June 2013

T h e N e w O f f i c i a l P u b l i c at i on o f t h e Lo s An g e l e s Co u nt y M e d i c a l A s s o c i at i on REPORTING ON THE ECONOMICS OF HEALTHCARE DELIVERY

A PUBLICATION OF PNN www.PhysiciansNewsNetwork.com

Physician Wellness CAUSE AND (ECONOMIC) EFFECT

LA Doctors Get It Right!

GARCETTI WINS MAYORAL RACE

The Fight for MICRA

JUNE 2013

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Volume 144 Issue 06

FEATURE

14

Physician wellness

Several studies have shown that burned-out and disruptive physicians can take a serious financial toll on healthcare organizations that fail to address the issue. More hospital and medical groups are implementing programs specifically designed to help physicians address their own wellness.

14 DEPARTMENTS 6 Front Office | Practice Management

Tips, hints, advice and resources 9 transitions | Career Management

A look at the questions and challenges associated with various phases of your medical career 10 Balance | Lifestyle & Wellness

9

News, studies, tips and opportunities to help physicians maintain a balanced lifestyle Garcetti Wins Mayoral Race

LACMA’s president said he’s excited about the nomination of Los Angeles Mayor-elect Eric Garcetti, who just recently talked to LACMA members about their concerns and vowed to support them.

25

The Fight for MICRA

LACMA is steadfastly opposed to taking away one of the great policy innovations in healthcare, pioneered in California, to reduce the risk to doctors who are providing care.

12 PNN | NEWS IN REVIEW

The latest headlines impacting the economics of healthcare delivery in Southern California 24 United We Stand | AT WORK FOR YOU

LACMA and CMA membership at work for you

From Your Association 4

President’s Letter | Samuel Fink, MD

26 CEO’s Letter | Rocky Delgadillo 27 LACMA News | Association Happenings

Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 04 Copyright ©2012 by LACMA Services Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. POSTMASTER: Send address changes to Physician Magazine, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 9001 7. Advertising rates and information sent upon request.

j un e 2013 | w w w. p h y s i c i a n s n e w s n e t w o r k .c o m 1

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Physicians News Network Los Angeles County Medical Association 707 Wilshire Boulevard, Suite 3800 Los Angeles, CA 90017 Tel 213-683-9900 | Fax 213-226-0350 www.physiciansnewsnetwork.com

sional association representing physicians from every medical specialty and practice setting

LACMA Officers

as well as medical students, interns and residents. For more than 100 years, LACMA has

President President-elect Treasurer Secretary Immediate Past President

been at the forefront of cur-

LACMA BOARD OF DIRECTORS

rent medicine, ensuring that its

CMA Trustee

members are represented in the

med student Councilor/usc keck

areas of public policy, government relations and community

Councilor Councilor-at-large young physician counsilor cma trustee ethnic physicians commitee representative Councilor Councilor

relations. Through its advocacy

med student Councilor/ucla david geffen

efforts in both Los Angeles

Chair of LACMA Delegation

Councilor Councilor-at-large

County and with the statewide

Councilor Councilor

California Medical Association,

Councilor Councilor

your physician leaders and staff

Samuel I. Fink, MD Marshall Morgan, MD Pedram Salimpour, MD Peter Richman, MD Troy Elander, MD

Councilor Councilor-at-large

strive toward a common goal–

RESIDENT/FELLOW Councilor

that you might spend more time

RESIDENT/FELLOW Councilor

treating your patients and less

Councilor-at-large

Councilor Councilor cma trustee (resident)

David Aizuss, MD William Averill, MD Erik Berg Stephanie Booth, MD Steven Chen, MD Jack Chou, MD Hector Flores, MD Sidney Gold, MD William Hale, MD Shelley Han Vito Imbasciani, MD Paul Kirz, MD Lawrence Kneisley Howard Krauss, MD Gideon Lowe, MD Carlos E. Martinez, MD Nassim Moradi, MD Ashish Parekh, MD Jeffrey Penso, MD Heidi Reich, MD Bob Rogers, MD Sion Roy, MD Pejman Salimpour, MD Robert Bitonte, MD Erin Wilkes, MD

time worrying about the challenges of managing a practice.

LACMA’s Board of Directors consists of a group of 30 dedicated physicians who are working hard to uphold your rights and the rights of your patients. They always welcome hearing your comments and concerns. You can contact them by emailing or calling Lisa Le, Executive Assistant, at lisa@lacmanet.org or 213-226-0304.

Subscriptions Members of the Los Angeles County Medical Association: Physician Magazine is a benefit of your membership. Additional copies and back issues: $3 each. Nonmember subscriptions: $39 per year. Single copies: $5. To order or renew a subscription, make your check payable to Physician Magazine, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. To inform us of a delivery problem, call 213-683-9900.

Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

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P R ESIDE NT ’S LE T T ER | SA M UEL FINK , M D

G r e e t i n g s! Ov e r t h e past month, there has been a very important development with regard to MICRA, the Medical Injury Compensation Reform Act. The trial attorneys, realizing that their legislative attempts to overturn MICRA have gotten them nowhere, are attempting to place an initiative on the November ballot that would overturn this crucial piece of legislation that has helped to control healthcare costs in California for the past 38 years.

Along with their puppet organization, Consumer Watchdog, the trial attorneys hope to overturn the $250,000 cap on non-economic damages that has kept malpractice premium rates in California up to 85% lower than they are in states such as New York and Florida. At press time, we do not have the wording of the initiative, and don’t know if there will be an attempt to raise the MICRA cap, or eliminate it entirely. What I can tell you is that simply doubling the cap is projected to cost California’s healthcare system over $9 billion annually.

This is the worst possible idea at the worst possible time. When California is struggling to implement federal healthcare reform, and attempting to cover another 5 million citizens (at least), eliminating MICRA would cause a crisis similar to that which existed in 1975. As you may remember, malpractice insurance premiums quickly soared out of control, forcing doctors and clinics to close their doors. Currently in New York, a state with no financial limitations on malpractice suits, there are 19 counties that don’t have an obstetrician, and 15 counties that don’t have surgical specialists—a disaster that should not occur in our state! The CMA and the New LACMA are ready for this fight, and we will be asking for your assistance in the coming months. MICRA is NOT negotiable!

We are also doing everything possible to eliminate California’s 10% budget cut in MediCal reimbursement. CMA has sponsored two bills, SB 640 (Lara) and AB 900 (Alejo) that eliminate this reduction. A coalition of physicians, dentists, healthcare workers and hospitals called We Care for California (www.wecareforca.org) is working to stop this cut. On June 4 there will be a rally in Sacramento on the steps of the State Capitol, with plans for 10,000 healthcare providers to attend.

The start date for the forced transition of the Medi-Medi dual eligibles to managed care has 4 PHYSICIAN MA G A Z INE | j un e 2013

been delayed to January 1, 2014. This is the same date when the Affordable Healthcare Act takes effect for millions of Californians—and the bureaucratic mess that could result from the simultaneous implementation of both programs has the potential to do great harm. We will continue to push hard to eliminate this program altogether, or shrink it as much as possible to prevent disrupting long-standing doctor-patient relationships.

On April 30, the New LACMA held its first ever Mayoral Healthcare Forum. We sat down with Eric Garcetti for a lengthy discussion, and feel strongly that we will have an excellent working relationship with him when he becomes the next mayor of Los Angeles. Mr. Garcetti understands the complex array of issues that affect the health of our 4 million residents, and shares our concerns over the onerous city business tax burden that we face each February, as well as the unfair effects of double taxation, which I have written about in previous columns.

To ensure that we can represent you fully, LACMA meets on a regular basis with all of our elected officials - just one more benefit of being a member!

In last month’s column I wrote about the scope of practice legislation that we have been fighting this year, as various health providers try to become physicians by legislative fiat. Assembly Bill 492 (optometrists) has been “rewritten” (gutted) at press time and, along with AB 493 (pharmacists), is languishing in the suspense file of the Senate Appropriations Committee. Assembly Bill 491 (nurse practitioners) remains of major concern, and will be heard shortly on the floor of the California State Senate. Updates will be continuously provided at www.cmanet.org, and we will be calling on you and your patients to express strong concern to your elected officials.

Nassim Moradi, MD, a member of LACMA’s Executive Committee, chaired the first meeting of our new Women’s Physician Action Committee. Please give our downtown office a call (213-683-9900) if you’d like to be involved with this dynamic group!

I’d also like to congratulate our hardworking treasurer, Pedram Salimpour, MD, on his appointment to the Los Angeles Board of Fire and Police Pension Commissioners by Mayor Villaraigosa. We hope that this will be the first of many physician appointments within our city as LACMA strives to raise the profile and community involvement of Los Angeles physicians.

Until next month...

Samuel Fink, MD, is an internist in private practice in Tarzana. He is the 141st president of the Los Angeles County Medical Association.

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High-Level Wellness for Organizations and Individuals

Why Wellness Matters

Bruce Underwood, DrPH with Teri Hollingsworth, VP, Human Resources Services, HASC

are high and are a real issue threatening the safety of patients, care providers and organizations. Evidence shows pursuing effectively designed wellness programs that encompass broad, even holistic, definitions of health can greatly reduce costs, improve productivity and increase patient satisfaction. The bottom line: organizations benefit from healthy employees.

H e a lt h c a r e co s t s

What is high-level wellness? Without an understanding of high-level wellness, or wellness, a company may find it impossible to define goals, measure impact, or report the ROI of a workforce health program. So, what constitutes wellness?

The ROI of High-Level Wellness Metrics from programs implemented in varying settings across the country show taking an active role in helping employees reach highlevel wellness has proven value: • Blue Cross Blue Shield of Indiana found its corporate fitness program has a 250% return on investment—$2.51 for every $1 invested over a five year period (American Journal of Health Promotion).

• The Canadian Life Assurance Company found turnover among fitness program participants was 32.4% lower over a seven year period compared with non-participants (Canadian Journal of Public Health).

• Johnson & Johnson estimates wellness programs have cumulatively saved them $250 million in healthcare costs over the last decade (Harvard Business Review).

• Preliminary results from a self-insured corporation that made omega-3 supplements freely available to 800 employees showed average employee health claim costs last year of $3,929 rather than the $5,184 USA average. Overall, that’s an annual difference of $1 million. (Prostaglandins & Other Lipid Mediators).

According to the Harvard Business Review, most people and organizations narrowly define wellness. To many, it’s simply diet and exercise. But wellness is more than being physically fit or watching what you eat. In fact, wellness has come to mean many things over the last 50 years, with a societal shift from the concept of health and wellness as the absence of disease to something more all-encompassing.

Appearing first in the 1960s, the word “wellness” 6 PHYSICIAN MA G A Z INE | j un e 2013

was defined by Dr. Halbert L. Dunn as an “integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable.

It requires that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning.”

Dr. Don B. Ardell, often cited as the founder of the modern-day wellness movement, later defined wellness as “a choice to assume responsibility for the quality of your life.” The areas most closely associated with wellness, says Ardell, are “self-responsibility; exercise and fitness; nutrition; stress management; critical thinking; meaning and purpose, or spirituality; emotional intelligence; humor; play; and effective relationships.”

In my own work, high-level wellness is defined as having the energy and enthusiasm to do what you want and need to do in everyday life. It is physical health that comes from the integration of the mind, body and spirit.

Common to all of these definitions is the intentional move beyond considering the body in isolation.

Wellness for Organizations

Organizations, including hospitals, sometimes ignore the connections between worker health and the overall health of the company. Organizations like tangibles, meaning physical health—if health is considered at all—is the focus of any potential programmatic changes instituted around wellness. When an organization understands that the total health and wellness of its workers is tied to the health of the organization—its productivity, absenteeism rates, job satisfaction/turnover rates, healthcare costs—and that these factors can be positively influenced by the level of individual wellness, real cultural change is possible.

The result of this disconnect is that some organizations spend more on healthcare for their employees than on providing services. And according to WELCOA, 20% of employees are responsible for creating 80% of a company’s healthcare costs.

Obviously, wellness and prevention make a difference

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to the bottom line. But it’s more than that. Organizational wellness—its ability to stay productive—is dependent on workers showing up, being efficient and fully present. If the health of an individual person is maintained, both the organization and the individual benefit.

While many factors impact the effectiveness of wellness programs—leadership buy-in, organizational alignment, accessibility, collaboration, messaging—taking into account a broader definition of wellness can be key. Because illnesses like depression and stress are more than physical and cost employers more in time and resources than some other diseases, it is important to think more broadly about designing programs that strategically invest in employees’ social, mental and physical health.

The successes of the above-mentioned programs lie at least in part in an understanding of wellness in the larger context. It is biology, lifestyle and environment.

Such an approach would radically redefine the culture within an organization, reaching workers beyond the halls of the hospital and into the community.

About the author: Bruce Underwood, Dr.PH, is vice president of Healthy Futures, Inc., an aging and preventive care organization dedicated to risk reduction, fitness and aging well. Underwood holds a Dr.PH in preventive care, and he brings his more than 25 years of experience in nutrition, fitness and program design to several health organizations and boards, including the editorial board of the Journal of the American College of Nutrition. Dr. Underwood wrote this article as part of a wellness initiative supported by the 2013 Hospital Association of Southern California Health Care Provider Wellness Conference Committee.

Teri Hollingsworth is the vice president of human resource services with the Hospital Association of Southern California, where she is responsible for addressing human resources issues and overseeing the association’s benchmark surveys, workforce studies, educational programs and strategic business partners.

RISK TIP: ‘Be Prepared’ Is the Motto to Follow When Testifying in a Malpractice Lawsuit with a malpractice lawsuit, you may feel that the entire litigation process— from discovery to trial—is beyond your control. But there is one very important element that you can control: your own testimony. Because the courtroom differs from the exam room or the surgical suite, and because opposing counsel’s job is to attempt to discredit you, being prepared is a must. Physicians can start the preparation process by reviewing these basic tips before testifying:

I f yo u ’ r e fac e d

Whether you’re on the witness stand or in a deposition room, your only obligation is to answer the question you were asked. You may be tempted to provide additional information that you think is relevant, but you could inadvertently harm your case.

Stay within the scope of the question. Your attorney—not you—has responsibility for making sure that all relevant information is introduced.

1. L i m i t Yo u r A n s w e r s

2. Provide a Careful , Precise Answer

When you answer precisely, you remove ambiguity from your testimony. But be sure not to box yourself in. If you are asked for a complete list of your actions, answer carefully. Unless you are absolutely sure you’ve provided every element, leave the list open. For example, if you are asked to detail the steps you took before arriving at a diagnosis, it is acceptable to say, “At this time, these are the steps I remember taking.”

3. Stay Calm Keep your cool. You lose credibility when you become sarcastic, raise your

8 PHYSICIAN MA G A Z INE | j un e 2013

voice, or get defensive. Opposing counsel may try to provoke you. Don’t take the bait. If you can feel your blood pressure rising, pause for a moment to collect yourself before answering the question.

4. Be Str aightforward The facts will come out in your deposition or at trial, so there is no point in trying to avoid an admission, even if you think that making it will hurt your case. When opposing counsel asks a question, don’t obfuscate.

Quickly provide a clear answer. Dancing around the issue will only give it more prominence.

The Doctors Company provides Litigation Education Retreats as an exclusive benefit for members facing claims. At these one-day seminars, litigation experts offer essential advice about what makes a winning case, and physicians learn the skills necessary to aid in their own defense. Find more information at www.thedoctors.com/LER. Contributed by The Doctors Company. For more risk tips, patient safety tips, and physician practice tips, visit www.thedoctors.com/patientsafety.

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LA Doctors Get It Right!

GARCETTI WINS MAYORAL RACE LACMA’s president said he’s excited about the nomination of Los Angeles Mayor-elect Eric Garcetti, who just recently talked to LACMA members about their concerns and vowed to support them.

“We are enthusiastic that Mayor-elect Garcetti believes in the health of Los Angeles,” said LACMA’s President Dr. Samuel Fink. “LACMA is looking forward to working with Mayor-elect Garcetti on a broad range of healthcare issues and challenges.”

Garcetti defeated City Controller Wendy Greuel on May 21.

He began the formal transition of power from his successor on May 23 during a meeting with Los Angeles Mayor Antonio Villaraigosa. Garcetti will officially take office on July 1.

Garcetti told news reporters that his top priority will be to help the city regain its financial footing, in part by continuing pension reform and addressing healthcare benefits.

He plans to restore some of the basic services that have been drastically cut in recent years and wants to make LA’s city government faster and more accountable.

On April 30, Garcetti sat down with LACMA’s CEO Rocky Delgadillo during an interview-style meeting to discuss hot button issues, from childhood obesity to the physician shortage. After hearing doctors’ concerns, Garcetti vowed his support.

“This is yet another win for LACMA and much appreciated,” said Dr. Fink.

During the meeting with LACMA members, Garcetti also addressed public health and safety concerns facing Los Angeles County.

“He said he would appoint more physicians to the Los Angeles Fire Department and Police Department commissions, recognizing the importance of having physician leadership,” said Delgadillo, LACMA’s CEO. Garcetti said in news reports, he also plans to restore city services that have been cut, including the response times in the Fire Department.

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LACMA President Sam Fink and CEO Rocky Delgadillo with Eric Garcetti and Andy Leeka, CEO of Good Samaritan Hospital

ba l a n c e | li fest yle & wellnes s

The Worst Patients

Ana Hernandez-Schneider, MD, FAAFP, Diplomate American Board Family Practice

physicians offers us an opportunity to belong to a noble, respectable group, which is good; amazingly, for better and for worse there is a strong set a values we uphold such as strong work ethic, self-questioning, devotion and caring toward people who are our patients. This we learn all along from our teachers in medicine, both in concept and in application, all through our training.We, physicians rise to the challenge of promoting and preserving health and well being in our patients.

O u r co m m u n i t y o f

Irrationally, physicians forfeit our humanness in regard to our own physical and mental health to such extreme and untenable degrees due to our unspoken, unwritten, but well-understood pact that the aforementioned values and actions of looking after patients do not apply to us when we become ill. We are not allowed in our medical culture, and furthermore, we are not taught how to be proper patients when we become sick. This is A 2007 report by the Health Policy & Economic Research Unit in Engwrong, perverse and deland identified seven major factors structive. Our medical in physicians that act to conspire culture needs to change. against doctors’ health and wellThe stigma of ill ness. These seven factors include the health has a powerful grip stigma of ill health, stress, drug and on us in that doctors do alcohol abuse, mental health, vulnernot seek early medical able doctors, self-treatment, and concare in regard to psychofidentiality gaps in our medical field. logical illness, i.e., depression and/or substance abuse, because it seems as though ill health is akin to inadequate performance and unacceptable conduct.

The risk of stigmatization is the risk of being the “weak link” in a supposedly “strong chain.”

What about stress? Well, the proverbial “chicken and egg” concept applies here. On the one hand, stress in doctors is a product of the interaction between the demanding nature of our work and our obsessive, conscientious and committed personalities, according to a study. However, on the opposite side of the argument, several studies have shown that the proportion of doctors and other health professionals showing higher than average levels of stress is constant at about 28% compared to 18% in the general working population.Thus, the conflicting results point to stress coming from both the workplace and from the doctor. Workplace stressors for doctors include,

1 0 PHYSICIAN MA G A Z INE | j un e 2013

among many others, excessive workloads, organizational and governmental changes, poor management with insufficient resources, dealing with patient suffering, medical mistakes, patient complaints, bullying from colleagues and staff, allied health worker complaints, medical litigation and the sheer pressure of our work. As human beings, we must understand that our stress must be honestly identified, and we must learn and practice modalities to turn it off when it is making us sick.

With regard to drug and alcohol abuse, studies have shown that abuse of alcohol and other drugs forms the major component of concern, and the largest group of doctors facing action are those with addictive problems. Many impaired medical colleagues continue in their alcohol and/or drug dependence with all their illness’s complexities due to the denial and collusion of their colleagues. I personally have seen colleagues drink alcohol excessively in medical staff holiday parties but turned a blind eye and a deaf ear in collusion, thus bypassing the psychological distress and alcohol dependence my colleague is dealing with.

Physicians’ mental health issues also seem to have some special characteristics.A 2005 Occupational Health Statistics Bulletin in the United Kingdom reported evidence that medical doctors are more likely to suffer from work-related mental ill health than other professions, with the prevalence of any common mental disorder in doctors as high as 28%, compared to 15% in the general population. Deep prejudices exist against people working in the medical field with personal mental illness.

This is perpetuated by the myth that you cannot be a medical doctor if you are mentally ill.This myth has been shown to be false and, although burnout and stress are loudly spoken about and important in medicine because of their frequency and the disability they caused, severe depression, near-lethal suicide attempts and psychotic

features are also all too frequent, according to Graske, J (2003). We must ponder what is behind the statistics; Torre and colleagues compared all-cause mortality between physicians and the general population; they found that suicide was the only cause of death where the risk for physicians was higher than the general population.

In all studies that have analyzed male and female physician suicide in comparison with the general population, the suicide rates for female physicians have consistently exceeded the rates for male physicians. Suicidal male and female physicians must be approached in a non-judgmental manner and offered help and support. Thinly veiled excuses of not wanting to be“disrespectful,” “benign neglect,” “status quo” misreading of a colleague in harm’s way might be regrettable. Generally, other factors in mental illness that weigh on our mental health are the long hours worked, the high workload, the pressure of work and their effect on the personal lives of doctors, according to a study sponsored by the Nuttfield Trust in 1996. Doctors who are in stable relationships seem to enjoy better mental health, according to several sources.

Who are the vulnerable doctors? Doctors who blame doctors for their own illnesses (most of us at one point or another). Many doctors hide their illness from colleagues, family and friends in an attempt to not appear vulnerable, while continuing to maintain a heavy workload. It is very hard for doctors to take time off work because of illness. Published anecdotal evidence suggests that many doctors are reluctant to seek help until the situation becomes serious because they are ashamed of failing and fear of harsh judgment by colleagues.

Thank God for our medication sample cabinets, ha? The well-documented stigma attached to ill health leads doctors to self-treatment. Self-treatment includes but is not limited to: diagnosing and treating one’s own illness and prescribing for oneself and our children and our partners and spouses, etc. It also includes the informal “curb-side” consultation and self-referring to a specialist. Unfortunately, self-medication avoids the human support element of treatment, and reinforces the withdrawal from others, particularly in relation to mental illness.This behavior is learned as early as in medical school, studies have shown. What may be at the core of the issue here is our reluctance to give up control.

And, lastly, confidentiality in our medical field is far from adequate. Doctors do not feel free and safe to seek medical care in their own communities through the usual routes and mechanisms and find it difficult to adopt the role of patient due to fear of lack of confidentiality. Doctors are compelled to portray a healthy exterior while being aware of their vulnerability in terms of their physical and mental health as well as their professional standing. Doctors are notorious for not having a regular physician and for not having regular visits for preventive and/or acute and chronic illness reasons. Then, of course, consulting a physician who is well out of the way geographically is difficult, except under serious and/or advanced physical or mental health circumstances, due to the time away from the office and having to follow the requirements for insurance, payment, waiting time, and other mechanisms involved that all patients have to comply with.

Fellow medical doctors, it is time we wake up and recognize the need to change ourselves and change the culture of medicine to allow us to be proper patients following the rules that patients need to follow while not feeling like inadequate doctors and thus stigmatized as less than the good-caliber physicians that we work hard for. We must accept and understand that caring for and preserving our health and that of our families is a noble and ethical principle as well.

WE TREAT DOCTORS RIGHT!

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reporting on the economics of healthcare delivery

St. John’s Health Center Confirms Sale to Providence

The manager of communications at St. John’s Health Center affirmed the Santa Monica-based hospital is in exclusive negotiations with Providence Health & Services. This comes after an ad sponsored by St. John’s hospital foundation, which ran in the Sunday edition of the Los Angeles Times on May 19, advocated for the sale of the health center to its long-time backer, Los Angeles billionaire Patrick Soon Shiong, instead.

California Legislators Consider Use of Medicaid Savings

Some California lawmakers want to use savings from the Medicaid expansion to offer basic health services for undocumented immigrants.

The plan could bring more uninsured into the doctor’s office for preventive care rather than waiting until their symptoms worsen and lead them to seek care in Los Angeles County’s already overcrowded emergency rooms, according to news reports.

LACMA Opposes Unnecessary Drug Substitutions

LACMA’s president recently sent a letter to the LA Daily News, urging state legislators to consider a bill to prevent health insurers from offering incentives to pharmacists to substitute prescribed medications with cheaper, nonequivalent drugs.

Dr. Samuel Fink stated in his letter that AB 670, introduced by California Assemblywoman Toni Atkins, would “close the loophole that allows pharmacists to receive kickbacks for a therapeutic switch.”

LA Prices for Procedures Beat OC Prices

New data from New Choice Health, a private company that encourages people to become smarter healthcare consumers, reveals that on average consumers pay less for medical procedures in Los Angeles County than in Orange County.

According to New Choice Health, a colonoscopy on average runs about $200 less in LA County than in Orange County; an MRI can run nearly $500 less in LA County than the state average; a mammogram runs about $90 less; and a CT scan costs nearly $1,000 less in LA than in the state as a whole.

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Within LA County there is big variation between hospitals, with some charging well above the county average for procedures. The most expensive colonoscopy in the county costs $13,440 and the most expensive MRI costs $11,550.

UCLA Scientist Discusses Shortage of Pediatric Subspecialty Care

A new study presented in April by UCLA Center for Health Policy Research scientist Daphna Gans, addressed the shortage of pediatric subspecialty care in California along with possible solutions.

Report Raises Fairness Issues for LA Doctors

An interim report released by the Institute of Medicine suggests that basing Medicare payment on geographic regions would reward underperformers in some areas while penalizing those who do well in others.

The report noted that healthcare spending could even differ among physicians in the same group and individual providers, which raises fairness issues for doctors in Los Angeles County and elsewhere.

Legislation Would Limit Role of State Medical Board

Lawmakers have proposed legislation to strip the Medical Board of California of its power to investigate physician misconduct, leaving it to deal mostly with licensing doctors.

The medical board has come under fire for failing to discipline doctors accused of harming patients, particularly those suspected of recklessly prescribing drugs, according to news reports. The issue was highlighted by a Los Angeles Times investigation that found that drugs prescribed by doctors played a role in nearly half of the prescription drug overdose deaths in Southern California, from 2006 through 2011.

HealthCare Innovation Funding Available to LA Doctors A second round of the government’s HealthCare Innovation Awards is making nearly $1 billion available for applicants who find cost-effective ways to improve medical care and deliver better outcomes.

With several Los Angeles County-based programs

Experts Agree on Major Real Estate Trends

Healthcare real estate experts at a recent conference predicted a continued rising trend of consolidations among physician group practices, mainly to cut costs, increase efficiencies and move to a more patient-centric environment.

Glendora Doctor Says Physicians Should Be Engaged in ACOs and ACNs

Dr. Lisa Thomsen, a Glendora-based family practitioner in private practice, says now is the time for primary care physicians to play more active roles in their medical communities to avoid being left behind in this era of health reform.

Osteopathic Medicine Could Help Reverse LA Doctor Shortage

The rising number of physicians graduating from osteopathic schools could help reverse a looming shortage of primary care doctors in Los Angeles County and rural areas, where there is a great need for medical care.

Torrance-Based All Medical Solutions Presents Audit Results

Andrew Kan, a partner at Torrance-based compliance firm All Medical Solutions, recently presented results from a 2012 electronic health system audit comprising 115 health organizations to the South Bay Independent Physicians medical group in Torrance.

He predicts that with health reform there will be a significant rise of EHR audits. Physicians need to be prepared at any given time, he holds.

Success in Efforts to Minimize Impact of Strike at UCLA Medical Center

The California Public Employment Relations Board (PERB) succeeded on May 20th in their effort to mitigate the effects of the strike by the American Federation of State, County and Municipal Employees (AFSCME). The board went to court and won an injunction to restrict union workers in critical health and safety positions from joining a planned two-day walkout on May 21-22.

California’s Public Employment Relations Board, which oversees collective bargaining activities for public employers, asked for the temporary restraining order on behalf of the UC System.

Burbank Center Partners with Community Hospitals for Stroke Treatment

Providence Saint Joseph Medical Center in Burbank announced last week it has entered into partnerships with four community hospitals to diagnose and treat stroke patients via telemedicine, using a robotic system. The joint venture aims to improve treatment time and patient outcomes.

USC Researchers Describe Plan to Ease Doctor Shortage

Researchers at the University of Southern California recently published a paper about lessons learned from transforming a downtown Los Angeles family practice, previously owned and operated

by USC, into a federally qualified health center eligible for federal grants and higher Medi-Cal reimbursements. The merger is seen as a model for serving newly insured patients and addressing the doctor shortage.

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already benefitting from the first round of government grants, the announcement made recently

by Department of Health and Human Services Secretary Kathleen Sebelius opens a window for local organizations to receive funding.

Physician Wellness

CAUSE AND (ECONOMIC) EFFECT

BY MARION WEBB

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The Economic Impact of Burnout Research over the last decade has shown that burnout is widespread. A 2011 study of 2,000 physicians showed that almost 87% of physicians felt moderately to severely stressed and burned out on an average day with 63% reporting feeling more stress and burnout compared to three years prior to the survey. The nationwide, multi-specialty survey on physician stress and burnout was done by Physician Wellness Services and Cejka Search in late 2011.

Despite the rising prevalence of physician burnout and stress, however, less than 16% of survey respondents said their organizations were doing anything to help them address the issue, according to the American Academy of Medical Administrators and AAMA Foundation.

For healthcare organizations, failure to deal with stress and burnout in their physician population can have serious and costly consequences: Among the biggest issues are retention and recruitment problems, turnover challenges, lowered productivity, and deterioration of employee morale and patient treatment outcomes. A 2009 study published in the Journal of the American Medical Association’s Annals of Surgery found that physician distress and fatigue also lead to medical errors.

Thomas Habib, a clinical psychologist and chair at the Well Being Committee at CHOC Hospital in San Juan Capistrano, cited a study from 1997 (Family Practice Management) suggesting that physician burnout costs the average practice an estimated $150,000 in lost productivity and turnover.

“I’m sure it is a lot more money today,” Habib added.

John-Henry Pfifferling, founder and director for the Center for Professional Well Being at Durham, N.C., echoed Habib’s findings.

“Burnout is very expensive,” Pfifferling said. “When people are physically or emotionally absent, because they are so exhausted, they will look for ways to cut time or try to leave early (from work) or both.”

This isn’t merely negatively affecting patient care and outcomes, but is costly for organizations in terms of lost productivity and a rise in absenteeism when physicians are not present, Pfifferling said.

When health organizations fail to address these issues

early on, there is also the potential for lawsuits. These can result from medical errors or when a terminated doctor sues the health system and its employees, according to reports.

Reasons for Burnout The good news is that in the last few years, the medical community has become increasingly aware of the problem of physician burnout with more organizations taking preemptive steps to address the issue before bad things happen.

Burnout—characterized as emotional exhaustion, depersonalization, and reduced personal accomplishment—and compassion fatigue—a form of burnout where a doctor gives himself or herself fully to their patients but looses the balance of empathy and objectivity—affect not only physicians in training, but also practicing physicians in a variety For healthcare organizations, failof disciplines, accordure to deal with stress and burnout in ing to a recent Physitheir physician population can have secian Stress and Burnrious and costly consequences: Among out survey. the biggest issues are retention and Some experts berecruitment problems, turnover challieve that physician lenges, lowered productivity, and deburnout appears to terioration of employee morale and have less to do with patient treatment outcomes hours worked or even the ability to balance personal life with work, but where they practice. Those practicing at the front-line of care seem to be at higher risk: More than half of the doctors in family medicine, emergency medicine and general internal medicine experienced some form of burnout, studies have shown.

A significant number of doctors express their discontent with the way medicine is practiced in the current healthcare system.

Many doctors report feeling trapped, dissatisfied with the time limit allowed to spend with each patient, stymied by the changing rules set by insurers and other payers on what they can prescribe or offer as treatment. With healthcare reform and the move to computerized systems, many doctors are also expressing increased frustrations with electronic health systems and the rising administrative burden, Pfifferling said. j un e 2013 | w w w. p h y s i c i a n s n e w s n e t w o r k .c o m 1 5

P HYSICIA N WELLNESS | feat u r e

With the alarming rise of physicians experiencing burnout, more hospital and medical groups are implementing programs specifically designed to help physicians address their own wellness. Granted, these efforts aren’t entirely altruistic.

Several studies have shown that burned-out and disruptive physicians undermine not only their own health and professionalism but can take a serious financial toll on healthcare organizations that fail to address the issue.

In this article, three leaders of physician wellness programs located in Los Angeles County and in Durham, N.C., discuss the prevalence of burnout and its impact on healthcare delivery systems. They also offer key insights behind the growing prevalence of physician burnout and disruptive behaviors, talk about their programs and provide tips for identifying symptoms and how to help doctors cope with burnout.

FEAT U R E | P HYSICIAN WELL NESS

He expects the changing health environment with its many uncertainties will likely exacerbate physician burnout.

That’s because “the greater system demands more expectations from doctors with less resources,” he said.

Pfifferling said he has seen a continued rise in physician burnout in the last few years. Many doctors express frustration with the switch to electronic health systems and the failure to integrate systems—especially those who have been practicing for a long time aren’t comfortable with typing on computers and using smartphones, he said.

Today’s patients also place unrealistic requests on physicians, which is tough on doctors who are trying to do their best to provide care, he said. Teamwork is also deteriorating creating issues for doctors.

“Physicians who Most physicians enter a practice with suffer from burnout the hope of fulfilling a caring, supportive, challenging and rewarding typically grieve for the role. What they get is unrelenting loss of a life dream—no pressure to see more patients in less question, a significant time, limited control over how medi- loss,” Pfifferling said. cal care is delivered, constant scru- “Most physicians enter a practice with the hope tiny and quality “assessments” and inof fulfilling a caring, creasing demands from patients. supportive, challenging and rewarding role.

What they get is unrelenting pressure to see more patients in less time, limited control over how medical care is delivered, constant scrutiny and quality “assessments” and increasing demands from patients.”

Programs/Intervention and Prevention for Burnout Center for Professional Well-being - Pfifferling said his center has been providing physician well-being at the preventive and intervention level since 1979.

The majority of doctors, or roughly 75%, are referred to the center by their superiors, because they have violated some of the guidelines of professionalism. Among the issues are anger-management problems and disruptive behavior.

Some doctors themselves recognize that they have a problem and come in voluntarily.

The center offers on-site coaching, workshops and Pfifferling often gives presentations to doctors as well. He also travels across country when asked by an organization that needs help in dealing with a problem doctor.

This April, Pfifferling flew to a doctor practice in Los Angeles to provide mediation intervention for a doctor who is exhibiting signs of disruptive behaviors. He explained what will happen when he arrives at the office.

“We will interview with the key principals and meet with the target physician and provide coaching,” he said. The goal is to give the doctor insight into his behavior, investigate causes for the disruptive behavior and intervene by teaching the physician coping strategies.

He charges $1,500-$4,000 for a one-day intervention session, plus expenses. Pfifferling said that every case is different, but said intervention can bring quick results. In some cases, doctors fly to his center for follow-up coaching as well.

CHOC Physician Well-being Program - At CHOC 1 6 PHYSICIAN MA G A Z INE | j un e 2013

hospital, doctors with a behavior problem, including those who are overworked, depressed or stressed, are referred to the physician well-being program in lieu of punitive actions.

When this happens, a psychologist and a physician will meet with the referred doctor with the understanding that this is a peer review and everything discussed is confidential, Habib said.

Out of 1,700 doctors working at the joint campus of CHOC Children’s Mission Hospital and CHOC Children’s main campus in Orange, 15 cases were open as of April, he said. The cases, however, were not limited to physicians.

“We try to take care of physicians rather than taking punitive actions, so their lives can go on,” Habib said. “Doctors are great at taking care of other people, but not so good in taking care of themselves,” he added.

Knowing this, CHOC has taken proactive measures. Habib said his team now meets with every new doctor coming to CHOC to address issues of compassion fatigue and burnout early on. A library section functions as a retreat and doctors have easy access to literature on wellness issues.

“We’ve had so much success with physician well-being that we are becoming more proactive with physicians’ wellbeing and not waiting for problems to develop,” Habib said.

UCLA Health System - At UCLA Health System, the Medical Staff Health Committee has also stepped up its efforts to reach out to doctors.

“We’re still experimenting with ways to reach out to doctors,” said Dr. Karen Miotto, chair of the health committee.

She echoed Habib’s views that doctors tend to shy away from talking about their own problems, which can create barriers for those trying to help.

“Doctors aren’t accustomed to talking about themselves, but they are accustomed to lecture programs,” Dr. Miotto said.

Consequently, the committee has created a networking group where doctors can meet and talk about their challenges.

A facilitator leads the effort where doctors meet once a month to discuss topics such as “Finding Meaning in Medicine.”

“The overall objective is to get doctors in an informal place and share and find areas that are most challenging to them and give them the tools to deal with their issues and the changing landscape of medicine,” Dr. Miotto said.

Burnout Proofing Strategies Many experts agree that medical institutions and professional organizations can create an atmosphere of acceptance and support where physicians are encouraged to address issues before they lead to serious consequences.

Pfifferling offers the following tips to guard against burnout. He calls it “burnout proofing.”

• Providing regular feedback so that adjustments can be made • Holding workshops on chaos and transition to help doctors cope • Offering leadership training and effective mentoring • Allowing access to trained mediators • Providing peer support and offering retreats.

Taking steps to prevent or address burnout will be even more critical given the major changes ahead in healthcare.

Thomas A. Habib, Ph.D.

This was Dr. Smith’s third surgery of the day and lunch was still an hour away. When he realized that the instruments for a hip replacement were not in the room, even though he had previously contacted central processing, he exploded in frustration. This was not his first eruption. A written complaint was filed with the department and made it’s way to the medical executive committee. In lieu of punitive action, Dr. Smith was referred to the Physician Well Being Committee.

Emotional Discipline Most people are too reactive to the unexpected events in their lives. Perceived incompetence, disrespect or delays, for example, launch many into a tizzy. In an instant, they go from 0 to 60, either spewing anger overtly, as did Dr. Smith, or holding it internally as a toxic brew. In effect, they have little or no emotional control and self-regulation. Because the vast majority of people emotionally overreact this way we do not label this as abnormal. Whether you are screaming or internally holding it, this is poorly developed emotional discipline. It is a form of impulsivity that is interpersonally unsuccessful and unhealthy for your body.

How does one become less reactive? How does one avoid huge mood swings and reduce one’s reaction to life’s inevitable gusts of ill wind? How does one avoid wasting precious energy on what’s inevitable and expected?

For men, driving a car provides an excellent opportunity to develop a less reactive cognition. I don’t need to tell you that a few people (not most) do indeed drive in ways one might describe as aggressive, selfish or perhaps oblivious to what’s around them. All too frequently we are reacting, overtly or internally, as mentioned above. The following exercise involves telling yourself ahead of time that you are going to observe what you usually overreact to, without criticism.

Don’t label it. Don’t personalize it. Just try to watch it.

Observe Without Criticism The next time you see someone driving aggressively, try to observe it without criticism. Try it as a thought experiment.

At first, you may only catch yourself after you reacted. Keep trying. What you will find is that you’ll progress from your current knee-jerk reaction, to a diminished level of reaction, to rarely reacting with much lower intensity. You should see significant progress in as few as ten practice sessions. Even if you slip back to “DEFCON 1,” get back into the practice mode to observe without criticism.

The moment will come when you finally find yourself not reacting. You may chuckle or otherwise feel self-satisfaction; just observing without criticism. You’ll enjoy that you haven’t invested a single iota of energy in useless reactions. Developing one’s ability to observe without criticism has also been de-

scribed as a higher developmental stage called “The witness.”

Most cannot stay at this stage very long, but even developing a little of this non-reactive space in one’s life can cascade throughout all cognition with very positive effects. As a result, you’ll find it much easier to handle life’s inevitable hurdles.

Your perspective will broaden, as will the complexity of your understanding. The wise practitioner applies this to their medical practice by visualizing ahead of time how they are going to react to the most demanding events and moments.

Whereas men can utilize anger as an opportunity to develop non-reactive cognitive space I find that a focus upon anxiety for women provides an excellent opportunity to do the same. It has been estimated that women experience up to five times more anxiety than men. This anxiety can be as distracting and debilitating to women as anger is to men. Much of it is anticipatory anxiety that serves as ongoing vigilance to dangers and threats, although anxiety associated with performance, acceptance and adequacy can also produce this persistent cognitive flotsam.

Observe without Participation This exercise involves telling yourself ahead of time that you are going to observe an event without participation. For men it’s observation without criticism. For women it’s observation with decreasing participation. Select an event that generates anxiety—perhaps one involving children, relatives or work relationships. Decide ahead of time you are will retain some observation, from this slightly altered perspective. Try to watch moments as the anxiety begins, with diminished participation. Even a few degrees of altered perspective will suffice. Eventually, you’ll realize moments where you are just observing. As with men, this will build into increasing amounts of observation without participation. Also, the development of even a little of this nonreactive space in one’s experience will cascade throughout all of your cognition with very positive effects. The persistent background noise of anxiety will make room for feelings of contentment, and energy will not be needlessly wasted on this hyper-vigilance.

Thomas A. Habib, PhD, is a clinical psychologist practicing in San Juan Capistrano, CA. Dr. Habib is Chairman of Medical Staff Well-Being Committee at CHOC at Mission Hospital in Mission Viejo, CA.

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P HYSICIA N WELLNESS | feat u r e

Taking Charge of YOur Own Well-Being

1 8 PHYSICIAN MA G A Z INE | j un e 2013

HEALTH REFORM HEATS UP AS THE CLOCK RACES More than three years have passed since the Affordable Care Act (ACA) was signed into law, setting in motion some of the most dynamic and volatile years the nation’s health care industry has ever seen.

BY JAMES NOONAN l CMA Staff Writer

S

ince its inception, the Affordable Care Act (ACA) has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation. For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy. >> j un e 2013 | w w w. p h y s i c i a n s n e w s n e t w o r k .c o m 1 9

Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional and active steps are being taken to move forward at the federal and state levels.

Despite being signed into law more than three years ago, the vast majority of activity has yet to come. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes.

The road has already been a somewhat rocky one.

Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse.

Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide.

As of early February, only 19 states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form state-federal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas.

Despite these problems, the march toward reform continues on.

THE NEXT MAJOR MILESTONE The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment.

In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either

2 0 PHYSICIAN MA G A Z INE | j un e 2013

Millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA.

through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California.

Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA. In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens – many of whom have never had the benefit of “open enrollment” or a similar purchasing period – understand how and where they can sign up for coverage under the reform law.

The task is daunting on its own, but with a deadline looming only months out, skeptics would be forgiven for questioning whether such a task is even possible.

CALIFORNIA LEADS THE WAY

Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines.

In the days following the ACA’s passage, California was the first state to establish a health benefit exchange (Utah and Massachusetts were operating their own versions of an exchange before the ACA was signed into law) and has been working toward implementation ever since. That exchange, recently named Covered California, has already launched its online consumer marketplace, www.coveredca.com, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level.

Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be

responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 18 geographical rating regions.

While the selection process is still far from over, it looks as though the Covered California board will not be short on options when it comes time to award the QHP designation. In October, more than 30 distinct insurance providers issued a “notice of intent to bid” to the board, and most of the state’s major insurance providers have since gone public with their intent to participate in California’s exchange.

The fact that insurance companies appear more than willing to play ball with the exchange, and

that Covered California was established as an independent government entity operating outside the control of the Legislature and governor, means that the exchange’s Board of Directors has a considerable amount of power when it comes to shaping California’s post reform heath care landscape.

PROTECTING PHYSICIAN INTERESTS Unfortunately several recent decisions by the exchange board have placed California’s physician community on its heels.

The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several of issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required

to meet in order to have their products considered for the QHP designation. One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs. Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could

become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

CMA has repeatedly asked Covered California’s board to reconcile the state and federal policies, but to date an adequate fix has not been presented.

Given the exchange’s accelerated timeline, as well as the exchange

INDUSTRY REFORMS DRAW NEAR: Beginning next January, a majority of the major insurance industry reforms in the Affordable Care Act (ACA) will go into effect, including a ban on lifetime caps and the “guaranteed issue” provision that prohibits health plans from denying coverage on the basis of health status or pre-existing conditions. In order to successfully offer coverage to these new populations, insurance providers must also draw healthy consumers in their risk pool, which is where the controversial “individual mandate” provision comes into play. Those who elect not to purchase or otherwise obtain coverage will be responsible for paying a penalty under the ACA. However, with some observers noting that the penalty could be as low as $95 in the first year, it remains to be seen whether young, healthy individuals might forgo a year of insurance premiums in lieu of this more affordable penalty payment.

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IMPORTANT DATES: October 1, 2013 – California’s exchange to open up pre-enrollment to those planning to purchase coverage through the new online marketplace.

January 1, 2014 – Exchanges across the nation set to become active, allowing tens of millions of currently uninsured Americans to purchase subsidized coverage through new online marketplaces.

January 1, 2014 – Major insurance industry reforms go into effect, including a ban on lifetime caps and a provision that prohibits health plans from denying coverage on the basis of health status or pre-existing conditions.

RESOURCES: The California Medical Association (CMA) has produced a number of resources to ensure that California physicians are ready to operate in a post reform landscape. Among them: CMA Reform Essentials– a regular publication available to both members and nonmembers covering the activities of the state’s health benefit exchange board and legislation significant to California’s ongoing reform efforts. Subscribe today at www.cmanet.org/newsletters.

CMA’s Got You Covered: A physician’s guide to Covered California, the state’s health benefit exchange –a member-only guide designed to educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting. Available at www.cmanet.org/exchange.

UPCOMING HEALTH REFORM WEBINARS: The California Medical Association (CMA) offers free programs to educate member physicians and their staff on a range of issues, including health reform. For more information on any of these programs, visit www.cmanet. org/events. If you are unable to participate in any of CMA’s live webinars, they are archived for on-demand viewing shortly after the live events in CMA’s online resource library at www.cmanet.org/webinars.

4/24: California’s Health Benefit Exchange: How it Will Impact Your Practice and Change Commercial Insurance 9/11: California’s Health Benefit Exchange: The Positives and Perils of Contracting

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board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014.

ACTION UNDER THE DOME

With all of the moving pieces present between the federal government and California’s exchange board, it’s sometimes easy to forget that the state Legislature is also playing a large role in ACA implementation. So large, in fact, that Gov. Jerry Brown saw fit to call for a special session dedicated to health care reform in California.

A total of six bills (three identical proposals being heard in both houses of the Legislature) were introduced during the special session, seeking to address individual market reforms (ABX1-1 and SBX1-1), Medi-Cal expansion (ABX1-2 and SBX1-3) and a proposal to establish a “bridge plan” (ABX1-2 and SBX1-3) that would allow for a seamless transition between Medi-Cal and exchange plans for those individuals whose income may fluctuate past the income thresholds called for in the ACA. Special sessions usually are reserved for a dire situation in need of immediate legislative action, which makes it somewhat surprising that members of the Legislature allowed the spring recess – their “soft deadline” for special session legislation – to come and go without any major action on these bills. As of early April, the individual market reform and Medi-Cal expansion bills had cleared their houses of origin and were set to be heard in committees within the second house, while the bridge plan proposal had yet to be heard on the floor of either house.

There’s also a considerable amount of activity related to health reform taking place outside of the special session, specifically regarding scope of practice expansions as a way of addressing the access to care issues that will inevitably take place when millions of currently uninsured Californians gain coverage beginning in 2014. Three bills, all authored by Sen. Ed Hernandez (D-West Covina), seek to expand the respective scope of practice for pharmacists, optometrists and nurse practitioners, while a fourth, authored by Sen. Fran Pavley (D-Agoura Hills) would call for a similar expansion for physicians assistants.

The ACA had two major goals: First, to expand access to health coverage to all, and second, to ensure efficient, high quality care. Those who are now invoking the ACA as the sole justification for allowing non-physicians to diagnose and treat California patients and perform complex medical procedures are attempting to achieve the first goal by undermining the second. Allowing non-physicians to practice beyond their training can only lead to inferior outcomes, higher costs and greater fragmentation of care.

CMA will be closely following and fighting these scope bills, working to ensure that California meets the ACA’s objectives without eroding quality or jeopardizing patient safety.

To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts.

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s cop e o f pr ac ti c e | u ni ted we sta n d

Consumers for Quality Health Care Oppose Legislation That Jeopardizes Patient Safety

SB 491, 492, 493: A Shortcut in Medicine is the Wrong Approach T H E IS SU E - Our state needs to address the state’s shortage of primary care physicians. All Californians – particularly those in underserved communities – need increased access to healthcare. We need a thoughtful approach that will not jeopardize quality of care, potentially endangering patients’ safety and privacy. That is why physicians, nurses, patient advocates oppose SB 491, SB 492 and SB 493. It’s the wrong medicine for California. Among the concerns include: D O E S N ’ T C LOS E T H E PR OV I D ER G A P

• The number of doctors in California is unevenly distributed with regards to its population, but these bills don’t solve that problem. The majority of nurse practitioners, optometrists, and pharmacists are practicing in the same regions as physicians, not in the areas with a shortage of providers.

• Medical professionals are unlikely to relocate from densely populated, urban areas to parts of the state that lack access – primarily low-income and rural communities – simply because their scope of practice is being expanded. In fact, the American Association of Colleges of Nursing (AACN) has projected a nationwide shortage of 260,000 nurses by 2024.

• There is little evidence that these bills will close the provider gap. Of the nineteen states that allow independent practice by nurse practitioners, the majority have a higher percentage of underserved individuals than California.

SU B -S TA N DA R D C A R E F O R U N D ER S ER V ED CO M M U N I T I E S

• The bill package does nothing to address the state’s physician shortage, particularly in poor and rural areas. Instead, it creates a two-tier system of care, one in which those in underserved areas rely on nonphysicians for primary care treatment, while the rest of the population receives care from physicians and physician-led teams.

• SB 491, 492, and 493 will create a new model of medicine for those who can’t afford to see the doctor.

Under these bills, nurse practitioners, optometrists and pharmacists will have the power to act like a doctor minus the same level of medical training.The individuals most likely to rely on these specialists for primary care are the lower-income and those who are newly insured under the Affordable Care Act. T R A I N I N G A N D CO L L A B O R AT I O N CO U N T I N M ED I C I N E

• Nurse practitioners, optometrists, and pharmacists are trained medical professionals, but they are not physicians. Allowing them to diagnose and prescribe and treat patients in areas in which they have not received training places patients at serious risk.

• In California, licensed physicians are required to have four years of medical school and up to seven years of additional residency and training. In comparison, most nurse practitioners receive the same amount of education as a second-year medical student.

2 4 PHYSICIAN MA G A Z INE | j un e 2013

• Experts agree that quality medical treatment requires a team-based approach where nurse practitioners, medical assistants and other trained professionals work under the supervision of a physician.

By removing the supervisory role, the bill package eliminates that collaborative aspect. The same concern applies when expanding the scope of practice for optometrists and pharmacists to treat patients for conditions that require a physicians’ expertise.

L E S S ACCO U N TA B I L I T Y

• All three bills set a dangerous precedent of allowing non-physicians to practice medicine without being subject to the Medical Practice Act (MPA), which regulates the practice of medicine and in which violations may result in the loss of a medical license and possibly criminal prosecution.

• Ultimately, nurse practitioners, optometrists, and pharmacists would be providing the same services as physicians, with less training, while being held to a lower standard of care.

T H R E AT EN S PR I VAC Y

• SB 492 would expand pharmacist’ scope of practice to include primary care. Many pharmacies are owned and operated by major retailers, such as WalMart and Rite-Aid. The handling of medical histories and other sensitive information in a retail setting compromises a patient’s right to privacy.

A B E T T ER S O LU T I O N

• Rather than rely on short-sighted fix, a responsible alternative is to focus on increasing primary care provider training; recruiting more physicians from outside California; and creating incentives for working in underserved areas. The California Medical Association supports the following approach: - SB 21 and AB 27, which allocates $15 million annually for the new UC-Riverside School of Medicine; - AB 565, which expands the Steve Thompson Loan Repayment Program to help repay medical school loans in exchange for students agreeing to practice medicine in underserved areas; - AB 1176, which creates residency positions in medically underserved communities by instituting insurer fees; and - AB 1288, which requires the Medical Board of California to prioritize applications for physician licenses from those who plan to treat members of a medically underserved population.

LACMA CEO Supports Fight for MICRA LACMA CEO Rocky Delgadillo has applauded the California Medical Association for urging doctors to join the effort to fight a ballot initiative that seeks to overturn California’s landmark Medical Injury Compensation Reform Act (MICRA). “While we are dealing with the scope of practice (issue) in the state legislature, it appears as though the trial bar is focusing again on a revision of MICRA,�

Delgadillo said. “LACMA is steadfastly opposed to taking away one of the great policy innovations in healthcare, pioneered in California, to reduce the risk to doctors who are providing care.�

This comes after a coalition, including the Consumer Attorneys of California and a trial-lawyer-funded Consumer Watchdog Group, announced intentions to overturn MICRA through a ballot initiative, according to CMA. The group has until September to submit a proposed initiative to qualify for the November 2014 general election ballot.

If successful, according to CMA, the efforts would cause malpractice rates to skyrocket and create the same conditions that threatened to throw California’s healthcare system into crisis during the early 1970s.

Prior to MICRA, out-of-control medical liability costs were forcing community clinics, health centers, physicians and other healthcare providers out of practice.

MICRA has stabilized liability costs. The initiative comes at a time when millions of new patients will be entering the healthcare system and reimbursements for Medicare, Medi-Cal, and Denti-Cal are being cut. If MICRA were changed, it would exacerbate the situation. “The threat of a ballot measure is nothing more than a money grab by trial lawyers,� said CMA President Dr. Paul Phinney. “And one that will come at the expense of higher health costs for all patients and decreased access for patients and clinics already struggling to keep their doors open. We cannot and will not let that happen.�

For more on the fight for MICRA visit http://www.lacmanet.org/Advocacy/ProtectMICRA.aspx

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u ni ted we sta nd | at work for yo u

PNN Extended coverage

a s s o c i at i on ha pp eni ngs | l ac ma news

ceo’s letter

LACMA’s Power In Taking a Stand L AC M A’ s p ow e r i n taking a stand for what is right for physicians and their patients turned victorious this May when the Department of Healthcare Services announced yet another delay of the dual-eligible demonstration project, or Cal MediConnect.

On May 8, the health department announced that Cal MediConnect would begin no earlier than January 2014. This marks a three-month delay from the state’s most recent plan for covering so-called dual-eligible patients, and comes after the schedule had already slipped from hopes to launch the program in early 2013.

The delay is a victory for LACMA and the California Medical Association as we continue our fight to protect our most vulnerable population from the negative consequences of the demonstration program.

The implementation of Cal MediConnect, as it is currently structured, would put a tremendous burden on our safety net clinics and drive patients away from the doctors and medical providers they know and trust.

Given the disproportionate number of dual-eligibles in Los Angeles County—capped at 200,000 eligibles, qualifying for both Medicare and Medi-Cal, a whopping 10% of the entire nation’s demonstration project—our efforts will focus on finding new ways for a more manageable enrollment of patients.

It just doesn’t make sense to have that many people of our most vulnerable population transitioning into a brand-new and untested program. This is a challenge at best and a disaster waiting to happen at worst.

We continue to believe that patients being moved from their trusted physicians to other programs without their permission will have severe consequences in terms of providing adequate healthcare.

And this comes at a time when 500,000 newly insured residents in Los Angeles County will qualify for medical insurance under health reform in 2014. We simply don’t have enough doctors in the County to provide the necessary care for this tremendous influx on newly insured patients.

During our first-ever mayoral forum on April 30, then-mayoral candidate, now LA’s mayorelect, Eric Garcetti, after hearing doctors’ concerns on the dual-eligibles project, vowed to stand behind LACMA. This is yet another win for LACMA and much appreciated.

Separately, Garcetti also addressed public health and safety concerns facing Los Angeles County.

Among others, the candidate said he would appoint more physicians to the Los Angeles Fire Department and Police Department commissions, recognizing the importance of having physician leadership.

The critical issues of the day, including Cal MediConnect among other changes under health reform, require that we are more closely connected to our political leaders than ever before.

We will continue to reach out to key legislators and stakeholders in Washington and California and Los Angeles County so that our voices are heard loud and clear.

We thank you for your ongoing support and hope that all of you will join us this summer to stand united and powerful.

Rocky Delgadillo

Rocky Delgadillo Chief Executive Officer

2 6 PHYSICIAN MA G A Z INE | j un e 2013

launches its first ever dedicated resource center for solo and small group practice physicians LACMA’s Preferred Partner Program provides menu of services and resources to help doctors run private practices more effectively The Los Angeles County Medical Association (LACMA) is happy to offer members access to the newly formed Preferred Partner Program, marking LACMA’s first ever initiative designed to provide exclusive discounts on the products and services physicians in private practice rely on to run a successful and sustainable business. The Preferred Partner Program consists of carefully vetted, industry leading vendors who share LACMA’s goal to advocate quality healthcare for all patients and serve the professional needs of its members.

Participating vendors and services include:

· Medline-Clinic Supply Distribution Services

Offers Members a Guaranteed 10 % savings and up to 30% savings on Clinic Supplies

· Marsh-Insurance Services

· UPS-Shipping Services

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· TigerText-HIPAA Compliant Mobile Messaging · GoodRx-Prescription Savings for Patients

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l ac ma news | a ssoc i at i on ha pp en i n g s

L o s A n g e l e s C o u n t y M e d i cal A s s o c i a t i o n

a s s o c i at i on ha pp eni ngs | l ac ma news

LACMA Memebers Out and About Beverly Hills Physician Networking Mixer, Porsche Beverly Hills

Almost 100 physicians gathered for an evening of wine, hors d’oeuvres, and Friday evening networking at the famous Beverly Hills Porsche Dealership.

Hosted by LACMA and supported by sponsors, including Ken Stern & Associates and UCLA’s Executive Education Programs in Health Policy and Management, members and non-members from across the county enjoyed valuable networking time with fellow colleagues. Wine for the evening was generously offered by The California Wine Club. LACMA recognizes the need for physicians to enjoy the social aspect of medicine and will plan to bring physicians together at future networking events across the county.

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Long Beach physicians met on May 9 at the Long Beach Yacht Club for a physician social hosted by LACMA’s Long Beach District 3. There were about 50 people in attendance. Carlos Martinez, MD, president of the Long Beach District, spoke to the attendees about the importance of getting involved now and answered questions about the current issues facing physicians, including expansion of scope of practice legislation and Cal MediConnect.

Physicians enjoyed networking with their fellow colleagues while learning about organized medicine and the powerful role they can have in influencing policy for their profession.

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specialties with the highest level of burnout were most of the generalists: family physicians, ob/gyns, internists, and general surgeons. The 2 specialties with the highest percentage of burnout were those that dealt with severely ill patients: emergency medicine and critical care. Surprisingly, pediatricians were among the least burned-out specialists, along with rheumatologists, psychiatrists, and pathologists.

More female physicians reported burnout (45%) than male physicians (37%), which may be attributed to the fact that women tend to enter generalist professions rather than the lower-stress subspecialties.

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More than a quarter of internists, general surgeons, and family and emergency medicine physicians take off for only 1-2 weeks a year.

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45.8%

of physicians are experiencing at least 1 symptom of burnout: loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.

46 55 FORTY -

Burnout peaks in midlife (46-55 years) at 32% and then declines thereafter.

The rate of burnout is lowest in the youngest and oldest physicians.

ONE

% of physicians rate their own professional morale as somewhat negative.

Sources: http://www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf; http://www.medscape.com/sites/public/lifestyle/2012

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