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NOVEMBER / DECEMBER 2012  |  Volume 18  |  Number 6

CMA's Legislative Wrap-up and House of Delegates Highlights

at your dental plan It’s Open Enrollment time for the Santa Clara County Medical Association and Monterey County Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). During Open Enrollment only, members may join as an individual or as a group with your employees. Low, calendar year deductible of $50 per person ($100 per calendar year maximum for families). Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on January 1, 2013. Call a Client Service Representative at 800-842-3761 for more information. Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.

Sponsored by:

Underwritten by:

Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage.

56602 ©Seabury & Smith, Inc. 2012

AR Ins. Lic. #245544 • CA Ins. Lic. #0633005 d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance@marsh.com • www.CountyCMAMemberInsurance.com



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


Feature Articles


10 CMA’S 2012 Legislative Wrap-Up

CME Tracking Discounted Insurance

22 What to Know Before You Store Patient Credit Card Numbers

Financial Services

30 House of Delegates 2012

Health Information Technology

50 Labeling of Genetically Engineered Food




Human Resources Services

6 From the Editor’s Desk

Legal Services/On-Call Library

8 Message From the SCCMA President

Legislative Advocacy/MICRA

9 Message From the MCMS President

House of Delegates

Membership Directory iAPP for the iPhone Physicians’ Confidential Line Practice Management Resources and Education Professional Development Publications Referral Services With Membership Directory/Website Reimbursement Advocacy/ Coding Services Verizon Discount

18 SCCMA Award Nominations 20 NORCAL, NORCAP, and SCCMA-MCMS: Anatomy of a Rebate 24 Medical Times From the Past 28 Member Benefit: CME Cruise 40 CMA Foundation Publishes 2013 AWARE Provider Toolkit 42 MEDICO News 46 Fundraiser for Assemblymember Jim Beall 54 Classified Ads NOVEMBER / DECEMBER 2012 | THE BULLETIN | 3

The Santa Clara County Medical Association Officers President Rives C. Chalmers, MD President-Elect Sameer Awsare, MD Past President William S. Lewis, MD VP-Community Health Cindy Russell, MD VP-External Affairs Howard Sutkin, MD VP-Member Services Eleanor Martinez, MD VP-Professional Conduct Seham El-Diwany, MD Secretary Scott Benninghoven, MD Treasurer James Crotty, MD

Chief Executive Officer


William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Dan Fox, MD Good Samaritan Hospital: Richard Newell, MD Kaiser Foundation Hospital - San Jose: Seema Sidhu, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Richard Kline, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Peter Koltai, MD Santa Clara Valley Medical Center: Richard Kramer, MD

AMA Trustee - SCCMA James G. Hinsdale, MD

CMA Trustees - SCCMA Thomas M. Dailey, MD (District VII) Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)



Printed in U.S.A.



President John F. Clark, MD President-Elect Kelly O'Keefe, MD Past President James Ramseur, Jr, MD Secretary Patricia Ruckle, MD Treasurer Steven Vetter, MD


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

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2012 by the Santa Clara County Medical Association.



DIRECTORS Paul Anderson, MD

David Holley, MD

E. Valerie Barnes, MD

John Jameson, MD

Jose Chibras, MD

Jeff Keating, MD

Ronald Fuerstner, MD

Eliot Light, MD

James Hlavacek, MD

R. Kurt Lofgren, MD

AMA Trustee - mcms David Holley, MD (Alternate)


DISABILITY Protecting the rights of all policyholders to be treated fairly and in good faith.

Unfortunately, the same insurer that readily accepts your premium dollars may not be so eager to pay benefits. Pillsbury & Levinson lawyers pursue insurance bad faith litigation on behalf of doctors and their patients in coverage disputes. We seek compensation for our clients’ financial losses, as well as punitive damages and attorney’s fees. We have collected hundreds of millions of dollars in policy benefits for clients throughout California in all types of insurance matters.

415.433.8000 | 888.433.8335


Lo n g -T e r m C a r e



Joseph S. Andresen, MD Editor, The Bulletin

Obamacare is the Law of the Land By Joseph S. Andresen, MD Editor, The Bulletin On November 7, 2012, a day after the re-election of President Obama, Republican and House Majority Leader, Congressman John Boehner, stated, “Obamacare is the law of the land.” This was an abrupt change from the rally cry to repeal the Affordable Care Act (ACA) on day one, if the presidential election had turned out differently. It is now certain that some uncertainty has been removed from the direction our nation is headed in health care reform.  The Supreme Court has settled the main questions of the constitutionality of the ACA, including the individual mandate and expansion of Medicaid.  The U.S. Department of Health and Human Services just extended the deadline for states to set-up health insurance exchanges from November 16th to December 14th.   “It’s full-steam ahead with implementation,” said Dan Mendelson, a consultant who ran the health portfolio in the Office of Management and Budget under President Bill Clinton. So what should we expect going forward?   As you may recall, the main provisions of the ACA are yet to be implemented.   In 2013, Medicaid payments for primary care providers will increase to 100% of the Medicare payment to be financed by the federal government.  There will be continued closure of the Medicare Part D drug coverage gap and a reduction in Medicare Disproportionate Share Hospital (DSH) payments to hospitals, based on the amount of uninsured and charity care provided.  The most far reaching provisions of the ACA will occur in 2014 and include the individual requirement to have insurance, the activation of health insurance exchanges administered by state or the federal government, guaranteed availability of insurance with essential benefits, and the expansion of Medicaid.  For a more detailed description and timeline of implementation see:  http://healthreform.kff.org/timeline.aspx.  So how do physicians respond to this tidal wave of change?  Certainly, we are already feeling some turbulence in the waters surrounding us and now we can see the crest of breaking waves on the horizon.  This past week, Dr. Ahmed Sadiq, outgoing ACCMA president, invited me to attend the 144th annual meeting of the Alameda-Contra Costa Medical Association. (http://www.accma.org/AboutUs/MissionHistory. aspx)  Much like our own SCCMA, the ACCMA is an active and vibrant physician organization, adding a strong voice to our profession.  A notably bright spot reported at the meeting was increasing membership and participation by physicians in their county organization over this past year.  The ability to successfully navigate the strong currents of change will require our engagement and advocacy in this regard. Perhaps the most illuminating and timely topic of the evening was comments made by the keynote speaker, Ken Nichols, PhD, director of 6 | THE BULLETIN | NOVEMBER / DECEMBER 2012

the Center for Health Policy and Research and Ethics and professor of Health Policy, George Mason University.   Dr. Nichols is a widely-respected health economist who has appeared over the past 30 years testifying before Congress to offer his expertise and advice on health care policy.  Both Democrats and Republicans respect him for his straight talk and ability to clearly explain the many complex issues at hand.   In his Arkansas, down-home accent, Dr. Nichols painted a clear and daunting picture of our move toward implementing the ACA.  As he began, “Supporters of the ACA always had TWO goals: to enable all Americans to finally have access to quality care, but in ways that are affordable for families and for our society as a whole. ...It is a complex piece of legislation, changing insurance market rules to enable access to all regardless of health status (a fundamentally moral stance), and financing the necessary subsidies with both Medicare savings and modest tax increases (a fiscally-responsible stance).” It is clear that the ACA is far from perfect and numerous resolutions at the CMA House of Delegates convention on October 17, 2012, resulted in heated debate.  Easing the transition of 1.6 million new Medi-Cal enrollees, ensuring network adequacy, and amendments of ACA to “address issues of concern to the practice of medicine” were all topics leading to resolutions.  More information can be found here:  http:// www.cmanet.org/resource-library/detail?item=cma-reform-essentialsoctober-25-2012. Dr. Nichols’ advice to the physician audience was simple, yet a provocative challenge.  “We are going to have to offer better value in the quality of medical care we provide.  We do great in treating patients with heart attacks or in neonatal care.  But our care has been uneven and spotty and we rank 37th in the world in life expectancy after age 60 (ranked even with Costa Rica), despite spending vastly more money per capita.  It is estimated that 18,000 Americans die each year because they do not have adequate access to care.”   We are going to have to do more with less. How we achieve this, whether it’s an accountable care organization or fee-for-service model or hybrid will be up to us.  There is a void of details that needs to be filled-in to lead us in the right direction.  And who better to lead us than those who provide the care, namely physicians.  If we don’t provide the leadership and fill this void in the coming months and few years, someone else will.  Physicians can do this much better than the bean-counters in Washington, DC.  So let us get to work, collaborate, and lead!

Joseph S. Andresen, MD, is the editor of The Bulletin. He is board certified in anesthesiology and is currently practicing in the Santa Clara Valley area.

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Rives C. Chalmers, MD President, Santa Clara County Medical Association

California Health Insurance Exchange (Cali-Health) By Rives C. Chalmers, MD President, Santa Clara County Medical Association Beginning January 2014, individuals and employers with up to 50 employees, then 100 employees after 2016, may purchase health insurance from an online exchange run by the state. There will be minimum benefits covered in each plan, based on the Kaiser Small Group HMO. The insurer’s plans must “qualify,” meeting the standards set nationally by the ACA law. Cost sharing, the amount paid by the patient in deductible and co-pay, is standardized with each plan level. The subsidy paid by the government (read taxpayer) depends on the income. FPL (Federal Poverty Level), $18,500, is the benchmark. For an individual – $24,645, for a family of three – $74,120 (133-400% FPL). At this level of income, the plan is subsidized. It appears the amount of subsidy is complex and may not be determined, as yet. The average cost of Kaiser Health Plan insurance is $11,500, as of November 2012, with the employee paying an average of $2,500. Therefore, the cost of the new plans will not be cheap, with an estimated 2.1 million newly insured through the exchange and an additional 1.6 million newly insured Medi-Cal enrollees under the expansion called for by the ACA law in California. Coverage details for the minimum plan are not finalized, but pediatric dental and vision care, physical therapy, smoking and substance abuse treatment, and home health visits will probably be included. Autism therapy, acupuncture, 100-day skilled nursing facility, and surgically-implanted hearing devices will likely be adopted. Pre-existing conditions, coverage of children through age 26, and no lifetime caps for persons with pre-existing costly chronic conditions will be continued. The premium for older

persons may not be more than three times the premium for the young and healthy. The younger insureds will help subsidize the old. There will be an open enrollment period to change or secure new insurance. A person who does not pay their premium has three months grace before they are off the plan. Physician services during these three months will be paid for the first month, then held, “pending” premium payment. If the person is dropped, they may apply for new insurance at the next open enrollment without penalty. The physician services during the last two months, however, will not be paid. This applies to persons receiving federal tax subsidies. This shifts risk of non payment to the physician. Although the plan must notify the physician of this risk, the responsibility for notification has been placed on the California Department of Managed Care, which is not adequately staffed to maintain up-todate network lists. The fixing of this graceperiod unpaid claims problem is being ad-

dressed by the CMA. At this time, only community clinics will be paid to advise, screen, and enroll patients in an Exchange Qualified Health Plan (QHP). They will be paid $58 per application. Primary care physician offices will not be compensated for counseling, screening, and helping to fill out the applications.

Rives C. Chalmers, MD, is the 2012-2013 president of the Santa Clara County Medical Association. He is a board certified orthopaedic surgeon and is currently practicing in the Los Gatos area.



John f. clark, MD President, Monterey County Medical Society

What is a Physician’s Role in this Debate? By John F. Clark, MD President, Monterey County Medical Society With the election of 2012 behind us and Barack Obama once again set firmly in the White House for another four years, it is natural to reflect on what this means for the country and, in particular, for health care. There is a general tendency, after any election, to be expansive about the mandate embodied in the outcome of the election. It is prudent to draw conclusions with care and sober humility. Health care played a major role in the campaigning of both candidates, as much as other major issues such as the war in Afghanistan and immigration. This attention was largely driven by the Republican determination to make repeal of the ACA a major plank in their party platform. Given the fact that Obama won, it is relatively safe to say that the country, at least, does not have a majority appetite to undo the changes that have been put in place by the ACA. This would also imply that we, as a country, continue to have an interest in some form of health care reform. For those in the medical community, this should be a welcome message. However, exit polls demonstrate very close percentages in those that would repeal the ACA and those that would expand it. There remains much controversy. That our health care system is broken has been well documented. Costs continue to rise unsustainably with little improved quality to show for the added expense, based on such measures as life expectancy and infant mortality relative to other countries. Millions of Americans go without insurance either because they do not receive it as a benefit from their employment, they are priced out of the market, or they are excluded due to pre-existing conditions. Market forces tend to provide health care for the well and the wealthy and exclude it for the sick and the poor. This necessitates large public programs to step into

the breach, but funding for these programs is either contracting or not keeping pace with rising costs. The ACA, as historic as it is, is more accurately characterized as insurance reform and does little to address the underlying dynamics that are driving costs. There is ample room and necessity for creative solutions to address these fundamental issues. A major impediment to finding such solutions is the public polarization around the role of government in providing health care, evidenced by this year’s exit poles. On the one hand is the notion that health care is a market failure with market forces being fundamentally incapable of equitably providing for the general welfare, with regards to the health of the people. This idea, in its purist form, considers health care a right and that the ultimate solution to our health care problems can only be met by a national health program that removes market inefficiencies and inequality in favor of a basic package provided for all and paid for by broad taxation. On the other hand is the notion that health care can only be delivered efficiently by market forces and the less government involvement, the better. This idea, in its purist form, considers health care more of a privilege and that individuals must take personal responsibility for providing for their own care through purchasing it on the open market with perhaps some form of minor government assistance for the needy, through a voucher system. These purist visions are obviously mutually exclusive, however, they are the extremes in a broad spectrum of opinions regarding a path forward. What currently exists is a blend of these two visions in a private and public partnership embodied by individual and employer purchased heath benefits, as well as publicly purchased care for the poor and the needy. The ACA does little to change this basic formula. What is a physician’s role in this debate? I had a discussion with one of my patients, dur-

ing a visit this week, concerning her fear that come 2014, my office will become inundated with new patients and she will not be able to get in to see me, if needed. I was at pains to reassure her, and this episode presented an opportunity to discuss the issue. There will be many such opportunities in the months and years to come for all physicians, both individually and as a group. It is a dynamic time and physicians will need to raise their voice not only in individual interactions, but collectively through organized medicine. Your medical society is a major conduit through which physicians can amplify their voice in order to influence the process. We are actively engaging local, state, and federal legislators in an effort to continue a dialogue concerning health care in our community and our country, based on input from our members. We are offering our members as a resource to these legislators, and are implementing innovative programs to facilitate engagement, such as interactive polling, up-to-date news bulletins, and meetings with local legislators. We look forward to broad participation and an active collaboration with all stakeholders. Please share this article with your colleagues. Together we are stronger!

John F. Clark, MD, is the 2012-2013 president of the Monterey County Medical Society. He is a board certified family medicine physician and is currently practicing with Salinas Valley PrimeCare Medical Group, Inc.


One Must IMagIne sIsyphus happy The California Medical Association’s 2012 Legislative Wrap-Up By Jodi Hicks, CMA VP of Government Relations

n years past, the California Medical Association (CMA) has defended physicians in battles waged by hospitals, health plans and mid-level practitioners, but this year we initiated a few fights of our own. CMA did what physicians do best: We fought to protect patients. CMA fought to keep patients out of the middle of billing disputes, to educate parents about immunizations, to require mandatory flu vaccinations for health care workers, to remove sugared beverages from schools, to create a physician health program, to expand residency programs and a last minute effort to save the Healthy Families Program. 10 | THE BULLETIN | NOVEMBER / DECEMBER 2012

Sponsoring legislation is the equivalent of pushing rocks up a hill‌ or rather big righteous boulders. The CMA Government Relations team struggled to push those rocks up the legislative hill while fighting off the enemies trying to get in the way, and at the same time stopping the many other rocks being thrown down at physicians. Sounds dramatic, but by all accounts, it was a crazy, precarious, contentious, hazardous and dramatic pathway to the finish line. We finished with some big wins and although we lost a few along the way, CMA fought for physicians and their patients until the very end.

Out of the gate in January, CMA came out swinging. We introduced AB 1742 (Pan), which would have enabled patients to assign their benefits directly to the provider furnishing medical services. Sounds simple enough, but the bill soon came under attack from the health plans and culminated in what was described on one blog as the “juiciest” health committee hearings of the year. After much back and forth, the bill came up one vote short before reaching a legislative deadline to move the bill. That same week, CMA battled the unions, championing a bill through both a health and labor committee that would mandate flu vaccines for health care providers in hospitals. Against all odds and much opposition, SB 1318 (Wolk) moved through the Senate in a decisive win for public health. Though CMA was able to maneuver this contentious bill all the way through the Legislature, it was subsequently vetoed by the Governor. CMA also joined a large coalition of health care providers in a valiant attempt to create a physician health program in California. The coalition worked tirelessly to address the opposition’s concerns surrounding funding, oversight and standards, and the bill made it all the way through both committee hearings and was on its way to the floor when it stalled. Despite the coalition’s diligence, the overwhelming demands of the opposition damaged the bill beyond repair before the last legislative deadline. Despite an end to this bill, we are confident that the conversation can continue and this will be an issue CMA will look to advance next year. And then came Rob Schneider. CMA, along with the American Academy of Pediatricians, the Health Officers Association of California and the California Immunization Coalition, sponsored AB 2109 (Pan) in an attempt to decrease the number of parents exempting their children from being vaccinated before entering public schools. Hundreds of anti-vaccine activists flooded the committee hearings to oppose the measure and eventually were joined by Saturday Night Live alum Rob Schneider. Now armed with “celebrity” status, the opposition was able to secure public rallies, television time and spread of social media to oppose our efforts. Despite attempts at negative media attention by the opposition, Governor Brown signed AB 2109 into law hours before the deadline. The year wouldn’t be complete without CMA revisiting some oldies but goodies, physical therapy and MICRA being no exceptions. Unfinished business from 2011, SB 924 (Steinberg/Price) would have fixed the ambiguity in law as to whether or not medical corporations

can legally employ physical therapists, but it would have also allowed patients to directly access physical therapy treatment for 30 business days, at which time a physician would have to sign off on a physical therapy treatment plan. CMA had an official “Oppose unless Amended” position on the bill, asking for amendments that would have required a medical diagnosis after 30 days of direct treatment. The Assembly Appropriations Committee passed the bill, adding in medical diagnosis as a requirement for direct access. The California Physical Therapy Association again amended the bill on the floor, changing the language so that instead of requiring a diagnosis it would require an examination or a diagnosis… and as the game of semantics wore on, the bill was quickly sent to Assembly Rules Committee where it stayed until its demise. Two bills that would have weakened the protections of MICRA, SB 1528 (Steinberg) and AB 1062 (Dickenson) were amended the last week of session adding to the flurry of the chaos in the final days. The provider community strongly opposed both bills and thanks to letters and phone calls from physicians across the state, they were ultimately killed with astoundingly low vote counts. The legislative session officially ended early Saturday morning, September 1, 2012, and CMA’s Government Relations team was at the Capitol until the very end. In the waning hours of the 2011-2012 Legislative Session, CMA successfully negotiated key amendments into the Workers’ Compensation bill and proudly fought to reinstate the Healthy Families program as part of a multi-part deal that died sometime after 1:00 am. Despite bipartisan support for our efforts, the Healthy Families program became collateral damage to partisan politics. CMA continues to work with stakeholders on the transition of kids to Medi-Cal. More to come on this issue… “The Myth of Sisyphus” tells us that toil is not futile, and hard work can be noble. CMA toiled throughout the year for physicians, honoring the labor physicians do for their patients every day. The struggle to push those legislative rocks up the hill was performed with pride, and as the essay reads, “The struggle itself toward the heights is enough to fill a man’s heart. One must imagine Sisyphus happy.” Of course, Sisyphus was not pushing the rock while simultaneously fighting labor lobbyists or Rob Schneider–but I still imagine him happy. On the following pages are details on the major bills that CMA followed this year. NOVEMBER / DECEMBER 2012 | THE BULLETIN | 11

CMA Sponsored Legislation AB 826 (Swanson/Williams/Perea): Healthy Families This CMA-sponsored bill was substantially amended in August at CMA’s request to include language to both (1) extend the Managed Care Organization (MCO) tax by one year, and to use the funding for the Healthy Families program, and (2) eliminate the transition of Healthy Families enrollees to Medi-Cal (done through the budget this year), thereby preserving the Healthy Families program. This bill is a critical part of CMA’s ongoing push to protect the successful Healthy Families program. Status: Failed pursuant to legislative deadline. AB 1742 (Pan): Assignment of Benefits This bill requires Knox-Keene regulated PPO products to authorize and permit assignment of an enrollee’s or subscriber’s right to reimbursement to the provider furnishing those services. This bill provides for the direct payment of individual insurance medical benefits by a health insurer to the person who provided the hospitalization or medical or surgical aid. It limits the amount of the reimbursement to the amount of the benefit covered by the policy. Status: Failed pursuant to legislative deadline. AB 1746 (Williams): Sale of Sports Drinks in Schools Current California law restricts the sale of soda and most other sweetened beverages on elementary, middle, and high school campuses. However, current law does allow the sale of one type of sugar-sweetened beverage – “sports drinks” – on middle and high school campuses. There is a common misconception that sports drinks are healthy. Yet many contain high fructose corn syrup and/or other calorie-laden sweeteners that have been linked to the rise in childhood obesity, the primary cause of type-2 diabetes. Sports drinks are designed to replace fluids after intense exercise and generally contain sodium and potassium to improve fluid absorption in the body; they are not designed to be an afternoon substitute for soda. A recent study indicated that eight of the top 10 beverages sold a la carte in California’s public high schools are sports drinks, clearly becoming the drink of choice for those students 12 | THE BULLETIN | NOVEMBER / DECEMBER 2012

wanting a substitute for soda. To close the loophole in current law that allows high-sugar sports drinks on school campuses, AB 1746 would prohibit electrolyte replacement beverages (sports drinks) from being sold to middle or high school students during school hours. Status: Failed pursuant to legislative deadline. AB 1848 (Atkins): Medical Expert Witnesses The goals of this legislation are twofold. It would (1) Authorize the state to discipline or deny licensure to physicians who offer deceptive or fraudulent expert witness testimony related to the practice of medicine; and (2) Require out-of-state expert witnesses to apply and become registered by the Medical Board of California to testify as a medical expert witness in California. Registration would require the completion of a written application accompanied by a fee. In the event a registered out-of-state medical expert witness deceives or commits fraud as an expert witness, the medical board could revoke his/her registration to prevent the individual from re-offending in any other potential court cases. Status: Failed pursuant to legislative deadline. AB 2064 (V.M. Perez): Vaccine Reimbursement This bill requires a health care service plan or health insurer that provides coverage for childhood and adolescent immunization to reimburse a physician or physician group in an amount not less than the actual cost of acquiring the vaccine plus the cost of administering the vaccine. It prohibits the imposition of deductibles, coinsurance or other cost sharing mechanism for the administration of childhood or adolescent immunizations or related procedures. It also prohibits provider contracts from containing a dollar limit provision for the administration of childhood and adolescent immunizations or including the cost of those immunizations in a dollar limit provision. This bill applies the current prohibition of a physician or physician group from assuming financial risk for the acquisition costs or required immunizations to all contracts between plans and physicians and physician groups. Additionally, it prohibits a plan from requiring a physician or physician group to assume financial risk for immunizations, whether or not those immunizations

are part of the current contract, and prohibits plans from including administration cost in the capitation rate of a physician who is individually capitated. Status: Failed pursuant to legislative deadline. AB 2109 (Pan): Childhood Immunizations California is one of 20 states that allows for the broad use of the personal belief exemption (PBE) from immunizations that are required for children to enter school. In California, obtaining a personal belief exemption is simple–parents are only required to sign their name to a two-sentence standard exemption statement on the back of the California School Immunization Record or provide a signed written statement. Over the past decade, the number of parents choosing to exempt their children from school immunization requirements has increased significantly, leading to more school children left vulnerable to preventable diseases. Parents have the right to make choices about immunizing their children; however, these choices should not be based on misinformation or lack of information. AB 2109 requires a parent or guardian seeking a personal belief exemption for their child to obtain a document signed by themselves and a licensed health care practitioner. The document will state that the health care practitioner has informed the parent or guardian of the benefits and risks of the immunization, as well as the health risks of the diseases that a child could contract if left unvaccinated. Status: Enrolled and sent to Governor. Signed into law 9/30/12. SB 301 (DeSaulnier/Cannella/Pavley/Rubio/ Strickland/Yee): Healthy Families This CMA-sponsored bill was substantially amended in August at CMA’s request to include language to both (1) extend the Managed Care Organization (MCO) tax by one year, and to use the funding for the Healthy Families program, and (2) eliminate the transition of Healthy Families enrollees to Medi-Cal (done through the budget this year, thereby preserving the Healthy Families program). This bill is a critical part of CMA’s ongoing push to protect the successful Healthy Families program. Status: Failed pursuant to legislative deadline.

SB 1318 (Wolk): Influenza Vaccinations for Health Care Providers in Health Facilities On a daily basis, health care workers come in contact with vulnerable populations such as seniors, young children and others with certain health conditions who may have depressed immune systems and cannot afford to catch the flu. The best way to ensure this does not happen is to have every health care worker vaccinated for the flu. Health care workers who get vaccinated reduce the transmission of influenza, staff illness and absenteeism, and influenza-related illness and death, especially among people at increased risk for severe influenza illness. Unfortunately, despite the benefits, many health care workers still voluntarily go unvaccinated. During the 2010-2011 influenza season, coverage for influenza vaccination among health care workers was estimated at 63.5 percent. However, those health facilities that had policies in place that required their health care workers to be vaccinated had a compliance rate at 98.1 percent. This discrepancy shows the great success of the required flu vaccination programs; programs that should be emulated. SB 1318 requires all health facilities and clinics to implement measures, including vaccine education programs, to help maximize influenza vaccination rates among their health care workers and medical staff. Workers who decline the vaccine will be required to declare in writing that they will adhere to the policy determined by the health facility or clinic to be the most effective measures to prevent workers from contracting or transmitting the virus. Any facility or clinic that fails to achieve a 90 percent or higher influenza immunization rate by January 1, 2015, will be required to adopt the model “mandatory vaccination policy” determined by the California Department of Public Health to be the most effective in achieving the 90 percent or higher goal. Status: Enrolled and sent to Governor. Vetoed 9/30/12. SB 1416 (Rubio): Physician Workforce This proposal would lay the groundwork to create the Graduate Medical Education Trust fund, to be administered by the Office of Statewide Health Planning and Development for the purposes of administering grants to expand the state’s residency programs. As


currently drafted, funding for this bill is dependent upon private donations. Status: Failed pursuant to legislative deadline. SB 1483 (Steinberg): Establishing a Physician Health Program in California This bill would establish a physician health program in California to refer physicians for treatment and monitoring services when they are suffering from substance abuse, mental and behavioral health issues. California is one of only five states in the nation that does not have such a program, following the Medical Board of California’s decision to eliminate its 27-year-old Diversion Program in 2007. This program will be structured fundamentally different than its predecessor, in that instead of taking on physicians who are under disciplinary review by the board, the program will be a voluntary model, encouraging physicians to actively seek treatment before their problems progress to the level that would lead to possible complaints and patients being put at risk. The program will be run by an external, private entity that contracts with the state, as opposed to the Diversion Program, which was run by the medical board. The program will be under the purview of the state Department of Consumer Affairs, instead of the medical board. The program will be funded by a fee charged to all new and renewed medical licenses issued in California, and will be periodically audited to ensure accountability. Status: Failed pursuant to legislative deadline. AB 589 (Perea): Medical School Scholarships Prior CMA sponsored legislation provided $1,000,000 per year in funding for the Steve Thompson Loan Repayment Program, which gives physicians up to $105,000 in loan repayment if they agree to practice in an underserved area for at least 3 years. This bill mirrors the loan repayment program and would create the Steve Thompson Scholarship Program, which would provide scholarships to medical students who agree to practice in one of California’s medically underserved areas upon completion of residency. Status: Enrolled and sent to Governor. Signed into law 9/17/12.


CMA Opposed Legislation AB 1062 (Dickinson): Elder Abuse/MICRA This bill was gutted and amended to lower the standard of evidence in elder abuse cases. It reduces proof required in elder abuse cases from clear and convincing to preponderance of the evidence. If enacted, it would encourage use of the elder abuse law to get around the MICRA cap and plaintiff attorney fee limits. Status: Failed pursuant to legislative deadline. SB 924 (Price): Physical Therapists–Direct Access to Services/Professional Corporations This bill addresses two significant issues pertaining to the practice of physical therapy. First, it allows physical therapists to remain employed in medical corporations, as well as create their own corporations, and requires the corporations to disclose to the patient that they are free to seek services elsewhere if they so choose. Second, it provides a framework where physical therapists may treat a patient directly without first seeing a physician, also known as “direct access.” Specifically, this bill allows physical therapists to treat patients for 30 business days, or 12 visits, without first seeing a physician. After the time limit, treatment would only be allowed to continue if the physical therapist’s plan of care was approved by a physician, which would include a physical exam. Current law requires that no physical therapy treatment may commence without a medical diagnosis. While CMA may wish to consider allowing a certain amount of treatment prior to a diagnosis, there must still be a diagnosis requirement at some point and 30 business days is just too long. Amendments should be adopted that would limit the amount of treatment to 30 calendar days and require at the end of the 30 days, that a medical diagnosis be obtained for treatment to continue. Status: Failed pursuant to legislative deadline. SB 1373 (Lieu): Health Care Coverage– Out-of-Network Coverage This bill would require that prior to providing out-of-network services a health care provider shall in writing inform the enrollee that he or she is out of

network and that the health plan may not cover some of the services, provide an estimate of the cost of the services

Bills of Interest

and direct the enrollee to contact the health plan for a list of contracted providers. Additionally, it prohibits a health facility or provider group from stating that it is part of a network unless all of the providers working at the facility are contracted with the insurer. The bill also requires plans

AB 369 (Huffman): Step Therapy Reform (CMA Position: Support)

to pay out-of-network providers the same rate as they pay in network providers on a non-capitated basis within the same geographic region as the contracted provider. A potential amendment would be to require disclosure language on an assignment of benefit agreement between a patient and a provider. Status: Failed pursuant to legislative deadline. SB 1528 (Steinberg): Damages–Medical Services This bill would overturn the, Howell v. Hamilton Meats case, by allowing an injured party of medical services to be compensated based upon the reasonable value of services rather than amount actually paid. Despite the trial attorneys’ assertion that the bill doesn’t affect damages under 3333.1, it would dramatically increase economic damage awards in ALL personal injury cases in the state. The rationale stated for the bill is flawed – that every person be treated the same regardless of how much was paid. Damages are intended to make someone whole. For medical expenses, that means giving them back in monetary damages the amount that was put out on their behalf – i.e., the amount paid. Lawsuits are not supposed to be like winning the lottery where you are put in a position more favorable than where you began. In other words, monetary damages are not supposed to go beyond recouping what was lost–for medical expenses, those are the dollars spent on medical care. Non-economic or emotional distress damages are the damages that compensate for the pain and suffering caused by the injury. This bill is going to bring up discussions about physicians billing practices and the definitions of, and differences between, billed amounts, usual and customary charges and reasonable value. Status: Failed pursuant to legislative deadline.

This bill would limit a health plan’s or health insurer’s ability to use step therapy or “fail first” protocols for the treatment of pain. The bill would require that the duration of any step therapy or fail first protocol be determined by the prescribing physician and would prohibit a health plan or health insurer from requiring that a patient try and fail on more than two pain medications before allowing the patient access to other pain medication prescribed by the physician. This bill would still allow step therapy to be used, but closes loopholes and puts the medical decisions back in the doctor’s hands so the patient can get the right medication in a timely fashion. Status: Enrolled and sent to Governor. Vetoed 9/30/12. AB 1000 (Perea) Health Care Coverage: Cancer Treatment (CMA Position: Support) This bill would help ensure that cancer patients are not denied the most appropriate and effective treatment by putting costs above care. According to the author, “there are significantly greater patient out-of-pocket costs for oral cancer therapies covered under the pharmacy benefit than IV therapies covered under the medical benefit. These out-of-pocket costs become a de facto denial of access, which, in a study by Prime Therapeutics, resulted in 1 in 6 patients not receiving treatment solely due to cost. Therefore, patient access to potentially the only life-saving cancer therapy available to them is restricted. Status: Enrolled and sent to Governor. Vetoed 9/30/12. AB 1533 (Mitchell) International Medical Graduates (CMA Position: Support) This bill would allow the UCLA International Medical Graduate program to create a five-year pilot for participants to engage in a physician supervised patient care activities, as part of an approved and supervised clinical clerkship/rotation at UCLA. With this legislation, UCLA International Medical Graduates would receive valuable clinical learning opportunities and not be at risk


for disciplinary action by the Medical Board of California.

allocation for physician services and protecting physicians’

In light of California’s physician supply crisis, this bill would have a more immediate impact toward increasing the amount of licensed physicians that could practice in the state.

ability to own an ambulatory surgery center. Based on these changes (including mandatory and ongoing coding updates by carriers and discarding ACOEM guidelines in favor of an expanded hierarchy of evidence), CMA took a support position on the measure.

Status: Enrolled and sent to Governor. Signed into law 7/25/12.

Status: Enrolled and sent to Governor. Signed into law 9/18/12. AB 1808 (Williams) Meyers-Milias-Brown, Act Public Employees (CMA Position: Support) This bill would only impact County of Ventura employed physicians that have, since 2006, sought union recognition. Since 2006, the county has rejected multiple legal opinions by the Public Employee Relations Board (PERB) that has sided with the physicians’ efforts for unionization. This bill simply includes the definition of “joint employer” used in the 2009 PERB decision, which would remove any doubt as to whether or not Ventura County is the employer of the physicians at the Ventura County Clinics. Status: Failed pursuant to legislative deadline. SB 863 (De Leon): Workers’ Compensation (CMA Position: Support) This bill was substantially amended in the final weeks of session to contain a package of policy changes in the name of reforming the state’s workers’ compensation system. The bill’s text was initially developed by labor and business interests, but CMA was able to negotiate a number of significant amendments to the bill. When those amendments were adopted, CMA took a support position on the measure. SB 863 does many things, but a couple of the biggest changes for physicians are that it directs the state to adopt the Medicare fee schedule—based on the Resource-Based Relative Value Scale (RBRVS)—as well as establishing Independent Medical Review and Independent Bill Review in an effort to utilize third-party processes to adjudicate treatment and billing disputes, instead of the court system. CMA was able to secure many important changes to the bill, including medical provider network reforms, expanding categories of payment for physicians, as well as increasing the entire funding


SB 1524 (Hernandez): Nurse Practitioners (CMA Position: Watch) This bill deletes the statutory requirement that nurse practitioners complete at least six months of physician and surgeon supervised experience in the furnishing or ordering of drugs and a course in pharmacology covering the drugs that will be furnished. The author contends this statute is antiquated and was put into place before there was any significant training in pharmacology. He contends the proper training and proper education now exists and the six month requirement only delays employment of new advanced practice registered nurses (APRN). However, not everyone’s experience and education is equal and should be dealt with on a case-by-case basis. CMA recommended amendments, which the author accepted, that clarified that the physician may include a six month supervised experience (or longer) requirement in the standardized protocol between the physician and the APRN. Status: Enrolled and sent to Governor. Signed into law 9/29/12. SB 1538 (Simitian): Mammograms (CMA Position: Neutral) This bill would require physicians to notify mammography patients with highly dense breasts about the density of their breast tissue. This issue has been debated within the house of medicine for nearly two years, but physician advocates were able to secure amendments to the bill that allowed both CMA as well as ACOG District IX to take neutral positions. Status: Enrolled and sent to Governor. Signed into law 9/22/12.

Bills Impacting Health Care Reform AB 43 (Monning): Medi-Cal Eligibility (CMA Position: Support if Amended) This bill would require the Department of Health Care Services to establish, by January 1, 2014, eligibility for Medi-Cal benefits for any person who meets these eligibility requirements. This bill would permit the department, to the extent permitted by federal law, to phase in coverage for those individuals. Status: Failed pursuant to legislative deadline. AB 1453 (Monning) / SB 951 (Hernandez): Essential Health Benefits (CMA Position: Support) These two bills, which are virtually identical, would establish a set of essential health benefits (EHBs) that insurers and health plans in California’s Health Benefit Exchange will be required to cover. This pair of bills would adopt the Kaiser small group HMO as the state’s EHB benchmark. Status: Enrolled and sent to Governor. Signed into law 9/30/12. AB 1461 (Monning) / SB 961 (Hernandez): Individual Market Reforms (CMA Position: Support) These bills conform state law to the Affordable Care Act in 2012, establishing guaranteed issue, Exchange open and special enrollment periods, rating (age, geographic region, and family size only), and same regions as PERS.

AB 1761 ( John Perez): Deceptive Marketing (CMA Position: Support) This bill would prohibit deceptive marketing by outlawing “copy cats” from representing themselves as part of the California Health Benefit Exchange. Status: Enrolled and sent to Governor. Signed into law 9/30/12.

AB 1846 (Gordon) CO-OPs (CMA Position: Watch) This bill authorizes Insurance Commissioner to issue a certificate of authority to Consumer Operated and Oriented Plans (CO-OPs). The Affordable Care Act calls for the creation of the CO-OPs, which are private, consumer-governed, non-profit health insurance plans that will be operated by its community beneficiaries (consumers, providers and employers). Status: Enrolled and sent to Governor. Signed into law 9/30/12. SB 970 (De Leon): CalHEERS Horizontal Integration (CMA Position: Support) This bill adds human services programs, such as CalWORKS and CalFresh, to those screened by the California Healthcare Elgibility, Enrollment and Retention System (CalHEERS), which will be used for California Health Benefit Exchange and Medi-Cal enrollment. Status: Enrolled and sent to Governor. Vetoed 9/30/12.

Status: Enrolled and sent to Governor. Vetoed 9/30/12.


Santa Clara County Medical Association 700 Empey Way • San Jose, CA 95128 • 408/998-8850 • FAX 408/289-1064 November 2012 TO:

All Members, Santa Clara County Medical Association (SCCMA)


Sameer Awsare, MD, Chair, 2012-2013 Awards Committee

At the 2013 Medical Association’s annual banquet, the association will honor several individuals with its perpetual awards. These awards are significant honors which reflect the respect, recognition, and appreciation of our membership. The recipients are selected from among our outstanding members who have distinguished themselves with extraordinary service to medicine in general, to the association, to the community, or to medical education. Selections are made by the Awards Committee, with the aid of input from the membership. Your suggestions for recipients for each of the awards outlined on the next page of this memo will be appreciated. Please complete the form below to submit suggestions, keeping in mind the requirements for each award as listed on the opposite page. If you would like to nominate more than one person, or for more than one award, please photocopy this form or send a letter. Suggestions must be received by January 20, 2013. Thank you for your recommendations. If you previously suggested a candidate who was not given an award, please feel free to resubmit that name. I THINK ______________________________________________________ WOULD BE A GOOD CANDIDATE FOR THE _____________________________________________________________________________________ (Name of Award) PLEASE ATTACH ALL SUPPORTING INFORMATION, INCLUDING ACCOMPLISHMENTS AND CONTRIBUTIONS THAT WILL HELP THE AWARDS COMMITTEE EVALUATE THE CANDIDATE FOR THE AWARD SELECTED. YOU MAY MAIL, FAX, OR EMAIL THE INFORMATION TO PAM JENSEN AT SCCMA. SUBMITTED BY: __________________________________________________________________________________ MD (Please print) MAIL FORM TO: SCCMA Attn: Pam Jensen 700 Empey Way San Jose, CA 95128 EMAIL: pjensen@sccma.org FAX: 408/289-1064 DEADLINE: January 20, 2013 18 | THE BULLETIN | NOVEMBER / DECEMBER 2012

Santa Clara County Medical Association

Annual Awards


For a physician member of the Association who has demonstrated extraordinary visionary leadership, tireless effort, selfless long-term commitment, and success in challenging and advancing the health care community, the well-being of patients, and the most exhalted goals of the medical profession. The only three recipients of this award are Robert D. Burnett, MD, Philipp Lippe, MD, and Robert Pearl, MD.


For a physician member of the Association who has displayed forward-looking, pioneering ideas, enterprise, enthusiasm, and prolonged professional stature and ability.


For a physician member of the Medical Association who, during his/her medical career, has made unique contributions to the betterment of patient care, for which he/she has achieved widespread recognition. Consideration shall be given to research and/or the development of procedures, methods of treatment, pharmaceutical agents, or technological advances in the field of medicine.


For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the Association over and above that expected of the membership at-large.


For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more medical education activities over and above that expected of the membership at-large.


For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the community over and above that expected of the membership at-large.


For an individual who is not a member of the Medical Association, who has achieved public recognition for a significant contribution in the health field. (This usually will be a nonphysician, although physicians are not categorically excluded.)


Benjamin J. Cory, MD Award

Outstanding Outstanding Contribution To The Contribution In Medical Association Medical Education

Robert W. Jamplis

Richard M. O’Neill

John B. Shinn

Thomas J. Fogarty

Robert W. Andonian

Ronald L. Kaye

Norman E. Shumway

David M. Rosenthal

William C. Fowkes

Thomas A. Stamey

Bernice S. Comfort

Robert J. Frascino

1995 1996

Christopher C. Chow


Outstanding Achievement In Medicine

Outstanding Contribution In Community Service Arthur A. Basham / Arthur L. Messinger ---

Citizen’s Award Gary W. Steinke, MD / Mrs. Pamela Steinke Mr. Howard W. Pearce

Cindy Lee Russell / Minoru Yamate

Florene Poyadue, RN

Michael R. Fischetti

Suzanne Jackson, RN


Mansfield F. W. Smith

Stanley D. Harmon

Howard R. Porter

Burton D. Brent

William A. Johnson

Judge Leonard Edwards


Donald J. Prolo

Steven S. Fountain

C. Michael Knauer

Jack S. Remington

M. Ellen Mahoney

Rigo Chacon


Sharon A. Bogerty

Stephen H. Jackson

Theodore Fainstat

Richard P. Jobe

Barbara C. Erny

Janet Childs

Roger P. Kennedy

Bert Johnson

Nelson B. Powell / Robert W. Riley

Robert Michael Gould

Tony & Brandon Silveria

Elliot C. Lepler

Allen H. Johnson

Bruce A. Reitz

David Morgan

Tom Campbell / Ted Lempert

Joseph E. Mason, Jr.

Anthony S. Felsovanyi

David A. Stevens

Martin D. Fenstersheib

Michael E. & Mary Ellen Fox

2001 2002

Robert M. Pearl

2003 2004

Robert Wuerflein

Eugene W. Kansky

Barry Miller

D. Craig Miller

Elizabeth Menkin

Jayne Haberman Cohen, DNSc


Harvey J. Cohen

Richard L. Miller

Gus M. Garmel

Rodney Perkins

Elouise Joseph

Doris Hawks, Esq.

Arthur A. Basham

Robert W. R. Archibald

G. David Adamson

Harmeet S. Sachdev

Edward A. Hinshaw, Esq.

2006 2007

Stephen H. Jackson

Cindy L. Russell

Catherine L. Albin

John R. Adler, Jr.

Madhur Bhatnagar

Debbi Ricks


Bernadette Loftus

Martin L. Fishman

George P. Kent

Thomas Krummel

Seham El-Diwany

Peggy Fleming-Jenkins


Melvin Britton

James G. Hinsdale

David Levin

Gary Steinberg

Leo Strutner

Judge Lawrence Terry

Tanya Spirtos

Dennis Siegler

Robert Armstrong

Gary Silver

Kathleen King

Robert Gould

William Jensen

Eleanor Levin

David Quincy

Assemblymember Jim Beall

2011 2012

Steven Fountain


Member benefits

NORCAL, NORCAP, and SCCMA/MCMS Anatomy of a Rebate In today’s legal climate, it’s difficult to believe that there was a time when medical malpractice suits were so infrequent and the cost of liability insurance was so low that the California Medical Association included professional liability insurance as a no cost benefit of membership. Although this idyllic situation came to an end after World War II, reasonably priced malpractice coverage remained available in California until the 1960s, when a new class of aggressive and creative personal injury attorneys identified physicians as ideal targets for contingency fee litigation. By the late ’60s, million dollar policy limit demands became common, and medical malpractice insurers began to raise premiums and withdraw from big metropolitan markets. In May of 1973, the major Northern California malpractice insurer no longer had the necessary reserves to continue writing malpractice insurance and withdrew from the state after nonrenewing all of its policyholders. Many of our physicians recall the ensuing malpractice crisis of 1975: many physicians left or threatened to leave California, many refused to treat any-

but-emergency cases, many went “bare,” and many refused to practice at all until the situation was satisfactorily resolved. Jerry Brown, then serving his first term as

non-meritorious claims, while disseminating information on best practices to avoid liability pitfalls. As a Mutual Insurance Company, NORCAL’s policyholders are its stockholders. Profits realized by the company, in excess of operating costs and necessary reserves, are returned to its policy owner-stockholders in the form of a premium credit. This year, for the 33rd time in the past 35 years, NORCAL has declared a $12 million dividend in California and Alaska, which is about 10% of the 2012 premium. Eligible insureds will see the dividend applied as a credit on their second quarter 2013 renewal invoice. Its commitment to aggressive defense of policyholders, its grassroots origin and corporate philosophy, and its continued extensive local involvement with sponsoring medical societies are a few of the reasons why the Santa Clara County Medical Association and Monterey County Medical Society endorse NORCAL as their preferred provider of medical professional liability insurance.

This year, for the 33rd time in the past 35 years, NORCAL has declared a $12 million dividend in California and Alaska, which is about 10% of the 2012 premium. governor, called the legislature into emergency session to deal with the situation, and in an uncharacteristically short amount of time, MICRA (the Medical Insurance Claims Reform Act) was passed. The same year, Northern California physicians banded together at the county medical association level to form NORCAP – the Northern California Physicians Council – which, in turn, formed NORCAL Mutual – a new kind of policyholder-owned medical liability insurance company. Founded by and for physicians, the company’s vision was and continues to be to insure and defend policyholders against

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3651_BulletinOfSantaClara_NovDec2012.indd 1

10/3/12 12:15 PM NOVEMBER / DECEMBER 2012 | THE BULLETIN | 21

risk management

What to Know Before You Store Patient Credit Card Numbers By Fran Cain Information Technology Department NORCAL Mutual Insurance Company Everyone uses credit cards. Patients love to rack up points for travel and cash-back rewards. But before you store a credit card number in your practice database, be aware of the consequences if your patient records ever become compromised. Credit card companies can impose huge fines if your office system is not securing patient credit card information adequately and it becomes compromised — to the tune of up to $100,000 per incident. After reviewing this article and weighing the risks, ask yourself, “Does my practice really need to store credit card information on file?”

I have a small practice. How does this apply to me? All credit card companies belong to the Payment Card Industry (PCI). PCI has established a Security Standards Council to set and manage standards known as the Data Security Standard, or PCI DSS. If your practice accepts or processes payment cards, you must comply with the PCI DSS. Patients prefer that I keep their credit card numbers on file. What if I want to store credit card numbers? There are many rules to follow to be in compliance. You will be required to build and maintain a strong network; protect cardholder data; maintain a vulnerability management program; implement strong access control measures; regularly monitor and test networks; and maintain an information security policy. Here are some tips from the Payment Card Industry website: • Encrypt all credit card numbers if stored in any system or database, including but not limited to logs and backups. • Ensure the network has adequate firewall and up-to-date antivirus software. • Use strong encryption for transmission of cardholder data over the Internet. • Regularly apply all systems and software security patches. • Quarterly, run external vulnerability scans or penetration tests on the network. • Limit access to cardholder information to staff with a legitimate business need. • Enforce strong passwords. • Avoid printing any card data on paper, but if any exists, it must be carefully secured and destroyed when no longer needed. • Maintain data security policies that provide clear guidance to staff about handling of sensitive data (e.g., never e-mail Primary Account Numbers or PANs) and how to respond in case they discover data is compromised. You must assess your business systems and processes annually to ensure you are in compliance. The PCI website can help you to assess 22 | THE BULLETIN | NOVEMBER / DECEMBER 2012

your environment. You may be able to use a Self-Assessment Questionnaire, which must be completed annually, depending on the bank card. For example Master Card allows you to self-assess if you process less than 50,000 transactions annually, while JCB International allows you up to 1 million transactions. Check with each credit card company or look on its website to determine your merchant level and the requirements for your business. If you are allowed to self-assess, it is not necessary to submit a report to the credit card companies or PCI, but compliance is still required at all times. There are several different self-assessment questionnaires, and it may be confusing to decide which one to use. Use the chart on the website to choose the questionnaire that most closely fits with your credit card collection practices. If you are not allowed to self-assess, you will need to use a Qualified Security Assessor (QSA) to conduct annual assessments.

What happens if I store credit card numbers and a practice computer is lost or stolen, or some other breach of my system occurs? You must be able to demonstrate that you have been in compliance with PCI DSS. If your practice computers, network, and/or database are compromised in any way, you must notify the credit card companies. If you cannot demonstrate that the data was completely protected and that you have been in compliance with PCI DSS, you will be subject to significant fines and lawsuits. If the credit card company does not terminate the contract, you may be treated the same as a higher level merchant and be required to conduct annual on-site assessments and validation by a Qualified Security Assessor. Expect the annual on-site assessments to cost in the $10,000–$20,000 range, or more. You will be required to remediate any inadequacies discovered during the annual assessments at your own expense. Who enforces compliance of the PCI DSS? American Express, Discover Financial Services, JCB International, MasterCard Worldwide, and Visa Inc. enforce compliance. Each of these institutions posts compliance guidance, which may be slightly different from the others. Before going to each credit card company website, read, understand, and follow all guidelines provided by PCI. Why aren’t card readers or software applications safe enough from hackers? According to the PCI, there are many reasons credit card readers or applications may not be secure. Card readers may inadvertently store magnetic stripe data, which contains Sensitive Authentication Data or card verification codes; they may not be installed properly or securely and might be easily compromised; default settings or passwords may not have been changed on readers or in applications; security patches were Fran Cain is the Network Systems Manager for NORCAL Mutual Insurance Company.

not kept updated; the credit card data on the network is not properly segregated to be secure; data may not be properly encrypted; web applications may not be hardened against vulnerabilities.

What if I complete a self-assessment and uncover deficiencies? If the self-assessment uncovers deficiencies, remediation is necessary. A remediation plan, known as an Action Plan for Non-Compliant Status, should be completed. PCI allows 12 months to remediate, but progress must be demonstrable. All remediation is at the expense of the merchant. If your practice is very large and you process many transactions, you will need to work with a data security firm. PCI provides a list of qualified assessors on its website. How do I avoid the need for assessments altogether? If you accept credit cards for payment, an annual assessment is required. But if you successfully follow these guidelines, the self-assessment questionnaire is short and painless: • Secure your credit card readers. • Use a virtual terminal solution provider validated by the PCI. • Do not store credit card numbers, or any of the information from the credit card, on any computer or system. • Do not store the Primary Account Number (PAN), commonly known as the credit card number. • Never store sensitive authentication data. • If the PAN is displayed, it must be masked. Only the first six and last four digits may be displayed. • Never store the data from the magnetic stripe or, if present, the chip. • Never store the Personal Identification Number (PIN). • Never store the card security code, the 3-digit number on the back of most credit cards or the 4-digit code on the front of American Express cards. Now that you know some of the risks and requirements of storing credit card information, do you really need them on file? For more information, visit the Payment Card Industry website at www.pcisecuritystandards.org.



An Ohlone Birth By Michael A. Shea, MD Leon P. Fox Medical History Committee For over 3,000 years, the Ohlone Indians lived along the Califomia coast from the San Francisco Bay to Point Sur. In the early 1700s, there were 40 separate and distinct tribelets, each consisting of approximately 250 people for a total population of 10,000. Under the ramada (shade hut), a young pregnant Ohlone woman is helping some of the older tribal women weave baskets for the fall acorn harvest. She is careful not to use an awl (a sharpened animal bone) in the work, as she has been told that it could cause her baby to be born blind. She is content to strip sedge roots with her teeth and let the others put the baskets together. The pregnancy is growing long and she has done all the proper things. She has avoided meat, fish, and salt, in order to keep her


weight down and lessen her chances of having a difficult labor that a large baby might cause. She has been polite to people, animals, and avoided looking into the night sky, lest she see an owl or a shooting star. All of these will help keep her baby healthy. As she works, there is a subtle firmness in her abdomen. The abdominal skin is warm to the touch and a mild backache accompanies the contraction. It lasts about 60 seconds. She feels apprehensive, as she has not felt pain with her contractions in the past. The basket weavers also take notice, especially the one who is known as the thin woman. She is recognized by the tribe as an experienced midwife. The mother-to-be is comfortable around the thin woman and is relieved to know that she will be with her for her labor and delivery. The pains occur more frequently and move from her back to her abdomen. They are stronger and she retires to her dwelling,

where there is a small fire burning. The thin woman stays with her, holding her gaze, and keeping her calm. Posture in labor took many forms in the Native Americans. Partially squatting, the Sioux pulled on a leather strap attached to a vertical pole. The Blackfoot kneeled during labor, hands grasping an upright pole. Other tribes, across the West, used other positions: kneeling while pulling on a horizontal crossbar, squatting alone, or the dorsal lithotomy position. Some even applied tourniquet belt devices above the abdomen and tightened down with each contraction. Among the Nez Perce, the squaws would squat during the first stage of labor, but lie down for the actual delivery, usually on their side. We do not know how the Ohlone labored, but the latter method is the best guess. Contractions are getting stronger, coming every five minutes, and the thought of some herbal medicine for pain comes to her mind. The Ohlones used Jimsonweed in tea form for the relief of pain. This herb contains atropine and scopolamine-like compounds which result in pain relief, sedation, and euphoria. Although it is tempting, she refuses the Jimsonweed for fear it will have an adverse effect on her baby. The hours pass. Daylight is fading. There is some concern in her mind that she is not progressing satisfactorily. The contractions are regular and strong, but are they strong enough? The Native Americans had knowledge of a powerful oxytocic found in rattlesnake tail beads. They knew it could help a labor that was not strong enough. (Sacagawea had used it in her labor just before she joined the historic Lewis and Clark Expedition.) The thin woman, sensing her fear, calmly reaches into her pouch and removes a bear claw, which she places on the young girl’s abdomen. This is followed by even stronger contractions and a sudden uncontrollable urge to push.

“I see the head” shouts one of the older women, excitedly. The thin woman stretches the perineum as the baby’s head emerges, followed quickly by a pink, squirming baby boy. Sighing deeply, the new mother feels the immediate relief of all the pressure and pain. The baby cries lustily and everyone smiles thankfully. Hardly noticed by her is the small gush of blood followed by the delivery of the placenta. This is quickly passed to one of the attending women, who takes it outside, where it is burned and properly disposed of. After a brief rest, mother and baby are led to a nearby stream, where clear cold water splashes on their skin. The baby wails, as if insulted, but to the mother, it is refreshing. Meanwhile, her husband, who had not

participated in the labor or delivery (this was the Indian custom), goes to the home where he digs a long pit and fills it with stones. He builds a fire on top of the stones. When the stones are warm, he rakes off the ashes and adds a deep layer of aromatic herbs and soft brush. When mother and baby return, she sees the new bed and inhales the fragrant aroma. She embraces her husband, and then tenderly places her baby beside her on the soft warm mattress, where both fall into a deep restful sleep. For several thousand years, this was the Ohlone way.

Tracy Zweig Associates A






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HOD 2012 CMA delegates set policy at annual meeting ore than 700 California physicians convened in Sacramento October 13-15 for the 2012 House of Delegates (HOD), the annual meeting of the California Medical Association (CMA). Each year, physicians from all 53 California counties, representing all modes of practice, meet to discuss issues related to health care policy, medicine and patient care and to elect CMA officers. by Elizabeth Zima and James Noonan


Over 120 resolutions were introduced and debated in reference committees on Saturday, October 13, 2012. Over the next two days, the complete house met again to debate and vote on reference committee recommendations. A total of 97 resolutions were adopted. The debates were passionate, polite and sometimes humorous. For example, during a debate on the health hazards of sitting, one speaker suggested that the House stand for the rest of the debate. In another instance, during a contentious debate on whether to support nurse practitioners’ ability to sign POLST forms, the debate was interrupted so that former CALPAC chair, and newly-elected CMA president elect Richard E. Thorp,

M.D., could have his mustache shaved off by his wife – part of a fund-raising challenge. On Sunday the House elected new officers, including Sacramento pediatrician, Paul R. Phinney, M.D., as the 2012-2013 CMA President, and the now clean shaven Dr. Thorp as president-elect. The rest of the CMA Executive Committee were affirmed by the HOD including the immediate past-president, James T. Hay, M.D., speaker, Luther F. Cobb, M.D., vice-speaker, Theodore M. Mazer, M.D., board chair, Steven E. Larson, M.D., and board vice-chair, David H. Aizuss, M.D. The following are summaries of some of the resolutions that were adopted as policy.


House of Delegates 2012 Revised blood donor deferral criteria (Resolution 108-12)

The delegates expressed support for the use of rational, scientifically-based deferral periods for blood donations, applied based on level of risk rather than on sexual orientation.

payor for physicians who do not adopt health information technology, such as electronic medical records and electronic prescribing. Health care equality for same-sex household members

Awareness and prevention of bullying

(Resolution 505-12)

(Resolution 113-12)

The delegates voted to recognize that denying civil marriage contributes to poorer health outcomes for gay and lesbian individuals, couples and their families. The resolution also calls on CMA to support measures providing same-sex households with the same rights and privileges to health care, health insurance and survivor benefits afforded to opposite sex households.

The delegates called on CMA to support awareness and prevention of bullying in all its forms and to support the development of family, school and community programs and referral services for victims and perpetrators of bullying. AB 32 and California’s clean air leadership (Resolution 117-12)

The delegates voted that CMA should support implementation of the California Global Warming Solutions Act of 2006, which protects the health of Californians from climate change. Safer furniture flammability standards (Resolution 125-12)

The delegates asked that CMA endorse a revision of the California TB 117 furniture flammability standards, which would not require harmful flame retardants yet provide more effective fire safety using barrier technology and flame resistant fabric covers. Support for amending the affordable care act (Resolution 201-12)

The delegates directed CMA to support amending the Affordable Care Act to address issues of concern to the practice of medicine. Duel eligible monitoring and reporting (Resolution 208-12)

This resolution directs CMA to collect data from its membership regarding difficulties with the planned transition of dual eligibles to managed care plans and to report the findings to the California Department of Health Care Services, the California Department of Managed Health Care and the federal Centers for Medicare & Medicaid Services. Electronic prescribing and EHR payment reductions (Resolution 214-12)

The delegates voted to oppose financial penalties by any


Pharmacist’s substitution of physician prescriptions (Resolution 507-12)

The delegates asked that CMA consider legislation to make it illegal for pharmacists to receive financial incentives to substitute a physician’s prescription. Increasing utilization of POLST orders (Resolution 512-12)

The delegates approved a resolution that calls on CMA to support awareness and use of Physicians Orders for Life-Sustaining Treatment (POLST) forms by physicians in all appropriate instances where medical services are provided to patients at the end of life. HIPAA and medical record accessibility (Resolution 606-12)

The delegates asked CMA support a study on the extent to which HIPAA laws impede the timely transfer of medical information necessary for the appropriate coordination of care. Helping physicians improve their health (Resolution 610-12)

The delegates voted to encourage all physicians and physicians-in-training to properly manage their own physical and mental health and to serve as exemplars of healthy behaviors. The complete and final actions of the 2012 House of Delegates are available to members at www.cmanet.org/hod under “Documents.”

Sacramento pediatrician elected CMA president

Sacramento physician Paul R. Phinney, M.D., was installed as the 145th president of the California Medical Association (CMA) during the organization’s annual House of Delegates held in Sacramento October 13-15. Dr. Phinney is a pediatrician at Kaiser Permanente and has been a member of CMA since 1988. He has served in a number of leadership roles, including president-elect, chair of the CMA Board of Trustees and previously served on the CMA Council on Legislation and on the CMA Political Action Committee (CALPAC) Board of Directors. Addressing the group of nearly 1,000 physicians, residents, medical students and others on Sunday, Dr. Phinney challenged his colleagues to lead change rather than succumb to the “default future.” “We owe it to the public and to our profession to be leaders in health care reform – to create a better future that we help invent,” he said to the crowd. “We live in turbulent and uncertain times that very likely will produce the most rapid change in the delivery of health care that the nation has seen in decades, and I look forward to tackling those challenges head on in my term as president,” concluded Dr. Phinney. Speaking to his goals for the next year, Dr. Phinney acknowledged the next generation of students entering

medicine. “Mentorship deserves our attention, and will be an area of my focus over the next year. A healthy future requires up-front investment,” he said. Dr. Phinney’s complete address to the delegates can be watched on CMA’s YouTube channel, www.youtube. com/cmaphysicians. Also serving on CMA’s 2012-2013 Executive Committee are: • Immediate Past President James T. Hay, M.D., a San Diego family physician • President-Elect Richard E. Thorp, M.D., an internal medicine physician in Paradise • Speaker of the House Luther F. Cobb, M.D., a surgeon in Humboldt County • Vice Speaker of the House Theodore M. Mazer, M.D., a San Diego ear, nose and throat specialist • Chair of the Board of Trustees, Steven E. Larson, M.D., an internist infectious diseases consultant in Riverside County • Vice Chair of the Board of Trustees, David H. Aizuss, M.D., a Los Angeles ophthalmologist


House of Delegates 2012

CMA says denial of civil marriage to same sex couples has negative health impact On Sunday, October 14, 2012, the California Medical Association (CMA) House of Delegates passed a resolution calling for health care equality for same sex households. Hundreds of physician representatives from across the state voted to support a resolution that states “denying civil marriage contributes to poorer health outcomes for gay and lesbian individuals, couples and their families.” In written testimony, the sponsors of the measure, the CMA Residents and Fellows Section, said, “legal protections afforded to same-sex couples are crucial given that marriage is a strong predictor of health insurance in the U.S. In particular, women in same-sex households tend to have less health insurance than women in opposite-sex households. “As a consequence, children in same-sex households


lack the protections of health insurance afforded by marriage,” the document continues. “Having health insurance does not provide same-sex couples with the financial and legal protections that married couples receive. Same-sex couples are not covered by the protections of COBRA or the Family and Medical Leave Act. Same sex couples are also not typically recognized as family by blood or marriage and are denied the right to make surrogate health care decisions for their loved ones.” The resolution (505-12) would also require CMA to work to reduce health care disparities among members of same-sex households, including minor children. It also calls on CMA to support measures providing same-sex households with the same rights and privileges to health care, health insurance and survivor benefits afforded by opposite-sex households.

CMA delegates call for increased advocacy on duals transition Recognizing the challenges that California’s planned shift of Medicare and Medi-Cal dual eligible patients to managed care plans will pose to patients and the physicians that serve them, the California Medical Association (CMA) has adopted policy to help keep physician concerns in clear view of the agencies orchestrating the transition. The policy (Resolution 208-12), which was adopted at the CMA’s annual House of Delegates meeting, calls on the association to collect data from its membership regarding difficulties with the planned duals transition and, if difficulties are found to be widespread, report them to the California Department of Health Care Services, the California Department of Managed Health Care and the federal Centers for Medicare and Medicaid Services. During the floor debate regarding the issue, delegates noted that the state’s Coordinated Care Initiative, which includes a pilot program to passively enroll patients eligible for both Medicare and Medi-Cal in eight of California’s largest counties, would see more than 75 percent of the state’s dual eligibles transitioned to managed care plans. The shift, speakers said, would likely lead to considerable confusion among patients and almost certainly interrupt relationships that have been established with their existing physicians. Under the pilot program, patients will be enrolled in a managed care plan unless they actively opt out. In addition to asking that CMA monitor the transition, the newly adopted policy also requests that the association advocate that the appropriate state agencies provide “full and clear disclosure” on options and consequences facing patients affected by the pilot program. More information regarding the dual eligible transition can be found in CMA’s online duals resource center, at www.cmanet.org/duals.

Delegates strongly oppose Medicare RAC audits Members of the California Medical Association’s (CMA) House of Delegates spoke out strongly against aggressive down coding efforts being taken up by Medicare’s Recovery Audit Contractor (RAC) firm, and have adopted policy that officially puts the association on record as opposing the practice. The resolution, 222-12, stems from an ongoing problem of an out-of-state auditing firm, Connolly Healthcare, selectively down coding claims on behalf of Medicare, forcing physicians to undertake costly and time-consuming appeals. The audits and subsequent down codes, which several speakers equated to financial “bounty hunting” on behalf of the Centers for Medicare & Medicaid Services (CMS), were almost always reversed upon physician appeal, which suggested that they were of little merit to begin with, speakers said. “I can’t tell you how outraged we doctors should be that this is going on,” James Hinsdale, M.D., a past CMA president, said during the resolution’s floor debate. In addition to asking that CMA work to stop the audit practice, the resolution also requests that, if efforts to halt the practice are unsuccessful, CMA urge CMS to reimburse physicians who file successful appeals for the time and resources expended in the appeal efforts. Successful passage of the resolution brought CMA in line with the American Medical Association’s (AMA) position on the matter. AMA has been actively lobbying CMS to halt the recovery audits.


House of Delegates 2012

ACA topic of heated debate at House of Delegates Since the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, it’s been virtually a certainty that delegates at the annual House of Delegates meeting would debate to influence policy regarding the landmark reform bill. This year’s gathering was no exception, as resolutions touching upon various aspects of the ACA were introduced, and in some cases, adopted as official California Medical Association (CMA) policy. Of the resolutions introduced and debated over the weekend, it appears that Resolution 202-12 will produce some of the most immediate results. The resolution, which deals with the California Health Benefits Exchange, asks that CMA support several actions that will help ease the transition of roughly 1.6 million new enrollees to the state’s Medi-Cal program, as well as a list of requirements that will help protect physicians when contracting with plans offered through the exchange’s online marketplace. Specifically, the resolution asks that county and state funding sources that currently help provide care for medically indigent adults follow those individuals when Medi-Cal is expanded in 2014, and that the exchange takes a more active role in monitoring network adequacy of its offered plans. The issue of network adequacy has already

garnered a significant amount of attention from CMA staff, but an agreeable solution has yet to be reached with exchange leadership. A separate resolution, 201-12, reaffirmed CMA’s position of continuing to work toward amending the ACA to “address issues of concern to the practice of medicine,” and was adopted by the House. Finally, two resolutions, 204-12 and 205-12, launched the seemingly annual debate over single payor coverage in California. During the reference committee hearings, supporters and opponents of single payor in California took to the microphone to voice their opinions on the matter, providing some of the most passionate and ideologically divided debate of the weekend. Ultimately, reference committee members recommended that delegates disapprove both resolution, noting that CMA has “well thought out and longstanding” policy on the issue of single payor. (CMA’s Policy Compendium is available to members at www.cmanet.org/ policies. The new policies passed this year will be added to the compendium soon.) For more information on any of these resolutions, or general reform activities in California, please subscribe to CMA’s regular reform newsletter, CMA Reform Essentials at www.cmanet.org/reform-essentials.

CMA debates resolution that calls on insurers to cover e-mail consultations As advances in technology continue to redefine health care, the California Medical Association (CMA) is taking steps to bring the physician-patient relationship into the 21st century. During the association’s annual House of Delegates meeting, a resolution was introduced that would ask CMA to support legislation requiring insurance providers in California to include “telephone or other electronic patient


management services” in their covered services, while also allowing physicians to bill patients directly for the provision of such services. Currently, insurance providers are not required to cover consultations that occur via telephone or email, and physicians in most instances have no legal way of billing patients or payers for such services. Throughout a lengthy period of floor debate, several

CALPAC fundraising record shattered at House of Delegates CALPAC, CMA’s political action committee, carried two things into the 2012 House of Delegates meeting – last year’s three-day fundraising record of $110,000 and a fully mustachioed chair posing a challenge to delegates in attendance. In the end, neither would emerge from the weekend unscathed. In a record-setting show of support for CALPAC, CMA members contributed a total of roughly $152,000, besting last year’s mark while also exceeding the $150,000 goal established before the House of Delegates. Throughout the weekend, attendees were informed that, should the goal be met, outgoing CALPAC Chair and new CMA President-Elect Richard Thorp, M.D., would shave his moustache during the full house session

held on Monday morning. With the final tally confirmed, Dr. Thorp took to the stage to have his upper lip shorn clean by his wife, Vicki. (Check out the photos on CMA’s facebook page, www. facebook.com/cmaphysicians.) While the record breaking weekend was a House-wide effort, several counties, including San Diego, San Francisco and Santa Clara, were recognized for their outstanding participation. The donations collected over the weekend, as well as all contributions made to CALPAC, will be used to support candidates who share medicine’s agenda and priorities and will work to affect policies beneficial to the House of Medicine.

speakers noted that patients are becoming increasingly reliant upon remote interaction with their physicians, while insurers only cover services offered in a face-to-face setting, with few exceptions. If this does not change, speakers noted, physicians would be facing considerable financial losses as the trend toward remote interaction continues. While support for the concept of requiring insurers to pay for telephone and email consults was nearly unanimous, the specific language of the resolution drew input from across the House, leading to nearly an hour of

open discussion of the issue. Ultimately, recognizing the importance of the matter and the limited time available for debate, delegates opted to refer the resolution to the CMA Board of Trustees for decision, an action which supporters claimed would allow the language to be crafted more thoughtfully. The matter will likely be taken up during the board’s January meeting and CMA staff will keep members updated on the resolution’s progress.


2012 CMA House of Delegates in Pictures

Photo credit: David Flatter and William Parrish 38 | THE BULLETIN | NOVEMBER / DECEMBER 2012

Thank You District VII Delegates! NOVEMBER / DECEMBER 2012 | THE BULLETIN | 39

Member benefits CMA Foundation Publishes 2013 AWARE Provider Toolkit The California  Medical  Association  (CMA)  Foundation’s     Alliance  Working  for  Antibiotic  Resistance  Education   (AWARE)  project  has  published  its  sixth  annual  antibiotic   awareness  toolkit  for  physicians  and  other  clinicians.  The   toolkit  contains  an  array  of  clinical  resources  and  patient   education  materials  to  help  reduce  inappropriate  antibiotic   use.    The  2013  toolkits  were  mailed  last  month  to  28,000   providers.  Physicians  are  encouraged  to  utilize  the  toolkit  to   educate  patients  about  antibiotic  resistance.       The  toolkit  can  also  be  downloaded  at  www.aware.md.       Physicians  are  also  encouraged  to  take  a  brief  survey  to  let  us  know  what  we  can  do  to  improve  future   versions  of  the  toolkit.         To  take  the  survey,  please  visit:  http://www.zoomerang.com/Survey/WEB22GHRJXVCQ4.  



Increase Your Referrals! Pictorial Membership Directory. This directory lists complete contact information and specialties for every SCCMA and MCMS member physician. It is mailed to all members in Santa Clara and Monterey Counties. The Bulletin. This official magazine of the Santa Clara County Medical Association and Monterey County Medical Society is published bi-monthly and distributed to over 3,700 physicians.

The deadline to participate is NOW! Space is limited.

Contact Pam Jensen today: 408-998-8850 or pjensen@sccma.org 40 | THE BULLETIN | NOVEMBER / DECEMBER 2012

Member benefits

Now Is the Time for a New Dental Plan! It’s Open Enrollment time for the Association/Society sponsored Group Dental program. This plan is designed to help you, your family, and your employees minimize the out-of-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). • During Open Enrollment only, members may join as an individual or as a group with your employees.

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• Low calendar year deductible of $50 per person ($100 per calendar year maximum for families). • Pay no deductible on oral exams, x-rays, and routine cleanings. Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on January 1, 2013. Call a Client Advisor at 800/842-3761, for more information. Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.

LWA is proud to announce that Edwin K.S. Ryu has been named to the 2012 Medical Economics Best Financial Advisers List. “In 2006, 2008 & 2009, Edwin K.S. Ryu of Legacy Wealth Advisors was named one of the 150 Best Financial Advisors to Doctors by Medical Economics. He has also been featured in publications such as the San Francisco Chronicle, Silicon Valley Business Journal and Forbes magazine.” NOVEMBER / DECEMBER 2012 | THE BULLETIN | 41

medico news

Ninth Circuit Court of Appeals hears MediCal reimbursement rate cut case The California Ninth Circuit Court heard oral arguments in a lawsuit filed by the California Medical Association (CMA) and a large coalition of organizations seeking to prevent the state from cutting Medi-Cal provider reimbursements by 10%. A lower court had ruled in February that the cuts would irreparably harm access to care for the state’s most vulnerable populations. The state of California has appealed the decision.

 “[The lower court’s] ruling clearly indicated that California’s fiscal crisis does not outweigh the serious irreparable injury plaintiffs would suffer, absent the issuance of an injunction,” says James T. Hay, MD, CMA’s immediate past president.

 The lawsuit was originally filed in No-

vember 2011 by CMA, in conjunction with the California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, National Community Pharmacists Association, AIDS Healthcare Foundation, American Medical Response, and the California Association of Medical Product Suppliers.

 In February, Judge Christina Snyder, of the California Central Federal District Court, ruled the federal Medicaid Act requires that government-insured and privately-insured patients have equal access to medical care. If the state and federal government continue to cut these programs, physicians will be forced to stop taking new patients, meaning that access to care will be greatly impacted.

CMA, AMA, and others developing alternative Medicare payment system to replace SGR The California Medical Association (CMA) and the American Medical Association (AMA), along with more than 100 state and specialty medical societies, sent a letter to Congress on October 15, 2012, outlining the principles and core elements needed to successfully transition from the critically-flawed sustainable growth rate (SGR) to a higher performing Medicare program.

 The principles outlined in the letter include the notion that successful delivery reform is essential, that the Medicare program must invest and support physician infrastructure, and that Medicare payment updates should not only reflect the costs of providing services, but should also take into consideration efforts to improve quality and managing costs.

 CMA, AMA, and other health care associations are also working on an alternative payment plan to replace the SGR.

 In June of this year, an AMA SGR Task Force began work on a payment system for physicians that would be tied to “payment points.” While the working draft is confidential, the plan would include payment for things like quality, e-prescribing, adoption of EHR, best practices, chronic disease management, patient-centered medical homes and outcomes.

 The AMA, CMA, Massachusetts Medical Society, American College of Physicians, and American College of Surgeons have formed a small work-group to refine these proposals. The principles outlined in the letter to Congress were devised by the group. (CMA Alert, October 29, 2012 issue)


“In January of this year, a federal court issued the decision to block California state officials from moving forward with a 10% cut to Medi-Cal payments,” said James T. Hay, MD, CMA immediate past president.

 In spring of 2011, the California Legislature passed and Governor Jerry Brown signed AB 97, which included a 10% reimbursement rate cut for physicians, dentists, pharmacists, and other Medi-Cal providers. Federal approval was required before the state could implement its proposed cuts.

 A ruling on this hearing is expected later this year or in early 2013.
 (CMA Alert, October 16, 2012 issue)

CMA eliminates dues for medical students, residents, and fellows In an effort to encourage physicians-intraining to become involved in organized medicine and help shape the future of medicine in California, the California Medical Association (CMA) House of Delegates voted to eliminate membership dues for medical students, residents, and fellows, and to ask county medical societies to do the same (Resolution C-7-12). Effective immediately, CMA dues will be $0.00 for students, as well as $0.00 for residents and fellows. More information on CMA resources for these groups can be found at http://www. cmanet.org/membership/future-of-medicine/. If not already a CMA member, join today at https://www.cmanet.org/join. (CMA Alert, October 29, 2012 issue)

medico news

CMA tells Senate committees that elimination of Healthy Families is irresponsible On October 16, the Senate Budget and Fiscal Review Committee and the Senate Health Committee held a joint hearing on Governor Brown’s plan to eliminate the Healthy Families program. The California Medical Association (CMA), represented by CMA President Paul R. Phinney, MD, told committee members that it is “irresponsible” to force these children into an already overburdened Medi-Cal program. “This transition will put almost a million children at risk for compromised care for negligible budget savings,” said Dr. Phinney, a Sacramento pediatrician.

 The Legislature, in July, approved Governor Brown’s plan to move the 863,000 children enrolled in Healthy Families into Medi-Cal by September 1, 2013. Children are expected to be transitioned in four phases, depending on whether their physicians and health plans participate in the Medi-Cal program. Parents will begin receiving notifications from the state next month.

 According to the state, eliminating Healthy Families will save the state $13 million this fiscal year and $73 million annually once the transition is completed.

 Dr. Phinney testified that the adequacy of Medi-Cal provider networks in plans that will absorb the Healthy Families enrollees is in doubt and that without adequate provider networks, the plans will be offering coverage “without true access to care.”

 “Even if a child is being moved within the

same plan,” Dr. Phinney said, “it does not necessarily follow that their physician contracts with that plan for both products. Further, as plans and risk-bearing organizations begin to reduce their provider reimbursement rates, many physicians [will drop out of the program].” 

Dr. Phinney advised the panel that the Department of Health Care Services will have to monitor the plans’ physician networks, going forward, to assess not only what physicians are in the plans’ networks, but if they are accepting new Medi-Cal patients. He also spoke about CMA’s having an independent entity assess the viability of health plans’ provider networks before the transition begins.

 Dr. Phinney also spoke to the need to have a dedicated individual or office within the state Department of Health Care Services charged with oversight of the transition, urged the state to be vigilant about ensuring that all new Medi-Cal physicians treating children formerly in the Healthy Families program have access to free and low cost vaccines through the federal Vaccines for Children (VFC) program, and to make sure that physician services delivered to this new group of Medi-Cal enrollees would be eligible for the Medicare-level reimbursement for primary care services provided through federal health reform, beginning on January 1, 2013.
 (CMA Alert, October 29, 2012 issue)

Unsure whether you should sign the new Blue Shield agreement? The California Medical Association (CMA) continues to receive a high volume of calls from physicians and their staff regarding the new Blue Shield contracts. However, more recent reports from physicians indicate that Blue Shield representatives have become more aggressive in their attempts to get physicians to sign the new contracts. To assist physicians, CMA has published an updated analysis of the new Blue Shield contract, which is available to members in CMA’s online resource library at http://www.cmanet. org/resource-library. CMA has also prepared answers to the most common questions received from physicians about the new contracts. The FAQ is available at http:// www.cmanet.org under “News.” (CMA Alert, October 29, 2012 issue)

November is national COPD awareness month In recognition of national COPD awareness month, the California Medical Association (CMA) Foundation is encouraging physicians to talk to their patients about simple measures they can take to improve their lung function. COPD (chronic obstructive pulmonary disease) is a serious lung disease that makes it difficult to breathe. Also known as emphysema and chronic bronchitis, it recently surpassed stroke as the third leading cause of death in the United States. More than 12 million people are diagnosed with COPD and an additional 12 million are likely to have the disease and don’t even know it. While one in five adults over

the age of 45 have COPD, many dismiss their symptoms as a normal consequence of aging or being out of shape. The CMA Foundation AWARE (Alliance Working for Antibiotic Resistance Education) project has posted on its website a number of patient education materials that physicians can use to help patients lower their risk of the disease and understand that with proper diagnosis and treatment they can breathe easier and enjoy an improved quality of life. The materials can be downloaded at www.aware.md, under “Patient and Consumer Education Materials.” COPD occurs most frequently in current and former smokers age 40 and up. However, as

many as one out of six people with COPD have never smoked. COPD symptoms – such as shortness of breath, chronic coughing or wheezing, producing excess sputum, or feeling unable to take a deep breath – come on slowly and worsen over time. COPD can occur through long-term exposure to substances that can irritate the lungs, such as certain chemicals, secondhand smoke, and dust or fumes in the workplace. COPD can also occur in people with a genetic condition known as alpha-1 antitrypsin deficiency. (CMA Alert, October 29, 2012 issue)


medico news

New Medicare private contracting advocacy materials available The California Medical Association (CMA) and the American Medical Association (AMA) continue to push Congress to pass legislation to allow a private contracting option for Medicare patients. There are two bills, jointly known as the Medicare Patient Empowerment Act, currently making their way through the legislative process, that would allow Medicare patients to enter into private contracting arrangements with physicians without penalties for either party.

 CMA and AMA have launched a grassroots campaign to secure cosponsors for the bills – HB 1700, introduced by Representative Tom Price (R-GA), and SB 1042, introduced by Senator Lisa Murkowski (RAK). A range of resource materials has been developed to support the campaign, including a downloadable patient flyer for physician offices and a web-based petition for patients and physicians, available at http:// www.cmanet.org. Physicians who sign the petition may also order patient brochures for their offices at no cost. These materials and more are

available at www.ama-assn.org/go/privatecontracting.

 CMA has long sought a private contracting option for Medicare patients. Currently, seniors who wish to see a doctor who does not accept Medicare must pay for all services by that physician out of their own pocket. The physician may not seek reimbursement from Medicare for the care provided, nor will Medicare reimburse the beneficiary—despite the fact that seniors have paid into the program in the form of payroll taxes throughout their working lives.

 Medicare private contracting approach would expand access to care without costing the federal government additional resources. It would allow seniors to continue to use their Medicare benefits, even if the physician they choose does not see them through the Medicare program. In such a scenario, the patient would only be responsible for the difference between what Medicare typically covers and what the physician charges. (CMA Alert, October 16, 2012 issue)

Anthem Blue Cross amending some physician contracts to include individual/ exchange product On October 24, Anthem Blue Cross sent a notice to 8,345 physicians who are part of the Blue Cross Select PPO network announcing its intent to participate in the California Health Benefit Exchange, the state’s new insurance marketplace, called for under the Affordable Care Act. Beginning in 2014, individuals and small businesses will be able to purchase health insurance using tax subsidies and credits from the exchange. According to the notice, Blue Cross will be creating a new provider network called the “Anthem Individual/Exchange Network,” which will serve both individuals who purchase coverage through the exchange and individuals who purchase coverage from Anthem Blue Cross in the individual market outside of the exchange. In other words, the fee schedule would apply to all individual business, whether bought on or off of the exchange. Blue Cross has clarified for the California Medical Association (CMA) that this fee schedule change will not apply to Small Business Health Options Program (SHOP) business purchased through the exchange. It’s important to note that the letter also

states that Blue Cross is amending the physician’s Blue Cross Prudent Buyer Agreement to automatically include the new individual/exchange network, effective January 1, 2014. The new fee schedule associated with this product was included with the notice. CMA has been actively working with exchange stakeholders to address significant concerns regarding the exchange grace period, monitoring of network adequacy, and clinician-level performance measurement in qualified health plans offered in the exchange. Though not mentioned in the Blue Cross cover letter, Sections VI and VIII of the enclosed amendment provide instructions for physicians who wish to opt out of the individual/exchange network. Physicians who do not wish to participate in this network must notify Blue Cross of their intent to opt out by December 31, 2012. Opt out notices should be in writing and sent via certified mail, return receipt, to the address specified in Section VI of the amendment. CMA is working with Blue Cross to obtain additional clarification on the amendment and will provide updates as they are received.


Please note that a small subset of Select PPO Network physicians did not receive the October 24 notice, automatically opting them into the individual/exchange network. This subset of physicians received a notice from Blue Cross, dated October 9, regarding fee schedule reductions. Physicians who choose to discontinue participation in the Select PPO network at the reduced rates have until December 14 to notify Blue Cross in writing. As always, physicians are encouraged to carefully review all proposed amendments to payor contracts. You do not have to accept substandard contracts that are not beneficial to your practice. Physicians who did not receive a letter and are unsure whether they are affected by this change or those who have general questions about the amendment can contact Blue Cross’s Network Relations Department at 855/2380095 or networkrelations@wellpoint.com. (Source: Letter from CMA’s Center for Economic Services)

medico news

Palmetto GBA loses Medicare MAC contract The Centers for Medicare & Medicare Services (CMS) announced on September 20 that Noridian Administrative Services (NAS) has been named the new Medicare Administrative Contractor (MAC) for Medicare Parts A and B in California, Nevada, and Hawaii, as well as the U.S. territories of American Samoa, Guam, and the Northern Mariana Islands (Jurisdiction E, previously called Jurisdiction 1). 

Jurisdiction E includes over 3.5 million Medicare fee-for-service beneficiaries, 500 Medicare hospitals, and 86,500 physicians. MACs process Part A and Part B claims and perform other critical Medicare operational functions, including enrolling, educating, and auditing Medicare providers.

 It is not yet clear whether Palmetto GBA plans to appeal the decision. If there is an appeal, the earliest the handover could take place would be mid-to-late 2013.

 CMA will work with CMS and the new contractor to help minimize any disruption to physicians and patients. (CMA Alert, October 1, 2012 issue)

CMA publishes handy guide to EHR meaningful use, stage 2 On August 23, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final rule for stage 2 of “meaningful use.” The rule is part of a federal incentive program for Medicare and Medicaid physicians who adopt and achieve “meaningful use” of electronic health records (EHR). The final rule also lays out the timelines physicians will have to follow in order to avoid payment reductions in 2015.

 In addition to detailing the stage 2 requirements, the rule also includes changes to stage 1, some of which will go into effect as soon as January 1, 2013.

 The California Medical Association (CMA) has analyzed the CMS reporting requirements for physicians and created a fact sheet about the final rule. The fact sheet, “Federal EHR Incentive Programs: Stage 2 of Meaningful Use and Changes to Stage 1,” is available to members in CMA’s online resource library, www.cmanet.org/resource-library. (CMA Alert, October 16, 2012 issue)



By William S. Lewis, MD The Santa Clara County Medical Association’s Political Action Committee (SACPAC) hosted a fundraiser for Assemblyman Jim Beall on September 13, 2012. Dr. Howard Sutkin deserves credit for organizing the event, which was held at the Rinconada Hills Clubhouse and included tasty treats grilled on-the-spot by Tacos el Compa. The approximately two dozen attendees enjoyed the company of colleagues, friends, and, most importantly, Mr. Beall, who provided his insights on state and local politics and answered questions from the crowd. Mr. Beall has a long history of advancing issues important to medicine. As a Santa Clara County supervisor, he helped launch the novel Children’s Health Initiative to provide health coverage for all children, and he supported the expansion and renovation of Valley Medical Center. As an assemblyman, he has thoughtfully considered our opinions on legislation and dependably supported the California Medical Associa-

tion’s position on key votes. After three terms representing the 24th Assembly district, Mr. Beall was running for the newly drawn 15th Senate district, which covers a wide area across the valley from San Jose in the east to the communities of Los Gatos, Saratoga, and Cupertino in the west. As you probably already know, Mr. Beall won the election. SACPAC plays a vital role for our medical association. No matter how logical or self-evident our reasoned opinions may seem, we cannot sway legislators who are overly biased against organized medicine by trial lawyers, insurance companies, or other competing interests. By identifying and supporting candidates that understand and share our vision, SACPAC helps ensure a level playing field in Sacramento. If you want the CMA to succeed in its lobbying efforts on your behalf, I urge you to support SACPAC generously.

photoS: Gregory Cortez



The Black Plague was a major pestilence in the 14th century.


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eVigils™ is compliant with HIPAA and the Joint Commission ruling on texting. * Institute of Medicine. “To err is human: building a safer health system.” Washington, DC: National Academy Press; 2000

© MITEM Corporation, 2012

Artwork copyright © 2012 Dan Harding

Cindy Russell, MD, VP-Community Health, wrote the following letter to the AMA House of Delegates, in support of their resolutions on labeling of genetically engineered foods.


American Medical Association Reference Committee E (Science and Technology) Office of House of Delegates Affairs (312) 464-4344 or 1-800-262-3211 hod@ama-assn.org Date: June 3, 2012 Dear AMA Reference Committee: I am writing a letter in support of an AMA position to call for mandatory labeling of genetically engineered foods, mandatory independent testing of genetically modified foods and as testimony regarding Resolution #508A-11, introduced by the Illinois Delegation, and Resolution #509A-11, introduced by the Indiana Delegation. I am the author of the California Medical Association House of Delegate Resolution in 2002 to ask for labeling of genetically modified foods. Even 10 years ago, there was insufficient scientific evidence to consider genetically modified foods as safe for long-term human or animal consumption. It is no different today. Although industry reports adequate safety testing, independent peer-reviewed studies show there is evidence of potential adverse health effects as well as environmental effects of GMOs. (18)(19)(20)(21)(39)(40) Some scientists question the validity of current in vitro allergy testing and call for more rigorous long-term animal studies. (8) Reports of acute effects of GMO crops to humans and animals have also been documented. (14)(44) Physicians and public health experts have reason to be concerned and ask the AMA to take action to address this issue, as genetically modified organisms (GMOs), by definition, create novel allergens and potential new pathogens. (29) Gene expression in GMOs can be altered as well, in ways we have yet to fully understand. Because 70%–80% of the population is exposed to GMOs in the food supply, this magnifies the public health risk of adverse effects, even if there is only a small percentage of sensitive individuals.

Public health concerns with genetically modified foods include the following: • Allergenicity and increasing food intolerances with inadequate testing of novel GMOs (8)(23(24)(25)(26)(27) (28)(36)(54) • Inadequate testing of reproductive or developmental effects (11) (60) • Adverse effects of unusual human/plant GMOs (35)(56)(57)(58) (59) • Spread of antibiotic-resistant genes (9)(49) • Adverse effects on nutritional value (25) • Transfer of genetically modified DNA to gut bacteria (10)(31) (41)(48) • Increase in pesticide use and levels in humans (11)(33)(45)(50) (51)(52)(53) • Maternal transfer of genetically modified DNA to fetal bloodstream (12) • Multigenerational reproductive toxicity (12)(13)(16) • Toxicity to liver, kidney, adrenal, immune system (14) (15) (16) In addition, there are concerns expressed by experienced-based farmers including toxicity of crops to livestock, increasing resistance of GM crops to pesticides, increased dependency on more toxic pesticides, reduction of biodiversity of crops, harm to beneficial insects, unwanted spread of genetically modified plants to organic crops or forests, transfer of GM traits to soil and native plants, food security, and seed saving ability. (18)(19)(21)(30)(31)(32)(33)(34)(38)(45)(46)(47) GMO food labeling, as well as valid independent pre- and post-mar-

ket testing, is necessary for public health officials, physicians, and their patients to be able to identify and monitor adverse reactions of GMOs, as well as for personal choice. The Food Allergen Labeling and Consumer Protection Act of 2004 requires packaged foods to list major allergens such as tree nuts, wheat, and soybeans, as well as colorings or flavorings that may be allergenic. (5) The USDA also requires food labeling to provide general information desired by consumers such as fat, sugar, protein, total calories, fiber, and vitamins. This allows the consumer to make individual choices about the food they eat. (6) (7) Most consumers wish to have GMOs labeled as such. Over 40 countries already require labeling of genetically modified foods including the EU, Japan, Australia, Brazil, and China. Whether or not one believes there are safety concerns, it is both sensible and responsible for physicians to ask for both accurate labeling of GM foods, as well as independent pre- and post-market testing of genetically engineered crops.

Genetically Modified Foods Are Different Genetically modified foods are profoundly different than conventional foods in how they are developed. They are legally patented as different. Genes are literally forced into cells by three different methods. The location of the desired genes is unpredictable. In addition, genetic expression and gene interaction on the entire cell or organism is unpredictable. The engineering is random and not precise, as we are led to believe. We also know that there is not one gene trait interaction for most processes directed by DNA. One gene trait may require several other genes in order for the organism to fully express a desired trait or to function in a certain environment. We do not fully understand these complex interactions of DNA, and its co-worker mRNA, on other genes. Scientists have discovered and are studying a new level of complexity in the genome called epigenetics. Developmental biologists have found that the inherited expression of DNA can be altered not by nucleotides as we have been traditionally taught, but also by processes including “methylation” of the DNA, mRNA effects, and conformational changes in protein structure. The new inherited mutations affect whether a gene will be over expressed or under expressed, or even be functional. These important genetic changes are not investigated by industry prior to commercialization of GMOs. One study of these effects, in Australia, found that the added genes in the GM crop were “methylated” and this was what was felt to be causing the toxicity of the GM PEA to rat kidney and liver. Epigenetic changes appear to be causing inherited metabolic syndrome in children whose parents are obese or have diabetes. (1) (2) (3) (4) In addition, the DNA in genetically modified organisms is not stable and can mutate with different effects on function, nutritional value, and toxicity. This may account for reports of acute human toxicity of some GM crops when pollinating. The gene cassette incorporated into the new GMO cell consists of the DNA for the desired trait, an antibiotic resistant gene, and promoter genes. Newer crops now contain genes that turn off reproduction, the “terminator technology.” This combination of genetic material undergoes changes as it is pushed into the gene into an unknown area of the chromosome and is further altered by the cells’ growth in tissue culture. Gene expression (temperature tolerance, yields, toxin production, pesticide production) may be altered depending on the location of the genes insertion on the chromosome. Physicians are particularly concerned with what appears to be an increase in food allergies and food intolerances. The desired trait may be expressed, but the protein produced by a GMO is truly a novel protein.

Continued on page 52 NOVEMBER / DECEMBER 2012 | THE BULLETIN | 51

Labeling of Genetically Engineered Food, from page 51 Testing of GMOs is currently performed on the new DNA code to determine if there is any DNA which is similar to common allergens such as soy or peanut. This testing is inadequate to fully know how the insertion of the genes affects the plant or animal DNA and whether or not epigenetic changes have occurred that would also affect the allergenicity of the GM crop. Scientists have called for more accurate allergy testing with rat models, prior to commercial introduction of the GM crop. (8) The introduction of antibiotic resistant genes is particularly troubling as we are seeing a dramatic rise in antibiotic resistance. It has now been demonstrated that DNA from GMOs can be transferred to soil and gut bacteria via horizontal transfer. Genetically engineered crops are novel synthetically-created foods and thus require advanced methods of safety assessment and labeling in order to protect humans and livestock, as well as the complex and fragile environment upon which we all depend.

References 1) Epigenetics and metabolism in 2011: Epigenetics, the life-course and metabolic disease. Nature Reviews Endocrinology 8, 74-76 (February 2012) |doi:10.1038/nrendo.2011.226 http://www.nature.com/nrendo/ journal/v8/n2/full/nrendo.2011.226.html 2) Effects of a High-Fat Diet Exposure in Utero on the Metabolic Syndrome-Like Phenomenon in Mouse Offspring Through Epigenetic Changes in Adipocytokine Gene Expression. Endocrinology March 20, 2012 en.2011-2161 http://endo.endojournals.org/content/early/2012/03/14/en.2011-2161 3) Epigenetic changes in early life and future risk of obesity. International Journal of Obesity 35, 72-83 (January 2011) |doi:10.1038/ ijo.2010.122 http://www.nature.com/ijo/journal/v35/n1/full/ ijo2010122a.html 4) Epigenetic changes predisposing to type 2 diabetes in intrauterine growth retardation. http://www.frontiersin.org/Pediatric_Endocrinology/10.3389/fendo.2010.00005/abstract 5) Food labeling guide http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/FoodLabelingNutrition/FoodLabelingGuide/ucm064880.htm 6) Food labeling fact sheet USDA http://www.fsis.usda.gov/Factsheets/Food_Labeling_Fact_Sheets/index.asp 7) Read the Food Label http://www.nhlbi.nih.gov/hbp/prevent/sodium/label.htm 8) Evaluation of biotechnology-derived novel proteins for the risk of food-allergic potential: advances in the development of animal models and future challenges. Arch Toxicol2010, Dec;84(12):909-17. Epub 2010 Sep 15. Ahuja V. http://www.ncbi.nlm.nih.gov/pubmed/20842347 9) Ampicillin threat leads to wider transgene concern. Nature. 2005 Jun 2;435(7042):56. Azeez G. http://www.ncbi.nlm.nih.gov/ pubmed/15931193 10) Degradation of transgenic DNA from genetically modified soya and maize in human intestinal simulations. Br J Nutr. 2002 Jun;87(6):533. Martín-OrúeSM4 http://www.ncbi.nlm.nih.gov/pubmed/12067423 11) Maternal and fetal exposure to pesticides associated to genetically modified foods in Eastern Townships of Quebec, Canada. Aris, A. Reproductive Toxicology. 2011 May;31(4):528-33. Epub 2011 Feb 1 http:// www.ncbi.nlm.nih.gov/pubmed?term=reproductive%20toxicology%20 31%3A528%20%20aris%20Cry1ab%20protein%20maternal%20fetal 12) Biological effects of transgenic maize NK603xMON810 fed in long term reproduction studies in mice. Dr. A. Velimirov http://www. 52 | THE BULLETIN | NOVEMBER / DECEMBER 2012

biosicherheit.de/pdf/aktuell/zentek_studie_2008.pdf 13) A comparison of the effects of three GM corn varieties on mammalian health. Seralini. Int J Biol Sci. 2009 Dec 10;5(7):706-2. http:// www.ncbi.nlm.nih.gov/pubmed/20011136 14) Mass Protests Against GM Crops in India. http://www.i-sis.org. uk/gmProtestsIndia.php 15) Study Proves Three Monsanto Corn Varieties’ Noxiousness to the Organism. Le Monde Dec 2009 http://archive.truthout.org/1215091 16) A three generation study with genetically modified Bt corn in rats: Biochemical and histopathological investigation. Asun Kılıc. Food and Chemical Toxicology 46 (2008) 1164–1170 http://www.somloquesembrem.org/img_editor/file/Kilic%26Akay08BtMaizeFeedingStudy. pdf 17) Sterility of animals linked to GMOs http://responsibletechnology.org/article-gmo-soy-linked-to-sterility 18) Farmer knowledge and a priori risk analysis: pre-release evaluation of genetically modified Roundup Ready wheat across the Canadian prairies. Environ Sci Pollut Res Int. 2009 Sep;16(6):689-701. Epub 2009 May 28.Mauro.IJ. http://www.ncbi.nlm.nih.gov/pubmed/19475440 19) Landscape-scale distribution and persistence of genetically modified oilseed rape (Brassica napus) in Manitoba, Canada. Environ Sci Pollut Res Int. 2010 Jan;17(1):13-25. Epub 2009 Jul 9. Knispel AL http://www.ncbi.nlm.nih.gov/pubmed/19588180 20) The Silent Forest. David Suzuki http://www.youtube.com/ watch?v=fSEVzwdjjWw 21) Transgenic DNA introgressed into traditional maize landraces in Oaxaca, Mexico. Nature. 2001 Nov 29;414(6863):541-3. Quist D, Chapela IH. http://www.ncbi.nlm.nih.gov/pubmed/11734853 22) Quantification and persistence of recombinant DNA of Roundup Ready corn and soybean in rotation. J Agric Food Chem. 2007 Dec 12;55(25):10226-31. Epub 2007 Nov 13. Lerat S, http://www.ncbi.nlm. nih.gov/pubmed/17997522 23) Testing of genetically modified novel proteins for allergenicity in food and feed: a toxicological and regulatory challenge. Arch Toxicol. 2010 Dec;84(12):907- Bolt, HM. http://www.ncbi.nlm.nih.gov/ pubmed/20859736 24) Starlink corn: a risk analysis. Environ Health Perspect. 2002 Jan;110(1):5-13. Bucchini L, Goldman LR. http://www.ncbi.nlm.nih. gov/pubmed/11781159xx 25) Potential adverse health effects of genetically modified crops. J Toxicol Environ Health B Crit Rev. 2003 May-Jun;6(3):211-2. Bakshi A http://www.ncbi.nlm.nih.gov/pubmed/12746139 26) Introduction: what are the issues in addressing the allergenic potential of genetically modified foods? Environ Health Perspect. 2003 Jun;111(8):1110-3. Metcalfe DD. http://www.ncbi.nlm.nih.gov/ pubmed/12826482 27) Taco Bell Recalls Shells That Used Bioengineered Corn http:// articles.latimes.com/2000/sep/23/news/mn-25314 28) “Assessment of Additional Scientific Information Concerning Starlink Corn,” FIFRA Scientific Advisory Report No. 2001-09, July 2001 29) Open Letter from Purdue University Emeritus Professor Don Huber. Pathogen New to Science Found in Roundup Ready GM Crops? http://www.i-sis.org.uk/newPathogenInRoundupReadyGMCrops.php 30) Researcher: Roundup or Roundup-Ready Crops May Be Causing Animal Miscarriages and Infertility http://farmandranchfreedom. org/gmo-miscarriages

31) The Myth of Coexistence: Why Genetically Engineered Crops and Agroecology are Incompatible. http://www.organicconsumers.org/ articles/article_875.cfm 32) The new PCB: Monsanto’s Roundup weed killer turning up in air, rain and rivers http://www.naturalnews.com/033699_Roundup_ pollution.html 33) Glyphosate Kills Rat Testis Cells. http://www.i-sis.org.uk/ glyphosate_kills_rat_testis_cells.php 34) Crops genetically modified to kill herbivorous insects may also have an effect on their natural enemies http://www.farminguk.com/ news/Crops-genetically-modified-to-kill-herbivorous-insects-may-also-have-an-effect-on-their-natural-enemies_17313.html 35) Human genes in Kansas crops http://www.naturalnews. com/035745_GMO_rice_human_genes_Kansas.html#ixzz1uK7xK300 36) IgE-mediated allergy to corn: a 50 kDa protein, belonging to the reduced soluble proteins, is a major allergen. Allergy, 57, 98–106, Pasini, G. http://www.ncbi.nlm.nih.gov/pubmed?term=Allergy%2C%20 57%2C%2098 –106%2C%20Pasi ni%2C%20G.%20<ht t p://w w w. ncbi .n l m .n i h .gov/pubmed?ter m=A l lerg y %2C%2 057%2C%2 0 98%E2%80%93106%2C%20Pasini%2C%20G.%20> 37) Detection of corn intrinsic and recombinant DNA fragments and Cry1Ab protein in the gastrointestinal contents of pigs fed genetically modified corn Bt11. Chowdhury, E.H. J ANIM SCI October 2003 vol. 81 no. 10 2546-2551 http://www.animal-science.org/content/81/10/2546. full 38) Increased frequency of pink bollworm resistance to Bt toxin Cry1Ac in China. PLoS One. 2012;7(1):e29975. Epub 2012 Jan. Wan, J. http://www.ncbi.nlm.nih.gov/pubmed/22238687 39) Toxicity studies of genetically modified plants: a review of the published literature. Crit Rev Food Sci Nutr. 2007;47(8):721-33, Domingo JL http://www.ncbi.nlm.nih.gov/pubmed/17987446 40) A literature review on the safety assessment of genetically modified plants. Environ Int. 2011 May;37(4):734-42. Epub 2011 Feb 5,Domingo JL, Giné Bordonaba J. http://www.ncbi.nlm.nih.gov/ pubmed/21296423 41) Fate of genetically modified maize DNA in the oral cavity and rumen of sheep. Br J Nutr. 2003 Feb;89(2):159-6. Duggan PS. http:// www.ncbi.nlm.nih.gov/pubmed?term=Paula%20S.%20Duggan%2C%20 et%20al%2C%20%22Fate%20of%20genetically%20modified%20 maize%20DNA%20in%20t he%20ora l%20cav it y %20and%20rumen%20of%20sheep%2C%22%20Br%20J%20Nutr.%2089%2C%20 no%202%20(Feb.2003)%3A%20159Â%2066.%20<http://www.ncbi. nlm.nih.gov/pubmed?term=Paula%20S.%20Duggan%2C%20et%20 al%2C%20%22Fate%20of%20genetically%20modified%20maize%20 DNA%20in%20the%20oral%20cavity%20and%20rumen%20of%20 sheep%2C%22%20Br%20J%20Nutr.%2089%2C%20no%202%20 (Feb.2003)%3A%20159%C3%82%2066.%20> 42) Current understanding of cross-reactivity of food allergens and pollen. Ann N Y Acad Sci. 2002 May;964:47-68. Vieths S, http://www. ncbi.nlm.nih.gov/pubmed/12023194 43) Cross-reactivity between fruit and vegetables. Allergol Immunopathol (Madr). 2003 May-Jun;31(3):141-6. http://www.ncbi.nlm.nih. gov/pubmed/12783764 44) Mass Deaths in Sheep Grazing on Bt Cotton. Dr. Mae-Wan Ho http://www.i-sis.org.uk/MDSGBTC.php 45) Monsanto Pays Farmers to Up Herbicide Use. http://www.sustainlane.com/reviews/monsanto-pays-farmers-to-up-herbicide-use/ USTDUNH4YXW98XCSRUC2UNNSVO3A 46) Farmers Cope With Roundup-Resistant Weeds. New York

Times, May 3, 2010. http://www.nytimes.com/2010/05/04/business/energy-environment/04weed.html?_r=1 47) Genes From Engineered Grass Spread for Miles, Study Finds. September 21, 2004. http://select.nytimes.com/gst/abstract.html?res=F7 0812FA395D0C728EDDA00894DC404482 48) The stability and degradation of dietary DNA in the gastrointestinal tract of mammals: implications for horizontal gene transfer and the biosafety of GMOs. Crit Rev Food Sci Nutr. 2012;52(2):142-61. doi: 10.1080/10408398.2010.499480. Rizzi A. http://www.ncbi.nlm.nih.gov/ pubmed/22059960 49) Problems in monitoring horizontal gene transfer in field trials of transgenic plants. Nat Biotechnol. 2004 Sep;22(9):1105-9. Heinemann JA, http://www.ncbi.nlm.nih.gov/pubmed/15340480 50) [Cytotoxicity of the herbicide glyphosate in human peripheral blood mononuclear cells]. Biomedica. 2007 Dec;27(4):594-604. Martinez, A. http://www.ncbi.nlm.nih.gov/pubmed/18320126 51) Glyphosate-based herbicides are toxic and endocrine disruptors in human cell lines. Toxicology. 2009 Aug 21;262(3):184-91. Epub 2009 Jun 17. Gasnier, C. http://www.ncbi.nlm.nih.gov/pubmed/19539684 52) Differential effects of glyphosate and roundup on human placental cells and aromatase. Environ Health Perspect. 2005 Jun;113(6):71620. Richard, S. http://www.ncbi.nlm.nih.gov/pubmed/15929894 53) New evidences of Roundup (glyphosate formulation) impact on the periphyton community and the water quality of freshwater ecosystems. Ecotoxicology. 2010 Apr;19(4):710-21. Epub 2009 Nov 29. Vera, M.S. http://www.ncbi.nlm.nih.gov/pubmed/20091117 54) Effect of diets containing genetically modified potatoes expressing Galanthus nivalis lectin on rat small intestine. Lancet. 1999 Oct 16;354(9187):1353. Pusztai A. http://www.ncbi.nlm.nih.gov/ pubmed?term=Effects%20of%20diets%20containing%20genetically%20modified%20potatoes%20expressing%20Galanthus%20nivalis%20lectin%20on%20rat%20small%20intestine.%20Ewen%20S.W.%20 and%20Pusztai%20A.%20The%20Lancet%2C%20354%3A%2013531354%2C%201999 55) Ultrastructural morphometrical and immunocytochemical analyses of hepatocyte nuclei from mice fed on genetically modified soybean. Malatesta M et al. Cell Struct Funct., 27: 173-180, 2002. http://www.ncbi.nlm.nih.gov/pubmed?term=Malatesta%20M%20et%20 al.%20Cell%20Struct%20Funct.%2C%2027%3A%20173-180%2C%20 2002 56) Morphological and physiological characteristics of transgenic cherry tomato mutant with HBsAg gene. Genetika. 2011 Aug;47(8):10445. Guan ZJ, http://www.ncbi.nlm.nih.gov/pubmed/21954613 57) Retention of the ability to synthesize HIV-1 and HBV antigens in generations of tomato plants transgenic for the TBI-HBS gene. okl Biochem Biophys. 2009 Mar-Apr;425:120. , Rekoslavskaya NI, Stolbikov AS, Hammond RW, Shchelkunov SN. http://www.ncbi.nlm.nih.gov/ pubmed/19496338 58) Expression of the hepatitis B surface S and preS2 antigens in tubers of Solanum tuberosum. Plant Cell Rep. 2004 Jul;22(12):925-30. Epub 2004 Mar 2, Joung HY. http://www.ncbi.nlm.nih.gov/pubmed/15048583 59) GMO crops with pharmaceuticals and vaccines http:// en.wikipedia.org/wiki/Pharming_(genetics) 60) A novel endocrine-disrupting agent in corn with mitogenic activity in human breast and prostatic cancer cells. Environ Health Perspect. 2002 February; 110(2): 169–177. B. Markaverich http://www.ncbi. nlm.nih.gov/pmc/articles/PMC1240732/ NOVEMBER / DECEMBER 2012 | THE BULLETIN | 53

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