SEPTEMBER / OCTOBER 2011 | Volume 17 | Number 5
Is Your Practice Ready for the New Hipaa 5010 Standards?
Page 22 Inside: Nanotechnology to Nanotoxicology: A New Cause for Concern
Not oNly caN a disability slow your pace…
it could also stop
your income. Studies show that 43% of people age 40 will suffer a long-term disability before they are 65 1 and one in seven workers are disabled for five years.2
If you suffer a disabling injury or illness and can’t continue working, do you have a reliable financial source to replace your income? Santa Clara County Medical Association and Monterey County Medical Society members can turn to the endorsed Group Disability Income Insurance Plan for help. This plan is designed to provide a monthly benefit up to $10,000 if you become Totally Disabled from practicing your medical speciality.
learn more about this valuable plan today!
call marsh for free information, including features, costs, eligibility, renewability, limitations and exclusions at 800-842-3761. Endorsed by:
New York Life Insurance Company New York, NY 10010 on Policy Form GMR
1 Statistic attributed to Insurance Information Institute, for Loeb, Marshall. “Excessive or Necessity: Is Disability Insurance Worth the Price?” MarketWatch, Viewed 4/9/11. NationalAssociation of Insurance Commissioners (NAIC). Article found at http://articles.moneycentral.msn.com/Insurance/InsuranceYourHealth/DisabilityInsuranceCanSaveYourLife.aspx. “Disability Insurance Can Save Your Life” Viewed 4/19/11
51749 (9/11) ©Seabury & Smith, Inc. 2011 • AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 • Member.Insurance@marsh.com • www.MarshAffinity.com •
CA InS. LIC. #0633005
2 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
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 Discounted Insurance Referral Services With Membership Directory/Website Membership Directory iAPP for the iPhone Legislative Advocacy/MICRA House of Delegates Representation Practice Management Resources and Education Financial Services Professional Development Health Information Technology Resources Publications CME Tracking Physicians’ Confidential Line Verizon Discount Human Resources Services
Joseph Andresen, MD
Message From the SCCMA President
Managing Professional Risk: Safeguarding Data
10 11 12 14
From the Editor’s Desk William S. Lewis, MD NORCAL Mutual Insurance Company
Veteran Status May Be Factor in Diagnosis Upcoming CMA Webinars CME Offerings Use CURES to Monitor Prescription Drug Use John McCarthy, MD
16 Is Your Practice Ready for the New HIPAA 5010 Standards? 20 Finding Money
22 Nanotechnology to Nanotoxicology: A New Cause for Concern
Cindy L. Russell, MD
28 Refer Patients to 211 for Everyday Needs and in Times of Disaster 30 CALPAC – Fighting For You!
Richard Thorp, MD
32 Breastfeeding Awareness – A Plea to Physicians for Education and Action
36 Medical Times from the Past: The Valley’s First Practitioner 37 SCCMA Alliance News 38 Electronic Health Records: From Selecting a System to Demonstrating Meaningful Use 40 Classified Ads 42 MEDICO NEWS SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 3
The Santa Clara County Medical Association Officers President William Lewis, MD President-Elect Rives Chalmers, MD Past President Thomas Dailey, MD VP-Community Health Cindy Russell, MD VP-External Affairs Howard Sutkin, MD VP-Member Services Scott Benninghoven, MD VP-Professional Conduct Eleanor Martinez, MD Secretary Sameer Awsare, MD Treasurer James Crotty, MD
AMA Trustee - SCCMA
James G. Hinsdale, MD
El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Lynn Gretkowski, MD Good Samaritan Hospital: Jeff Kaplan, MD Kaiser Foundation Hospital - San Jose: Seham El-Diwany, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Elaine Nelson, 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)
Chief Executive Officer
Tanya Spirtos, MD (District VII)
William C. Parrish, Jr.
Debbi Ricks (Alliance)
THE MONTEREY COUNTY MEDICAL SOCIETY
Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
Printed in U.S.A.
Joseph S. Andresen, MD
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. 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 firstname.lastname@example.org © Copyright 2011 by the Santa Clara County Medical Association.
4 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
President James Ramseur, Jr, MD President-Elect John Clark, MD Past President John Jameson, MD Secretary Eliot Light, MD Treasurer Steven Vetter, MD
CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.
DIRECTORS Paul Anderson, MD
R. Kurt Lofgren, MD
Valerie Barnes, MD
Jeff Keating, MD
Ronald Fuerstner, MD
Kelly O'Keefe, MD
David Holley, MD
Patricia Ruckle, MD
Nicotine Replacement Therapy Your Clinic may be eligible for FREE nicotine replacement therapy Please contact Breathe California for more information and access to clinically proven medication to help smokers quit
Call: (408) 998-5865 E-mail: email@example.com
of the Bay Area Nicorette速, NicoDerm速CQ速, and logo design, step design, and overall trade dress are trademarks owned by or licensed to GlaxoSmithKline. Behavioral support program increases chances of success. Read and follow dosing schedule. Individual results may vary. Use as directed.
FROM THE EDITOR’S DESK
Joseph Andresen, MD Editor, The Bulletin
A Harvest of Information By Joseph Andresen, MD
can prevent it. • How the EHR Desk Reference, published by the CMA and CMA Foundation, can help you get up to speed with electronic health records. • What are the new HIPAA 5010 Standards and what do we need to know? Grab a cappuccino, coffee, or cup of tea, pull up a chair, and let us help you get back in the swing of things with this month’s Bulletin.
September comes and goes, as October looms upon us. This is a time when we resume our many routines. Back to school. Back to work. A return to the predictability of schedules that resemble well-worn paths through the meadows of our lives. These changes and expectations come with some reluctance. The fond memories of extra time unscheduled, unhurried, now seem well behind us. Life marches forward. The alarm is set a bit earlier. The roads are more hurried. The morning air signals the changes that a new season beckons in. On the flip side of things, these renewed activities energize us in new ways. We may get back to our exercise routines, sign up for a new seminar or class, or have a chance to catch up with colleagues and friends Joseph Andresen, MD, is the editor of The Bulletin. He is board that we haven’t seen in a while. Time is now more precious. With that recertified in anesthesiology and is currently practicing in the Santa alization, we squeeze more out of each waking moment. Clara Valley area. Given these thoughts, this issue of The Bulletin will bring you upto-date, snap you out of your summer daydreams and, hopefully, get you through your to-do list more promptly. • Should veteran status be an important factor in diagnosis? Learn why. • The dilemma of emergency room A REGISTRY & PLACEMENT FIRM coverage is an ongoing challenge for medical staff and hospital administrators. Gain some insight from recent experiences at Good Samaritan Hospital. • What can we do to garner more support from physicians for the benefits of breastfeeding? Read about the “Big Latch On” that took place around the world during breastfeeding awareness month. • Like the Internet, nanotechnology has been hailed as the next big technological breakthrough. But what are the costs and potential dangers? • What has the California Medical Association Political Action Committee (CALPAC) been up to? You’ll want to read this whether 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 your Republican, Democrat, or FA X : 8 0 5 - 6 4 1 - 9 1 4 3 Independent. • Your office computer just crashed. A virus has infected your software. firstname.lastname@example.org What could be worst? Loss of patient w w w. t r a c y z w e i g . c o m confidential information and how you
Tracy Zweig Associates Physicians
Nurse Practitioners ~ Physician Assistants
Locum Tenens ~ Permanent Placement
6 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
MESSAGE FROM THE SCCMA PRESIDENT
william s. lewis, MD President, Santa Clara County Medical Association
To Take Call or Not to Take Call By William S. Lewis, MD President, Santa Clara County Medical Assoc. At Good Samaritan Hospital, the medical staff recently met with administration to discuss emergency room coverage. Administration was threatening to cut back on compensation for back-up coverage and physicians were ready to retaliate by dropping off emergency room call panels. What was once only a disturbing thought is now an imminent threat. How do physicians balance their professional responsibilities with their economic realities? This problem is widespread. A 2011 study by the California Healthcare Foundation found 80% of hospital executives considered securing specialty back-up emergency room coverage one of their top ten business challenges. Also, 80% of California emergency room doctors reported that specialists became twice as reluctant to take emergency room call between 2000 and 2006. As a result in 2008, California hospitals collectively spent $1.6 billion on specialists for stipends and uncompensated emergency medical care. Wasn’t federal health care reform supposed to help this situation? Millions of uninsured Americans would become insured and see physicians in their offices, instead of the emergency department. Problem solved, right? Wrong. Instead, in an ironic twist, health reform is a looming aggravation, and California hospitals know it. Soon, we will have millions of additional Medi-Cal patients with nowhere to go but the emergency room because they cannot find a Medi-Cal physician provider. But physicians won’t want to treat them in the emergency room either, when reimbursement is so bad and, incredibly, getting worse. Hospitals that help compensate
specialists for uninsured and underinsured emergency room patients see their future costs escalating. So, they are acting now to drop compensation for Medi-Cal patients. And physicians are reacting—unfavorably. The emergency room is not the practice builder it used to be. In fact, some might call it a practice killer because it interferes with the office and elective surgery schedule, the two things that keep most practices running. Emergency department interruptions are a real headache for most specialists. They are time consuming and, in our age of sub-specialization, fraught with liability. Specialists who have narrowed their practices are being asked to act as “gen-
on-call coverage and services should be a shared responsibility of hospitals, medical staffs, health plans, medical groups, local EMS agencies, and public payors. 3. The burden of providing emergency and on-call services should be broadly shared among physicians who are qualified to provide them. Unfortunately, the recommendations are wistfully utopian. Enabled by EMTALA, health plans and public payors shirk their responsibilities and place the onus upon hospitals and physicians. Meanwhile, hospitals battle with physicians over ER stipends and on-call coverage. The CMA gives the following legal advice to physicians: “Neither federal nor California law affirmatively requires an individual physician to serve ‘on-call.’ Rather, the responsibility to provide specialty medical coverage rests with the facility that offers emergency services. However, it is obviously the physicians on the medical staff who must provide the professional services. Thus, if the hospital and medical staff agree to maintain the emergency department, medical staff members, either voluntarily or through some other mechanism, will have to serve on-call.” So, it seems an independent medical staff is free to choose how to cover the ER, but not whether to cover the ER. Are we doomed by powers beyond our control in this burgeoning crisis? Or can we, as Cassius suggests to Brutus, take responsibility for our own destiny? The answer may lie somewhere in the middle. Individually, we cannot afford to work for nothing, but collectively we cannot afford to stubbornly deny the emergency medical services we alone can provide. It seems we must do our part to offer solutions and bear some of the burden. Organized medicine can help by educating our legislators and the public. Ultimately, only public respect and support for our profession will keep us from being the “underlings.”
“The fault, dear Brutus, is not in our stars, but in ourselves, that we are underlings.”
William S. Lewis, MD, is the 2011-2012 President of the Santa Clara County Medical Association. He is a board certified ENT physician and is currently practicing in the Los Gatos area.
Shakespeare From: Julius Caesar eral” specialists and manage cases they would rather avoid. If they take on the case, they assume medical liability; if they refuse the case, they fear legal liability through EMTALA regulations. Why would physicians do it for little or nothing? Why even serve on ER call panels? If hospitals and insurance companies are going to make business decisions, why shouldn’t physicians? But is it purely business? What are our professional responsibilities to each other and the public, not to mention our social obligations or ethical standards? These are the questions we face. The California Senate Office of Research published a comprehensive report on emergency on-call services in 2003. Among the major recommendations were the following: 1. Emergency medical care and related on-call services are essential services that must be available on a timely basis to all Californians, regardless of insurance status or ability to pay. 2. The responsibility to provide, and to ensure the provision of, appropriate
SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 7
MANAGING PROFESSIONAL RISK
Safeguarding Data By Fran Cain Information Technology Department NORCAL Mutual Insurance Company and the NORCAL Group What is the worst computer problem you need to prepare for? Is it arriving at the office to find your server doesn’t boot? Is it finding that a friend’s computer was compromised by a virus which your computer now has? Is it the power going out in the middle of the day? Or maybe you just downloaded the latest Microsoft updates and your software stopped working. These are all serious problems, and the threats are seemingly endless. Risks need to be mitigated by backing up your systems; using up-to-date operating system software, antivirus, and anti-spyware software; and having reliable batteries in your uninterruptible power supplies. But arguably the worst computer problem you could face would be compromised data. If data containing personally-identifiable patient information (also known as protected health information) leaves your possession and you know it—or, in the view of regulators, you should have known it—you will be subject to notification and reporting requirements under state and federal law (including but not limited to HIPAA). In other words, you must not keep this security breach hidden under the rug. But when you notify patients that confidential information about them and their medical conditions has been taken and could be misused, your reputation may suffer considerable damage. We will discuss some of the ways data can be compromised, how to guard against this happening, and how to respond if it happens despite best practices. There are many ways data can be compromised. One of the simplest is for a staff member to make a copy of data. While it has always been possible for staff to easily photocopy records in paper form, digitized data can be copied in huge quantities. It would be quite conspicuous to copy 1,000 patient files on a photocopier, but it would take only moments using a com-
puter, and it’s possible no one would ever notice. Duplication of data is difficult to control. Mitigation begins with strong written policies that clearly notify staff that data should only be copied for specific, approved purposes, and with proper processes in place to safeguard security and privacy. For example, staff may copy medical records to removable media (e.g., USB flash drives, CDs, or DVDs) in response to patient requests. Consequences for failure to follow policy, up to and including termination, must be outlined. (Read on for more information on removable media.) Another way data can be compromised is if the computer sends data across an unencrypted (undisguised) Internet connection. Data flowing across a network can be intercepted by eavesdroppers. Always look for indications that Secure Socket Layer (SSL) is being used when connecting to sites on the Internet for business purposes, such as banking. This is indicated by a gold padlock in Internet Explorer, or a grey padlock in other browsers. There are dozens of web browsers, so familiarize yourself with the SSL graphic in the address line of the web browser you use. Mitigation also requires using a good antivirus software product and keeping the vi-
8 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
rus signatures updated daily (virus signatures are like fingerprints that can be used to detect and identify specific viruses). You need to keep computer operating systems and software upto-date and patched (problems repaired) on a regular basis (at least monthly). For computers running Windows, each time Microsoft issues security updates for operating systems and/or programs, all computers in the network or accessing the network should be updated. Avoid using wireless connections to communicate confidential patient information unless you are certain you are using current encryption methods (currently WPA or WPA2), and institute strong written policies about this. (Policies regarding use of antivirus software and regular updates must be in place, even if Macintosh computers are used instead of Windows computers. While Windows computers are at much higher risk, any computer can become infected with a virus.) If you use laptops in your practice, staff members need to be advised to avoid storing patient data on the hard drive (that is, on the C drive or in My Documents, etc.). If the laptop is lost or stolen, the password can be easily hacked, and any data on the local hard drive can become accessible. This is one case in
which you must contact ALL of your patients to notify them that their data has been stolen. (It is strongly advised that you seek assistance from your professional liability insurance carrier in the event that protected health information or other patient data is stolen or compromised in any way.) One excellent way to mitigate the damage when a laptop is stolen or lost is to use disc encryption on all laptop hard drives. A few years ago, the idea of encrypting hard drives struck fear into the IT community. Doing so slowed down the system and made it difficult to recover data if the computer crashed. While it is still true that it is tricky to recover data when the computer crashes, it is not necessarily impossible, and new encryption software does not noticeably slow down the computer. In fact, once your laptop is encrypted, chances are good that you will never even notice that your data is encrypted. The encryption software runs quietly in the background, and automatically decrypts data for e-mailing, exporting, or copying. If the encrypted laptop is stolen, the data cannot be accessed—and no letters need to be sent to patients or anyone else. The peace of mind that comes from knowing this is worth the tradeoff
of any inconvenience. Encryption software can be configured to encrypt not only hard drives, but also removable media, such as USB flash drives. USB flash drives are a headache to IT security personnel. As mentioned earlier, staff can easily steal data by copying to a USB flash drive. Automatic encryption when copying to an external device, such as a USB flash drive, makes it more difficult to steal data. If the miniature drive is dropped, lost, or stolen, the data on it cannot be read by another computer. (Note: Before attempting to encrypt any hard discs on your own, or even with the help of a consultant, be sure to back-up all existing data to reliable media.) When copying a medical record to removable media for a patient, the encryption feature should be disabled. While raising awareness of the many serious threats to data, this article merely scratches the surface of the subject. NORCAL Mutual Insurance Company provides extensive information to assist you in understanding information risks and formulating appropriate policies and procedures. You have online access to this information through your MyNORCAL account (access is at www.norcalmutual.com). You also
Billing Collections Consulting
Honest Fair Accountable
have full access to a wealth of state-specific information through the DataShield™ Learning Center, also located in MyNORCAL under the Risk Solutions tab. For example, you will find detailed sample policies which can easily be adapted to your practice, sample newsletters, up-to-date information on compliance, and training materials. If you already have a MyNORCAL account, go to the DataShield™ Learning Center and check out the Top Ten Cyber Security Tips under Training / Training Bulletin. Here are some additional free online articles, if you would like to learn more about data security: http://www.ama-assn.org/resources/doc/ psa/hipaa-phi-encryption.pdf — A good overview, including helpful graphics and additional resources. http://www.brighthub.com/computing/ smb-security/articles/61722.aspx — More insight into security breaches. http://en.wikipedia.org/wiki/Man-in-themiddle_attack — Discusses eavesdropping or “man-in-the-middle” attacks.
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Veteran Status May Be Factor in Diagnosis By California Department of Veterans Affairs Over the years, military men and women have suffered every manner of physical and emotional injury. Those injuries have had significant health consequences for millions of California veterans. Vietnam veterans who were exposed to Agent Orange (http://www.publichealth. va.gov/exposures/agentorange/), the toxic herbicide sprayed over the jungles between 1962 and 1971, now have increased rates of prostate, respiratory and other cancers, lymphoma, Type 2 diabetes, ischemic heart disease, nerve damage, and digestive and skin disorders. Veterans of every era frequently suffer from hearing loss and tinnitus or struggle with post traumatic stress disorder or traumatic brain injury. The U.S. Department of Veterans Affairs
(VA) (http://www.va.gov/) now presumes that 14 diseases and disorders (http://www.publichealth.va.gov/exposures/agentorange/diseases.asp) found in “boots-on-the-ground” Vietnam veterans are the result of Agent Orange exposure. “It would be easy for a doctor to overlook Agent Orange exposure as the cause of a patient’s Type 2 diabetes when genetic and lifestyle risk factors are present. The post traumatic stress disorder or military sexual trauma at the root of patient’s chronic depression could also be missed,” said California Department of Veterans Affairs (CalVet) Secretary Peter Gravett. “That is why it is so important to ask patients whether they have ever served in the military when evaluating, diagnosing, and treating them.” CalVet encourages medical, health education, and support organization professionals to:
10 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
• Ask patients whether they have served in the military; • Become familiar with the diseases and disorders that commonly affect the veteran population; and • Consider a patient’s veteran status when evaluating symptoms, making diagnoses, and offering treatment. Veterans may be entitled to monetary benefits, health care, vocational rehabilitation services, and free assistive devices, such as hearing aids, through the VA. Veterans who have been diagnosed with any service-connected health condition should contact their County Veteran Service Office (http://www.cacvso. org/page/2011-1-22-13-52-31/) for assistance. For more information about veteran health or benefits, visit www.calvet.ca.gov or call 1-877/741-8532.
CMA Center for Economic Services
Upcoming Webinars Oct 19: “EOB Analysis: Successful Claims Appeal” – 12:15 – 1:15pm
Webinar: There’s a healthy chance that some of your insurance claims will be denied or your reimbursement will be whittled down to where you say “ouch.” Scrutinizing your explanation of benefits or remittance advance is a key to successful claims appeal. Led by Mary Jean Sage of Sage Associates.
Oct 26: “Key Financial Ratios to Increase Profitability” – 12:15 – 1:15pm & 6:15 – 7:15pm
Webinar: Debra Phairas of Practice and Liability Consultants will teach critical skills in analyzing the practice profit/loss statement for overhead expense ratios, accounts receivable ratios, staffing ratios, and how to access specialty comparison norms for benchmarking.
Nov 1: “Risk Management & Long Term Care – Understanding Your Options” – 12:15 – 1:15pm
Webinar: Please join us on this webinar as Janie DeCelles, representing Long Term Care Resources and CMA’s partner, Marsh, helps you not only learn how to identify the risk and potential of needing long term care, but to help you understand the options that are available to you through the CMA LTC program.
Nov 2: “EMR / EHR Update” – 12:15 – 1:15pm
Webinar: This informative webinar will be presented by David Ford from CMA’s Center for Medical and Regulatory Policy.
Nov 9: “EHR Meaningful Use” – 12:15 – 1:15pm & 6:15 – 7:15pm
Webinar Open to Members and NonMembers: Meaningful Use is the set of criteria that physicians will have to meet in order to receive federal EHR provider incentives. On this webinar, CMA’s David Ford will give an overview of the criteria for achieving meaningful use and what physicians and their office staff need to know to qualify for the incentive payments. This webinar will also introduce the CMA Guidebook to Meaningful Use, a new tool developed by CMA which will help physicians understand the details of the requirements.
Nov 16: “Top Ten Ways to Save Your Practice Money” – 12:15 – 1:15pm & 6:15 – 7:15pm
Webinar: Learn the top 10 ways that can help curb expenditures and improve revenues in many practices. Find out if your practice is one of many that has inadequate training and is costing you thousands of dollars. You will gain confidence in helping your physicians make wise choices and learn multiple ways to save your practice thousands of dollars!
Nov 16: “Medicare 2012: Final Rules” – 12:15 – 1:15pm
Webinar: This informative webinar will be presented by Michele Kelly from CMA’s Center for Economic Services.
The above webinars are being hosted by the California Medical Association. Please register at www.cmanet.org/events. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar. Questions? Call the CMA Member Help Line at (800)786-4262.
SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 11
Websites Help Physicians Meet State CME Requirements The Virtual Lecture Hall (www.vlh.com), a CME website that is 100% funded by physician users, offers a number of online programs to help physicians meet special state CME requirements:
“Improving Outcomes in Chronic Pain”
A comprehensive, multimedia, 14.5 credit program developed with research support from the National Institute for Neurological Disorders and Stroke. Written by national pain experts and shown to be educationally effective in a randomized trial.1 Physicians can take all 14.5 credits or as much as they need. This course can be combined with other programs on the Virtual Lecture Hall to meet California’s CME requirement for training in pain management and end-of-life care.
“Current Management of Domestic Violence: Responding to Intimate Partner Violence”
Learn how to comfortably and successfully manage the difficult clinical problems posed by DV. A 16 credit, case-based program that deals with DV presentations in five primary care specialties. Physicians can earn 0.75-16 credits, including AAFP prescribed credit. The program was prepared by DV experts and developed as part of a research project funded by the National Institute of Mental Health. It has been shown to be educationally effective in a randomized trial.2
“Managing Type 2 Diabetes in Diverse Populations”
Enhance your knowledge of the current therapy of type 2 diabetes and improve your cultural competency. This 9 credit, case-based program was authored by cultural competency and diabetes experts. This program also provides AAFP prescribed credit. It was developed with research support from the National Institute of Diabetes and Digestive and Kidney Diseases.
The Virtual Lecture Hall offers more than 40 online CME programs, including: • • • • • •
Pain Management Patient Relations/Safety Domestic Violence Professional Responsibility Cultural Competency Ethics
The Virtual Lecture Hall does not contain advertising or CME programs that are underwritten by commercial interests. The Virtual Lecture Hall is entirely supported by its users. CME certificates can be obtained from the website and credits cost $25 each. 1. Harris JM, Elliott TE, Davis BE, et al. “Educating Generalist Physicians About Chronic Pain: Live Experts and Online Education Can Provide Durable Benefits.” Pain Medicine. 2008;9:555-563. 2. Short LM, Surprenant ZJ Harris JM. “A Community-Based Trial Of An Online Intimate Partner Violence CME Program.” American Journal of Preventive Medicine. 2006;30:181-185.
12 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
PlatformQ hosts virtual events, and the health care section of their company focuses on producing CME that is presented by the Johns Hopkins University School of Medicine. It is all online and it is all complimentary, streaming live and offered on-demand for six months over its live date. They have three health care branches: CardioCareLive (www. CardioCareLive.com), IDCareLive (www.IDCareLive.com), and OncologyCareLive (www.OncologyCareLive.com) which focus on different areas of study. They have events throughout the year in each of these events with speakers from medical schools and hospitals across the country.
Physicians will find a useful source of continuing medical education (CME) at the Annotated List of Online Continuing Medical Education, http://www.cmelist. com/list.htm. They now have links to more than 325 online CME sites offering more than 13,500 CME courses and more than 24,000 hours of CME credit. The list is updated regularly as new online CME sites and courses become available. There is no charge for accessing the list and no registration is required.
We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of “Books for Botox®” community outreach program, benefitting the libraries of underfunded public schools
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 San Francisco facial plastic surgeon Corey Maas, 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. SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 13
Using CURES to Monitor Prescription Drug Use By John McCarthy, MD President, ACap Asset Management, Inc. This article originally appeared in the May/ June 2011 issue of Sierra Sacramento Valley Medicine. California is one of many states with a Prescription Drug Monitoring Program called CURES (Controlled Substances Utilization Review and Evaluation System). It tracks prescriptions of all scheduled substances, including names and addresses of patients, prescribing physician, and pharmacies. This program offers us the opportunity to know the past year of prescription use history of any patient we treat. As an addiction specialist using methadone and buprenorphine to manage opiate addiction, I have found it helpful in identifying patterns of use that assist in the diagnosis of opiate addiction â€” at least in those where prescriptions are the source of the drugs. And it helps detect those few who continue overuse of prescription meds in spite of treatment. In our case, this usually involves benzodiazepine prescriptions. So, the CURES program has become a regular part of our initial evaluation and on-going assessment. This program should also be incorporated into all practices with high risks for dealing with opiate and benzodiazepine addictions, such as primary and urgent care clinics, pain clinics, and ER departments. That said, this information can be misused to just kick patients out of our offices and ERs. Our job as physicians is to screen, do a brief intervention, and refer for treatment. Addicts are patients in need of help, but first they must be diagnosed and non-judgmentally engaged in a discussion of
treatment options. Showing a patient pattern of overuse of prescription drugs can be the first step in helping them to recover. The system is now close to real time, i.e., we can see very recent prescriptions. It is statewide, and there are plans at the federal level for an integrated nationwide system. Once a physician registers in the system, a patient name and address will lead to a Patient Activity Report (PAR). Access to the system requires registering on the state Bureau of Narcotic Enforcement (BNE) website, and providing notarized physician or AHP credentials to BNE for review and approval. One of our UCD psychiatry residents, rotating through Bi-Valley for addiction medicine training, got a CURES report in the course of an assessment of anxiety in one of our patients. She discovered that the patient got 16 benzodiazepine prescriptions from 10 different doctors in a one-month period and was taking at least 10-15mg/day of Xanax and/ or Klonopin. We got releases for the two doctors we knew to advise them of the situation, but most were ER docs and we havenâ€™t figured out how to deal with ERs. We tried to start a controlled detox from benzos, but the patient left treatment and is no doubt still visiting ERs. Most of our CURES interventions have better outcomes. There is an epidemic of prescription drug abuse locally and nationally, and while doctors
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are not the primary source of all the pills out there (the cartels are dealing pills as an avenue to heroin), doctors in certain practice settings are constantly bombarded with requests for pain meds and benzodiazepines. CURES can help us in our efforts to provide appropriate medications for those who need them and appropriate diagnosis for those needing addiction treatment.
NEW MEMBER BENEFIT The Santa Clara County Medical Association has partnered with the premier car wash company in Santa Clara County, Classic Car Wash, to provide a valuable new member benefit. Now as a valued member of SCCMA you will receive a five-dollar ($5.00) discount on a car wash! This represents an 18% - 28% savings depending on which car wash you select! In addition, we wanted to thank each member by providing a benefit you can extend to your staff and family members. Therefore, under the terms of our agreement, you may share this exclusive member benefit with your family and staff as well. Classic Car Wash has four locations in Santa Clara County to serve you. Details and locations are listed in the coupon below (one must present a coupon to receive this discount). Additional discount coupons will be available on SCCMA/MCMS’s website at www.sccma-mcms.org under the “Membership” tab, so you can print additional coupons as needed. There are no restrictions on the number of coupons you can use for yourself, your family, or your staff. For more information and offers regarding Classic Car Wash, please visit their website at www.classiccarwash.com. Thank you for being a member of SCCMA and remember… keeping your car clean can reduce maintenance costs and increase the resale value of your car.
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NEW HIPAA REGULATIONS
Is Your Practice Ready for the New HIPAA 5010 Standards? By CMA Staff Background: HIPAA 5010 Physician practices may need to make adjustments to the patient data they collect and report in order to comply with a new HIPAA requirement that takes effect January 1, 2012. The new “HIPAA 5010 regulations” impact all health care providers who conduct administrative transactions electronically (including submitting claims, checking eligibility and claims status, or obtaining remittance advice and referral authorizations). The regulations cover all HIPAA-covered transactions, and therefore apply to most physician practices, health insurance companies, and clearinghouses. The changes primarily impact software vendors and billing clearinghouses, but compliance may require medical practices to change some business processes as well. The SCCMA/MCMS is advising members to familiarize themselves with these regulations and be proactive about making the needed changes to comply. The Centers for Medicare & Medicaid Services (CMS) has advised that the regulations will not be delayed, and failure to comply will result in nonpayment of claims effective January 1, 2012. There are no exemptions for physicians who bill electronically based on specialty, practice size, or any other criteria. The remainder of this article provides background on the HIPAA 5010 regulations and guidance for physicians to plan ahead to minimize the risk of payment interruptions in 2012.
Physician practices who conduct administrative transactions electronically (including
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submitting claims, checking eligibility and claims status, or obtaining remittance advice and referral authorizations) are required to meet Health Insurance Portability and Accountability Act (HIPAA) standards to perform such transactions. These standards ensure consistency in the type and format of data required in a given electronic transaction regardless of which billing vendors, clearinghouses, or payers are involved. Currently, electronic transactions utilize the 4010 version of the HIPAA electronic transaction standards. In 2006, CMS began the process of updating from the 4010 standards, which were originally developed in 2000 (and subsequently revised in 2002), to the “5010 standards.” The rationale for making the switch is that the 4010 version, just like any other software application, has become outdated. Many technical issues have been found in transactions since 2000 and new business needs have been identified that cannot be accommodated with the 4010 version of the standards. For example, conversion to the 5010 standards is a prerequisite for the conversion from the current ICD-9 diagnostic code set to the new ICD-10 code set, which is mandated for October 1, 2013. The ICD-10 codes have a different format and length than the ICD-9 codes, which cannot be reported in the current 4010 version of the HIPAA transactions, so the upgrade to 5010 needs to be completed before ICD-10 codes can be reported. Work was completed between 2006 and 2007 on a newer version of each transaction, Version 005010, commonly called “5010.” In 2009, the Department of Health and Human Ser vices (HHS)
and CMS announced that physicians and other health care providers would be required to use the updated 5010 versions of the HIPAA transaction standards by January 1, 2012.
What is actually changing? Who does it apply to?
Physicians and other health care providers are HIPAA “covered entities,” which means they must comply with HIPAA requirements when conducting electronic transactions. Therefore, if you currently send and receive HIPAA-covered electronic transactions (including submitting claims, checking eligibility and claims status, or obtaining remittance advice and referral authorizations) and plan to continue doing so, then you will be required to upgrade to the 5010 standards. The 5010 standards have reporting requirements that differ, somewhat, from the current standards. These changes may require you to collect additional data or report data in a different format. Some (but not all) examples include: no longer reporting a PO Box in the Billing Provider Address field (PO Box addresses, for payment purposes, will now be reported in the Pay-to Address field); reporting a 9-digit ZIP code in the Billing Provider and Service Facility Location address fields; reporting a patient with a unique health plan member ID as the subscriber; and, only reporting minutes rather than units of anesthesia time. You should consult your billing service, clearinghouse, and payers to determine what changes will apply to your practice.
Is there any flexibility on the January 1, 2012, compliance deadline?
CMS has advised that these regulations will not be delayed. The necessary software and system changes need to be in place by the compliance date in order for you to continue sending and receiving HIPAA electronic transactions. Failure to comply will result in nonpayment of claims effective January 1, 2012. Any 4010 transactions sent on or after January 1, 2012, will be rejected as non-compliant and will not be processed. You may begin using the 5010 standards in advance of January 1, 2012, to test the system and minimize the chances of billing interruptions. You can begin to use the 5010 transactions if you are ready and mutually agree to this with your clearinghouses or payers. Using the transactions before the deadline will give you the ability to see that transactions are working smoothly and are continuing to be processed. If any issues are identified, you can
resolve them before the compliance deadline. If you will not be ready by the compliance deadline, you will need to talk to your payers, clearinghouses, and billing service to determine what actions you can take to continue to have your transactions processed and receive payments.
What do physicians have to do to comply?
The biggest concern for physician practices will be complete implementation and full functionality of the 5010 transactions at or before the compliance deadline of January 1, 2012. Not all of the 5010 changes are IT changes and some will impact your business functions. To avoid rejected claims and cash flow interruptions, physicians should work with their vendors, clearinghouses, billing services, and payers to upgrade and test their systems, to ensure that they are able to successfully implement the new standards prior to the compliance date. The American Medical Association (AMA) has developed several resources to assist physicians make the transition to 5010, including the following checklist: 1. Talk to your current practice management system vendor. Be sure to ask the following questions: a. Will you be upgrading my current system to accommodate the 5010 transactions? b. Can my current system accommodate both the data collection and transaction conduction for 5010? c. Will there be a charge for the upgrade? d. When will the upgrades be available? e. When will the installation to my system be completed? f. What resources do you have to help us convert to 5010 before January 1? 2. Talk to your clearinghouses or billing service, and health insurance payers. Ask the following questions: a. Will you be upgrading your systems to accommodate the 5010 transactions? b. Will you be increasing your fees for the 5010 transactions? c. When will your upgrades be completed? d. When can I send test transactions to you to test that the system will work? e. Will I need to renegotiate my provider contract or electronic
data interchange (EDI) agreement based on the move to the 5010 transactions? f. What resources do you have to help us convert to 5010 before January 1? 3. Identify changes to data reporting requirements. Questions to consider are: a. Can we identify the data reporting changes for the various transactions we use? b. Can we find resources to assist us in identifying the data reporting changes? c. What is the cost of the resources we need? d. Should we use a consultant to assist us in identifying the data reporting changes? e. What is the cost of hiring a consultant? f. Which of this new data can be stored in our current system? g. Which of this data relies on the system upgrade in order to store it? 4. Identify potential changes to billing and EMR systems, existing practice work flow, and business processes. Questions to consider are: a. Do we need to make any system upgrades? What is the cost? b. Do we currently collect this data? c. If not, how will we capture the data? d. What added costs will result from new data collection methods, e.g., longer appointment times, revising existing forms? e. What work flow processes do we need to change or add to capture the new data? f. What are the costs of the newly revised work flow processes? 5. Identify staff training needs. Questions to ask include: a. Who should be trained on the transaction changes? b. How long will it take to train the staff on the changes? c. Will there be “downtime” during the training? d. Should we use a consultant to conduct the training and, if so, what is the cost of a consultant? e. What resources do we need for the training and to support staff after training? f. What is the cost of purchasing or creating the training resources?
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Is Your Practice Ready..., from page 17 g. When should training be completed? 6. Test with your trading partners, e.g., payers and clearinghouses. Questions to consider about testing: a. What transactions should I test? b. Which trading partners should I test with? Test the 5010 transactions with your payers, through the channels you use today, to send and receive transactions. Specifically test with the payers and clearinghouses that make up your highest volume and/or highest dollar amount of claims. c. When should I begin testing? Talk to your billing service, clearinghouses, and payers about the processes they will be using for testing. Follow their procedures and make certain that your testing is completed. d. Will the testing be truly test data or will it use live production data? e. Does everything work? Work with your vendor to fix any issues identified during testing and retest with your billing service, clearinghouses, and payers. 7. Budget for implementation costs, including expenses for system changes, resource materials, consultants and training. a. Do we have a backup plan? A major concern is the potential for disruptions in transactions processing after January 1, 2012. Physicians should develop a “backup plan” or safety net to address what they will do if their transactions do not work and they do not receive payments.
Where can I find more information?
A broad group of health care industry stakeholders (including the AMA) are coordinating their efforts to support a smooth and timely transition to the 5010 transactions and have developed free archived webinars that are available for viewing at GetReady5010. org. These webinars will focus on testing the 5010 HIPAA electronic administrative transactions and feature speakers from the Centers for Medicare & Medicaid Services (CMS), and provider and payer organizations. In addition, there are numerous online
Five Action Steps Your Practice Can Take Now The following are five simple actions you can take now to start getting ready for the 5010 conversion. Please note: These are not all of the 5010 data reporting changes; you should check with your clearinghouses and billing vendors to determine the full scope of changes that apply to your practice. Action 1: Is your practice reporting the appropriate Type 2 (organizational) National Provider Identifier (NPI) number for the Billing Provider on all electronic claim submissions? In 5010, you must bill all payers the same way using your lowest “level” Type 2 NPI for the Billing Provider. (For example, if your practice has an NPI at the practice level and you have a lab facility under the practice that received a separate NPI, then when billing for the lab services, you will be required to report the lab’s NPI. The lab’s NPI will need to be reported the same way to all of your payers.) If you are not doing this today, work with your payers now on making the changes to report your Billing Provider NPI correctly for 5010. Action 2: Is your practice using the 9-digit ZIP code in the Billing Provider and Service Facility Location address fields in your electronic claim submissions? In 5010, the 9-digit ZIP code is required in these two address fields. Begin using the 9-digit ZIP code today in these locations in preparation for the 5010 requirements. Action 3: Is your practice currently reporting a PO Box in the Billing Provider address field of electronic claim submissions? PO Boxes are not permitted in the Billing Provider Address field in the 5010 claim transaction. The Billing Provider Address must be the street address or physical location of the Billing Provider. If you wish to have payments delivered to a PO Box or different address from the Billing Provider street address, report this address in the Pay-to Address field. If you will be changing the address you report today in the Billing Provider Address field, you should contact your payers about updating your enrollment information. Many payers use the address in their provider files to validate the physician, so they may pend or reject your claims if you begin submitting a different address in your claim. You may also need to update your information in the National Plan & Provider Enumeration System (NPPES) (https://nppes.cms.hhs.gov/NPPES/Welcome.do). Action 4: Is your practice currently submitting electronic claim submissions that accurately balance at the line level? This will be a requirement in 5010, so begin making the claim balance at the line level. Payers will also be required to ensure the electronic remittance advice accurately balances at the line level. Action 5: Do you receive paper explanations of benefits? If not, now is the time to consider moving to electronic remittance advices. Use of the electronic transaction is more efficient and cost-effective for physician practices. In preparation for the electronic remittance advice transaction, become acquainted with the HIPAA mandated Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) that are used in the transactions. To access the current HIPAA CARC and RARCs, visit www.ama-assn.org/ go/claims-assistant to access a complimentary look-up tool or visit www.wpc-edi.com and select “Code Lists.” resources available from the AMA, the GetReady5010.org website, and CMS: American Medical Association website on “Version 5010 Electronic Administrative Transactions” (http://www.ama-assn.org/ama/ pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/
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hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards/ version-5010-electronic.page). The AMA’s website includes: • 5010 FAQs • AMA’s archived webinar, “5010 and ICD-10: What They Are and How to Prepare for Them”
• “5010 Checklist” that lists activities to guide physicians through their implementation of the Version 5010 HIPAA transactions • “5010 Project Plan Template – Helping Practices Prepare for the New HIPAA Standards” • “7 Steps Practices Can Take Now to Prepare for 5010” • 5010 Fact Sheet Series • Links to additional resources Centers for Medicare & Medicaid Services (CMS) website (http://www.cms.gov/Versions5010andD0/ ). The CMS website includes:
• Preparing for the Electronic Data Interchange (EDI) Standards: The Transition to Version 5010 and D.0 • New Health Care Electronic Transactions Standards Versions 5010, D.0, and 3.0 • Transition to Versions 5010 and D.0: Checklist for Level I Testing Activities • Transition to Versions 5010 and D.0: Provider Action Checklist for a Smooth Transition GetReady5010 website (http://getready5010.org): • An education effort supported by the
AMA and other health care industry stakeholders to support a smooth and timely transition to the 5010 transactions • Includes physician resources, as well as free webinars and materials on testing of 5010 transactions If you have questions or need assistance obtaining additional information, please call the SCCMA/MCMS at 408/998-8850 or 831/455-1008.
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Finding Money Every state has an unclaimed property list By Ara Oghoorian President, ACap Asset Management, Inc. This article originally appeared in the August 2011 issue of Southern California Physician Have you ever found money in the pocket of an old pair of jeans, or your lab coat, that you had completely forgotten about? It’s always a nice feeling to find “lost” money, but there is a much bigger pocket full of money that you may be overlooking—California’s unclaimed property list. Chances are that over the course of your medical education and training, you have lived in a few different cities and states. You diligently closed your accounts—telephone, cable, utilities, maybe even a bank account. But maybe there was some seemingly insignificant account you overlooked…anytime a company owes you money and cannot contact you, for whatever reason, the company cannot legally keep your money and is required to turn it over to the state as unclaimed (also known as escheat). Laws vary by state, but the general rule is that companies must escheat assets in-
active for three years. The most common types of property turned over to the state are earned interest on a closed savings account, rebate or refund check, dividends, stocks, and bonds; real estate and unused gift certificates are usually excluded. According to their website, the State of California is currently in possession of more than $5.7 billion in unclaimed property belonging to approximately 11.6 million individuals and organizations. The good news is that it is easy to find and collect your money. Collecting your money is as easy as filling out a simple form. I know firsthand that especially in the banking sector, unclaimed property laws are strictly enforced; while I was working at the Federal Reserve as a bank examiner, we regularly checked bank records to ensure banks were escheating unclaimed property to the states in a timely manner. There are many unclaimed property scams, so be careful of any unsolicited requests to help you claim
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your money for a fee. There is no cost to claim and collect money escheated to the state. However, if your unclaimed property exceeds a given amount, which varies by state, you may be required to get your claim form notarized. Once you make your claim, most states also allow you to check the status of the claim. I recommend you search any state you have ever lived in for your unclaimed properties. Start your search here: www.unclaimed.org and then click on your state to go directly to your state’s treasury and/or controller’s website. Always make sure the site you are visiting is an official government site with “.gov” or “.us” in their web address—you don’t want to get duped into scam sites trying to get your personal and financial information. Remember, unclaimed property is escheated to the state when a company cannot contact you, so to minimize future unclaimed properties, always update your contact information with any company you do business with, especially your financial institutions. Most of the time, the value of escheated property is a few hundred dollars. With medical insurance reimbursement dwindling, and gas prices rising, who couldn’t use a few hundred dollars?
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ENVIRONMENTAL HEALTH NEWS
Nanotechnology to Nanotoxicology A New Cause for Concern By Cindy Russell, MD VP of Community Health, SCCMA Nanotechnology using ultrafine particles (UFP) has been hailed as the next industrial revolution, but like many other industrial processes such as chemical manufacturing, human toxicity and ecotoxicity are studied well after their release into the environment. Early studies show that some nanoparticles can have significant long-term toxic effects due to their shape, small size, structure, biopersistence, and attachment to the product. These are, unfortunately, the very properties that give nanoparticles their unique functionality. The first nanoparticles created were thin film in 1974. Carbon soccer ball shapes, called “fullerenes,” were developed in 1986. (41) Since the early 2000s, nanoparticles have found their way into over 1,200 consumer products including electronics, sunscreen, food packaging, and health drinks. They have also found their way into recycled wastewater and farming soil. There is no requirement for labeling of products with nanoparticles. Many government agencies, both in the U.S. and abroad, have concerns about the safety of this technology. To date, there is no organized effort to monitor the chemicals or set responsible regulations for the protection of public health or the environment. The information in this article is taken from both peer reviewed journals as well as a comprehensive report from the University of San Francisco and California’s Office of Environmental Health Hazard Assessment. (1) It is hoped by many governmental and non-governmental scientists that action will be taken now to identify, monitor, and strictly regulate nanoparticles instead of following the path of our failed chemical policies.
What Is Nanotechnology?
The word nanotechnology is derived from the Greek word “nanos” which means dwarf. Nanotechnology creates and manipulates a new class of materials on the scale of atoms and molecules. As currently defined, these particles are from 1 to 100 nanometers and can only be seen with an electron microscope. One million nanometers equals one millimeter. A flea is 1million nm. A red blood cell is 7,000 nm. A bacteria is 1,000 nanometers. Nano scale particles are close in size to biological molecules such as DNA, proteins, and viruses. Their small size
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enables nanoparticles to be inhaled or ingested and taken into cells. With transcytosis, they can cross epithelial cells and endothelium entering into blood and lymph circulation. (38) Nanomaterials can contain one or more nanoparticles in different shapes and can have a metal base such as silver, titanium, or gold. They can also have a complex structure, such as in Quantum dots with a metal core of zinc, cadmium, or lead, and a biologically-friendly outer shell. Carbon-based nanomaterials can be in the shape of tubes (carbon nanotubes) or in the shape of a ball frame with hundreds of carbon atoms (fullerenes or “buckyballs”). Dendrimers and Polymeric nanomaterials refer to a large range of particles which branch out from a central core, which may be a metal such as gold. Dendrimers are typically highly biologically active or biocompatible. Because their use is highly specialized in pharmaceutical applications, there is a low public-health risk, whereas other nanoproducts in wide consumer use are much more of a concern at this time.
What Makes Nanoparticles So Special?
The small size of nanomaterials with a high surface area affects their electronic, optical, fluorescent, and chemical reactivity. Certain carbon-based nanotubules can behave as semiconductors, like metals. Nanotubes can also be valuable in instrument manufacturing and medicine. Manufactured nanoparticles usually serve as additives or ingredients to existing products such as silver impregnated fabrics, antifogging coating to glass, or paint dispersives. The science of nanoparticles spans every physical discipline. California has three of the five leading centers in nanotechnology in the U.S. which combine academics, research, non-governmental, and industry organizations. Nanotechnology is a rapidly growing big business. It is estimated that by 2014, nanotechnology-enabled products may be worth $2.9 trillion. (2)
What Consumer Products Contain Nanoparticles?
There are a variety of applications for nanomaterials. In some instances, the particles are “fixed” in the product and thus are less likely to be of concern. In other products, the nanomaterials are free floating and can then disperse in the environ-
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â€œFor those nanoparticles designed to stabilize food or to deliver drug via intestinal uptake, other, more demanding, rules exist and should be followed before marketing these compounds.â€?
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Nanotechnology to Nanotoxicology, from page 23 ment and can be absorbed into living systems. In electronics, nanoparticles are used in batteries, memory, and display modules. In sporting goods, carbon fibers are an integral part of the structure making tennis rackets and bicycles lighter. Nanoparticles are used in pigments, car coatings, antifog coatings, anti-fingerprint coatings, and on solar panels. In agriculture, nanoparticles are used to make pesticides and fertilizers adhere and persist. In medicine, nanoparticles, such as dendritics, are used for drug delivery, and in cellular regeneration, on various matrices. Silver nanoparticles are used as antibacterial coatings or additives for wound dressings. Nanoparticles are used for imaging and displays in medical devices. In personal care products, nanoparticles are now widely found in cosmetics. Titanium dioxide nanoparticles are used as a sunscreen to help disperse the product so it is not seen and also confer increased UV protection. These are “non-chemical” sunscreens with titanium dioxide that is “micronized.” Nanoparticles are used as glidants in mineralbased and other makeup, now totally over 160 personal care products. Nanoparticles are also used in nutraceuticals and as dietary supplements. They claim enhanced absorption and bioavailability of medications and vitamins. (16) Silicone dioxide, magnesium oxide, and titanium dioxide are used to coat confectionary products (Mars Bars) to increase shelf life. (16) Nanoclay polymers mix nylon, polystyrene, polyurethane, and other chemicals, and are now used to coat the interior of beer bottles (Miller Brewing Co. and Hite Brewing Co.). (16) Nanosilver is the largest material being utilized in household products. It is used in silver non-stick surfaces and utensils, nanosilver coatings on children’s products (i.e., baby bottles, pacifiers, wet wipes, and stuffed animals all claiming antibacterial properties), washing machines, and antibacterial socks, to mention a few. (23) The project for emerging technologies inventories products with advertised nanoparticles. (42) There is no requirement for labeling, thus many more products may contain them.
How Are Nanoparticles Harmful? Size Matters
Studies have shown that nanoparticles elicit different toxic cell responses and target different organs, depending on their size, shape, surface functionality, stability, and reactivity. Nanoparticles can enter the body via inhalation, ingestion, or with dermal exposure through injured and sometimes normal skin. Metal nanoparticles can bioaccumulate in the kidneys or liver. Unlike conventional chemicals, nanoparticles may trigger phagocytosis, whereby the cell membrane surrounds the particle, transports it to the center of the cell in order to break it down. Bacteria and viruses can be destroyed, however, nanoparticles may not be changed with normal biological processes and may accumulate in the cell and cause chronic irritation of the cell to the point of cell death. Nanoparticles can also cross cell membranes via diffusion or adhesion. Inside the cell, they can react with proteins, organelles, and DNA increasing their toxic potential. (26) Like some chemicals, they cannot be broken down, thus persist in the body. Scientists studying the mechanisms of action of toxins state the simple dose response curve does not always apply. Cell death after ex-
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posure to a toxin is a very complex interaction. The chemical or material may directly injure the cellular processes, but may also interfere with the immune system and tumor surveillance, thus causing cancer from long term exposure. Another method of cell death is called aptosis. Some call this cell suicide. It is a natural and programmed cell death found in normal development and initiated by the cell itself. Recent studies have shown that a variety of environmental contaminants, including heavy metals (copper, cadmium, mercury, lead), can cause aptotic cell death. (39) Engineered nanoparticles have been shown to induce aptotic cell death of macrophages after inhalation of single-walled nanotubes. (39) There is growing concern, as neurodegeneration is seen in some nanoparticle animal studies.(43)
Nanoparticle Effects on the Lungs
We know that exposure to complex mixtures of air pollutants produces inflammation in the upper and lower respiratory tract. Interest has risen in recent years with regards to the potential effects of ultrafine particles on pulmonary function. Nanoparticles have a much higher inflammatory potential than larger particles. When inhaled, they are efficiently deposited in all regions of the respiratory tract and they can translocate out of the respiratory tract to other parts of the body as well. (36)(38) Inhalation studies demonstrate that these smaller particles create oxidative stress, free radical formation, inflammation in cell culture, and in vivo in the lung. (26)(27)(28)(29)(30)(31)(32) Titanium dioxide nanoparticles have been shown to induce inflammation in the lungs in animal studies. (51) Carbon nanotubes have toxicologically significant structural and chemical similarities to asbestos. Multiple inhalation and injection studies have shown that carbon nanotubes act like the long fibers of asbestos and get stuck in the pleural lining causing pulmonary inflammation, granuloma formation, and fibrosis, which like asbestos could lead to mesothelioma. (33)(34)(35) (49)(50)(57) All these studies point to a potential for increased lung disease in populations already facing rising chronic pulmonary disease from chemical and air pollution.
Intestinal Absorption of Nanoparticles
Particulate uptake across the intestinal cells and into the bloodstream has been well documented since 1926. (58) Ingested nanoparticles are absorbed, depending on morphology, and charge through or around normal intestinal cells or through Peyer’s patches (PP). Peyer’s patches are aggregates of lymphoid tissue in the small intestine which are responsible for immune surveillance and response. Particulates, once in the sub-mucosal tissue, are able to enter both lymphatic and capillaries to other organs.(58)(59)(60) Jani found increased uptake with smaller diameter. Nanosized polystyrene particles were much better absorbed than larger particles. (61) (62) The GI tract is an efficient delivery system for vaccines and drugs, thus is well studied. An increasing route of exposure to nanoparticles is through consumer products, food additives, packaging, and drugs. “For those nanoparticles designed to stabilize food or to deliver drug via intestinal
uptake, other, more demanding rules exist and should be followed before marketing these compounds.” Dr. Hoet (55)
Nanoparticles: Destination Brain
“The current state of oversight regimes should raise serious concerns for policymakers tasked with the challenge of encouraging nanotechnology innovation in a responsible and sustainable manner.”
We have known for years that air pollution causes chronic lung disease. But recent studies now show brain damage from air pollution. CalderonGardciduenas, et al., found significant inflammatory neurodegenerative changes in the olfactory bulbs, olfactory mucosa, and cortical and subcortical brain structures in dogs from a heavily polluted area in Mexico City, whereas these changes were not seen in a less polluted rural control city. (52) As it turns out, the nasal cavity, olfactory bulb, and respiratory epithelia are a common portal of entry to the brain and targets for toxicological damage. (36) This circumvents the very tight blood brain barrier. Oberdörster, in 2002, reported the translocation of inhaled nanoparticles via the olfactory nerves. (38) A translocation pathway from the respiratory tract to the brain was demonstrated over 60 years ago for polio viruses. Herpes virus travels long distance in a similar pattern along the axon. Transport velocity for nanoparticles in nerve axoplasm has been shown to be 2.4mm/hour. (36) A Japanese study, in 2009, showed that titanium dioxide nanoparticles could transfer from pregnant mice to their offspring and cause nervous system damage and reduced sperm production in the male offspring. (44) Sárközi, in 2009, instilled manganese nanoparticles into the airways of adult rats and found that manganese had access from the airways to the brain with resulting behavioral, electrophysiologic, and toxicologic effects. (45) In vivo studies of fish indicate that nanoparticles already in use can have adverse effects on wildlife. Oberdorster studied carbon based lipophilic fullerenes, which are now being manufactured by the tons and used in cosmetics and face creams. (65) He found oxidative brain damage in large mouth bass. (46) The cumulative effects of these increasing exposures are unknown. (68) Trickler, in 2010, studied silver nanoparticles effects on rat brain. He found inflammation and an increase in the blood brain barrier with smaller nanoparticles. He states that “if left unchecked, these events may further induce brain inflammation and neurotoxicity.”(67) Wang found that titanium dioxide nanoparticles instilled intranasally directly entered the brain through the olfactory bulb in the whole exposure period, and deposited more heavily in the hippocampus region where spatial navigation and both short term and long term memory are located. Toxicity was seen via oxidative damage leading to an inflammatory response. (86) There is great cause for concern as more research indicates that inflammation of the brain can directly cause Alzheimer’s disease.(66)
Reactive Oxygen Species and Cardiovascular Effects of Nanoparticles
Reactive Oxygen Species (ROS) are highly reactive chemical molecules in living organisms implicated in many disease states including aging, DNA damage, brain dysfunction, cell damage, organism stress, inflammation, Alzheimer’s disease, to name a few. Reactive Oxygen Species are the normal byproduct of metabolism and function to signal cells for apoptosis (cell death), immune stimulation, and platelet aggregation. Chemicals and heavy metals can increase ROS in our bodies. Our bodies make natural antioxidants to combat free radical formation (ROS). These are chemicals like glutathione and enzymes such as superoxide dismutase that scavenge the free radical before much harm can be done. If there is excessive ROS, these free radicals damage cellular DNA, oxidize proteins, inactivate enzymes, signal inflammation, or cell death. Oxidative stress is believed to be one of the major deleterious consequences of exposure to nanomaterials. (29)(30)(56)(40) Radomski, in 2005, showed that some carbon nanoparticles and microparticles have the ability to activate platelets and enhance vascular thrombosis. (48) Other studies have shown similar effects. (75)
Lifecycle of Nanoparticles : Entrance Into the Soil and Water Cycle
What is the fate of nanoparticles in our sunscreen, powdered makeup, microbe proof teddy bear, or silver impregnated socks once they are washed down the drain? The solids that go to the treatment plant are put on agricultural fields as fertilizer and the liquid is used for irrigation in landscaping and agriculture, with the rest pumped into local rivers or bays. Soon, we will be drinking this reclaimed water and paying a lot more for it, as we are approaching serious water shortages. Will we be able to remove nanoparticles in sewage treatment? Good question, considering we are not removing many persistent toxic chemicals now such as flame retardants, pharmceuticals, estrogenic synthetic compounds from primary wastewater treatment, which are effecting fish and other aquatic organisms. (89)(90)(91)(92)(93)(94)(95)(96)(97)(98)(99) (100)(101) We have yet to control known toxins in the environment, as we add newer emerging contaminants to the list. Studies have shown that nanoized copper causes acute toxicity and gill injury in Zebrafish. (82) Silver particles are known to be toxic to freshwater fish and have now become a major pollutant in San Francisco Bay and other surface
Continued on page 26
SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 25
Nanotechnology to Nanotoxicology, from page 25 waters from wastewater discharge. (85) (5)(6)(7)(8)(9) Nanoparticles are already in our soil and wastewater.
Beneficial Bacteria at Risk: Antibacterials Gone Awry
While we need antibacterial products in medicine, too much of a good thing can cause disruption in healthy ecosystems including our gastrointestinal tract. Studies have now shown that E. Coli bacteria strains were greatly inhibited by even small amounts of titanium dioxide nanoparticles. Most of these are beneficial friendly bacteria that keep the gut healthy by preventing establishment of pathogenic bacteria and producing vitamin K. Titanium dioxide particles have been considered non-toxic, as they do not incite a chemical reaction. Nanoparticles of titanium, however, interact with living organisms in a much different way. They can travel through the body and cause oxidative stress. Schiestl exposed mice to titanium dioxide in their drinking water. By the fifth day, they began to show genetic damage with double stranded DNA breaks and signs of inflammation. (76) Silver has broad spectrum antimicrobial activity towards many pathogens and it has been used in the past for medicinal purposes. The bactericidal activity of silver, however, inhibits soil microbial growth at levels below the concentrations of other heavy metals. (77) The antimicrobial effects of silver nanoparticles also have impacts at the ecosystem level affecting beneficial soil organisms (bacteria and fungi) that “feed” nutrients to plants. Researchers grew plants in biosolids with and without the addition of ecologically relevant silver nanoparticles. These levels of silver nanoparticles were within the range that the U.S. Environmental Protection Agency reported finding in a recent survey of biosolids from water treatment plants. The nanoparticles reduced the growth of one of the tested plant species by 22 % compared to silver-free biosolid treatment. Similarly, microbial biomass was reduced by 20%. (80) Considering nanoparticles do not degrade, are biologically active, and bioaccumulate, this has serious implications for the future of agriculture. Canada, in 2010, joined several other countries banning nanotechnology as a prohibited substance or method in organic food production. (81)
Hijacking Wastewater Treatment
Sewage treatment is a several step process of removing contaminants from wastewater prior to discharge into local waterways or for non-potable uses. In southern California, sewage effluent is used as drinking water after additional treatments. Usually, there are three steps. Primary treatment involves separating solids from liquids. Secondary treatment involves biological degradation of the suspended organic matter in the effluent by microorganisms. Tertiary treatment occurs when additives are used to clean the water if discharged into a sensitive ecosystem or if used for non-potable uses, such as golf courses. Nanoparticles have been shown to inhibit bacteria that are used to help degrade the organic matter in sewage treatment plants. (88)(89) Preliminary studies to evaluate removal of nanoparticles in wastewater
26 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
show that it is not as easy as predicted. (83)(84) Dr. Limbach states “results indicate a limited capability of the biological treatment step to completely remove oxide nanoparticles from wastewater.” (83) Next Steps in Growing a Sustainable Nanotechnology Industry While there has been an avalanche of research and development in commercial nanotechnology, there has been a sharply contrasted lack of data with regards to human and environmental safety testing. The emerging science of nanotoxicology has identified some real concerns for some nanoparticles with regards to public health and the environment, including wildlife, fragile aquatic, and soil ecosystems. “The current state of oversight regimes should raise serious concerns for policymakers tasked with the challenge of encouraging nanotechnology innovation in a responsible and sustainable manner,” says David Rejeski, Director, Project on Emerging Nanotechnologies, Woodrow Wilson International Center for Scholars. Many government and non-governmental organizations have written extensive reports with regards to the concerns of nanotechnology and its oversight. The conclusion of these reports is that there is inadequate data on toxicology of these diverse particles, exposure data, and biomonitoring, as well as a lack of adequate regulation. A comprehensive 2011 report by the Office of Environmental Health Hazard Assessment Cal/EPA and the University of California San Francisco titled “Recommendations for Addressing Potential Health Risks From Nanomaterials” discusses these issues, and specific goals for government agencies were suggested. (1) Many lessons have been learned about chemical contamination too late. It is hoped that earlier action will prevent major public and environmental health problems. Below are some policy recommendations from the report.
UCSF-OEHHA Recommendations for Addressing Potential Health Risks From Nanomaterials
1. Traditional mass-based dose models may not be sufficient to characterize toxicity. New traits or properties will need to be defined and considered. 2. Heeding early warnings and using environmental monitoring is integral to identifying, evaluating, and monitoring potential hazards. 3. Persistent and/or bioaccumulative materials should be identified early, as build-up of exogenous chemicals are usually detrimental in some way. 4. Targeted research in the area of biological transport and distribution of nanomaterials, including sources, routes of contact, and internal distributions. Integrate this with the information gathered on exposure potential. 5. Require sufficient toxicological testing information to assess safety of risks to consumers, including susceptible subpopulations such as infants preferable premarket, and postmarket as necessary. 6. Require testing of release and exposure potential for nanomaterials in consumer products that have widespread
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use, such as titanium 3210_BulletinSantaClara.indd 1
dioxide, silver nanoparticles, and carbon nanotubes. Testing must be completed for products to remain on the market. 7. Collect information on fate and transport of nanomaterials, including monitoring in environmental and biological media. Require centralized reporting mechanisms, and maintain them in a systematic manner. 8. Susceptible sub-populations should be characterized in risk assessment and considered in decision-making. 9. Implement a labeling system that requires labeling products that contain nanomaterials. 10. Support a publicly accessible clearinghouse and inventory of products and sources of nanomaterials, requiring disclosure of where nanomaterials are manufactured, in what quantities, and for what new or existing products such as through product labeling. 11. Develop a framework for making policy and regulatory decisions based on nanomaterials’ use, exposure potential, and exposure to susceptible subpopulations, while weighing public health or societal benefit. 12. Integrate nanomaterial safe handling practices into standard lab safety training for academic, industrial, and other laboratory workers and students. 13. Continue to include provisions for public input and comment during the decision-making processes.
Nanoparticle Nanotoxicity References
7/29/11 11:16 AM
For a full report of all references, visit www.sccma-mcms.org and click on the “Environmental” tab, then “Articles.” 1. Recommendations for Addressing Potential Health Risks From Nanomaterials in California. Office of Environmental Health Hazard Assessment and University of California San Francisco, Obstetrics, Gynecology and Reproductive Sciences. June 2011. http://www.prhe.ucsf.edu/prhe/nanodocument.html 2. Davies, J., EPA and Nanotechnology: Oversight for the 21st Century. 2007, Project on Emerging Nanotechnologies, Woodrow Wilson International Center for Scholars: Washington DC. p. 76. 3. Toxicity and cellular responses of intestinal cells exposed to titanium dioxide. Koeneman BA. Cell Biol Toxicol. 2010 Jun;26(3):225-38. Epub 2009 Jul 18. http://www.ncbi.nlm.nih. gov/pubmed/19618281 4. Sunscreens With Titanium Dioxide (TiO2) Nano-Particles: A Societal Experiment. Jacobs JF, van de Poel I, Osseweijer P. Nanoethics. 2010 Aug;4(2):103-113. Epub 2010 Jun 2 http:// www.ncbi.nlm.nih.gov/pubmed/20835397 5. Toxicity and bioaccumulation of TiO2 nanoparticle aggregates in Daphnia magna. Zhu X, Chang Y, Chen Y. Chemosphere. 2010 Jan;78(3):209-15. Epub 2009 Dec 5. http://www.ncbi.nlm.nih.gov/pubmed/19963236
SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 27
HELP STARTS HERE
Refer Patients to 211 for Everyday Needs and in Times of Disaster When your patients need non-urgent help and don’t know where
or exam rooms, contact Victo-
to turn, suggest they dial 211. These three simple digits connect the
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edwaymcca.org) in Monterey
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United Way Silicon Valley
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211mc.org in Monterey County for community resources.
is a program of United Way
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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
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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
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CALPAC — Fighting for You! By Richard Thorp, MD Chair, CALPAC As Chair of CALPAC (California Medical Association Political Action Committee), I wanted to give you an update on how CALPAC has been fighting for you in the political arena. CALPAC supports candidates and elected officials that are friendly to the House of Medicine. There have already been four special elections throughout the state this year: • Assembly District 4 (North of Sacramento) – CALPAC supported Beth Gaines, a republican businesswoman from Roseville. Mrs. Gaines handily won the election over democrat Dennis Campanale. • Senate District 17 (Antelope Valley) – CALPAC supported former Assembly Member Sharon Runner, a republican businesswoman from Antelope Valley. Mrs. Runner also handily won the election over Darren Parker. • Senate District 28 (Los Angeles) – CALPAC supported former democratic Assembly Member Ted Lieu. Assembly Member Lieu defeated republican James Thompson and moved to the upper house. • Congressional District 36 (Los Angeles) – CALPAC was instrumental in AMA’s Political Action Committee supporting democratic Los Angeles Council Member Janice Hahn. Council Member Hahn defeated republican Craig Huey in the high profile race. I can say that these members will now be strong advocates on our behalf. Despite our successes, we still face many challenges. Trial attorneys have already started a fight to overturn MICRA (California’s landmark Medical Injury Compensation Reform Act), there are ongoing efforts to erode the prohibition on the corporate practice of medicine, and there are continuous efforts to challenge your scope of practice. Your support is needed to build on our successes and ensure that we have the necessary resources to prepare for the 2011–2012 election cycle. These elections are going to be transformational for the California 30 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
Legislature. The Citizen’s Redistricting Commission has finalized Congressional, State Senate, State Assembly, and Board of Equalization districts. The perceptions of the commission’s decisions, good and bad, are likely to shape a national trend. These newly drawn districts, coupled with California’s open primary system, will result in a number of very contentious races. CALPAC has extensively studied the new districts and is preparing for these high profile races, on your behalf. The bottom line is this: we must be stronger than ever to defend against increased challenges to physicians, both in the legislature and in the upcoming elections. That is why I am asking for your support. I have believed for some time that donating to CALPAC is one of the most important contributions that I make because it ensures medicine has direct access to the policy makers that have the potential to come between me and my patients. Personally, I have been a President’s Circle member for nine years by donating $1,000 every year. By making a contribution today, you will ensure we continue to have the most active political affairs operation in California. 2012 is going to be a very challenging year, with many more high profile elections for us to be involved in than ever before. Please visit www.calpac.org to donate today! I look forward to working with all of you, on behalf of our patients and our profession.
California Medical Association Political Action Committee Participation Level: o $6500 - Diamond
2011 MEMBERSHIP FORM Fighting For You! CALPAC, the California Medical Association Political Action Committee, supports candidates and legislators who understand and embrace medicine’s agenda. Health care in California
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ever, you need to fight to keep medical decisions in your well-trained hands.
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Successful legislative advocacy depends upon an integrated approach, consisting of lobbying, continuing grassroots activity and political action through CALPAC. CALPAC
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Breastfeeding Awareness A Plea to Physicians for Education and Action By Jeanne Batacan, CMA, ICCE, CD, CLC,
August was Breastfeeding Awareness Month, and August 1-7 was World Breastfeeding Week. On Saturday, August 6 at 10:30 a.m., in more than 294 locations and time zones across the globe, women and their children came together and breastfed simultaneously as part of the Big Latch On. One of those locations was in Campbell, CA, and yet, it went unnoticed and unreported. This apparent apathy about breastfeeding is partially due to lack of physician support and the general lack of education on human lactation in our medical schools. The Surgeon General Regina M. Benjamin provides us with some of the best scientific information available on how to improve health and reduce the risk of illness and injury. The Surgeon General’s Call to Action to Support Breastfeeding contains specific steps to follow to make breastfeeding accessible. www.surgeongeneral.gov/topics/breastfeeding/calltoactiontosupportbreastfeeding. pdf Breastfeeding advocates struggle to fill the educational gap between physicians and the latest updates in breastfeeding medicine. One way physicians can fill the gap is by subscribing to the bi-monthly journal of Breastfeeding Medicine, www.liebertonline.com/bfm. Physicians should also become familiar with the AAP Policy Statements, http://aappolicy.aappublications.org/cgi/content/full/ pediatrics;115/2/496#SEC8. In part, they state the “role of pediatricians and other health care professionals in protecting, promoting, and supporting breastfeeding [is]:
Education: • Become knowledgeable and skilled in the physiology and the current clinical management of breastfeeding. • Encourage development of formal training in breastfeeding and lactation in medical schools, in residency and fellowship training programs, and for practicing pediatricians.
Use every opportunity to provide age-appropriate breastfeeding education to children and adults in the medical setting and in outreach programs for student and parent groups.
Clinical Practice: • Promote hospital policies and procedures that facilitate breastfeeding. • Work actively toward eliminating hospital policies and practices that discourage breastfeeding (e.g., promotion of infant formula in hospitals including infant formula discharge packs and formula discount coupons, separation of mother and infant, inappropriate infant feeding images, and lack of adequate encouragement and support of breastfeeding by all health care staff) • Encourage hospitals to provide indepth training in breastfeeding for all health care staff (including physicians) • Have lactation experts available at all times PEDIATRICS Vol. 115 No. 2 February 2005, pp. 496-506 (doi:10.1542/peds.2004-2491) This would include gifts of formula or literature by formula companies given out of medical offices as well. In fact, hospitals and offices that offer free formula to breastfed infants are in violation of the International Code of Marketing of Breast-milk Substitutes, www. who.int/nutrition/publications/code_english. pdf, as well as not complying with the U.S. Baby-Friendly Hospital Initiative designation protocols. According to the Academy of Breastfeeding Medicine (ABM), www.bfmed.org, recent studies indicate that formula feeding in the U.S. causes substantial numbers of excess infant deaths. The risk of post-neonatal (29–365 days of age) mortality is about 27% higher among infants who are never breastfed compared to infants who are ever breastfed. On this basis, nearly 1,000 infant deaths in the U.S. alone occur each year. This does not take into account the rates of infant morbidity due to formula feeding.
32 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
What are some of the risks of NOT breastfeeding? Among full-term infants: • Surgery for acute otitis media • Hospitalization for lower respiratory tract diseases in the first year • Asthma (no family history) • Childhood obesity • Type 2 diabetes mellitus • Acute lymphocytic leukemia • Acute myelogenous leukemia • Sudden infant death syndrome Among preterm infants: • Necrotizing enterocolitis ■■ The gastrointestinal (GI) tract of a normal fetus is sterile ■■ The type of delivery has an effect on the development of the intestinal microbiota ■■ Tight junctions of the GI mucosa take many weeks to mature and close the gut to whole proteins and pathogens ■■ Intestinal permeability decreases faster in breastfed babies than in formula-fed infants ■■ Open junctions and immaturity play a role in the acquisition of NEC, diarrheal disease, and allergy ◆◆ Vaginally-born infants are colonized with their mother’s bacteria ◆◆ Cesarean-born infants’ initial exposure is more likely to environmental microbes from the air, other infants, and the nursing staff which serve as vectors for transfer (See full report with references at www. nababreastfeeding.org/images/ Just%20One%20Bottle.pdf) Implications for all babies – it is important that babies are colonized with their mother’s bacteria. It is imperative that serious consideration of policy be made regarding any unnecessary separation of mothers and babies
Continued on page 34
August was Breastfeeding Awareness Month
SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 33
Breastfeeding Awareness, from page 33 and that immediate skin-to-skin becomes the routine policy whenever possible (even with cesarean sections). Introducing just one supplement of formula can make undesirable changes in the gut flora that can take up to 2-4 weeks of exclusive breastfeeding to return back to where it (physiologically) should be. http://massbfc. org/formula/bottle.html Among mothers (who do not breastfeed), there are increased rates of: • Type 2 diabetes • Breast cancer • Ovarian cancer • Postpartum depression and child abuse • Osteoporosis Breastfeeding benefits society. The nation benefits overall when mothers breastfeed exclusively for six months. In addition to saving lives, the United States would also save $13 billion per year from sick visits, hospitalizations, prescriptions, insurance, and lost time from work for parents of breastfed infants. • Breastfeeding protects the environment by producing less trash and plastic waste compared to formula cans and bottle supplies. www.womenshealth.gov/breastfeeding/whybreastfeeding-is-important/ In addition to the many significant health, environmental, societal, psychological, and ecological benefits, breastfeeding provides food security in the event of disaster and in these challenging and uncertain financial times. Even a poorly nourished mother can provide her infant/s with superior nutrition. Our hospital policies must be reexamined, so that healthy babies are not separated from their mothers (even after cesarean section), and that mothers practice Kangaroo Care with not only at-risk babies, but healthy babies as well. And supplemental feedings of formula are sharply curtailed. First, do no harm. http://my.clevelandclinic.org/healthy_living/ Infant_Care/hic_Kangaroo_Care.aspx According to the CDC, only 13.3% (2007) of infants were exclusively breastfed for the first six months. The Healthy People 2010 target goal for any breastfeeding at six months of age is 50%. None of the race-ethnicity groups achieved the target goal. These statistics must be changed, and it is up to the health care community to take a stand and help make this change by becoming more informed, involved, and educated. Exercise your vote for breastfeeding within the AAP by joining the Section on Breast-
feeding (SOBr). The SOBr works to educate its members and all physicians about breastfeeding care. Networking opportunities are also available for AAP members interested in or concerned about breastfeeding support, promotion, and protection. http://practice.aap. org/content.aspx?aid=1451. Join the Academy of Breastfeeding Medicine and become familiar with their protocols and statements, www.bfmed.org/Resources/ Protocols.aspx. There’s help close at hand. Here are some educational web links for you and your patients: • Dr. Jack Newman, pediatrician and breastfeeding expert, www. breastfeedingonline.com/newman. shtml • HHS Office of Women’s Health has a great website and downloadable breastfeeding guides, http:// womenshealth.gov/breastfeeding/ index.cfm • NIH has information, www.nichd. nih.gov/health/topics/Breastfeeding. cfm • NIH’s MedlinePlus has all the latest medical and scientific facts and research about breast feeding, www.nlm.nih.gov/medlineplus/ breastfeeding.html • CDC also has some terrific resources, www.cdc.gov/search.do?queryText=br eastfeeding&action=search&searchBu tton.x=10&searchButton.y=11 • Kellymom.com provides evidencebased information for breastfeeding moms. Learn more by becoming familiar with organizations such as: • The Baby-Friendly Hospital Initiative – www.babyfriendlyusa. org/eng/index.html and campaign for your facility to become designated as Baby-Friendly. Shamefully, there are none in Santa Clara County! And, it doesn’t take years to become designated. Many dedicated, committed facilities have achieved this in as little as eighteen months. • The Coalition for Improving Maternity Services (CIMS) – focuses on Mother-Friendly Maternity Care. How women give birth does affect breastfeeding success. www. motherfriendly.org In our own back yard, several educational organizations help inform, educate, empower,
34 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
and support expectant and new families in your practice. These local organizations exist for the sole purpose of educating, nurturing, and supporting local families. Partner with them. Refer your patients to them. By working together, we can improve the statistics and improve access for all moms and babies. • Morgan Hill – The Loft Family Enrichment Center, 408/933-3978 http://www.TheLoftMorganHill.org/ • Campbell – Harmony Birth & Family, 408/370-3702 http://www.harmonybirth.com/ • Palo Alto – Blossom Birth, 650/3212326 http://blossombirth.org/ • Bay Area Birth Information (BABI), 408/874-6686 http://www.bayareabirthinfo.org/ • WIC provides eligible breastfeeding mothers with educational materials, peer counselor support, breast pumps, and other supplies, http://www.fns.usda.gov/wic/ Breastfeeding/mainpage.htm • Santa Clara County Breastfeeding Taskforce, Kathy Sweeney, 408/3703702 http://www.californiabreastfeeding. org/SantaClara.html • Mothers’ Milk Bank, Pauline Sakamoto, MS, PHN, RN, 408/9984550 http://www.sanjosemilkbank.com/ • Nursing Mothers Council http://www.nursingmothers.org/html/ counseling.html • La Leche League http://lllnorcal.org/LocalGroups.html
About the Author:
For over 30 years, Jeanne Batacan has been an advocate for birthing and breastfeeding mothers. She received her lactation training through UCLA as well as her three breastfed children. Jeanne is also a certified childbirth educator and holds a CA state adult teaching credential through UCSC, and is a certified labor and postpartum doula (ICEA). Jeanne is a co-owner of The Loft Family Enrichment Center in Morgan Hill and a founding member of Bay Area Birth Information (BABI). She is also a member of the Santa Clara County Breastfeeding Taskforce and the Coalition for Improving Maternity Services (CIMS).
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“Even when you think you have your life all mapped out, things happen that shape your destiny in ways you might never have imagined.” - Deepak Chopra “I learned to embrace risk, as long as it was well thought out and, in a worst-case scenario, I’d still land on my feet.” - Eli Broad The LWA team includes Michelle Hamilton, MBA as a specialist in financial planning and portfolio administration. SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 35
MEDICAL TIMES FROM THE PAST
The Valley’s First Practitioner By Michael A. Shea, MD Leon P. Fox Medical History Committee Before the Americans, before the Mexicans, before the Spanish, there were the Ohlones. This Indian tribe lived and flourished in our county for over 5,000 years. The art of healing among the tribe evolved over time. By the 1800s, they could treat minor aches, pains, colds, and flu with a variety of herbal medicines. They knew how to set fractures, tamponade bleeding wounds with compresses of animal hair, and even induce abortion. For serious illnesses, there was a special healer called the shaman. He or she (mostly male) received their calling at an early age. This was usually through a dream-type vision. Apprenticeship with the current shaman would then commence until the student was deemed ready to practice on his own. This would take several years. A shaman was held in high esteem by the tribe and was considered wealthy by Indian standards. When a family member became seriously ill, the shaman was offered a fee of clam shell beads (Ohlone money) and, if accepted, the patient-healer relationship was established. The Indian concept of disease was that it was caused by the victim’s enemy (i.e., putting a hex on someone). It was the shaman’s job to find the pain caused by an evil one and remove it. Proper attire was important to the shaman and certainly impressed the fretting family. His face was painted black, and black stripes lined his wrists, shoulders, thighs, and ankles. He would wear a skirt of raven feathers and hold a wand of eagle feathers in his hand. Suspended from his belt was the foot of a coyote, while around his neck hung a string of bear claws and the head of a falcon. Tufts of feathers on weasel skin bracelets dangled from his wrists, while cocoon rattles jangled around his ankles. Chanting and dancing would then go on for hours. This was designed to call on help from the animal gods. These could be any of the following: coyote, eagle, hummingbird, falcon, lizard, or grizzly bear. These animal gods could be of real benefit to the shaman, especially if seen in a dreamlike state brought on by the repetitive dancing and chanting.
After hours, even days of this ritual, the final part of the treatment was begun. A medicine pouch of otter skin was produced. It contained a hollow bone tube, a small flint knife, coyote hair, fingernails, cougar whiskers, an inchworm, and other assorted objects. The shaman made a small superficial incision over the area of suspected disease and placed the hollow tube over the cut. He sucked hard and strong. Gagging and choking, he put his hand to his mouth and spat out the offending agent. It could be a ball of coyote hair or any of the other
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objects in the medicine pouch. If the shaman was lucky, the patient would awaken refreshed and cured. If he was unlucky, the patient would die. Crestfallen, he would return the beads to the family, in hopes they would not plot to harm him. A colorful character, a magician, a spiritualist, a practitioner, could all describe the person who held this high ranking position among the local tribe. He was, above all, their shaman, and he practiced his art for thousands of years right here in our Bay Area.
SCCMA Alliance News Alliance Fall Tastings
On Sunday, September 11, twenty-four SCCMA Alliance members, family, and friends met at Byington Winery in the beautiful Santa Cruz Mountains to enjoy the vistas and ambience of this local winery. Alliance members included Meg Giberson; Suzanne Jackson, SCCMAA Chair; Dr. Bill Lewis, SCCMA President and Alliance member; Carolyn Miller; our hostess Kathleen Miller; and Donna Spagna. We were given a guided tour of the winery and learned the process of wine making. Byington Winery buys grapes from vineyards around the state, specifically in Paso Robles (Chardonnay grapes) and Ventana Vineyards (Sauvignon Blanc grapes). We learned that Pinot Noir grapes were the only estate-grown grapes. The winery had introduced a new wine in 2009, “Liage,” made from a pairing of Viognier (bringing a tropical aroma and full mouth feel) with Sauvignon Blanc (highlighting acidity for a clean finish on the palate). This wine was a big hit with the group. The afternoon concluded with a potluck lunch and great conversation, enjoyed by all Alliance members and guests.
The new exhibit at the deYoung Museum inspired several Alliance art lovers to head to San Francisco to view Picasso: Masterpieces from the Musée National Picasso. This rare viewing of more than 100 masterpieces by the Spanish artist was made possible because of a temporary closure and extensive renovation of the Musée National Picasso in Paris. Alliance members were dazzled by the colors and shapes of Picasso’s drawings, paintings, and sculptures. Driving through Golden Gate Park, the members concluded the day with a lovely lunch in the cool fog of the Beach Chalet. Alliance members are planning additional social events in the near future. See our website at SCCMAA.org to find out more.
SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 37
Electronic Health Records: From Selecting a System to Demonstrating Meaningful Use CMA and CMAF Publish a Resource to Help Physicians at Every Step of the Process The 2009 federal economic stimulus package provides funding to promote the adoption of health information technology (HIT), the vast majority of which will be directed to physicians to subsidize the purchase and usage of electronic health records (EHR) systems. Beginning in 2011, qualifying Medicare providers stand to receive up to $44,000 and qualifying Medi-Cal providers stand to receive as much as $63,750. The promise of the federal EHR incentives is causing a wide range of reactions among California physicians. There is excitement about the financial benefits available both through the incentives and practice efficiency. There is also confusion about issues such as how to get started, how to select the right system, and what does “meaningful use” mean? To help physicians through this process, the California Medical Association (CMA) and the CMA Foundation have published a comprehensive EHR guide called the EHR Desk Reference. The reference was funded by a generous contribution from the Physicians Foundation. Due to the foundation’s support, the Reference is available free-of-charge to any physician. The EHR Desk Reference brings together information, tools, and resources from many sources into one comprehensive tool to help physicians and their practices make the transition to EHR. It includes in-
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formation from CMA, the American Medical Association, the California Academy of Family Physicians, the Texas Medical Association, and many others. The Desk Reference can help both specialists and primary care physicians in all modes of practice. It is designed to help physicians at any stage of the EHR implementation process. Some of the topics covered in the book include: • Understanding the Federal Incentive Programs • Selecting the Right EHR for Your Practice • Talking to Your Patients About Your EHR • HIPAA Compliance • Meaningful Use In conjunction with the release of the Desk Reference, CMA staff and physicians will be traveling the state distributing copies and speaking about EHR adoption. Watch your county medical society publications for a seminar taking place in your area. Or, if you would like to schedule a speaker at your hospital medical staff meeting, medical group, or other gathering, please contact the CMA member helpline at 800/786-4262. To download a copy of the Desk Reference, or to view CMA’s collection of tools and resources around HIT, please visit the CMA HIT Resource Center at www.cmanet.org/hit.
California Medical Association & California Medical Association Foundation
Electronic Health Records Desk Reference Funded by The Physicians Foundation
The California Medical Association (CMA) would like to introduce the Physicians’ EHR Desk Reference. This resource was developed with the help of the California Medical Association Foundation and the Texas Medical Association and made possible by generous support from The Physicians Foundation with the goal of promoting efficiency and quality improvement in healthcare. Electronic health record (EHR) adoption, implementation and achieving Meaningful Use can be challenging tasks. The CMA Physicians’ EHR Desk Reference is comprised of information created, collected and organized into a user-friendly format which can help guide you and your staff to successful EHR implementation and qualifying for thousands of dollars in federal EHR incentives. This reference has been developed for physicians at any stage of EHR adoption. The information and resources contained within the reference will be useful to you at any stage whether you are Produced by the trying to decide if you are going to adopt an EHR system, planning the purchase of an EHR system, beginning the implementation process, working to achieve Meaningful Use, or just looking for additional tips on fine tuning your current system and workflow.
Download a free copy of the Physicians’ EHR Desk Reference at: http://www.cmanet.org/resource-library/ detail?item=ehr-desk-reference
California Medical Association & California Medical Association Foundation
Electronic Health Records Desk Reference Funded by The Physicians Foundation
Produced by the
The California Medical Association (CMA) is an advocacy group dedicated to “promote the science and art of medicine, protection of public health, and the betterment of the medical profession.”
SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 39
Classifieds office space for rent/lease ATRIUM STYLE PROFESSIONAL BUILDING • SALINAS Located one block from Salinas Valley Memorial Hospital. Medical/ Dental suites from 1,250 sq. ft. to 2,500 sq. ft. Off street parking, conference room, beautiful common area. Move-in incentives. Call Nick at 831/771-5515. 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. 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. 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. MEDICAL OFFICE FOR LEASE • SALINAS 4,816 sq. ft. Class “A” medical office for lease/sublease – all or part. Modern professional office in sought after medical office area on Abbott Street in Salinas. The office space has nine exam rooms, two waiting rooms with two patient entrances. There is A/C, emergency power, travertine floors, and granite counters. Lease a third, two-thirds, or all. $2.75/sq. ft. Not triple net. Call 831/238-9001.
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/PROFESSIONAL OFFICE FOR LEASE Medical/Professional office 2,600 sq. ft, ground floor near Santana Row. $2.00 sq. ft. Available now. Email at email@example.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. 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 408/867-1815 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.
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.
ELEGANT AND SPACIOUS LOS GATOS MEDICAL OFFICE
Available to share with prominent aesthetic dermatologist. This upscale office has seven 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.
Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families Owners Bill & Debbi Ricks 408-354-5613
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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 Rick Flovin, CEO at 408/228-0454 or e-mail email@example.com for additional information.
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PHYSICIAN OPPORTUNITY Established Internal Medicine group is searching for new partner or group to consolidate with private practice in Los Gatos. Opportunity is available immediately. Practice has in-house lab and ancillary testing; no HMO accepted. Please forward CV to fax 408/358-0261 or email cristine.lrpg@yahoo. com. INTERNIST WANTED San Jose Medical Group has an immediate opening for a Board Certified, experienced Internist. One of our busy Internists relocated to Southern California recently, creating an opportunity for the right candidate to step into a successful growing practice. Must have excellent communication, clinical, and interpersonal skills. Excellent salary and benefits with bonus opportunities. Please fax CV to 408/278-3181 or email tania_mcadams@ sanjosemed.com.
Dave Breithaupt's 2nd novel-just released!
'Thee Needs Killing, Marly' Tells the story about an addicted San Jose attorney who tries to kill, then stalks his doctor, a lifelong pacifist who despises guns, but soon changes his mind. Summaries of the 2 books concerned with addicted professionals — those who love them and those who treat and police them, along with splendid but humble details about the old geezer author can be seen at www. davebreithaupt.com SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 41
$3.8 billion in federal loans available to fund new co-op insurance plans The federal health reform law—the Patient Protection and Affordable Care Act (ACA)— calls for creation of private, consumer-governed, non-profit health insurance plans, called co-ops (consumer operated and oriented plans). Co-ops will offer qualified health plans through state health insurance exchanges as an alternative for consumers to traditional, forprofit plans. $3.8 billion in federal loans are available to these new entities to cover startup costs and to help them meet state insurance solvency and reserve requirements. The Centers for Medicare & Medicaid Services (CMS) recently began accepting applications for co-op start up and solvency loans. First round applications are due October 17, 2011, and successful applicants will be awarded funds by January 12, 2012. The U.S. Department of Health and Human Services (HHS) also recently released proposed rules governing the creation of coops. The rules describe standards that co-ops
must meet and the process through which they can apply for the federal start up and solvency loans. According to the proposed rules, co-ops will qualify for startup loans if they have a high probability of becoming financially viable, which CMS will determine based on evaluations of their legal, operational, and business plans. Startup loans must be repaid within five years and solvency must be repaid within 15 years. Earlier this year, the California Medical Association (CMA) sent a letter to HHS on the issue of co-ops, urging the agency to allow flexibility in its loan and grant provisions. CMA believes that while the not-for-profit, local governance co-op model will be attractive to California physicians and patients, one of the greatest barriers to their success will be ability to amass the financial reserves necessary to cover unexpected catastrophic claims and losses. “Thus, co-ops will either have to carry
large financial reserves or be forced to purchase reinsurance to mitigate unexpected catastrophic losses,” CMA noted in its letter. CMA has urged HHS to explore ways the federal government could sponsor reinsurance to co-ops. CMA’s letter emphasized that in order for co-ops to provide access to comprehensive, quality patient services, they must have “robust provider networks of primary care and specialist physicians, who must be paid fairly and adequately.” To this end, CMA stressed that coops must be able to pay physicians actuarially sound rates, which are essential to attracting and maintaining physician participation in a start-up co-op. CMA also urged HHS to promote physician involvement in co-ops – on their governing boards and in their management and provider networks. (CMA Alert, September 6, 2011 issue)
CMS pushes back deadline for e-prescribing exemption The Centers for Medicare & Medicaid Services (CMS) recently issued a final rule that makes several significant changes to the 2011 Medicare e-prescribing initiative. Among the changes is a one-month extension to the deadline to apply for a hardship exemption. Physicians now have until November 1 to file for an exemption. The final rule requires physicians in individual practices to have submitted at least 10 Medicare Part B claims with the electronic measure code eRx G8553 and an eligible encounter code by June 30, 2011. Physicians who failed to do so will see their 2012 Medicare payments reduced by 1%, unless they fall into one of the six new exemption categories: • Physician’s practice is located in a rural area without high speed Internet access. • Physician’s practice is located in an area without sufficient available pharmacies for electronic prescribing. • Physician is registered to participate in the Medicare or Medicaid electronic health record incentive (EHR) program and has adopted certified EHR technology. • Physician is unable to electronically prescribe due to local, state, or federal law or regulation (e.g., prescribes controlled substances). • Physician infrequently prescribes (e.g., prescribe fewer than 10 prescriptions between January 1, 2011, and June 30, 2011) . • There are insufficient opportunities to report the e-prescribing 42 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
measure due to program limitations. Physicians can apply for more than one exemption category if applicable to their particular situation. Individual physicians will be able to apply for an exemption from the 2012 e-prescribing penalty via an online web-portal at http://www. cms.gov/erxincentive. Exemption requests from individual physicians will not be accepted via mail, e-mail, or fax. Group practices already participating in the 2011 e-prescribing group practice reporting option must submit an exemption request via mailed letter (group exemptions cannot be submitted online or via e-mail). Physicians who met the 10-claim minimum by June 30, and who report at least 15 more qualifying electronic prescriptions before the end of 2011, will be eligible for a 1% Medicare bonus next year. Questions regarding the use of CMS’s web-portal should be directed to the Quality Net Help Desk at 866/288-8912, or firstname.lastname@example.org. Although the California Medical Association (CMA) is pleased that CMS provided more flexibility under the exemption categories and extended the deadline to apply for an exemption, we had hoped for even greater flexibility, including an additional reporting period. CMA remains concerned that physicians will be unfairly penalized because they have not been given enough time to comply. (CMA Alert, September 6, 2011 issue)
Appeals court upholds constitutionality of MICRA’s $250,000 cap on noneconomic damages California’s 5th Appellate District Court recently upheld the constitutionality of our state’s landmark Medical Injury Compensation Reform Act (MICRA), which caps noneconomic damage awards at $250,000. This case, Stinnett v. Tam, is just the latest in many legal challenges to MICRA that have been funded by trial lawyer groups from across the country. The California Medical Association (CMA) filed a “friend of the court” brief and also participated in oral argument, telling the court that the broader goal of MICRA—to ensure access to care—is just as relevant today as it was in 1975. CMA noted that as recently as 2005, the Legislature declared that there was a “growing crisis” in physician supply, and that California needs to continue to attract and retain physicians rather than drive them away. CMA was joined in this case, through CMA’s Amicus Curiae Committee, by the California Hospital Association, the California Dental Association, and the American Medical Association. The original complaint, filed in 2007, concluded with a jury verdict awarding the plaintiff $148,302 for past economic loss, $1,242,093 for future economic loss, and $6,000,000 for noneconomic damages, also called “pain and suffering.” In a post-verdict motion, the defendant moved to reduce the noneconomic damages award pursuant to MICRA’s $250,000 cap. The plaintiff opposed the motion, arguing that MICRA is unconstitutional, because the medical professional liability insurance crisis of 1975 no longer
exists, thereby eliminating the rational basis that originally justified MICRA. The trial court disagreed and granted the defendant’s motion. The appeals court agreed with the lower court’s ruling. Today, MICRA is still working to restrain premium rates in California, while states without liability reform are seeing dramatically higher premiums. Because of MICRA, California has a system that is affordable, pays patients for their full economic and medical losses, and promotes patient safety and improved patient care. MICRA allows patients with justifiable medical negligence claims to receive the following forms of compensation: • Unlimited economic damages for past and future medical costs. • Unlimited damages for lost wages, lifetime earning potential, or any other economic losses. • Unlimited punitive damages. • Up to $250,000 for noneconomic damages (pain and suffering) MICRA’s $250,000 cap on noneconomic damages has proven to be an effective way of limiting meritless lawsuits and keeping health care costs lower, but has been targeted by the trial lawyers because it restricts the amount of money they can collect in attorney’s fees. MICRA includes a sliding pay scale to control attorney contingency fees, ensuring that more money goes to patients, not lawyers. (CMA Alert, September 19, 2011 issue)
Blue Cross seeking to settle overpayment refund requests; physicians encouraged to carefully review settlement language before signing As previously reported, the California Medical Association (CMA) has received a number of complaints from physicians that the Anthem Blue Cross Special Investigations Unit (SIU) is requesting refunds outside of the 365-day period allowed by California law. State law allows health plans to pursue recovery of any type of overpayment made to providers within 365 days of the date the claim was paid. For claims older than 365 days, plans can seek to recover overpayments only if the alleged overpayment was “caused in whole or in part by fraud or misrepresentation on the part of the provider.” CMA believes that Blue Cross is using an overly broad definition of “misrepresentation” to seek recoupment on claims older than one year. In June, CMA filed a formal complaint with the Department of Managed Health Care (DMHC) asking that it investigate these potential violations. DMHC subsequently referred CMA’s complaint to its Enforcement Division. CMA has received calls from physicians who report that they have
been contacted by Blue Cross SIU, offering to reduce overpayment amounts due if they agree to sign settlement agreements. CMA believes some of the recoupment requests that the SIU is trying to settle may be the same requests that are the subject of our complaint filed with DMHC. Physicians who are approached to sign any type of settlement agreement are strongly encouraged to ask for the offer in writing and to have an attorney review the settlement before signing. Often, these types of settlement agreements require that physicians waive and abandon their legal rights over the moneys at issue. To help physicians understand their rights and options when it comes to health plan refund requests, CMA has published a “Special Investigations Unit Audit Guide.” This document is available free to members in CMA’s online resource library at http://www.cmanet.org/ resource-library. (CMA Alert, September 19, 2011 issue) SEPTEMBER / OCTOBER 2011 | THE BULLETIN | 43
Board urges State Fund to reconsider restrictions on opioids for intractable pain The California State Compensation Insurance Fund (SCIF), the state’s largest workers’ compensation insurer, recently notified the physicians in its medical provider network (MPN) that they must agree to refrain from prescribing opioids for a period longer than two months and not prescribe compounded medications without prior authorization from the insurance adjuster or by order of a workers’ comp judge. The new rules, detailed in SCIF’s “General Provisions and Criteria” document, also stipulate that MPN physicians cannot even prescribe certain medications at all, regardless of medical necessity. The California Medical Association (CMA) believes that these new provisions are an attempt by SCIF to exert control over physicians’ practice of medicine and clinical judgment, require physicians to treat injured workers differently than other patients and violate state law, which allows for prescribing, dispensing, furnishing, or administering controlled substances for the treatment of a condition causing pain, including but not limited to intractable pain. The restrictions also violate the Medical Board of California’s Guidelines for Prescribing Controlled
Substances for Pain. In addition to the concerns above, SCIF’s notice required physicians to agree to the new preauthorization rules within two weeks or be kicked out of the MPN. State law requires insurers to provide physicians with at least 45 business days’ notice of a material change to a contract. The law also gives physicians the right to terminate the contract prior to implementation of the change. At CMA’s request, the California Medical Board reviewed SCIF’s preauthorization requirements for opioid prescriptions and has informed CMA that it shares the association’s concerns. The board recently sent a letter to SCIF, urging the fund to review the board’s guidelines for the treatment of intractable pain and to reconsider whether the preauthorization requirements are “a necessary component of effective treatment provided in the workers’ compensation arena.” If SCIF doesn’t voluntarily withdraw the provisions, the medical board has told CMA that it will take further action. (CMA Alert, September 6, 2011 issue)
CMA applauds passage of resolution to increase physician supply in California The California State Senate recently gave bipartisan support to a joint resolution that urges the President and Congress to provide resources to increase the supply of physicians in California to improve access to care in underserved areas. The resolution also encourages the President and Congress to consider solutions that would increase the number of graduate medical education residency positions to keep pace with the growing need for physicians in California and the United States. “With the baby boomers beginning to retire, national health care reform expanding coverage to millions of previously uninsured citizens, obesity rates hitting epidemic levels, and the repercussions of the national recession and California’s own severe budget deficit still playing out, it is more important than ever that we continue to assess, address, and reform the obstacles facing California’s health care system,” said California Medical Association (CMA) President James G. Hinsdale, MD. “The most important of these obstacles, and one that is projected to grow substantially in the coming years, is ensuring sufficient and timely physician access for every Californian in need of a physician’s care.” The Council on Graduate Medical Educa-
tion (COGME) recommends that a state have between 60-80 primary care physicians per 100,000 people. In California, there are on average 63 primary care physicians for every 100,000 people. However, 42 out of California’s 58 counties fall below COGME’s minimum recommendations regarding adequate physician supply for primary care. “Our state is barely meeting the recommended supply of primary care physicians and those numbers are unevenly dispersed throughout the state, leaving some communities without access to care for miles,” Dr. Hinsdale added. CMA has been active on a number of fronts to address the challenges of physician supply and distribution, including: • Working with the legislature to create the Steve Thompson Scholarship program. The program would provide up to $105,000 in scholarships to selected participants who agree in writing prior to completing an accredited medical or osteopathic school to serve a minimum of three years in “medically underserved areas” or where unmet propriety needs for physicians exist, as determined by the
44 | THE BULLETIN | SEPTEMBER / OCTOBER 2011
California Healthcare Workforce Policy Commission; • Creating the Steve Thompson Loan Repayment Program that provides grants to pay off medical loans for physicians working in underserved areas. Each participating physician receives up to $105,000 in exchange for a three-year service commitment in a medically underserved area of the state; • Supporting new medical schools, UC Merced and UC Riverside, and pushing an expedited timeline to build them; • Supporting efforts to increase the diversity of the physician workforce through CMA’s Ethnic Medical Organization Section; and • Promoting increased incentives for pursuing primary care and supporting primary care physicians to keep their practices viable. “On behalf of the California Medical Association, I want to thank Assembly Member Ricardo Lara for his leadership in seeing this resolution through,” Dr. Hinsdale said. “Clearly, this is an issue that we can all agree needs attention, as the need for physicians is certainly not going away.” (CMA Alert, September 6, 2011 issue)
New voluntary Medicare initiative will test bundled payment models The Centers for Medicare & Medicaid Services (CMS) announced last month that it will pilot four different models for bundling payments to physicians and hospitals. Under CMS’s new Bundled Payments for Care Improvement Initiative, hospitals, physicians, and others will be able to propose discounted fees for bundled payments across a single episode of care during a hospital stay in an acute care hospital and during post-discharge recovery. The pilot projects were authorized by last year’s federal health reform legislation. Currently, when a Medicare patient undergoes a course of treatment, the various providers involved are paid separately by Medicare, which, according to CMS officials, often results in inefficient, uncoordinated care. CMS believes that the new payment models will motivate providers to cooperate to improve quality and lower costs. Providers would be paid under the Medicare fee-for-service system, but at a discounted, negotiated rate. Any savings achieved from holding costs below the negotiated price could be shared among participating physicians and hospitals. Current Medicare gain-sharing rules prohibit hospitals from sharing savings with physicians who help them lower costs. The bundling initiative waives these prohibitions so that hospitals, physicians, and post-acute
AMA Launches 2011 Billing Code iPhone, iPad App The AMA released a free application that allows physicians to search for CPT billing codes. The app was developed to help physicians identify the correct E&M codes for billing purposes. The app is compatible with Apple’s top mobile products.
care providers can coordinate and share in savings. Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively. Through the bundled payments initiative, providers will have great flexibility in negotiating the fees, selecting conditions to bundle, developing the health care delivery structure, and determining how payments will be allocated among participating providers. However, the bundled payment will only be made to hospitals for distribution to the other providers. Therefore, CMA recommends that participating physicians, medical staffs and medical groups be fully engaged in the design and implementation of local pilot projects. Previous demonstration projects suggest tremendous savings potential. A recent heart bypass surgery bundled payment demonstra-
tion, for example, saved Medicare $42.3 million—about 10% of expected costs—and saved patients $7.9 million in coinsurance. More importantly, the program improved care and lowered hospital mortality. Providers interested in participating in the initiative must apply by September 22 for model 1 and by November 4 for models 2–4. More information about the various models and their requirements is available on the CMS Innovation Center website at http://www.innovations.cms.gov/areas-of-focus/patient-caremodels/bundled-payments-for-care-improvement.html. CMA is working to submit other California pilot proposals to the CMS Innovation Center that allow physicians in all modes of practice to participate in new physician-led delivery and payment models. (CMA Alert, September 6, 2011 issue)
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