2011 May/June

MAY / JUNE 2011 | VOLUME 17 | NUMBER 3

Accountable Care Organizations: • What Providers Need to Know • Improving the Quality of Care • Summary of Proposed Rule Provisions

A former employee sued me for wrongful termination.

What do I do now?

You are not alone. Employment related lawsuits are becoming more commonplace. What many physicians don’t realize is that help is literally a phone call away. SCCMA/MCMS members have access to a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the endorsed Employment Practices Liability program are: • A Helpline staffed by experienced employment defense attorneys. Any manager, officer or principal of

your practice has access to the Helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline and employee terminations.

• If a member seeks Helpline advice on an employee termination which later results in a claim, there is

a 50% reduction of the member’s EPLI deductible for that claim.

• Free comprehensive criminal background checks for newly hired and promoted managers/supervisors.

• EEO compliance training for managers/supervisors. An internet-based training program, compliant with

California law, provides supervisors with sexual harassment training.

• A low minimum premium of $750 annually.

For more information on these important benefits, and the special SCCMA/MCMS First Time Buyers program, please contact Marsh at 800-842-3761 or email us at Member.Insurance@marsh.com.

Administered by:

•

Y MEDIC UNT A CO

C AL

IAT SSOC ION • LA

TA CLARA SAN

Endorsed by:

IF O R N I A

55168 (5/11) ©Seabury & Smith, Inc., 2011 • AR Ins. Lic. #245544 • 777 S. Figueroa St., Los Angeles, CA 90017 • www.MarshAffinity.com • Member.Insurance@marsh.com

d/b/a in CA Seabury & Smith Insurance Program Management • CA Ins. Lic. #0633005 • 800-842-3761 2 | THE BULLETIN | MAY / JUNE 2011

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org

MEMBER BENEFITS Legal Services/On-Call Library Reimbursement Advocacy/ Coding Services Billing/Collections

5

Free iPhone App Connects You to Society Members

6

From the Editor’s Desk

8

From the MCMS President

10 14

Membership Directory/Website Membership Directory iAPP for the iPhone Legislative Advocacy/MICRA

Financial Services Professional Development Health Information Technology

CMA President Dr. James Hinsdale’s Letter to CMS

20

Medicare Fact Sheet: What Providers Need to Know; Accountable Care Organizations

23

Medical Times From the Past: Trephination in History Michael Shea, MD; Leon P. Fox Medical History Committee

24

Medicare Fact Sheet: Improving the Quality of Care for Medicare Patients; Accountable Care Organizations

26

Medicare Fact Sheet: Summary of Proposed Rule Provisions for Accountable Care Organizations Under the Medicare Shared Savings Program

28 30

SCCMA Alliance News

32 36

MEDICO News

Resources Publications CME Tracking Physicians’ Confidential Line Verizon Discount Human Resources Services

Prevention and Treatment of STDs: How You Can Help

16

Practice Management Resources and Education

Accountable Care Organizations Regulations Released

Santa Clara County Public Health Department

House of Delegates Representation

John T. Jameson, MD

James G. Hinsdale, MD

Discounted Insurance Referral Services With

Joseph Andresen, MD

Federal Agencies Address Legal Issues Regarding Accountable Care Organizations Classified Ads MAY / JUNE 2011 | THE BULLETIN | 3

THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS

AMA TRUSTEE - SCCMA

COUNCILORS

President Thomas Dailey, MD President-Elect William Lewis, MD Past President Howard Sutkin, MD VP-Community Health Cindy Russell, MD VP-External Affairs Rives Chalmers, MD VP-Member Services Scott Benninghoven, MD VP-Professional Conduct Eleanor Martinez, MD Secretary Sameer Awsare, MD Treasurer James Crotty, MD

James G. Hinsdale, MD

El Camino Hospital of Los Gatos: Art Basham, MD El Camino Hospital: Lynn Gretkowski, MD Good Samaritan Hospital: Jeff Kaplan, MD Kaiser Foundation Hospital - San Jose: Efren Rosas, MD Kaiser Permanente Hospital: Allison Schwanda, MD O’Connor Hospital: Jay Raju, MD Regional Med. Center of San Jose: Emiro Burbano, MD Saint Louise Regional Hospital: John Huang, MD Stanford Hospital & Clinics: Peter Cassini, MD Santa Clara Valley Medical Center: John Siegel, MD

Tanya W. Spirtos, MD (Alternate)

SCCMA/CMA DELEGATION CHAIR James Crotty, MD (District VII)

CMA TRUSTEES - SCCMA Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (President) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

Debbi Ricks (Alliance)

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Editor

OFFICERS

Joseph S. Andresen, MD

President John Jameson, MD President-Elect James Ramseur, MD Past President William Khieu, MD, MBA Secretary Eliot Light, MD Treasurer John Clark, MD

THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Printed in U.S.A.

Managing Editor Pam Jensen Opinions expressed by authors are their own, and not necessarily those of The Bulletin or the Santa Clara County Medical Association and the Monterey County Medical Society. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by the Santa Clara County Medical Association or the Monterey County Medical Society of products or services advertised.

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2011 by the Santa Clara County Medical Association.

4 | THE BULLETIN | MAY / JUNE 2011

DIRECTORS Paul Anderson, MD

R. Kurt Lofgren, MD

Valerie Barnes, MD

Patricia Ruckle, MD

Ronald Fuerstner, MD

Scott Schneiderman, DO

David Holley, MD

Steven Vetter, MD

NEW MEMBER BENEFIT

Free iPhone App Connects You to Society Members Would you like to communicate with your colleagues instantly? Exchange critical information such as pictures of x-rays or wounds?

Quickly find a local specialist or pharmacy?

Thanks to the generous sponsorship of NORCAL Mutual, the Santa Clara County Medical Association and Monterey County Medical Society are offering members seven months of free service with DocBookMD, a HIPAA-compliant iPhone app that lets you connect, communicate, and collaborate with your local medical community. A version for the Android operating system will be available in mid-July.

With DocBookMD, you carry on your iPhone a directory of all active society members — their photos, specialties, and contact information. Even better, you can exchange messages with all DocBookMD users in the directory.

NORCAL Mutual is sponsoring this service through 2011, with the option of continuing the sponsorship in 2012. To sign up for the free service, call the Santa Clara County Medical Association or Monterey County Medical Society for your Medical Society ID. Then go to DocBookMD.com to register. You will download the free iTunes app and log-in.

MAY / JUNE 2011 | THE BULLETIN | 5

FROM THE EDITOR’S DESK

JOSEPH ANDRESEN, MD Editor, The Bulletin

Accountable Care Organizations

By Joseph Andresen, MD The saying goes that April showers bring May flowers. However, at the time of this writing, May showers fall here in California while the Mississippi River continues to crest and flood towns from North Dakota to Louisiana. For all the non-believers who still doubt the phenomenon of global warming, could this convince skeptics that we do indeed face a looming climate crisis? Of course, as physicians and scientists by training, we are taught to be skeptical observers of the world around us. Pose a question, create a hypothesis, design a test, carefully document observations, and analyze data to answer the original question. But, as Iceland becomes a misnomer, hundreds of destructive tornados wreak havoc in the Southeast, and weird weather now seems a common occurrence, a double-blind study is not needed to suggest that global warming and climate change are upon us.

As promised in our last issue of The Bulletin, accountable care organizations continue to be a timely topic of discussion. In fact, the Central Maine Medical Center in Lewiston, Maine, became the first nationwide applicant for the Pioneer ACO track by submitting their letter of intent Tuesday, March 17 at 2:45 p.m. CMMC, which has two critical access hospitals and one tertiary hospital, has been working on integrated care since the late 1980s and is part of the Maine Health Management Coalition, a nonprofit organization with nearly 50 members including hospitals, health plans, doctors, employers, and unions. “We are 20 years into these types of collaborative models. So if there’s an innovative model out there, we want to be part of it,” said Vice President of Public Affairs Chuck Gill.

In this edition, we present Dr. James Hinsdale’s letter regarding the California Medical Association principles on implementation of accountable care organizations.

“Guiding Principle – The goal of an Accountable Care Organization (ACO) is to increase access to care, improve the quality of care, and ensure the efficient delivery of care. Within an ACO, a physician’s primary ethical and professional obligation is the well-being and safety of the patient.”

I encourage all to read CMA President Dr. James Hinsdale’s letter to Dr. Don Berwick, administrator for Medicare and Medicaid Services. He puts forth CMA guiding principles for ACOs that were adopted by a consensus of the CMA House of Delegates. CMA remains our strongest advocate representing physicians throughout California, including those working as solo practitioners, in small group practices, large medical groups, and integrated health organizations.

Joseph Andresen, MD is the editor of The Department The Bulletin. He is board certified in of Health and Human anesthesiology and is currently practicing in the Santa Clara valley area.

Services, Centers for 6 | THE BULLETIN | MAY / JUNE 2011

Medicare and Medicaid Services released the following that are included for your review: 1. Medicare Fact Sheet: Improving the Quality of Care for Medicare Patients: Accountable Care Organizations 2. Medicare Fact Sheet: What Providers Need to Know; Accountable Care Organizations 3. Medicare Fact Sheet: Summary of proposed rule provisions for Accountable Care Organizations under the Medicare Shared Savings Program 4. Federal agencies address legal issues of Accountable Care Organizations. Here CMS and the Office of Inspector General (OIG) are proposing waiving the physician self-referral law (Section 1877(a)), the Federal anti-kickback statute (Section 1128B) and civil monetary penalties law (Section 1128A) in three circumstances related to ACO operations and shared savings.

Finally, Dr. John Jameson, Monterey County Medical Society’s outgoing president, shares a personal story of his travels to the base of K2, the second highest mountain in the world, located in northern Pakistan.

His experience is particularly insightful and relevant, in view of recent current events.

Law OямГces of

Michael J. KHOURI Michael J. Khouri

CRIMINAL DEFENSE

ATTORNEY AT LAW

FORMER DEPUTY DISTRICT ATTORNEY OVER 29 YEARS EXPERIENCE ADMITTED IN ALL CALIFORNIA STATE AND FEDERAL COURTS

PROFESSIONAL BOARD DISCIPLINE DEFENSE MEDI-CARE AND MEDI-CAL AUDIT AND FRAUD DEFENSE

OFFICE: (949) 336-2433 CELL: (949) 680-6332 4040 BARRANCA PARKWAY SUITE 200 IRVINE, CALIFORNIA 92604 www.khourilaw.com w w w.Law yer- Medicare.com MAY / JUNE 2011 | THE BULLETIN | 7

MESSAGE FROM THE MCMS PRESIDENT

JOHN T. JAMESON, MD President, Monterey County Medical Society

A Trip Up The Mountain...

Or How I Just Missed Bin Laden

By John T. Jameson, MD President, Monterey County Medical Society Since this is my last column, but there’s little going on of immediate import in the world of medicine, either nationally or on the state level, I will regale you with a story of one of my personal adventures. Truth can be stranger than fiction, they say, and this one may be an example.

In 2006, after a stint as chief of staff at Natividad Medical Center, I decided to reward myself with a trip to the Himalayas. I received a catalog from SnowLion Expeditions that detailed a number of Asian trips, but the one that really resonated with me was a trek to the base of K2, in the Karakoram Mountains of northern Pakistan. Now, it’s only the second highest mountain in the world; but, whereas the fatality rate on Everest is only 1 per 20 successful ascents, for K2, the equivalent ratio is 1 death per 4 summits – somewhat worse odds than playing Russian roulette. So clearly, Everest is for wusses, and there was no point in seeing it! And, I figured I was still young enough to make the trip.

My wife wasn’t crazy about my plan, saying “there are bad guys there!” I reminded her that there are bad guys in East Salinas, and sensed it was probably about like going to Germany in 1938. There was no talking me out of it, and off I went in July.

Our group traveled by van up the Karakoram Highway, along the mighty, menacing Indus River, to the resort town of Skardu, thence by jeep over treacherous gravel roads John T. Jameson, MD, is the 2010-2011 President of the Monterey County Medical Society. He is board certified in pathology and is currently practicing at Natividad Medical Center.

8 | THE BULLETIN | MAY / JUNE 2011

here to the hamlet of Askole, where we began our trek. For days, we ier, hiked along the Baltoro Glacier, he reputed to be the longest in the ng world. I had my first sighting ed of K2 on July 29, and we hiked bto its base on the 31st, climbing up 200-or-so feet to seee the monuments to many off the climbers who have died there.

The hardest part was yet to come. However, at one in the morning on August 2, when we were to begin our traverse of the 18,500 foot Gondogoro La, a mountain pass back to civilization, I came down with an intestinal virus. But, it was either going over the pass or wn hiking the 65 miles back down the Baltoro Glacier without my group, so I gritted my teeth and moved forward. Nonetheless, as dawn broke and I saw the route, my heart quailed, and I thought, “If only Superman would swoop down and carry me over!” I realized I had to squelch that fantasy and concentrate on putting one foot in front of the other.

It took me nine hours to ascend the thousand or so feet, stopping periodically to relieve myself. I had calculated with my oxygenstarved brain that I needed to make a minimum of five vertical feet per minute, and it turned out I did six. We descended the other side after a last view of K2, using fi xed ropes to ease our way. But the ordeal was not quite over. At one point, I lost my footing and dangled from a rope by my hands. My rock climbing instincts took over and I pushed myself away from the

rock face with my feet. The guide just below me pointed out where there were useful steps carved in the ice, which I duly descended. Later, he told me that he thought I was going to be his first fatality, because most people would have tried to push away from the rock with one hand and lose their grip with the other, which would have resulted in a tumble of hundreds of feet.

Our plane out of Islamabad on August 13 was late, and I missed my connection in Heathrow. All this on the very day that people in Pakistan were arrested for scheming to blow up airliners flying out of Heathrow to the United States! The British Airways clerk advised me to get whatever flight out I could, as soon as possible; so off I went to New York, while my lug-

gage went to San Francisco.

Not surprisingly, at my arrival at JFK at 1:00 a.m., the customs people found my circumstances rather peculiar (no luggage, from Pakistan on this day of all days), and asked me about my military background (Special Forces), weapons experience (various deadly automatic weapons), etc. Fortunately, I thought to direct them to the website of SnowLion Expeditions, where they could view the summary of the K2 trek, and decide I was legit after all.

When I got back home, my wife told me that about the time I left K2, a team of Russian climbers was simply blown off the top by high winds. But here’s the real zinger: on my way to and from the mountain, our van had passed through Abbottabad; and while before the trip I guessed that I might have been within about 100 miles of bin Laden, it never occurred to me that it could have been less than one. I had gone halfway around the world to within 12,000 feet of the top of one of the most dangerous mountains and, unknowingly, within 5,000 feet of one of the world’s most dangerous men!

Dr. Jameson climbed to the base of K2, the second highest mountain in the world, located in northern Pakistan.

MCMS Annual Installation Dinner Tuesday, June 28, 2011 6:00 pm Social 7:00 pm Dinner & Program Monterey Beach Hotel Installation: James Ramseur, MD, MCMS President 2011-12 Honoring: John Jameson, MD, MCMS President 2010-11

Call Sharon Jensen at MCMS to reserve your seat!

831/455-1008 MAY / JUNE 2011 | THE BULLETIN | 9

JAMES G. HINSDALE, MD President, California Medical Association

Accountable Care Organizations Regulations Released

By James G. Hinsdale, MD CMA President On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS) issued its long awaited proposed regulations on the Medicare Shared Savings/Accountable Care Organizations (ACOs) program, which was authorized by the Affordable Care Act (ACA). The Medicare ACO program is a voluntary program.

The CMA has acted swift ly to educate our members regarding ACOs and other new delivery models that are being incentivized, in part, by the ACA. Now that the regulations have been issued, CMA is not only developing material for members to help them understand what is in the regulations, but also working to shape the regulations so that ACOs are physician-led, patient-centric, and ensure voluntary participation from physicians, including independent physicians, under the California Medical Association’s principles for ACOs. To view the principles go to cal.md/acoprinciples.

These proposed regulations are not final.

CMS Administrator Don Berwick, MD, has emphasized the Administration’s interest in our comments to help CMS shape the regulations.

CMS and the Office of the Inspector General (OIG) also issued a joint solicitation of comments on proposed waivers for Medicare ACOs from the self-referral, anti-kickback, and civil monetary penalties statutes. The Federal Trade Commission (FTC) and the Department of Justice (DOJ) issued a proposed policy statement on antitrust and ACOs, and the Internal Revenue Service (IRS) issued a notice pertaining to tax-exempt entities. All these agencies James G. Hinsdale, MD, is the current president of the California Medical Association. He is a trauma surgeon currently practicing in the San Jose area.

10 | THE BULLETIN | MAY / JUNE 2011

are providing opportunities for the public to comment. The CMA and the Board of Trustee’s Technical Advisory Committee on PhysicianHospital Alignments are reviewing the hundreds of pages of documents in-depth and will be working on developing comments based upon the CMA House of Delegates (HOD) adopted ACO principles. The CMS documents can be viewed at: • CMS proposed rule on ACOs: http:// www.gpo.gov/fdsys/pkg/FR-2011-0407/pdf/2011-7880.pdf • CMS/OIG notice on waivers for ACOs from self-referral, anti-kickback, and civil monetary penalties laws: http:// www.gpo.gov/fdsys/pkg/FR-2011-0407/pdf/2011-7884.pdf • FTC/ DOJ notice on antitrust enforcement policy and ACOs: http://www.ftc.gov/os/ fedreg/2011/03/110331acofrn.pdf • IRS notice on ACO participation by tax-exempt organizations: http:// www.irs.gov/pub/irs-drop/n-11-20.pdf

•

OVERVIEW OF ACO REGULATIONS To help you understand your rights and options and to help shape the final regulations, CMA is developing a detailed and thorough analysis of the ACO regulations. In the meantime, to help you grasp the scope and tenor of the proposed regulations, below is a general overview of some of the key provisions.

• Summary of ACO model. The ACO concept couples payment and delivery system reform. ACOs are paid through a shared savings payment approach. ACOs allow physicians to be jointly rewarded for the efficiencies they achieve in both the Medicare Physician Part B and the Hospital Part A programs. Physicians in ACOs will continue to bill Medicare under the traditional fee-for-service program. If

•

an ACO reports on quality measures, among other things, and achieves savings by meeting a cost benchmark, Medicare will share 50-60% of the cost savings with the ACO. ACOs do not have to involve a hospital and may be physician-led and comprised of physicians only. CMA fought very hard to maintain such physician autonomy. ACOs can be primary care or multi-specialty medical groups, or they can be IPAs or other networks of individual physician practices, all with or without integration with hospitals.

In a controversial move, the regulations require ACOs to be responsible for “downside” financial risk. “CMS is proposing to implement both a one-sided risk model (sharing of savings only for the first two years and sharing of savings and losses in the third year) and a two-sided risk model (sharing of savings and losses for all three years), allowing the ACO to opt for one or the other models.”

Under the first, “one-sided” risk model, an ACO that creates a savings of at least 2% would get 50% of the money above that threshold, but it would have no penalty if it spent more in the first and second year. Under the “two-sided” model, an ACO could receive 60% of the money above the threshold, but also would be penalized if it led to higher costs. By the third year of the program, all ACOs would become responsible for expenditures above the benchmark.

While beneficiaries will continue to have the ability to choose any physician in the Medicare FFS program, they may be assigned to an ACO. Beneficiaries who choose a primary care physician

•

•

•

who participates in an ACO will be “assigned” to that ACO. In addition, CMS is “proposing to assign beneficiaries for purposes of the Shared Savings Program to an ACO if they receive a plurality of their primary care services from primary care physicians within that ACO.” However, if a beneficiary received the intensity of their primary care services from a physician outside the ACO, the beneficiary will be retroactively “unassigned” to the ACO for purposes of calculating shared savings.

Beneficiaries will not be assigned to more than one ACO and will not receive advance notice of their ACO assignment. However, providers participating in ACOs will be required to post signs in their facilities indicating their participation in the program and to make available standardized written information to Medicare fee-for-service beneficiaries whom they serve. Additionally, all Medicare patients treated by participating providers must receive a standardized written notice of the provider’s participation in the program and a data use opt-out form.

An ACO must have at least 5,000 beneficiaries. If an ACO accepted into the program falls short of the 5,000 requirement, it will be placed on a corrective action plan.

The ACO governing body must include some Medicare beneficiaries and representation from all ACO participants and the governing body cannot be controlled by

•

non-ACO participants. According to CMS, ACOs “will be required to demonstrate a partnership with Medicare FFS beneficiaries by having representation by a Medicare beneficiary serviced by the ACO, in the ACO governing body.” CMS requires representation from all ACO participants in order to ensure all ACO participants are provided “an appropriate proportionate control over the ACO’s decision-making process.” “In order to be eligible for participation in the Shared Savings Program, the ACO participants must have at least 75% control of the ACO’s governing body.”

CMS will set spending benchmarks based on Medicare expenditure data. CMS proposes to establish an individualized benchmark for each ACO based on three years of previous data. Whether an ACO will be eligible to receive shared savings, and how much, depends on a series of complex calculations that vary depending on the ACO’s size and whether the ACO is using a one-sided or two-sided model. Most important to California physicians, the benchmark will then be risk-adjusted for patients’ socioeconomic status and health status according to the Medicare Advantage methodology. The proposed geographic cost adjustments may not be adequate. To account for increases in costs, the benchmark will be further adjusted to the national health care spending growth rate instead of the local spending growth rate. Generally, the national growth

•

•

•

•

rate exceeds the California spending growth rates.

To be eligible to receive shared savings, the ACO must also meet certain quality standards. There are five standard measures for quality or areas. These include patient care giver experience, care coordination, patient safety, preventive health, and at risk population/frail elderly health. CMS will designate scoring and measurement concepts. “Each of the [five] domains is equally weighted in determining an ACO’s overall quality performance score, regardless of whether the ACO is in Track 1 or Track 2.” ACOs will also be required to report on 65 quality measures that are consistent with the current Medicare Physician’s Quality Reporting Initiative and the Meaningful Use standards. The measures are listed on pages 174 to 194 of the proposed regulations.

ACOs must get approval for any changes in ACO participants (i.e., providers) during the three-year contract period.

Primary care providers may only participate in one ACO. However, a hospital can participate in more than one ACO, as can non-primary care medical and surgical providers.

ACOs must develop policies and programs to improve quality and improve patient care. An ACO, for instance, must develop a process to promote evidence-based medicine, patient engagement, and coordination of care. ACOs must have a patient

Continued on page 12

MAY / JUNE 2011 | THE BULLETIN | 11

Accountable Care Organizations Regulations Released, from page 11

•

•

•

•

•

•

survey tool in place. ACOs must have a process for evaluating the health needs of the population it serves.

ACOs must have systems to identify high risk beneficiaries and develop individual care plans for target populations.

At least 50% of an ACO’s primary care physicians must be meaningful EHR users as defined by the HITECH Act and subsequent Medicare regulations.

ACOs must meet significant public reporting requirements in a standardized format.

CMS may monitor the ACO to ensure they are not avoiding atrisk beneficiaries or distributing unapproved marketing materials (among other things). CMS must approve, for instance, any marketing materials or other communications promoting the ACO. An ACO’s shared savings agreement with CMS can be terminated on various grounds (e.g., failure to report quality standards or failure to meet quality thresholds and avoidance of at-risk beneficiaries).

There are various decisions which are not subject to appeal by an ACO if it is terminated from the program

by CMS. The regulators’ policy statement on antitrust laws provides some guidance on how they intend to regulate ACOs. ACOs with two or more participants who have a combined share of 30% or less for each common service in a defined geographic area will be declared to be in a “safety zone.” Those in the zone are “highly unlikely to raise significant competitive concerns and the antitrust agencies will not challenge” them absent “extraordinary circumstances.” The ACOs in this safety zone have no obligation to contact the Federal Trade Commission (FTC) or Department of Justice (DOJ). An ACO applicant with a share of 50% or more will need to obtain a letter from either the DOJ or the FTC saying the agency does not intend to challenge or recommend a challenge of the ACO. If the DOJ or FTC says it plans to do so, the ACO won’t be eligible for the Medicare program. The regulators

12 | THE BULLETIN | MAY / JUNE 2011

•

will provide an expedited, 90-day review of requests from ACOs that are above the 50% standard. For ACOs between 50% and 30%, a review won’t be required. Such ACOs, however, can seek a review from either DOJ or FTC, and it will still be completed within the expedited 90-day window.

In their joint notice, CMS and the OIG propose waivers of the civil monetary penalty, anti-kickback, and self-referral laws. It appears that for the self-referral and anti-kickback statutes, the waiver applies only to distributions of shared savings (not any other financial relationships).

GENERAL OBSERVATION ON ACO REGULATIONS While the regulations provide some helpful guidance on governance issues that may help prevent the control of ACOs by lay entities, it appears that physicians are not likely to rush to create new accountable care organizations (ACOs) under the proposed regulations issued by CMS. The 429-page CMS proposal imposes more micro-management-rules over ACOs than many expected and requires downside financial risk that was not expected in the shared savings program. The proposed regulations also fail to provide up-front flexibility and resources to help solo and small practices join or create ACOs (although there is some indication that CMS will be looking to fund solosmall group practices through the Center for Medicare and Medicaid Innovation).

CMA’S PROACTIVE ASSISTANCE FOR PHYSICIAN MEMBERS CMA’s overarching goal is to provide the best possible information to help physicians make individual decisions about the best practice arrangement for their professional situation. Some physicians will decide to join ACOs. CMA will provide information to help those physicians negotiate optimal arrangements and change the regulations so that they are optimal for those who choose to participate.

Other physicians will choose to form their own non-ACO organizations. CMA will provide information, tools, and models to help physicians establish such organizations.

Strategies for Independent Physicians: To assist independent physicians in navigating these uncharted reform waters, the CMA is working with county medical societies and associations to schedule a series of conferences

called “Strategies for Independent Physicians to Collaborate and Succeed in the Era of Reform.” The conferences will provide information on the various business models that can help physicians pool their talents to effectively compete in the new health care marketplace.

Topics also will include ways to provide improved quality of care through clinical integration, and whether it is feasible to form physician-led networks, including ACOs. At each conference, a comprehensive resource manual will be provided. Upcoming conferences will be posted at http://www.cmanet.org/events and announced in CMA Alert.

Innovation Center: CMA Assistance with the CMS Center for Innovation: CMS indicated in its proposed ACO regulations that the newly-formed Center for Medicare and Medicaid Innovation (“The Innovation Center” or “IC”) will strive to assist small physician practices develop innovative practice models. The ACA provided $12 billion in funding to the IC to fund such programs. CMA will be helping physicians obtain funding and approval from the Innovation Center.

Webinars: CMA has launched a series of webinars on Accountable Care Organizations, other payment models, and the health care reform law in general, to help familiarize physicians with the new law and educate physicians about its impact on their practices. Upcoming webinars will be posted at http://www.cmanet. org/events and announced in CMA Alert.

Archived Webinars: If you missed any of our recent webinars, they are available for ondemand viewing at the CMA website. Go to http://www.cmanet.org/resource-library and click on “On-Demand Webinars.”

ACO/Payment Model Issue Briefs: CMA has prepared a series of issue briefs on the Accountable Care Organizations and Medical Homes which can be found in CMA’s online resource library at http://www.cmanet.org/resource-library. Search “Federal Health Reform Issue Brief.”

CMA GOAL As your organization, CMA’s goal is to help you take charge of your own destiny in these challenging and changing times, particularly related to the health reform legislation and the regulatory changes it is generating. We want to ensure that medical decisions remain in your hands so that you can serve your patients.

Why choose between national resources and local clout?

In California, The Doctors Company protects its members with both.

With nearly 55,000 member physicians nationwide, we constantly monitor emerging trends and quickly respond with innovative solutions, like incorporating coverage for privacy breach and Medicare reviews into our core medical liability coverage.

Our over 20,000 California members also benefit from significant local clout provided by long-standing relationships with the state’s leading attorneys and expert witnesses, plus litigation training tailored to California’s legal environment.

This uncompromising approach, combined with our Tribute® Plan that has already earmarked over $106 million to California physicians, has made us the leading national insurer of physician and surgeon medical liability.

To learn more, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293, or visit us at www.doctorsagency.com.

We relentlessly defend, protect, and reward the practice of good medicine.

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

A3209_Bulletin_SantaClara_Regional.indd 1

MAY / JUNE 2011 | THE BULLETIN | 13 4/4/2011 12:14:58 PM

PUBLIC HEALTH NEWS

Prevention & Treatment of STDs: How You Can Help

By Santa Clara County Public Health Department There are over 19 million cases of sexually transmitted diseases (STDs) that occur annually in the United States. Most of these infections are asymptomatic and cannot be correctly managed without appropriate diagnosis and treatment. Left untreated, even asymptomatic infections can cause serious health problems ranging from infertility to increased risk of HIV infection.

Diagnosis and treatment can improve women’s reproductive health; without treatment, 10-20% of chlamydia or gonorrhea infections in women may lead to pelvic inflammatory disease (PID). The Centers for Disease Control and Prevention (CDC) estimates about 24,000 women become infertile in the United States each year due to untreated chlamydia and gonorrhea.

Diagnosis and treatment can also reduce infant morbidity and mortality by preventing neonatal HIV, herpes simplex virus, congenital syphilis, gonococcal, and chlamydial infections.

STDs are associated with a 2-5 fold increased risk of acquiring HIV infection—appropriate diagnosis, treatment, and counseling may reduce HIV transmission.

STDs incur substantial costs to the U.S. health care system; the estimated direct medical costs of treating STDs and their consequences are 16.4 billion dollars per year.

You play a critical role in preventing and treating STDs. As health care providers, you can help reduce STD rates by integrating the following prevention and treatment strategies into your routine care: • Talk to your patients about

preexposure vaccinations such as human papillomavirus, and Hepatitis A and B. • Conduct a sexual history and STD risk assessment with your patients.

• Provide or refer your patients to riskreduction counseling.

• Talk to your patients about testing.

• Assess your patients’ risks and test accordingly.

• Provide or refer partner of patient for partner services.

• Report STD and HIV cases (go to www.sccphd.org to the Health Providers tab for an updated Confidential Morbidity Report (CMR) form).

Did you know that our local Youth Risk Behavior Data (2010) found that 79% of adolescents reported changing their sexual behaviors after having received STD prevention and education information from their health care provider?

STDs are not just a problem afflicting the young population. Recent statistics from the CDC have shown that the number of new STD infections is actually growing faster in individuals over 50 than in people 40 years and under.

Elderly are usually overlooked in many STD studies, and are less likely to get screened for STDs than their younger counterparts.

1 in 2 sexually active young people will get an STD by age 25— most will not know it!

14 | THE BULLETIN | MAY / JUNE 2011

SANTA CLARA COUNTY DATA In Santa Clara County – as is the case in California and across the U.S. – more chlamydia is reported than any other infectious disease.

• The rate of reported chlamydia infections has risen slowly over the last 10 years.

• Women between the ages of 15 and

24 years are most likely to have chlamydia infection.

In Santa Clara County, gonorrhea rates increased between 2009 and 2010.

• Gonorrhea rates in 2009 were highest among 20- to 24-year-olds, and 25- to 29-year-olds.

• Gonorrhea rates among AfricanAmerican females (61.6/100,000 population) were the highest, followed by African-American males (53.6/100,000 population), and significantly higher than the population as a whole (females 27.3/100,000 population; males 33.7/100,000 population).

In the past 10 years, rates of primary and secondary syphilis have increased dramatically, from a rate of 0.1/100,000 population in 2000 to a rate of 4.6/100,000 population in 2010.

• More cases of primary and secondary syphilis were reported in 2010 (n= 85) than have been reported since 1988 (n= 102).

• The majority of the cases are among Men Having Sex with Men (MSM).

• Over a third of the MSM cases are coinfected with HIV. Dr. Marty Fenstersheib, Santa Clara County Health Officer, is concerned because “Many people do not get tested for sexually transmitted diseases because they do not have

symptoms. Private doctor’s offices are where most STD cases are discovered. We are asking you to offer education to all patients and to offer screening based on risk. This, of course, depends on obtaining a good sexual history.”

RESOURCES 2010 STD Treatment Guidelines Updated 2010 CDC STD Treatment Guidelines are available at http://www.cdc.gov/ std/treatment/2010/. The updated recommendations advise physicians and other health care providers about the most effective methods for diagnostic evaluation, the most appropriate treatment regimens and prevention, and vaccination strategies for STDs.

Taking a Sexual History A sexual history is important for identifying those at risk for STDs and other conditions.

A sexual history: • Helps to guide risk-reduction counseling and to identify indicated STD screening tests.

• Needs to be taken during a patient’s initial visit, during routine preventive exams, and when you see signs of STDs. • Can be taken by the clinician as part of the history and physical, or done by the patient as a self-administered questionnaire.

Resources for talking with your patients about STDs can be found at:

http://www.itsyoursexlife.com/gyt/providers/talking-about-testing.

A Guide to Sexual History Talking with Men who have Sex with Men can be found at: http://www.stdhivtraining.org/resource. php?id=4&ret=resource_search.

STD/HIV Promotion and Education Materials Get free, downloadable and locally-developed promotional and educational materials.

Call 510/625-6000 or go to www.stdhivtraining.org/swap.

The Santa Clara County Public Health Department is here to help, for additional information, please contact us at 408/792-5030 or at www.sccphd.org.

“Many will not seek testing because of lack of information, stigma, cost, and other barriers associated with testing.”

MAY / JUNE 2011 | THE BULLETIN | 15

October 29, 2010 Don Berwick, MD Administrator Medicaid Services Centers for Medicare and 7500 Security Boulevard Baltimore, MD 21244 Dear Doctor Berwick:

ns physicians in solo and n membership, which spa cia ysi ph its and ion iat systems, we are a Medical Assoc and integrated health care s up gro al On behalf of the Californi dic me ge lar in by the Patient ysicians practicing ganizations as authorized Or re Ca small group practice to ph ble nta cou Ac of entire House of the implementation pted by consensus by our ado re we s submitting principles for ple nci pri ese nting regulations Care Act (ACA). Th ples as you draft impleme nci pri ng idi gu Protection and Affordable se the er . We urge you to consid other ACO programs being Delegates earlier this month Savings Program and the d are Sh ) CO (A n tio iza Organ for the Accountable Care Innovation Center.

S CM the contemplated by S RE OR GA NI ZA TI ON AC CO UN TA BL E CA R FO ES PL CI IN PR CM A GU ID IN G increase access to care, Organization (ACO) is to re Ca ble nta cou Ac an of a physician’s primary – The goal of care. Within an ACO, ry 1. Gu idi ng Pr inc ipl e ive del ent ici eff the e and ensure patient. improve the quality of car ll-being and safety of the we the is on me nt of ati lig ob nal en co ur ag e an en vir on d ethical and professio an d -le an ici ys ph a ph ys ici an ’s – AC Os mu st be an -le d to en su re tha t ici ys ph 2. AC O Go ve rn an ce be st mu Os na l me dic al ph ys ici an s. AC bu t rat he r on pr of es sio , sts ere co lla bo rat ion am on g int ial erc mm no t ba se d on co me dic al de cis ion s are tie nts ’ int ere sts fir st. nally structured and jud gm en t tha t pu ts pa ns. ACOs must be operatio cia ysi ph by de ma be uld decisions are made by a. Medical decisions sho ns to ensure that medical cia ysi ph of er mb nu te ria cians are the medical governed by an approp ients’ interests first. Physi pat ce pla and s) itie ent gnosis and treatment physicians (rather than lay experience to provide dia and , ion cat edu , ng ini tra by d trolled entity. The professionals best qualifie physician or physician-con the by de ma be st mu s on qualified providers of patients. Clinical decisi cians, hospitals, and other ysi ph en we bet s ort eff e orativ ns control medical CMA supports true collab ements ensure that physicia ang arr se tho of ce nan ver the go iteria” – see for Integrated Entities Cr to form ACOs, as long as y rit tho Au ng aki n-M sio A’s “Deci issues consistent with CM sionals. Any elected by the ACO profes is attached. t tha ors ect dir of ard t contracts verned by a bo , Medical Group, etc.] tha A) (IP b. The ACO should be go ion iat soc As n cia ependent Physi governed by an elected physician-entity [e.g., Ind physician-controlled and be uld sho O AC the of, t with, or is otherwise par O operates and in the board of directors. the state in which the AC in ed ens lic be uld sho s leader c. The ACO’s physician area. arate, and ine in the ACO’s service dic me of ce active practi of the ACO should be sep ard bo g nin ver go the O, t of an AC d. Where a hospital is par spital governing board. ho the m independent fro sh ou ld be vo lun tar y. rti cip ati on in an AC O pa nt tie assignment to an ACO by pa d an an ici 3. Ph ys y rather than a mandatory tar lun vo be uld sho O AC Patient participation in an cians under a single tax Medicare. that bills on behalf of physi ion zat ani org an g din clu (in n affirmative consent of Any physician organization ACO must obtain the writte an s ate cre t tha ity ent er an ACO as a condition of any oth identification number) or uld not be required to join sho ns cia ysi Ph O. AC te in the tal medical staff. being admitted to a hospi each physician to participa or er pay e vat pri a or l, , Medi-Ca contracting with Medicare

16 | THE 16 THE BULLETIN TH BU B UL LL LET ETIN IN | MA MAY Y / JUNE JUNE 2 2011 011

4 . Th e sa vin gs an d rev en ue s of an AC O sh ou ld be ret ain ed fo r pa tie dis tri bu ted to the AC nt ca re se rv ice s an d O pr ov ide r pa rti cip an ts.

5. Fl ex ibi lit y in pa tie nt ref err al an d an tit ru st law s. The federal and referral laws and the federa state anti-kickback and sel l Civil Monetary Penaltie fs (CMP) statute (which pro physicians to reduce or lim hibits payments by hospital it care) should be sufficien s to tly flexible to allow physicia hospitals in forming ACOs ns to collaborate with without being employed by the hospitals or ACOs. Th for physicians in small- and is is particularly important medium-sized practices wh o may want to remain ind integrate and collaborate ependent, but otherwise with other physicians (i.e ., so-called virtual integrati in the ACO. The ACA exp on) for purposes of partic licitly authorizes the Secre ipating tary to waive requirement Penalties statute, the Anti-K s under the Civil Monetary ickback statute, and the Eth ics in Patient Referrals (St should establish a full ran ark) law. The Secretary ge of waivers and safe har bors that will enable indepe existing or new organizat nd ent ional structures to participa physicians to use te as ACOs. In addition, the the Federal Trade Commiss Secretary should work wi ion to provide explicit exc th eptions to the antitrust law Physicians cannot comple s for ACO participants. tely transform their practi ces only for their Medicare enforcement could preven patients, and antitrust t them from creating clinic al integration structures inv patients. These waivers and olving their privately insure safe harbors should be all d owed where appropriate to initial agreement between exist beyond the end of the the ACO and CMS so tha t any new organizational struct participate in the program ures that are created to do not suddenly become ille gal simply because the sha pilot program does not con red savings program or the tinue.

6. Ad dit ion al res ou rce s sh ou ld be pr ov ide d up -fr on t in or de r to en CMS’s Center for Medicare co ur ag e AC O de ve lop and Medicaid Innovation me nt.

(CMI) should provide gra finance up-front costs of nts to physicians in order creating an ACO. ACO inc to entives must be aligned wi group’s risks (e.g., start-u th the physician or physicia p costs, systems investme n nts, culture changes, and Developing the capacity to financial uncertainty). form an ACO for physicia ns practicing in rural com practices requires time and munities and solo-small gro resources and the outcome up is unknown. Providing add up-front costs will encourag itional resources to cover e the development of AC the Os , sin potential savings at the bac ce the “shared savings” mo k-end, which may discourag del only provides for e the creation of ACOs (partic independent physicians and ularly among in rural communities).

7. Th e AC O sp en din g be nc hm ark sh ou ld be ad jus ted fo r dif fer en ce co sts an d ris k ad jus ted s in ge og rap hic pr ac tic fo r ind ivi du al pa tie nt e ris k fac tor s. a. The ACO spending ben chmark, which will be bas ed on historical spending service area and negotiate patterns in the ACO’s d between Medicare and the ACO, must be risk-adju incentivize physicians wi sted in order to th sicker patients to partic ipate in ACOs and incent treat sicker patients, such ivize ACOs to accept and as the chronically ill. b. The ACO benchmark should also be risk-adjuste d for the socioeconomic and patients that are assigned health status of the to each ACO, such as inc ome/poverty level, insura Medicare enrollment, rac nce status prior to e and ethnicity, and health status. Studies show that factors have experienced patients with these barriers to care and are mo re costly and difficult to tre Medicare eligibility. at once they reach c. The ACO benchmark must be adjusted for geogra phic differences in practice office expenses related to costs, such as physician rent, wages paid to office staff and nurses, hospital (i.e., hospital wage index) op erating cost factors , and physician HIT costs. d. The ACO benchmark should include a reasonabl e spending growth rate bas physician and hospital pra ed on the growth in ctice expenses as well as the patient socioeconomic e. In addition to the sha and health status factors. red savings earned by AC Os, ACOs that spend less Medicare beneficiary sho than the national average uld be provided an additio per nal bonus payment. Many and physician groups hav California physicians e worked hard over the yea rs to establish systems and pra costs below the national per ctices to lower their Medicare beneficiary exp enditures. Accordingly, the be able to achieve significa se practices may not nt additional shared saving s to incentivize them to cre bonus payment for spend ate or join ACOs. A ing below the national ave rage would encourage the ACOs and continue to use se practices to create resources appropriately and efficiently. This is an ext principle to incent the for remely important mation of Medicare ACOs in California. If Californi are essentially ACOs now a me dical groups – who – are only held to their loc al benchmark, they will no participate in the program. t be incented to To ensure robust participa tion in California, we urg that allow ACOs to meet e CMS to adopt models the national benchmarks.

MAY MA Y / JUNE 2011 | TH THE T HE BULLETIN BULL BU UL LL LE ET TIIN N|1 17 7

y mu st be lis he d by the Se cre tar tab es be to ed uir req must meet the an ce sta nd ard s quality reporting program O AC e Th 8 . Th e qu ali ty pe rfo rm ty. ali qu cian specialtypo lic y reg ard ing nationally-accepted, physi of use the co ns ist en t wi th CM A ing lud inc , ing ion of a s for quality report ality consortium; the inclus qu y iet soc CMA and AMA principle lty cia spe Adeveloped by the AM appropriate attribution validated clinical measures valid quality information; lly ica e them tist sta ce du pro to ts rate quality reports and hav ccu ina eal app to sufficient number of patien ns cia ysi nt; and the right for ph ns regarding the quality methodology; risk adjustme dback provided to physicia fee and ion cat tifi no ely o be tim ty reporting. corrected. There must als CMA principles for quali ed ach att the cre tar y’ s dis cre tio n e Se s. ult w ith res pe ct to the Se measures and res s es oc pr e du al ur ed rfo rm an ce aff or de d pr oc to me et the qu ali ty pe e lur 9. An AC O mu st be fai r fo O AC an me nt wi th to ter mi na te an ag ree red-savings de ls. While the ACO sha mo sta nd ard s. t en ym pa t en fer Secretary has ow ed to us e dif ursement methodology, the mb rei ice erv 10 . AC Os sh ou ld be all r-s -fo fee are nt options and traditional Medic be given a variety of payme st mu program is limited to the Os AC ts. jec pro tion, partial O demonstration ing fee-for-service, capita lud inc ds, discretion to establish AC tho me nt me must also be employ different pay Any capitation payments s. ing sav allowed to simultaneously red sha and s, s, care management fee capitation, medical home A- se e ns rec om me nd ed by CM tio ica dif mo risk-adjusted. the ith (w d wh eth er an AC O nt Sa tis fac tio n Su rv ey pa tie nt sa tis fac tio n an 11 . Th e CA HP S Pa tie ne mi ter de to l too a rnia medical groups, ed as by the AC O law . Califo att ac he d) sh ou ld be us ed uir req ia ter cri ss isfaction with their red ne to determine patients’ sat w me ets the pa tie nt- ce nte no a rni lifo Ca in vey sur s use this health plans, and employer rd Sy ste ms are ke y t-effective tool. cos nt, rta ec tro nic He alt h Re co El d care. It is an impo an y log no ch Te eroperable to allow h In fo rm ati on information systems are int lth hea t 12 . In ter op era ble He alt tha ure ens st mu ty. Unless there . Medicare e care and report on quali nat rdi coo to the su cc es s of AC Os and ate nic mu to effectively com physicians and institutions ll not be successful. wi fin an cia l so lve nc y is interoperability, ACOs mu st me et ap pr op ria te O AC the k, ris l cia an ng to ris k- be ari ng 13 . If an AC O be ars fin or nia sta te law pe rta ini lif Ca in d he lis tab es se ly sound and can provide sta nd ard s, su ch as tho ng that ACOs are financial uri ens to l cia cru are s ard stand or ga niz ati on s. These patients. ir the to e car continuity of n of Accountable contemplate the formatio u yo as s, ple nci pri ng idi physicians eration of these basic gu ny successful models where ma has a rni lifo We appreciate your consid Ca s. del rtant, CMS er innovative delivery mo with you. But most impo es enc eri exp se tho Care Organizations and oth re sha ty care and we are eager to collaborate to provide quali patients to participate. that allow all physicians and should develop programs A contact is Elizabeth these programs. The CM of n tio nta me ple im the . Thank you. ng with you on cmanet.org; 415/310-2877 il@ cne We look forward to worki em s, ion lat Re ent deral Governm McNeil, Vice President, Fe Sincerely,

James G. Hinsdale, MD, President

FACS

18 | THE 18 THE BULLETIN TH BU B UL LL LET ETIN IN | MA MAY Y / JUNE 2011

It’s Here……Your Stimulus Money to start your

Electronic Health Record Systems

Incentive payments directly to you Medicare $44,000 Move your hardware to a

Dynamic Virtual Computer System The same computer system used by all fortune 100 companies WHY ??

Cheaper to own & maintain Faster Better performance Lower energy usage Increased security Looks like / works like your current desktop

Call ATS for free evaluation 866-207-2419 MAY / JUNE 2011 | THE BULLETIN | 19

MEDICARE FACT SHEET

What Providers Need to Know Accountable Care Organizations On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), proposed new rules under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).

ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first. Patient and provider participation in an ACO is purely voluntary.

Under the proposal, ACOs – teams of doctors, hospitals, and other health care providers working together – would coordinate and improve care for patients with original Medicare – Medicare Parts A and B. ACOs would have to meet high quality standards to ensure patients are happy with the care they receive and have better health outcomes.

And if ACOs can help save money by getting patients the right care at the right time, they can share in those savings with Medicare. As proposed, ACOs could also have to pay back Medicare for failing to provide efficient, cost-effective care. The new program would begin on January 1, 2012.

This fact sheet describes the proposals to ensure that ACOs provide high-quality care, including proposed quality measures, and a proposed method for scoring the performance of the ACO for purposes of the Medicare Shared Savings Program.

Under the proposed rule, an ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the patients they serve in original Medicare. The goal of an ACO is to deliver seamless, high-quality care for Medicare beneficiaries, instead of the fragmented care that often results from different providers receiving different, disconnected payments. The ACO would be a patient-centered organization where the patient and providers are partners in care decisions.

The Affordable Care Act specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services: • ACO professionals (i.e., physicians and hospitals meeting the statutory definition) in group practice arrangements; • Networks of individual practices of ACO professionals; • Partnerships or joint ventures arrangements between hospitals and ACO professionals, or hospitals employing ACO professionals; • Other Medicare providers and suppliers, as determined by the Secretary.

In the proposed rule, the Secretary has made clear that certain critical access hospitals are eligible to participate in the Shared Savings Program.

How Could Providers Participate?

To participate in the Shared Savings Program, providers must form 20 | THE BULLETIN | MAY / JUNE 2011

or join an Accountable Care Organization (ACO) and apply to CMS. An existing ACO will not be automatically accepted into the Shared Savings Program. If accepted, they would serve at least 5,000 Medicare patients and agree to participate in the program for three years. Medicare providers who join an ACO that participates in the program would continue to receive payment under original Medicare fee-for-service (FFS) rules.

The statute also requires each ACO to establish a governing body representing ACO providers of services, suppliers, and Medicare beneficiaries. The ACO would be responsible for monitoring and reporting of the care it delivers. The proposed rule outlines a monitoring and reporting plan that includes analyzing claims and specific financial and quality data, producing quarterly and annual aggregated reports, performing site visits, and conducting beneficiary surveys.

How Would Shared Savings Work?

Under the proposed rule, Medicare would continue to pay individual providers and suppliers for specific items and services as it currently does under the original Medicare payment systems. CMS would also develop a benchmark for each ACO against which ACO performance is measured to assess whether it qualifies to receive shared savings, or be held accountable for losses. The benchmark is an estimate of what the total Medicare fee-for-service Parts A and B expenditures for ACO beneficiaries would otherwise have been in the absence of the ACO, even if all of those services would not have been provided by providers in the ACO. The benchmark would take into account beneficiary characteristics and other factors that may affect the need for health care services.

This benchmark would be updated for each performance year within the three-year performance period.

CMS is proposing to implement both a one-sided risk model (sharing of savings only for the first two years and sharing of savings and losses in the third year) and a two-sided risk model (sharing of savings and losses for all three years), allowing the ACO to opt for one or the other models. CMS believes this approach would have the advantage of providing an entry point for organizations with less experience with risk models, such as some physician-driven organizations or smaller ACOs, to gain experience with population management before transitioning to a risk-based model, while also providing an opportunity for more experienced ACOs that are ready to share in losses to enter a sharing arrangement that provides a greater share of savings, but at the risk of repaying Medicare a portion of any losses.

CMS is also proposing to establish a minimum sharing rate that would account for normal variations in health care spending. The minimum savings rate is a percentage of the benchmark that ACO expenditure savings must exceed in order for an ACO to qualify for shared savings in any given year. Under the proposed rule, ACOs in the one-sided risk program that have smaller populations (and having more variation in expenditures) would have a larger MSR, and ACOs with larger populations (and having less variation in expenditures) have a smaller MSR. Under the two-sided approach, CMS is proposed a flat 2% minimum sharing rate.

If an ACO meets quality standards and achieves savings exceeding the minimum saving rate, the ACO would share in savings, based on the quality score of the ACO.

ACOs That Participate in the Two-Sided Risk Model Can Obtain Greater Shared Savings To qualify for shared savings, ACOs must meet certain quality and performance standards and have total per capita costs for assigned beneficiaries in the performance year to be both below the estimated updated benchmark and above the minimum savings rate. Once the ACO surpasses the minimum savings rate, it may share in savings, if it is eligible to receive shared savings based on its quality performance score.

To provide a greater incentive for ACOs to adopt the two-sided risk approach, the maximum sharing percentage is 60% for ACOs in the twosided model compared to 50% in the one-sided model. In addition, under the two-sided model, ACOs would receive shared savings for the first dollar after the minimum savings rate is achieved. In contrast, under the one-sided model, ACOs would share on savings after a 2% threshold is met, with an exemption for small ACOs in rural or underserved communities. Under both models, an ACO would be eligible for a greater portion of shared savings the higher its quality and performance score.

The proposed rule also provides a methodology for determining shared losses for ACOs in the two-sided model (or year three of the one-sided model) if the per capita cost per beneficiary were more than 2% higher than the benchmark. As with shared savings, the amount of shared losses would be based in part on the ACO’s quality performance score. Additionally, CMS is also proposing a shared loss cap of 5% of the benchmark in the first year of the Shared Savings Program, 7.5% in the second year, and 10% in the third year.

Participation in the First Program Year Allows for ACOs to Obtain the Maximum Sharing Rate if They Successfully Report Quality Measures CMS is encouraging providers to participate in the Shared Savings Program in 2012 by setting the quality performance standard to reporting only. ACOs would be eligible for the maximum sharing rate (60% for the two-sided model and 50% for the one-sided model) if the ACO generates sufficient savings and successfully reports the required quality measures. This flexibility would allow newly formed ACOs a grace period as they start up their operations and learn to work together to better coordinate patient care.

CMS has proposed to measure quality of care using nationally-recognized measures in five key domains: patient experience, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. These measures are aligned with the measures in other CMS programs such as the Electronic Health Records (EHR) and Physician Quality Reporting System (PQRS). An ACO that successfully reports the quality measures required under the Shared Savings Program would be deemed eligible for the PQRS bonus.

ACOs may not participate, however, in any other shared savings program or demonstration under the Center for Medicare and Medicaid Innovation or Independence at Home Medical Practice pilot program, to ensure that savings are not counted twice.

Existing Clinically Integrated Entities Need Not Form New Entities to Participate in the Shared Savings Program If an ACO is already comprised of a self-contained financially and clinically integrated entity that has a pre-existing board of directors or other governing body, the ACO need not form a separate governing body or create a new legal entity. The existing entity, however, must be recog-

nized under applicable State law, be capable of receiving and distributing shared savings and repaying shared losses, and meet the other ACO functions identified in the statute.

How ACOs Help Doctors Coordinate Care Health care providers have reported that an important barrier to improving care coordination is lack of information. While they may know about the services they provide to the beneficiary, they don’t know about other services provided to the beneficiary. To better treat patients and to coordinate their care, ACOs would be able to request claims information about their patient from CMS. Before doing so, ACOs must notify a beneficiary in writing that it would request the beneficiary’s claims information from CMS. ACOs must allow beneficiaries to optout of having their claims information shared with the physician and the ACO. This opting out of having claims information shared, however, does not affect the patient’s participation in the ACO or CMS’s use of the patient’s data for the purpose of assessing quality or cost measures. This notification must happen the first time the ACO cares for the beneficiary.

CMS has worked closely with agencies across the federal government to facilitate participation in the Shared Savings Program by coordinating federal fraud and abuse requirements, tax guidance, and antitrust considerations. In particular, the Federal Trade Commission and the Antitrust Division of the Department of Justice have proposed an antitrust policy statement that clarifies application of the antitrust laws to Medicare Shared Savings Program-approved ACOs that negotiate and contract with commercial payers. See: Medicare Fact Sheet: Federal agencies address legal issues regarding Accountable Care Organizations The Shared Savings Program will begin operating on January 1, 2012.

For more information, please see: www.ofr.gov/inspection.aspx?

AspxAutoDetectCookieSupport=1 .

MAY / JUNE 2011 | THE BULLETIN | 21

Class-A Medical Building!

Fantastic Location!

+HDOWK0HG5HDOW\ FRP _ /LFHQVH

(408) 217-6000 See listing below...

2,397 SF AVAILABLE

2,589 SF AVAILABLE

919 Fremont Ave, Los Altos Turn-key dental suite, fully plumbed, gorgeous, must see! 5+1 Operatories included.

14777 Los Gatos Blvd, Los Gatos Newer Class-A medical property at gateway of Los Gatos Blvd. Great visibility & location!

$3.00/SF NNN

15,215 SF AVAILABLE

80 Saratoga Ave, Santa Clara

$2.75/SF NNN

1,400-2,886 SF AVAIL.

393 Blossom Hill Road San Jose Modern Class A medical building.

Easy access to 85 and 101, and great promotional rate! $2.25/SF FULL-SERVICE!

743 S. Winchester Ave, San Jose

Corner of National Ave. and Los GatosAlmaden Rd. Excellent & clean interiors with great location near Good Samaritan Hospital.

CALL FOR PRICING $2.35 GROSS

Newer medical/retail center near Santana Row & freeways. New building, must see!

Fantastic Location near Stevens Creek & Hwy 280. Ti’s available.

1,607-1,792 SF AVAILABLE

1301 Sunnyvale-Saratoga Sunnyvale Newer ofďŹ ce/medical project on corner of Fremont and Sunnyuvale-Saratoga Rd. Divisible to 1,000 SF

4155 Moorpark Ave, San Jose Great medical location at Saratoga & Moorpark Ave. Convenient freeway access, excellent price! $2.45/SF GROSS

1,300-4,485 SF AVAILABLE 788-1,632 SF AVAILABLE 650-4,400 SF AVAILABLE

15899 Los Gatos-Almaden Rd, Los Gatos

2,500 SF AVAILABLE

800-2,500 SF AVAILABLE

1757 Blossom Hill Rd, San Jose Newer dental property, great location & signage. Ideal for pediatric dentist.

Infrastructure included.

$2.85/SF NNN

22 | THE BULLETIN | MAY / JUNE 2011

$1.95/SF NNN

$2.25/SF NNN

2,387 SF AVAILABLE

2550 Samaritan Drive, San Jose Great medical building, Class-A, steps away from Good Samaritan Hospital.

Ground oor unit, Ti dollars available. $2.55 NNN

825 Pollard Rd, Los Gatos Great medical building, steps away from El Camino Hospital. Ground oor unit, Ti dollars available. $2.40/SF GROSS

330-2,933 SF AVAILABLE

2255 South Bascom Ave Campbell Close to Pruneyard with easy access to Good Sam and O’Connor. Medical improvements to suit your needs. $2.45 MG

MEDICAL TIMES FROM THE PAST

Trephination in History

By Michael A Shea, MD Leon P. Fox Medical History Committee Primitive cranial trephining, the surgical opening of the skull performed with primitive tools and techniques, is one of the most interesting surgical practices in human history. It is thought to have originated in the Neolithic Period, seven thousand years ago. Hippocrates and Galen wrote about trephining and the practice continued throughout the Middle Ages and into the Renaissance.

Evidence has been found for this practice in Peru, Bolivia, Europe, Asia, New Zealand, and North America. The Ohlone Indians in our bay area also practiced trephining.

The operation consisted of removing a piece of skull (frontal, parietal, or occipital) from a living patient to expose the dura mater. If the dura remained intact, the patient in the pre-anesthesia, pre-antisepsis era had a fair chance of surviving the operation. The skull has relatively few sensory nerve fibers and this allowed trephining to be tolerated without anesthesia.

The procedure has been done on men, women, and children, with the majority being men. As many as two-thirds of the skulls examined reveal various degrees of new bone growth. This is considered evidence for survival. Considering the danger of severe bleeding, brain damage, and infection, survival of two-thirds of subjects suggest considerable skill and experience of the operator.

WHY IT WAS DONE The motives for ancient trephining have been the subject of speculation since the discovery of the first specimens in the nineteenth century.

Possible reasons include all of the following: to allow for the escape of evil spirits, headaches, fractures, infections, or convulsions. Another suggestion has been to acquire rondelles (discs of bone) which were used as charms or amulets.

TECHNIQUE There were three general techniques: scraping, drilling, and cutting.

The earliest skulls from the Stone Age were done long before metallurgy. The holes were made with a sharp-edge flint or knife. The practioner would go deeper and deeper until the dura was exposed. A circular or rectangular opening was the result. Some healing of new bone would occur, but unless the opening was only one centimeter or less, the hole would remain open. They would cover the wound with a shell, gourd, or even a piece of silver.

The bow drill was one of the more common methods used for trephining. It was made of a wood drill with an obsidian tip and a leather thong wrapped around it several times. The operator would place the drill tip on the head and pull the leather thong. There are some skulls that have up to five holes present.

Neurosurgery, a relatively modern specialty, seems to have its roots in an operation done seven thousand years ago.

MAY / JUNE 2011 | THE BULLETIN | 23

MEDICARE FACT SHEET

Improving the Quality of Care for Medicare Patients: Accountable Care Organizations This fact sheet describes the proposals to ensure that ACOs provide high quality care, including proposed quality measures, and a proposed method for scoring the performance of the ACO for purposes of the Shared Savings Program.

BACKGROUND The Medicare Shared Savings Program, which is to be implemented on January 1, 2012, is intended to encourage providers of services and suppliers (e.g., physicians, hospitals, and others involved in patient care) to coordinate patient care and improve communications with each other to get each beneficiary the right care at the right time, and see that the care is provided right the first time. To accomplish this, the Act allows providers to create ACOs that will be held accountable for improving the health and experience of care for individuals, improving the health of populations, and reducing the rate of growth in health care spending. Studies show that better care often costs less because coordinated care helps avoid unnecessary duplication of services and preventing medical errors.

PROPOSALS FOR ASSESSING QUALITY INCLUDED IN THE ACO PROPOSED RULE: Proposed Quality Measures: For 2012, CMS proposes to use a number of quality measures to establish the quality performance standard ACOs must meet in order to share in savings, provided they also meet the program’s cost savings requirement. These 65 measures span five quality domains: Patient Experience of Care, Care Coordination, Patient Safety, Preventive Health, and At-Risk Population/ Frail Elderly Health. The list of proposed measures is included in the appendix to this fact sheet.

CMS considered a broad array of process and outcome measures would help in assessing an ACO’s success in delivering high-quality health care at both the individual and popu24 | THE BULLETIN | MAY / JUNE 2011

lation levels. Several of the proposed quality measures align with those used in other CMS quality programs, such as the Physician Quality Reporting System, the Electronic Health Record (EHR) Incentive Program, and the Hospital Inpatient Quality Reporting Program. CMS also sought to align the proposed ACO quality measures with the National Quality Strategy and other Department of Health and Human Services priorities. CMS proposes that the measures would be reported to CMS through a combination of claims submission, data collection using a tool designed for clinical quality measure reporting, and surveys.

CMS is proposing to define the first quality performance period as beginning January 1, 2012 and ending December 31, 2012.

Proposed Quality Performance Scoring: As required by the Affordable Care Act, before an ACO can share in any savings created, it must demonstrate that it is delivering high quality care. Thus, a calculation of the quality performance standard will indicate whether an ACO has met the quality performance goals that would allow it to be considered eligible for shared savings. The proposed method for scoring the measures and determining the performance level that must be achieved to share in savings under the Shared Savings Program is described in the proposed rule.

CMS proposes that the performance on each measure will be scored on a linear points scale and roll up into five scores for each of the five domains. The percentage of points earned for each domain will be aggregated using an equal weighting method to arrive at a single percentage that will be applied to the maximum sharing rate for which the ACO is eligible.

For the first year of the Shared Savings Program, CMS proposes to set the quality performance standard at the reporting level. This means that during the first performance period, ACOs will be required to report the quality measures completely and accurately in order to share in savings. However, CMS proposes to still score quality in the first year for informa-

tional purposes and to help define the benchmarks for future program years. CMS proposes to set the quality performance standard at a higher level in subsequent years.

Proposed Incorporation of the Physician Quality Reporting System Into the Shared Savings Program: The Affordable Care Act allows CMS to incorporate the Physician Quality Reporting System reporting requirements and incentive payments into the Shared Savings Program. ACO participant providers/suppliers who are also Physician Quality Reporting System eligible professionals may earn the Physician Quality Reporting System incentive as a group practice under the Shared Savings Program, by meeting its quality performance standard.

The Shared Savings Program will begin operating on January 1, 2012.

For more information, please see: www. ofr.gov/inspection.aspx?AspxAutoDetectCook ieSupport=1

APPENDIX Proposed Quality Measures for Accountable Care Organizations for First Year of the Medicare Shared Savings Program

Patient/Caregiver Experience Domain: 1. Clinician/Group CAHPS: Getting Timely Care, Appointments, and Information 2. Clinician/Group CAHPS: How Well Your Doctors Communicate 3. Clinician/Group CAHPS: Helpful, Courteous, Respectful Office Staff 4. Clinician/Group CAHPS: Patients’ Rating of Doctor 5. Clinician/Group CAHPS: Health Promotion and Education 6. Clinician/Group CAHPS: Shared Decision Making 7. Medicare Advantage CAHPS: Health Status/Functional Status Care Coordination Domain: 8. Risk-Standardized, All Condition Readmission

9. 30-Day Post Discharge Physician Visit 10. Medication Reconciliation 11. Care Transition Measure 12. Ambulatory Sensitive Conditions Admissions: Diabetes, short-term complications 13. Ambulatory Sensitive Conditions Admissions: Uncontrolled Diabetes 14. Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease 15. Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure 16. Ambulatory Sensitive Conditions Admissions: Dehydration 17. Ambulatory Sensitive Conditions Admissions: Bacterial Pneumonia 18. Ambulatory Sensitive Conditions Admissions: Urinary Infections 19. % All Physicians Meeting Stage 1 HITECH Meaningful Use Requirements 20. % of PCPs Meeting Stage 1 HITECH Meaningful Use Requirements 21. % of PCPs Using Clinical Decision Support 22. % of PCPs Who Are Successful Electronic Prescribers Under the eRx Incentive Program 23. Patient Registry Use

Patient Safety Domain: Preventive Health Domain: 24. Health Care Acquired Conditions Composite: •Foreign Object Retained After Surgery •Air Embolism •Blood Incompatibility •Pressure Ulcer, Stages III and IV •Falls and Trauma •CatheterAssociated UTI •Manifestations of Poor Glycemic Control •Central Line Associated Blood Stream Infection (CLABSI) •Surgical Site Infection •AHRQ Patient Safety Indicator (PSI) 90 Complication/Patient Safety for Selected Indicators (composite) •Accidental puncture or laceration •Iatrogenic pneumothorax •Postoperative DVT or PE •Postoperative wound dehiscence •Decubitus ulcer •Selected infections due to medical care (PSI 07: Central Venus Catheter-related Bloodstream Infection) oPostoperative hip fracture •Postoperative sepsis 25. Health Care Acquired Conditions: CLABSI Bundle 26. Influenza Immunization 27. Pneumococcal Vaccination 28. Mammography Screening 29. Colorectal Cancer Screening 30. Cholesterol Management for Patients With Cardiovascular Conditions

31. Adult Weight Screening and Follow-up 32. Blood Pressure Measurement 33. Tobacco Use Assessment and Tobacco Cessation Intervention 34. Depression Screening

At-Risk Population – Diabetes 35. Diabetes Composite (All or Nothing Scoring): • Hemoglobin A1c Control (<8%) • Low Density Lipoprotein (<100) • Blood Pressure <140/90 • Tobacco Non-Use • Aspirin Use 36. Diabetes Mellitus: Hemoglobin A1c Control (<8%) 37. Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus 38. Diabetes Mellitus: Tobacco Non-Use 39. Diabetes Mellitus: Aspirin Use 40. Diabetes Mellitus: Hemoglobin A1c Poor Control (>9%) 41. Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus 42. Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients 43. Diabetes Mellitus: Dilated Eye Exam in Diabetic Patients 44. Diabetes Mellitus: Foot Exam At-Risk Population – Heart Failure 45. Heart Failure: Left Ventricular Function (LVF) Assessment 46. Heart Failure: Left Ventricular Function (LVF) Testing 47. Heart Failure: Weight Measurement 48. Heart Failure: Patient Education 49. Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 50. Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 51. Heart Failure: Warfarin Therapy for Patients With Atrial Fibrillation At-Risk Population – Coronary Artery Disease 52. Coronary Artery Disease (CAD) Composite: All or Nothing Scoring •Oral Antiplatelet Therapy Prescribed for Patients With CAD •Drug Therapy for Lowering LDL-Cholesterol •BetaBlocker Therapy for CAD Patients With Prior Myocardial Infarction (MI) •LDL Level <100 mg/dl •AngiotensinConverting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients With CAD and

Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) 53. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients With CAD Percentage of Patients Aged 18 Years and Older With a Diagnosis of CAD Who Were Prescribed Oral Antiplatelet Therapy.

54. Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol Percentage of Patients Aged 18 Years and Older With a Diagnosis of CAD Who Were Prescribed a Lipid-Lowering Therapy (Based on Current ACC/AHA Guidelines). The LDL-C Treatment Goal is <100 mg/dl. Persons With Established Coronary Heart Disease (CHD) Who Have a Baseline LDL-C 130 mg/dl Should be Started on a CholesterolLowering Drug Simultaneously With Therapeutic Lifestyle Changes and Control of Non-Lipid Risk Factors (National Cholesterol Education Program (NCEP).

55. Coronary Artery Disease (CAD): BetaBlocker Therapy for CAD Patients With Prior Myocardial Infarction (MI) 56. Coronary Artery Disease (CAD): LDL Level < 100 mg/dl 57. Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients With CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD)

At-Risk Population – Hypertension 58. Hypertension (HTN): Blood Pressure Control 59. Hypertension (HTN): Plan of Care At-Risk Population – Chronic Obstructive Pulmonary Disease (COPD): 60. Chronic Obstructive Pulmonary Disease (COPD) : Spirometry Evaluation 61. Chronic Obstructive Pulmonary Disease (COPD): Smoking Cessation Counseling Received 62. Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy Based on FEV1 At-Risk Population – Frail Elderly 63. Falls: Screening for Fall Risk 64. Osteoporosis Management in Women Who Had a Fracture 65. Monthly INR for Beneficiaries on Warfarin

MAY / JUNE 2011 | THE BULLETIN | 25

MEDICARE FACT SHEET

Summary of Proposed Rule Provisions Under the Medicare Shared Savings Program: Accountable Care Organizations OVERVIEW In developing the proposed rule, CMS has worked closely with agencies across the federal government to ensure a coordinated and aligned inter- and intra-agency effort to facilitate implementation of the Medicare Shared Savings Program (Shared Savings Program).

This fact sheet describes the proposals addressing the proposals for what ACOs are, how they can be created, and other general topics. CMS has posted separate fact sheets on its website to address in greater detail specific aspects of the proposed rule, such as the quality measures and performance scoring.

BACKGROUND Section 3022 of the Affordable Care Act added a new section 1899 to the Social Security Act (the Act) that requires the Secretary to establish the Shared Savings Program by January 1, 2012. This program is intended to encourage providers of services and suppliers (e.g., physicians, hospitals and others involved in patient care) to create a new type of health care entity, which the statute calls an “Accountable Care Organization (ACO),” that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populations while reducing the rate of growth in health care spending.

Studies have shown that better care often costs less, because coordinated care helps to ensure that the patient receives the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.

ACOS AND THE MEDICARE BENEFICIARY An ACO provides an opportunity for Medicare beneficiaries to receive high quality evidence-based health care that eliminates waste and reduces excessive costs through improved care delivery. However, there would be significant differences between ACOs, as described in the proposed rule, and the private managed care plans offered under the Medicare Advantage program. Beneficiaries would not enroll in a specific ACO. Instead, the proposed rule calls for Medicare to take a retrospective look at the beneficiary’s use of services to determine whether a particular ACO should be credited with improving care and reducing expenditures. This means that an ACO would have an incentive to improve the quality of care for all patients seen by its member providers and suppliers.

The proposed rule would require providers participating in an ACO to notify the beneficiary that they are participating in an ACO, and that the provider will be eligible for additional Medicare payments for improving the quality of care the beneficiary receives while reducing 26 | THE BULLETIN | MAY / JUNE 2011

overall costs or may be financially responsible to Medicare for failing to provide efficient, cost-effective care. The beneficiary may then choose to receive services from the provider or seek care from another provider that is not part of the ACO. The proposed rule would also require each provider in an ACO to notify the beneficiary that the beneficiary’s claims data may be shared with the ACO. This data sharing is intended to make it easier to coordinate the beneficiary’s care; however, the provider may not require a beneficiary to obtain services from another provider or supplier in the same ACO. The provider must give the beneficiary the opportunity to opt-out of those data sharing arrangements. For Medicare beneficiaries who choose not to opt-out of the data sharing arrangements, the proposed rule would limit data sharing to the purposes of the Shared Savings Program and would require compliance with applicable privacy rules and regulations, including the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

PROPOSED ELIGIBILITY REQUIREMENTS FOR AN ACO Under the proposed rule, an ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare fee-for-service beneficiaries they serve. The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries, instead of the fragmented care that has so often been part of fee-for-service health care. The ACO would be a patient-centered organization where the patient and providers are true partners in care decisions.

The Affordable Care Act specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services: • ACO professionals (i.e., physicians and hospitals meeting the statutory definition) in group practice arrangements; • Networks of individual practices of ACO professionals; • Partnerships or joint ventures arrangements between hospitals and ACO professionals, or hospitals employing ACO professionals; • Other Medicare providers and suppliers, as determined by the Secretary.

In the proposed rule, the Secretary has used her discretion to add certain critical access hospitals as eligible to participate in the Shared Savings Program.

The statute also requires each ACO to establish a governing body representing ACO providers of services and suppliers and Medicare beneficiaries. The proposed rule would make each ACO responsible for routine self-assessment, monitoring, and reporting of the care it delivers.

To participate in the Shared Savings Program, the proposed rule would require an ACO to complete an application providing the information requested by CMS, including how the ACO plans to deliver high quality care at lower costs for the beneficiaries it serves. As proposed, the ACO must agree to accept responsibility for at least 5,000 beneficiaries.

If the application is approved, the ACO must sign an agreement with CMS to participate in the Shared Savings Program for a period of three years. An ACO will not be automatically accepted into the Shared Savings Program.

The proposed rule outlines a monitoring plan that includes analyzing claims and specific financial and quality data as well as the quarterly and annual aggregated reports, performing site visits, and performing beneficiary surveys.

Under the proposed rule, there are a number of circumstances under which CMS may terminate the agreement with an ACO, including avoidance of at risk beneficiaries and failure to meet the quality performance standards.

TYING PAYMENT TO IMPROVED CARE AT LOWER COST Under the proposed rule, Medicare would continue to pay individual providers and suppliers for specific items and services, as it currently does under the fee-for-service payment systems. The proposed rule would require CMS to develop a benchmark for savings to be achieved by each ACO, if the ACO is to receive shared savings, or be held liable for losses. Additionally, an ACO would be accountable for meeting or exceeding the quality performance standards to be eligible to

receive any shared savings.

The proposed rule would establish quality performance measures and a methodology for linking quality and financial performance that will set a high bar on delivering coordinated and patient-centered care

by ACOs, and emphasize continuous improvement around the threepart aim of better care for individuals, better health for populations, and lower growth in expenditures. The proposed rule would require the ACO to have in place procedures and processes to promote evidencebased medicine and beneficiary engagement in their care. The proposed rule would require ACOs to report quality measures to CMS and give timely feedback to providers. CMS expects that ACOs will invest continually in the workforce and in team-based care. To assure program transparency, the proposed rule would require ACOs to publicly report certain aspects of their performance and operations.

Under the proposed rule, an ACO that meets the programâ&#x20AC;&#x2122;s quality performance standards would be eligible to receive a share of the savings it generates below a specific expenditure benchmark that would be set by CMS for each ACO. The proposed rule would also hold ACOs accountable for downside risk by requiring ACOs to repay Medicare for a portion of losses (expenditures above its benchmark). To provide an entry point for organizations with varied levels of experience with and willingness to take on risk, the proposed rule would allow an ACO to choose one of two program tracks. The first track would allow an ACO to operate on a shared savings-only track for the first two years, but would then require the ACO to assume the risk for shared losses in the third year.

The second track would allow ACOs to share in savings and risk liability for losses beginning in their first performance year, in return for a higher share of any savings it generates.

The Shared Savings Program will begin operating on January 1, 2012. For more information, please see: www.ofr.gov/inspection.aspx?AspxAutoDetec tCookieSupport=1 .

MAY / JUNE 2011 | THE BULLETIN | 27

SCCMA ALLIANCE NEWS

The Weather Is Warming up… and…

The Santa Clara County Medical Association Alliance (SCCMAA) will again be spearheading the “Not Even for a Minute” awareness poster campaign starting in May through October. We will be distributing posters and bookmarks in highly visible community areas throughout the county. We will also have static stickers available to place on car and office windows.

The Alliance would like to encourage you to become a partner in this important campaign by posting the fliers in your offices and businesses.

You can also be an active observer, if you see a child in a locked car, by alerting the business owner or public safety officials when shopping or just out and about. In the past, multiple deaths of infants and children were documented in the United States with heatstroke after being left in hot cars, trucks, or vans. Heatstroke can raise the core temperature of an individual to 104 degrees. The core temperature of a child can rise three to five times faster than an adult, due to smaller size.

Since January 2002, “Kaitlyn’s Law” has made it a citable offence to leave a child under the age of six unattended in a vehicle without supervision of someone at least 12 years of age.

Please join with us in keeping our community safe and healthy.

Contact Suzanne Jackson at 408/354-3447 or suepurr@gmail.com for more information and educational materials.

The Santa Clara County Medical Association Alliance is the philanthropic and volunteer arm of SCCMA that consists of physicians, physician spouses, students in training, and friends of medicine. To join, please visit the website at http://www.sccmaa.org. You will also find the most current updates and contact information on that site.

28 | THE BULLETIN | MAY / JUNE 2011

Accounting and Tax Services for medical practices and professionals UÊ VV Õ Ì }Ê-iÀÛ Vià UÊ V iÊ/>Ý UÊ ii« } UÊ />ÝÊ* > }ÊEÊ*Ài«>À>Ì UÊ ,-Ê,i«ÀiÃi Ì>Ì UÊ > V > Ê-Ì>Ìi i Ìà Diaz-Christians Tax Service, Inc. is a full service certified public accounting firm that offers both superior quality and value to small and midsized businesses. We provide Accounting, Income Tax, and Tax Representation Services. Our accounting services include compilations of financial statements, bookkeeping, and tax consulting.

We have been delivering personal service to closely held businesses, high net worth individuals, and trusts for over 28 years. Our approach is very hands-on; we work hard to live up to our promises to be your most trusted tax and accounting advisors. We have a passion for what we do and are focused on delivering exceptional service to meet your needs.

Let us show you how we will earn your business and develop a long lasting relationship. Call us to arrange a free consultation at a time and place that is convenient for you and your busy schedule.

UÊ ÃÕ Ì }Ê-iÀÛ Vià UÊ Õà iÃÃÊ Ì ÌÞÊ-i iVÌ UÊ -> iÃÊ/>ÝÊ-iÀÛ ViÃ

Diaz-Christians Tax Services, Inc.

Osvaldo Diaz-Christians Jr., CPA

408.554.6594

www.diaz-christians.com

dctax@diaz-christians.com

RECORD MANAGEMENT SOLUTIONS Electronic Document Management s !PPLICATION 3ERVICES

s "USINESS 0ROCESS !UTOMATION 3OLUTIONS s 3CANNING #ONVERSION 3ERVICES Record Retention Management & Confidential Destruction Secure Offsite Storage 1.800.957.5051 x137 www.srcpdeliverex.com

3AN *OSE \ 3AN &RANCISCO \ (AYWARD \ 3ACRAMENTO MAY / JUNE 2011 | THE BULLETIN | 29

MEDICARE FACT SHEET

Federal Agencies Address Legal Issues: Accountable Care Organizations Accountable Care Organizations require health care providers to work closely and share information – and share in the savings achieved through providing more efficient care. To do so, providers may need to address certain legal or tax issues. Th is fact sheet describes the proposals to ensure that ACOs provide high quality care, while not violating federal law.

The HHS Centers for Medicare & Medicaid Services (CMS) has worked closely with agencies across the federal government to ensure a coordinated and aligned inter- and intra-agency effort to address these legal and tax implications. In particular, CMS, the HHS Office of Inspector General (OIG), the Federal Trade Commission (FTC), the Antitrust Division of the Department of Justice (DOJ), and the Internal Revenue Service (IRS) have released three documents in conjunction with the proposed ACO rules on which they seek comment: 1. A joint CMS and OIG notice and solicitation of public comments on waivers in connection with sections 1899 and 1115A of the Social Security Act. 2. An IRS notice, Notice 2011-20, requesting comments regarding the need for guidance on participation by tax-exempt organizations in the Medicare Shared Savings Program through ACOs. 3. A joint FTC and DOJ proposed statement of enforcement policy regarding Accountable Care Organizations participating in the medicare Shared Savings Program (Antitrust Policy Statement).

Notice and Solicitation of Public Comments on Waivers in Connection With Sections 1899 and 1115A of the Social Security Act: Sections 1899 and 1115A give the Secretary of Health and Human Services authority to waive certain fraud and abuse laws as necessary to achieve the goals of each section, respectively. In conjunction with the issuance by CMS of the proposed rule that would establish ACOs, CMS and the Health and Human Services Office of Inspector General (OIG) issued a joint notice with comment period outlining proposals for waivers of certain federal laws – the physician self-referral law, the antikickback statute, and the civil monetary penalty law – for the Shared Savings Program. CMS and OIG have also solicited comments on further waiver design considerations for the Shared Savings Program and Innovation Center.

The Laws Addressed in the Notice: The joint CMS and OIG notice and solicitation of public comments addresses the application of the following federal laws to ACOs participating in the Shared Savings Program: • The Physician Self-Referral Law (Section 1877(a) of the Social Security Act (the “Act”)), which prohibits physicians from making referrals for Medicare “designated health services,” including hospital services, to entities with which they or their 30 | THE BULLETIN | MAY / JUNE 2011

immediate family members have a financial relationship, unless an exception applies.

• The federal anti-kickback statute (Section 1128B(b) of the Act), which provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration to induce or reward the referral of business reimbursable under any federal health care program, as defined in section 1128B of the Act. • The civil monetary penalties law (Section 1128A(b)(1) and (2) of the Act) that prohibits a hospital from making a payment, directly or indirectly, to induce a physician to reduce or limit services to Medicare and Medicaid beneficiaries under the physician’s direct care (the CMP).

What Waivers Are CMS and the OIG Proposing? The agencies have outlined proposals to waive the laws listed above in three circumstances (as further detailed in the notice and solicitation of public comments): • The distribution of program’s shared savings payments received by an ACO to or among qualified ACO participants and ACO providers/suppliers described in the notice with comment period.

• An ACO’s distribution of program’s shared savings payments to other individuals or entities for activities necessary for and directly related to the ACO’s participation in the Shared Savings Program.

• For the anti-kickback statute and CMP only, certain financial relationships that are necessary for and directly related to the ACO’s participation in the Shared Savings Program and fully comply with an exception to the physician self-referral law.

These waivers would cover shared savings earned during the agreement period with CMS and, as applicable, financial relationships existing during the agreement period. The notice and solicitation of public comment explains the conditions that would apply to the waivers in more detail.

Solicitation of Comments: CMS and OIG solicit public comments on a list of topics regarding other waiver design considerations. For example, the notice solicits comment on exercising the waiver authority to address start-up costs, continuing operating expenses, non-shared savings relationships between ACO members or outside entities, and special considerations relating to two-sided risk. CMS and OIG ask specific questions about each of these topics and others in hopes of eliciting detailed information from the public.

The notice also solicits comments on the best way to exercise the separate waiver authority under Section 1115A of the Act, which applies to the Innovation Center.

For more information on this document, please contact: Centers for Medicare & Medicaid Services: Ellen Griffith, ellen.griffith@cms.hhs. gov; 202/690-6161, Office of Inspector General, Health and Human Ser-

vices: Erin Lemire, erin.lemire@oig.hhs.gov, 202/205-9523 (O); Donald White, donald.white@oig.hhs.gov; 202/619-0088

Notice Addressing Federal Tax Issues Affecting Tax-Exempt Organizations: With the issuance of the Medicare Shared Savings Program’s proposed rule, the IRS anticipates that tax-exempt organizations (such as hospitals and other health care organizations) will be participating in the program through ACOs. Accordingly, the IRS has issued a notice, Notice 2011-20, soliciting comments as to whether its existing guidance is sufficient for those tax-exempt organizations planning to participate in the program through ACOs and, if not, what additional guidance is needed.

Tax Issues Addressed in the Notice: A tax-exempt organization must ensure that its participation in the Shared Savings Program through an ACO will not result in its net earnings inuring to the benefit of “insiders,” with respect to the organization, or in its being operated for the benefit of private parties, such as other participants in the ACO. Whether prohibited inurement or impermissible private benefit has occurred is determined on a case-by-case basis, based on all the facts and circumstances. The notice describes the proposed CMS regulation and oversight of the Shared Savings Program and identifies certain circumstances in which, in light of the CMS regulation and oversight, the IRS expects that a tax-exempt organization’s participation in the Shared Savings Program through an ACO generally would not result in prohibited inurement or impermissible private benefit to the private party ACO participants.

In addition, because Congress created the Shared Savings Program to lessen the government’s burden associated with providing Medicare benefits, the IRS expects that program payments received by a tax-exempt organization from an ACO that complies with all program requirements generally would not result in unrelated business taxable income.

Solicitation of Comments: The IRS is soliciting comments regarding whether additional guidance is needed to facilitate participation by tax-exempt organizations in the Shared Savings Program through ACOs. The IRS is also soliciting comments concerning whether guidance is needed regarding the tax implications for tax-exempt organizations participating in activities unrelated to the program, including shared savings arrangements with commercial health insurance payers, through an ACO. In particular, comments should describe the activities a tax-exempt organization might expect to participate in through an ACO, identify how such non-program activities might further exempt purposes and explain what criteria, requirements, and safeguards would ensure the furtherance of these exempt purposes.

For more information on this document, please contact: Internal Revenue Service: Michelle Eldridge, michelle.l.eldridge@ irs.gov; 202/622-4000 Department of the Treasury: Ruth Madrigal, Ruth.Madrigal@treasury.gov, 202/622-0224 Proposed Antitrust Policy Statement Regarding ACO Participation in the Medicare Shared Savings Program: The DOJ and FTC have worked together to facilitate the creation of ACOs by giving providers the clear and practical guidance they need to form innovative, integrated health care delivery systems without running afoul of the antitrust laws. Accordingly, DOJ and FTC have issued a joint Proposed Statement of Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program (“Antitrust Policy Statement”).

Antitrust Agency Review of ACOs: The proposed Antitrust Policy

Statement applies to collaborations, not including mergers, among otherwise independent providers formed after March 23, 2010, that seek to participate, or have otherwise been approved to participate, in the Medicare Shared Savings Program. DOJ and FTC will provide rule of reason treatment to an ACO if, in the commercial market, the ACO uses the same governance and leadership structure and the same clinical and administrative processes as it uses to qualify for and participate in the program.

Safety Zone: The Antitrust Policy Statement describes a safety zone for certain ACOs that participate in the Shared Savings Program. ACOs that fall within the safety zone are highly unlikely to raise significant competitive concerns and the antitrust agencies will not challenge ACOs that fall within the safety zone, absent extraordinary circumstances. To fall within the safety zone, independent ACO participants that provide a common service must have a combined share of 30% or less for each common service in each participant’s Primary Service Area (“PSA”), wherever two or more ACO participants provide that service to patients from that PSA. Mandatory Antitrust Review: An ACO applicant that has a share above 50% for any common service that two or more independent ACO participants provide to patients in the same PSA is required to obtain a letter from one of the antitrust agencies advising that the reviewing agency has no present intent to challenge or recommend challenging the ACO. • If DOJ or FTC advises it is likely to challenge or recommend challenging an ACO if it proceeds, the ACO as proposed will be ineligible to participate in the Shared Savings Program.

• DOJ and FTC have committed to provide a 90-day expedited review of ACOs that exceed the 50% PSA share threshold. The reviewing agency, therefore, must receive all of the required documents and information at least 90 days before the last day on which CMS has stated that it will accept applications to participate in the Shared Savings Program for the relevant calendar year.

Additional Antitrust Guidance: ACOs that are outside the safety zone and below the 50% mandatory review threshold, that do not impede the functioning of a competitive market and that engage in procompetitive activities, will not raise competitive concerns and may participate in the Shared Savings Program without antitrust agency review.

An ACO that desires further antitrust certainty can seek an expedited review from one of the antitrust agencies, similar to the mandatory review for ACOs above the 50% threshold. The reviewing agency will complete the review within 90 days of receiving all of the necessary documents and information and will inform the ACO of the outcome of the review.

In addition, the Antitrust Policy Statement identifies five types of conduct that an ACO can avoid to reduce significantly the likelihood of antitrust concern.

For more information about this document, contact: Federal Trade Commission: Cecelia Prewett cprewett@ftc.gov or Mitchell Katz mkatz@ftc.gov; 202/326-2180, Department of Justice: Gina Talamona gina.talamona@usdoj.gov; 202/514-2007.

The proposed rule and joint CMS/OIG notice are posted at: www. ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1#special.

The Proposed Antitrust Policy Statement is posted at: www.ftc.gov/ opp/aco/.

The IRS Notice 2011-20 will be posted at: www.irs.gov/pub/irsdrop/n-11-20.pdf.

MAY / JUNE 2011 | THE BULLETIN | 31

MEDICO NEWS

CMA urges CMS to modify unworkable ACO regulations The California Medical Association (CMA) recently submitted comments to the Centers for Medicare & Medicaid Services (CMS) on their proposed rule on Medicare accountable care organizations (ACOs).

CMA has been supportive of the ACO concept, but the current regulations are burdensome and complicated and make ACO participation either impossible or unattractive for large medical groups and small independent practices.

CMA is concerned with the elimination of the “shared savings” model and its replacement with a two-track system that imposes financial risk upon physicians. The ACO shares, at most, only 50% – 60% of the savings, which makes it financially unviable for small group physicians to become ACOs. Even more troublesome is the requirement that if an ACO spends more than its benchmark, it must repay the over-expenditure to CMS. CMA is urging CMS to provide for a shared savings model, eliminate the minimum savings threshold and allow an ACO to receive a greater share of the savings without the downside risk. CMA is also urging CMS to hold physicians to the national spending benchmark rather than their local benchmark.

While California’s large physician groups already meet most of the ACO requirements, it will be difficult for them to achieve additional Medicare savings as their spending is already 20% below the Medicare

national average expenditure per beneficiary. And the 50% – 60% shared savings is not enough to make ACO participation financially attractive to large groups.

Given the financial resources required to establish and maintain an ACO, it is likely that the vast majority of sponsors will be hospital systems. In order to ensure ACO buy-in by physicians, CMA urges CMS to ensure that ACOs are physician-led and that clinical decisions are made by physicians.

Finally, CMA is urging CMS to develop alternative models that provide more up front funding for small practices to form ACOs and to allow a longer transition period for smaller practices to implement a complicated ACO. CMA has met with the CMS Innovation Center, which was given $12 billion under the Affordable Care Act to fund innovative physician payment methodologies as well as delivery systems. CMA will be submitting alternative proposals to CMS to help physicians succeed in the era of health care reform.

For more information, see CMA’s letter to CMS Administrator Donald Berwick, MD, on this issue (http://www.cmanet.org/fi les/assets/ news/2011/06/cmaacocomments060511.pdf).

Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.

(CMA Alert, June 13, 2011 issue)

CMS announces two CMA publishes new ACO models Electronic Health Records Desk Reference In the shadow of the heavily criticized accountable care organization (ACO) regulations, the Centers for Medicare & Medicaid Services (CMS) recently announced two new physician ACO models.

The first model is called the Pioneer ACO Model, which CMS says “...provides a faster path for mature ACOs that have already begun coordinating care for patients.” This model is intended for ACOs working with private payers.

CMS is also seeking comments on the idea of an Advance Payment Initiative, which would give ACOs an upfront shared savings payment “...helping them make the infrastructure and staff investments crucial to successfully coordinating and improving care for patients.” The California Medical Association (CMA) met with CMS earlier this year, urging them to provide up front funding to help solo physicians form ACOs. And finally, CMS is offering Accelerated Development Learning Sessions to help physicians form ACOs. For more information or to register, visit https://acoregister.rti.org.

CMA will be providing CMS with comments on these two new models. More information on the new ACO models and ACOs in general can be found at the CMS website www.cms.hhs.gov by clicking on the CMS Innovation Center.

Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.

(CMA Alert, May 31, 2011 issue)

32 | THE BULLETIN | MAY / JUNE 2011

The California Medical Association (CMA) and the CMA Foundation recently published the “Electronic Health Records Desk Reference.”

The guide, which was funded by a grant from the Physicians Foundation, brings together tools and resources to help physicians make a successful transition to electronic health records (EHR) in their practices.

The guide is designed to help physicians at every stage of the EHR implementation process, from understanding the federal incentive programs to selecting and implementing the right EHR system and achieving meaningful use.

The Desk Reference is available free of charge to all physicians in the CMA resource library (http://www.cmanet.org/resource-library/ detail?item=ehr-desk-reference), thanks to the generous support of the Physicians Foundation.

(CMA Alert, May 16, 2011 issue)

IOM study finds inequities in Medicare’s geographic payment formula The data that Medicare relies on to adjust for geographic variation in costs to pay physicians and hospitals is flawed and leads to inaccurate payments, according to a report recently released by the Institute of Medicine (IOM).

This represents a huge victory for the California Medical Association (CMA) and will go a long way toward ensuring that California physicians are reimbursed accurately for the differences in geographic practice costs.

“San Francisco and Los Angeles are two of the most costly cities in which to practice medicine,” says CMA President James G. Hinsdale, MD. “Recognizing those cost differences and adjusting payments accordingly will allow adequate care for seniors in many parts of California. The California Medical Association applauds the time and effort that IOM put into this careful analysis.”

CMA has for years been urging Congress to reform the flawed and outdated geographic payment regions. CMA testified before the IOM on this issue last fall. The costs of running a physician’s practice differs substantially across the country and failing to take that into account in Medicare payments is a big mistake that harms senior citizens’ access to care, CMA said in its testimony.

Geographic adjustments to Medicare payments are intended to accurately and equitably cover regional variations in wages, rents, and

other costs incurred by physicians and hospitals. The study found, however, that almost 40% of hospitals have been granted exceptions to how their adjustments are calculated, strongly suggesting that the mechanisms underlying the adjustments are inadequate.

The IOM committee concluded that the rationale for fine-tuning Medicare payments based on geographic variations in expenses is sound and should be continued. However, the report urges fundamental changes to the data sources and methods used to calculate the adjustments and increase the accuracy of the payments.

One such change recommended by the committee would be to place physicians and hospitals into the same Metropolitan Statistical Areas (MSAs), which reflect regional costs more accurately than the outdated payment localities that are currently used to determine reimbursement. In California, for example, the physician payment localities haven’t been updated in more than 12 years, leaving many recently urbanized counties inappropriately grouped into payment localities with lowercost (mostly rural) counties.

“This recommendation represents an enormous victory for California physicians and their patients who have been advocating for CMS and Congress to update the payment regions for a decade,” Hinsdale added. Under

the current system, 14 recently urbanized California counties are still designated as rural and are consequently underpaid by up to 13% annually.

Additionally, the committee recommended that Congress standardize the labor markets and the wage and benefits indexes used to adjust Medicare payments for hospitals and physicians. Importantly, IOM also recommended that public policy goals, such as improving access to care in rural physician shortage areas, should be addressed, but not through the Medicare geographic payment formula.

Health care reform legislation passed and signed into law last year directed IOM to study regional differences in Medicare costs and spending. This report is the first of three to be issued by the committee. A supplemental report that discusses physician payment issues further will be issued this summer. A final report to be released in 2012 will present the committee’s evaluation of the effects of the adjustment factors on health care quality, population health, and the distribution of the health care workforce.

CMA urges Congress and the Centers for Medicare & Medicaid Services to implement these data-driven policies as soon as possible to improve Medicare payment accuracy and access to care.

(CMA Alert, June 13, 2011 issue)

CMA creates governance guidance for new physician organizations, including ACOs and IPAs Are you being asked to join an accountable care organization (ACO), independent practice association (IPA), or other new organization? If so, governance will be a critical issue for you to consider as a fair and efficient governance structure is essential to the success of any organization.

CMA has produced a new medical-legal document that discusses the numerous, complex challenges that owners face in governing “physician organizations.”

Such organizations come in many forms and include not only entities that provide medical care, such as medical groups or IPAs, but also health-related entities that provide nonmedical services in which nonphysicians may also hold ownership interests, such as management service organizations.

Regardless of the type of organization, physicians, in conjunction with their legal counsel, need to address how the organization will be controlled and whether appropriate safeguards are in place to ensure

that the board of directors fairly represents the organization and its purpose.

To help physicians in this process, CMA has created medical-legal document #0239, “Governance Issues for Physician Organizations.” This document includes sample provisions that are illustrative of the language that is typically used in governance documents, such as bylaws. It defines the three different types of governance roles, paying particular attention to the powers of the board of directors and the relationship between the board and the shareholders.

CMA medical-legal document #0239 as well as the rest of the medical-legal library (formerly known as CMA On-Call), is available free to members in CMA’s online resource library at (http://www.cmanet.org/ resource-library/detail?item=governance-issues-for-physician-organizations).

(CMA Alert, May 16, 2011 issue) MAY / JUNE 2011 | THE BULLETIN | 33

PH: (408) 452-7700 FAX: (408) 452-7470 Email: michelle@lwallc.com

We are Wealth Advisors and Financial Planners to high net worth individuals, families and institutions.

LWA is proud to announce Edwin K.S. Ryu has again been named to the Medical Economics 2010 Best Financial Advisers for Doctors list. He was also named one of their 150 Best Financial Advisers to Doctors in 2006 & 2008.

The LWA team includes Michelle Hamilton, MBA as a specialist in financial planning and portfolio administration.

When someone in your family gets sick, it feels like you are going walking by yourself. But when hospice comes, you feel like somebody is guiding you and you are not alone. Thank God there’s a program like this that picks you up and helps prepare you for the journey you and your loved ones are going to take. Hospice of the Valley helps everyone prepare for that.

— Carmen V. Gary Bertuccelli, social worker Pam Nates, chaplain

When patients and families are coping

with serious, life-limiting illness, they require expert care, compassion and personal attention. Whether it is spending time with loved ones, fulfilling dreams, or simply remaining comfortable and independent for as long as possible, Hospice of the Valley guides patients and their families to meet their goals.

• The hallmark of hospice care is that it serves patients wherever they live—be it in their home, nursing home, hospital or assisted-living facility • Hospice of the Valley team members consist of physicians, nurses, social workers, chaplains, hospice aides, volunteers, and grief counselors who are experts in palliative and hospice care and are available to assist in the management of your patient’s needs Margarita Vizcaya, hospice aide

Jeanne Fabricius, RN, case manager

• For those dealing with grief and loss, the Community Grief and Counseling Center at Hospice of the Valley provides families and individuals with one-on-one counseling and loss-specific support groups to adults, teens and children • Since 1979, Hospice of the Valley‘s legacy of compassionate palliative and hospice care, community education, advocacy and outreach has set the standard for quality hospice care state wide and nationally, and our organization is a locally-based, operated, and supported non-profit organization Monique Kuo, MD, medical director

4850 Union Avenue, San Jose, CA 95124 408.559.5600 l hospicevalley.org

34 | THE BULLETIN | MAY / JUNE 2011

We Celebrate Excellence – Calvin Lee, MD CAP Member, Internationally Renowned Violinist, and Dedicated Philanthropist

800-252-7706 www.cap-mpt.com/physicians

SAN DIEGO ORANGE LOS ANGELES PALO ALTO SACRAMENTO

For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like general surgeon Calvin Lee, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.

MAY / JUNE 2011 | THE BULLETIN | 35

Classifieds OFFICE SPACE FOR RENT/LEASE PRIMARY CARE/LOS GATOS SPACE FOR LEASE Part- or full-time physician sought to join existing practice to share rent and staff. 3,400 sq. ft. recently remodeled space with onsite lab.

Currently, we have one full-time MD and one part-time MD. Concierge practice setting. Very light call schedule, approximately one weekend in 17. Hospital work by choice only, close to Good Samaritan Hospital.

If interested, or for further details, please call 408/829-3033.

MEDICAL SUITES • LOS GATOS – SARATOGA Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking. Located next door to Los Gatos Community Hospital.

Both units currently available. Call 408/355-1519.

MEDICAL OFFICE FOR LEASE/SUBLEASE/SALE Office in close proximity to O’Connor Hospital for lease/sublease/ sale. Please call 408/923-8098 for more information.

OFFICE SUITE AVAILABLE Location is highway 85 at De Anza. One suite available. Currently configured with six Tx rooms/offices, entry, large master office with balcony. Street signage to 100,000 cars a day. Marble entry. Zoned medical/office. No variance required. Looking for established business/practice that values prime location in beautiful building. Please be qualified. No start ups. Contact Dr. Newman at 408/996-8717. Brokers welcome if you have a client. $2.00 per sq. ft. plus 3N. Located at 1196 South De Anza at Rainbow.

MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/2280454.

OFFICE/LAB SPACE FOR LEASE • MTN VIEW One room space. Office/lab – upstairs. Located at 2500 Hospital Dr, Bldg I, Mtn View. Call 831/375-6105.

MEDICAL/DENTAL OFFICE SPACE FOR LEASE • MTN VIEW Medical/dental office space located at 2500 Hospital Dr, Bldg I, Mountain View. Call 831/375-6105.

exam rooms, a lab, two large administrative offices, and a marble and granite waiting room with comfortable seating for eight patients. Call Irene at 408/358-5757 to schedule your private showing. Price is negotiable.

MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/644-9800.

MEDICAL OFFICE TO SHARE • SAN JOSE Conveniently located off The Alameda near Hwy 87 and 880, with quick access to both O’Connor Hospital and Regional Medical Center of San Jose. Excellent parking, recently remodeled suite with two dedicated exam rooms and private office, shared reception, and waiting area. Please email: nel1958@yahoo.com.

MEDICAL OFFICE TO SHARE IN MEDICAL BUILDING O’CONNOR HOSPITAL One large exam room and one office, shared waiting room, and receptionist area. Email at minasehhat@yahoo.com.

MEDICAL/PROFESSIONAL OFFICE FOR LEASE Medical/Professional office 2,600 sq. ft, ground floor near Santana Row. $2.00 sq. ft. Available now. Email at sksiddiqui@yahoo.com.

OFFICE SPACE FOR LEASE OR PURCHASE • SAN JOSE For lease or purchase. 900 sq. ft. space in a medical/dental office building opposite Regional Medical Center. Please call 408/926-2182.

SAN JOSE DENTAL/MEDICAL/PROFESSIONAL OFFICE FOR LEASE Two suites, 1,532 sq. ft. and 2,518 sq. ft. Plumbing ready for dental offices. Can be used as medical, lab, or professional offices. Located across the street from Regional Medical Center of San Jose, 2380 Montpelier Dr.; easy freeway access to 680/101/880. Call Thuy Le at 408/272-3706.

MEDICAL OFFICE FOR LEASE • PALO ALTO Excellent opportunity to establish a Palo Alto presence. 1,500 sq. ft. at Middlefield and Manning. Four exam rooms, two doctor offices, large waiting room, Lab Corp on-site. $2,900/ month full service. Contact Darren Phelan, MD at 650/326-0840 or email: docphelan@hotmail.com.

Pajaro Dunes Beachfront Condo Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families

MEDICAL OFFICE TO SHARE • SUNNYVALE One exam room plus one large office, shared waiting room and front office. Newly built, 1,280 sq. ft. Call 408/438-1593.

ELEGANT AND SPACIOUS LOS GATOS MEDICAL OFFICE Available to share with prominent aesthetic dermatologist. This upscale office has seven 36 | THE BULLETIN | MAY / JUNE 2011

Owners Bill & Debbi Ricks 408-354-5613

Rental Agent Pajaro Dunes Company 1-800-564-1771

METRO MEDICAL BILLING, INC.

CHANGE THE WAY PATIENTS SEE YOU Medical Practice Solutions Billing • Coding • Reimbursement • • •

Practice Analysis Strategic Market Planning Train to Retain Staff

All medical practices are unique in services and the part of the community they serve Call for a complimentary consultation for a “check up” on your practice

Integrated Physician Services 831-324-0441 ipsmonterey.com PRIME MEDICAL OFFICE FOR LEASE • SAN JOSE Excellent location. Westgate area. 1,584 sq. ft. West Valley Professional Center, 5150 Graves Ave., Suite 2/stand-alone unit. Private office, reception area, exam rooms with sinks. Available 2/1/11. Call owner at 408/8671815 or 408/221-7821.

SANTA CLARA OFFICE • HOMESTEAD AND JACKSON Plumbed for Dental/Medical, or other use.

1,200 sq. ft. Downtown across from post office and weekly farmers market. Excellent location! Dentist on site, please do not disturb.

Don’t miss! Come see! Call 408/838-8191 or 408/741-1956.

MEDICAL/PROFESSIONAL OFFICE SPACE • SAN JOSE Located off The Alameda near Race Street, conveniently accessible to both O’Connor Hospital and Regional Medical Center of San Jose. 1,100 sq. ft. quite with excellent parking. Asking $1.25 per sq. ft. with no triple net.

Please email: tgallo@svmsmg.com or call 408/410-7533.

PRIVATE PRACTICE/OFFICE FOR SALE PRIVATE PRACTICE FOR SALE IM/FP/GP. Primary care practice for sale, including inventory and equipment. Close to O’Connor Hospital. If interested, please call Stacy at 408/297-2910.

• • • • • •

Full Service Billing 25 years in business Book Keeping ClinixMIS web based software Training and Consulting Client References

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website www.metromedicalbilling.com

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Dan R. Azar MD, MPH at 408/790-2907 or e-mail dazar@allianceoccmed.com for additional information.

PHYSICIAN OPPORTUNITY Established group has opportunity for Internal Medicine physician to join. The practice is located in Los Gatos; has reasonable call schedule. Please send letter of interest and CV to fax 408/358-0261 or email to Christine at: lrpg@yahoo.com.

CONDO/COTTAGE RENTALS BETWEEN SAN FRANCISCO & CARMEL Tri-level condo right on ocean. Bedroom/bath on every level. Master bedroom offers sitting area, stereo, sauna, and hot tub overlooking ocean. Living room has wood burning stove, TV, spiral staircase to third level bedroom with access to ocean front deck. 468 Ocean View, La Selva Beach, CA. Kendall & Potter Property Management, 800/386-6826 or www.montereycoast.com.

FOR SALE BEAUTIFUL PALMILLA TOWNHOME • CABO 2 Bedroom/2.5 bath/1,600 sq. ft.; golf, beach.

Villa Diamonte D403. Call 408/309-8457. http://bit.ly//caboforsale.

WANTED PEDIATRIC PRACTICE Will buy Pediatric practice in South Bay. Call 408/455-2959.

NURSE PRACTITIONER/PHYSICIAN ASSISTANT Part-time Nurse Practioner/Physician Assistant to provide care under MD supervision.

Includes H&P and occasional detoxification from drugs/alcohol. Knowledge in CD is desirable, but not necessary. Physician training is provided. Call Robert Daigle, MD at 408/568-7004.

OPHTHALMOLOGIST WANTED Part-time, board certified General Ophthalmologist to compliment dynamic MD/OD group. Oculoplastic specialist a plus. Must have superb communication, clinical, and warm interpersonal skills. Offering a competitive salary. Located in Sunnyvale. Send CV to lbeem@eyelink.com.

MAY / JUNE 2011 | THE BULLETIN | 37

_\cg)`e]fid Discover investment strategies for a rising-tax environment Prepare your investments for future tax increases Taxes may be heading higher for a number of reasons. While this could have a significant impact on your investment portfolio and long-term goals, there are strategies that can help you address rising taxes within the context of your overall wealth management picture. As your Merrill Lynch Financial Advisor, I’ll work with you and your tax advisor to determine how to adjust your investment strategies to help meet your needs and potentially mitigate the impact of tax increases.

Learn how to take advantage of strategies for rising taxes N Find out why taxes may be increasing N Understand the impact of higher taxes on your portfolio N Explore ways to protect your investments, retirement savings and estate from future tax hikes

I CAN HELP YOU INCORPORATE TAX-EFFICIENT INVESTMENTS IN YOUR PORTFOLIO. Gary McRae, AAMS® Financial Advisor 333 Middlefield Road Menlo Park, CA 94025 (650) 473-7884 http://fa.ml.com/garymcrae

Merrill Lynch Wealth Management makes available products and services offered by Merrill Lynch, Pierce, Fenner & Smith Incorporated (MLPF&S) and other subsidiaries of Bank of America Corporation. Investing in securities involves risks, and there is always the potential of losing money when you invest in securities. Neither Merrill Lynch nor its Financial Advisors provide tax, accounting or legal advice. You should review any financial transactions with your personal professional advisors. Investment products provided: Are Not FDIC Insured

Are Not Bank Guaranteed

May Lose Value

MLPF&S is a registered broker-dealer, Member SIPC and a wholly owned subsidiary of Bank of America Corporation. © 2010 Bank of America Corporation. All rights reserved.

Tracy Zweig Associates A

REGISTRY

&

PLACEMENT

FIRM

Physicians Nurse Practitioners ~ Physician Assistants

Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m 38 | THE BULLETIN | MAY / JUNE 2011

gloEMR™ 6.0 was one of ONC-ATCB 2011/2012

The Microsoft® Office of Medical Practice Software

A Certified Success!

The facts speak for themselves: t gloEMR™ is proven to have all of the functionality you need to show Meaningful Use and collect your Stimulus funds. t gloEMR™ comes with a Stimulus Guarantee. If it doesn’t help you achieve Meaningful Use, we’ll refund the purchase price of your software.* t gloEMR™ is the only locally supported EMR with Microsoft® It’ s familiar, powerful and easy to use. t gloStream™ is the only EMR company with a 100% implementation success rate. t SCCMA / MCMS has selected gloStream™ as a new member benefit.

More information

West

A LLIA NC E

Web: proficientEMR.com Email: info@proficientEMR.com Toll Free: 866.456.7995 Bay Area: 408.540.6775 Monterey: 831.920.0525

gloEMR™ 6.0 from gloStream™ endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments. gloEMR™ from gloStream™

*Please refer to the gloStream License Agreement for details and conditions.

MAY / JUNE 2011 | THE BULLETIN | 39

BULLETIN THE

Address service requested

OfďŹ cial magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way, San Jose, CA 95128-4705

25

$416 m

30

PRSRT STD U.S. Postage PAID San Jose, CA Permit No. 503

20 15

5 Years

Dividends Declared

10

$416 million in declared dividends to our policyholders since 1979.

Trust is something you earn from your patients.

For 35 years NORCAL Mutual has earned the trust of our insureds. Award winning Risk Management programs, outstanding claims defense and $416 million in policyholder dividends, are just a few of our strengths.

To learn more about our products and services, please contact:

We value your trust at NORCAL Mutual.

>

Ken Stacey, Senior Account Executive License #: 0A00400 Fax: 415-735-2353

NORCAL Mutual is proud to be endorsed by the Monterey County Medical Society and the Santa Clara County Medical Association as the preferred medical professional liability insurer for their members.

Phone: 800-652-1051, ext. 2054 E-mail: kstacey@norcalmutual.com

Our passion protects your practice