ensuring that the interested physicians have adequate information initially, before an ill-advised path is chosen. Professionals can also help identify local market opportunities. Strategic Planning Process Defining mission, vision, and values: It is essential for the initial leaders/participants to convene a strategic planning session to define the new organization’s mission, vision and values and assess whether the physicians’ expectations are realistic. For example, is the goal simply financial success, or is improving quality of care, outcomes and other values, such as reducing hassles and wasted time also important? The definition of the organization’s mission, vision, and values becomes its foundation and will help guide decision-making and communications with patients, hospitals, and payers.

Retaining Independence While Embracing Accountability: Part 2: Care Coordination and Integration Strategies for Small Physician Practices Business strategy and planning: Taking the time to determine the strengths, weaknesses, opportunities, and threats as a means of developing a short-and long-term strategic business plan that makes sense for the participating physician practices and the new physician organization is essential. It is through that strategic business plan that the new organization’s mission, vision, and values must be operationalized. A strategic business plan will help: • Tailor the organization’s mission, vision, values, and the services it will provide, to the individual and organizational purchasers and health insurers to whom it expects to market its services; • Identify the specific capabilities that the organization will need to develop and prioritize the sequence in which those capabilities will be acquired. • Identify potential business partners who may help implement the new organization’s mission, vision, and values and business and clinical goals, e.g., through the availability of financial or in-kind administrative or clinical support, and increase the likelihood of maximizing long-term success and retaining professional autonomy in the context of new health care delivery and payment models. Local Market Opportunities: Understanding what local market opportunities exist is essential. It makes no sense to form an organization unless there is some understanding of what is occurring in the community (keeping in mind that the relevant market may extend beyond the local geographic area due to medical tourism, telemedicine, etc.). At a minimum, things physicians and their expert consultants should look at include: the individual participating physician practices, including patient demographics and referral patterns; the local hospital community and the potential relationship of those hospitals to the new physician venture; existing independent practice associations (IPAs), management services organizations (MSOs) or other physician organizations that might obviate the need to create a new organization; third-party payers, including Medicare, including their respective market shares and willingness to contract with a new physician organization; major public and private employers that may be willing to contract directly with the new venture, the demographics of their employees and any specific services they may value; potential competitors, including retail clinics, telemedicine providers, urgent or ambulatory care centers, other physician groups; changing technologies which the new venture may need to adopt and their costs (AMA resources on these topics are available at www.ama-assn.org/go/hit); changing patient demographics and expectations, such as new residential or retirement community developments, large numbers of “baby boomers” who will become Medicare beneficiaries in

the near future, or younger people who will demand email consults and social media interactions; and ACA changes or other regulatory developments, such as the potential for a large influx of patients assuming state exchanges become operational in 2014. Potential organizational structures Much has been written about large medical groups and fully integrated health systems. Many physicians, however, choose to retain as much autonomy as possible when providing care to their patients. Structures are available that allow physicians to obtain the benefits of a large group practice, yet maintain a considerable amount of independence. Those options are more fully discussed in Appendix II of the resource. Communication of Mission, Vision, and Values to Additional Physician Participants Once the initial planning is complete, potential physician participants should be identified and the mission, vision, values, and goals of the organization must be communicated and agreed to by everyone. If the structure involves quality improvement and care coordination, it is important that these physicians demonstrate a commitment to team work, acceptance of transparency of data and practice records within the organization, and the ability and willingness to be responsible for improvement using data-driven decisionmaking. A sample “organizing letter” is included in Appendix III of the resource. Organizational and Operational Issues At the same time, there are a number of key issues concerning the group’s organizational structure and operations that need to be addressed, with the advice of an experienced attorney. The issues cover a host of matters such as liability, office personnel, dispute resolution, term and termination, and restrictive covenants. Some of the more sensitive ones involve the following: capitalization, ownership, governance, compensation, and buy-sell agreements. 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. But regardless, no collaborative effort can succeed without the enthusiastic engagement of the physician participants and effective physician leadership. ■

april 2013 | SAN MATEO COUNTY PHYSICIAN 17

Executive Report (continued from page 7) a wait-and-see approach, and wait until 2015 to assess the impact of the ACA on their revenue for services provided to Medi-Cal and currently uninsured patients. It is extremely important that your patients who will benefit from the ACA are informed about the benefits that will be available to them. They need to learn how to shop for a plan that gives them the best value. As you may know, the plan designs and benefits and coverage are categorized into four plans: Platinum, Gold, Silver, and Bronze, as well as a Catastrophic Plan. Then there are certain variables within each metal plan and the patient’s FPL level. For more information you can access Covered California’s website at www.coveragedca.com.The Milliman report is available at www.healthexchange.ca.gov. The Kaiser Family Foundation offers a “Health Reform Subsidy Calculator” at www.kff.org/insurance/subsidycalculator.cfm. ■

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Walk with a Doc Returns this Spring! Walk with a Doc is a free program of the SMCMA Community Service Foundation that provides a walking route and an opportunity for members of the public to walk with physician volunteers and to ask questions about general health topics. The first walk is set for Saturday, June 8th at 10:00 a . m . Initially, we are planning Walk with a Doc every other Saturday.

San Mateo Medical Association Physician volunteersCo. are needed to walk with participants, for approximately 60 minutes at a designated public park 06-18-09 in San Mateo County. Walks commence with a free blood pressure check, followed by a five-minute talk by the physician on the importance of regular physical activity. We also need our members’ help to recruit members of the public to get involved. If you are interested in volunteering to walk with County residents and/or publicizing scheduled Walk with a Doc events, please contact Karen Stone at kstone@smcma.org or (650) 312-1663.

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