2013 May/June

MAY / JUNE 2013 | Volume 19 | Number 3

Health Reform Heats up as the Clock Races

PLUS:

New HIPAA Privacy and Security Requirements Reporting Unsafe Drivers: Know Your Obligations!

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BULLETIN THE

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

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

MEMBER BENEFITS Billing/Collections CME Tracking Discounted Insurance Financial Services Health Information Technology Resources House of Delegates

Feature Articles 8 Health Reform Heats Up as the Clock Races 14 New HIPAA Privacy and Security Requirements 16 Reporting Unsafe Drivers: Know Your Obligations!

18 A Physician’s Guide to Personal Health 20 Opportunities for Retired Physicians

Departments

Representation

5 From the Editor’s Desk

Human Resources Services

6 CMA President’s Letter

Legal Services/On-Call Library

7 MICRA Savings

Legislative Advocacy/MICRA

22 Letter to FDA: Genetically Engineered Salmon

Membership Directory iAPP for

26 Welcome New Members

the iPhone

27 In Memoriam

Physicians’ Confidential Line

28 CMA Webinars At-A-Glance

Practice Management

30 Member Benefit News

Resources and Education Professional Development Publications Referral Services With Membership Directory/Website

32 Medical Times From the Past 34 Legislative Leadership Day 36 MEDICO News 42 Classified Ads

Reimbursement Advocacy/ Coding Services Verizon Discount MAY / JUNE 2013 | 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

Councilors

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Arthur Basham, MD El Camino Hospital: Imtiaz Qureshi, 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: Michael Champeau, 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)

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Printed in U.S.A.

OFFICERS

Editor

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

THE

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 2013 by the Santa Clara County Medical Association.

4 | THE BULLETIN | MAY / JUNE 2013

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

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)

FROM THE EDITOR’S DESK

Joseph S. Andresen, MD Editor, The Bulletin

June, a Month of New Beginnings

By Joseph Andresen, MD Editor, The Bulletin June is graduation season. All around the country, families gather to witness their son, daughter, niece, nephew, brother or sister, granddaughter or grandson walk across the stage and accept their diploma. Our family has traveled 3,000 miles to share in my son’s college graduation. He is my youngest and last to leave the nest, so to speak. Despite 92 degree and muggy New Jersey weather, the hundreds of parents sitting on folding chairs don’t seem to mind as we relish each breath of breeze. We listen to Ben Bernanke, the baccalaureate speaker, concisely summarize his wisdom in 10 simple points including choosing one’s life partner and career path, but excluding any advice on future interest rates. And as the ceremony draws to a close, I look around at the many young faces of enthusiasm, excitement, and accomplishment. I have renewed hope in the future that our next generation will manage and create.

This month’s Bulletin presents a watershed of important information for all physicians. As you may well know, in less than six months, major provisions of the Patient Protection and Affordable Care Act will be implemented. The hope and promise is for a marked improvement in patient access to medical care while drastically reducing those without health care insurance. The success or failure of this major change rests, in large part,

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.

on our physician shoulders. CMA President Paul R. Phinney, MD, reaffirms the importance of physician leadership in this process in his article, “Health Reform: Physicians Leading Change.”

A roadmap of the pertinent changes to expect are detailed in “Health Reform Heats Up as the Clock Races,” nicely summarized by CMA staff writer James Noonan.

Major change undoubtedly creates profound and new stresses. “A Physician’s Guide to Personal Health” has pearls of wisdom that we must take to heart and not overlook in maintaining our own well-being.

With a historical perspective, Elizabeth Ahrens-Kley recalls the story of Dr. Benjamin Cory and others who faced the Cholera epidemic of 1850 in San Jose, California.

And finally, I now know much more about AquAdvantage Salmon than before. Read the Santa Clara County Medical Association’s letter to the FDA regarding proposed genetically engineered salmon.

And in this time, in recognition of higher learning and life’s most rewarding pursuits: be quick to love, make haste in helping others, and recognize your power in making our world a better place.

MAY / JUNE 2013 | THE BULLETIN | 5

cma president's letter

PAUL R. PHINNEY, MD President, California Medical Association

Health Reform: Physicians Leading Change

By Paul R. Phinney, MD President, California Medical Association As I am sure most of you are acutely aware, the medical profession in our country is undergoing rapid unprecedented change.

In a little more than six months, major provisions of the Patient Protection and Affordable Care Act (ACA) – the driving legislation behind the national effort for health care reform – will be implemented, undoubtedly reshaping the national system for delivering care for years to come.

Some of you have already felt the effects of the ACA in your day-today practice. Perhaps you have treated a patient whose only avenue for coverage was a temporary high-risk pool plan designed to ensure that her pre-existing condition could no longer be denied coverage. Or maybe you have simply noticed an influx of young adults into your office, a result of the provision allowing children to remain on their parents’ insurance until age 26.

While these reforms are laudable, the bulk of the planned legislative reforms will be introduced and overseen by an entirely new entity in the nation’s health care delivery model – state-based health benefit exchanges.

Beginning on January 1, 2014, these state-based exchanges will introduce new, online insurance marketplaces through which consumers will be able to purchase health coverage subsidized according to their income levels. Between the exchanges and the planned expansion of Medicaid programs across the country, as many as 32 million Americans are expected to gain coverage over the next few years.

With the January deadline drawing near, the pace is frantic, and as providers begin to plan for this massive influx of new patients, state and federal regulators are still issuing guidance outlining exactly how these exchanges will function.

We are changing out our jet engines mid-flight, while the runway we approach is still being built.

But while there is still much to be done, California physicians are making progress toward a successful implementation.

Only days after the federal enacting legislation was signed, California emerged as the leader in ACA implementation by authorizing formation of its own health benefit exchange. Now called Covered California, our state exchange has since that time selected an executive director and board who have been aggressively assembling, preparing, for the opening of a successful marketplace in 2014.

This progress has not come easily.

Throughout the effort, the exchange board has been faced with input from many competing interests. Every decision, no matter how large or 6 | THE BULLETIN | MAY / JUNE 2013

small, has come with comments and suggestions from payors, consumer advocates, hospitals and, of course, your California Medical Association (CMA).

CMA staff has worked diligently to position our association as a prominent stakeholder in the development and future function of Covered California, ensuring that our state does not end up with a model of health care in which quality is measured in dollars, value is available only to those who can pay for it, and medical decisions are controlled by payors and regulators rather than by doctors.

Only physicians know how to balance medical care wisely as we figure out how to realign incentives towards a sustainable health system and stable fiscal future, and our leadership at this juncture is critical.

Furthermore, with important major tasks still yet to be accomplished, design and implementation of the exchange continues to hold significant risks for California physicians. Only now, roughly six months before the exchange goes live, is the model contract being finalized. Following that, the exchange must select which insurance providers will be eligible to offer a plan in the new, online marketplace.

As these decisions are finalized, it is vital that physicians pay attention, educate themselves, and choose wisely the nature and extent of their future participation.

The choices we make today – both individually and collectively – will have important ramifications for how medicine is practiced in California for years to come. As you consider these choices, you can rest assured that CMA will be there to help.

And as we begin to land our retooled aircraft on a brand-new runway, the efforts we have made as physicians and as CMA members will help to ensure a safe, sensible, and successful journey into a professional future we have helped to both envision and create.

With only months to go, it is critical that we remember and reaffirm the importance of physician leadership in the California health care reform effort, knowing that absent our involvement and our effort, the default future would have been much different. Physician leadership – in the vision for, implementation of, and provision of medical care going forward – is the only way to ensure the people of California have access to the health care system they truly deserve.

Thank you for your leadership. It has – and will – make all the difference.

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MAY / JUNE 2013 | THE BULLETIN | 7

8 | THE BULLETIN | MAY / JUNE 2013

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

BY JAMES NOONAN l CMA Staff Writer

S

ince its inception, the Affordable Care Act (ACA) has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation. For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy. >> MAY / JUNE 2013 | THE BULLETIN | 9

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

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

The road has already been a somewhat rocky one.

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

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

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

Despite these problems, the march toward reform continues on.

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

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

10 | THE BULLETIN | MAY / JUNE 2013

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

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

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

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

CALIFORNIA LEADS THE WAY

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

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

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

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

responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 19 geographical rating regions.

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

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

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

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

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

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

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

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

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

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

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

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

MAY / JUNE 2013 | THE BULLETIN | 11

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

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

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

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

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

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

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

12 | THE BULLETIN | MAY / JUNE 2013

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

ACTION UNDER THE DOME

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

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

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

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

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

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

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PRACTICE MANAGEMENT

New HIPAA Privacy and Security Requirements

By David Ginsberg This article is reprinted with the permission of San Diego Physician SCCMA-MCMS physicians should be aware of major changes to HIPAA privacy and security compliance that have been finalized and released in a rule published on January 25, 2013. These changes formally go into effect on March 26, 2013, with compliance required by September 23, 2013.

Many of the changes are a result of the 2009 American Reinvestment and Recovery Act/HITECH Act, which provided for increased use of electronic health records and exchange of patient data to improve patient safety, health care quality and access, and to reduce inefficiencies.

Most physicians are aware of the incentive payments under the HITECH Act for achieving meaningful use. Recognizing that increased adoption of EHRs also increases threats to the privacy and security of patient information, HITECH also included additional compliance requirements under HIPAA. A few (and only a few) of the major changes that affect HIPAA compliance include: • Breach Notification Requirements: The obligation to notify patients if there is a breach of their PHI is expanded and clarified under the new rules. Breaches are now presumed reportable unless, after completing a risk analysis applying the following four factors, it is determined that there is a “low probability of PHI compromise.” The four factors to be considered include: 1. The nature and extent of the PHI involved. Issues to be considered include the sensitivity of the information from a financial or clinical perspective and the likelihood the information can be reidentified.

2. The person who obtained the unauthorized access and whether that person has an independent obligation to protect the confidentiality of the information.

3. Whether the PHI was actually acquired or accessed, determined after conducting a forensic analysis.

4. The extent to which the risk has been mitigated, such as by obtaining a signed confidentiality agreement from the recipient.

The four factors replace the previous determination of “significant risk of financial, reputational, or other harm” analysis for establishing a breach. The new rules do not modify the actual reporting and time frame requirements for breach notification, i.e., covered entities must still adhere to requirements for individual notification, HHS notification, and, where applicable, media posting of the breach.

We encourage all physician practices to update their breach notification procedures since we often find these lacking during our HIPAA reviews!

• Disclosures to Health Plans: At the patient’s request, physicians may not disclose information about care the patient has paid for out-of-pocket to health plans, unless for treatment purposes or 14 | THE BULLETIN | MAY / JUNE 2013

Mr. Ginsberg is president of PrivaPlan Associates, Inc., and a long-term HIPAA advisor. Many members use the CMA/PrivaPlan HIPAA Toolkit for their HIPAA compliance.

•

•

•

•

•

in the rare event the disclosure is required by law. Previously, physicians could refuse a request for restrictions on use and disclosure of PHI. The new law requires restrictions when the patient has paid out-of-pocket and requests the restriction (to a health plan). This change is likely to have the greatest impact on your practice work flow in terms of documentation, follow-up to ensure the restriction is adhered to, and how you will handle the payment.

Childhood Immunizations: Under the new rules, physicians may disclose immunizations to schools required to obtain proof of immunization prior to admitting the student, so long as the physicians have and document the patient’s or patient’s legal representative’s “informal agreement” to the disclosure.

Decedents: The new rules allow physicians to make disclosures to the deceased’s family and friends under essentially the same circumstances such disclosures were permitted when the patient was alive, for example, when these individuals were involved in providing care or payment for care and the physician is unaware of any expressed preference to the contrary. The new rule also eliminates any HIPAA protection for PHI 50 years after a patient’s death.

Copies of ePHI: Physicians will now have only 30 days to respond to a patient’s written request for his or her PHI with one 30-day extension (compared to the current allowance under HIPAA of one 60-day extension), regardless of where the records are kept. They must provide access to EHR records in the electronic form and format requested by the individual if the records are “readily reproducible” in that format. Otherwise, they must provide the records in another mutually agreeable electronic format. Hard copies are permitted only when the individual rejects all readily reproducible electronic formats.

Physicians must also consider transmission security, and may send PHI in unencrypted emails only if the requesting individual is advised of the risk and still requests that form of transmission.

This only applies to a copy request and not general communication and correspondence with a patient. Physicians are cautioned to continue to prohibit emailing PHI for other purposes, unless a secure email system or a patient portal are used!

Charging for Copies of ePHI or PHI: The new rule limits the costs that may be charged to the individual for copy requests to labor costs and supply costs if the patient requests a paper copy, or, if electronic, the cost of any portable media (such as a USB memory stick or a CD).

Notice of Privacy Practices (NPP): Physicians will need to amend their NPPs to reflect many of the changes. Most

physicians have not amended their NPP since the initiation of the Privacy Rule, so this is an excellent time to update the NPP. SCCMA-MCMS members who use the CMA/PrivaPlan HIPAA Compliance Toolkit will receive an updated NPP template in English and Spanish over the next month or so.

• Business Associates (BAs): The new rules expand the universe of individuals and companies that must be treated as business associates, such as health information organizations, e-prescribing gateways, or health information exchanges that transmit and maintain PHI, and personal health record vendors that physicians sponsor for their patients (such as those offered through an EHR). Thus, physicians must review their relationships and determine if they must enter new BA

agreements with these entities or others that create, receive, store, maintain, or transmit PHI on their behalf. These rules also modify the requirements for BA agreements including: ȧȧ Physicians no longer must report failures of their BAs to the government when termination of the agreement is not feasible, as HHS has concluded that the BA’s direct liability for these violations is sufficient. ȧȧ BAs are now responsible for their subcontractors. ȧȧ BAs must comply with the Security and Breach Notification Rules. ȧȧ Physicians are liable for the actions of their BAs who are agents, but not for the actions of those BAs that are independent contractors.

MAY / JUNE 2013 | THE BULLETIN | 15

MANAGING PROFESSIONAL RISK

Reporting Unsafe Drivers: Know Your Obligations!

By Karen K. Davis, MA, CPHRM Risk Management, NORCAL Mutual Insurance Company Case Consider the following case scenario: A physician had a 42-year-old male patient who was a diabetic on insulin. This patient lost consciousness while he was driving, and his car struck two pedestrians, a woman, and her 10-year-old son. Both pedestrians suffered severe injuries as a result of the accident. The woman later sued the driver’s physician, alleging that the physician was liable for the actions of his patient, which resulted in the injuries to her and her son. She asserted that the patient’s diabetes caused him to suffer a temporary loss of consciousness with loss of control of his vehicle, ultimately resulting in the crash. She claimed that the physician had neglected his duty to report the patient as an unsafe driver to the state’s department of transportation and was therefore responsible for the injuries to the third-party victims (her and her son).

Case Discussion At trial, this case was decided in favor of the defendant physician. Attorneys for both sides acknowledged that physicians in that particular state have a responsibility to report to the department of transportation when a patient is unable to drive in a safe manner. The patient in this case, however, was not an unstable diabetic, and he had never before experienced a loss of consciousness as a result of his diabetes. Therefore, the jury ultimately decided the physician had properly evaluated the patient’s ability to drive and did not owe a duty to the accident victims.

Liability Risk Reduction Although the physician in this case was not held liable, there is a possibility that physicians across the United States could be answerable for injuries or property losses affecting third-party victims, but caused by patients. Therefore, if you are in medical practice, you should know what 16 | THE BULLETIN | MAY / JUNE 2013

conditions are reportable to your specific transportation department (or local health officers or other officials or agencies working in cooperation with the transportation department), and you should report as required when, in your clinical judgment, a patient meets the criteria.

Most states set forth a list of what is reportable, and the lists often include conditions such as epilepsy, unstable diabetes, cerebral vascular insufficiency, neuromuscular diseases, loss or impairment of a limb, mental or emotional disorders, visual impairment, substance abuse, and other conditions that could hinder safe driving. Physicians are generally required to report when they diagnose a person with a disease or disorder that would interfere with a patient’s safe operation of a motor vehicle. Generally, the physician is responsible for reporting, but the transportation department makes the decision about whether to retest the driver and/or to revoke a patient’s privilege to operate a motor vehicle.

What Does My State Require?

Each state has its own laws governing reporting procedures and obligations. To find information about your state’s department of transportation reporting requirements, you can consult an American Medical Association resource “State Licensing and Reporting Laws” (a chapter of the Physician’s Guide to Assessing and Counseling Older Drivers) at www.amaassn.org/ama1/pub/upload/mm/433/older-drivers-chapter8.pdf. This publication summarizes transportation department reporting laws for all states and the District of Columbia. As the publication notes, however, this information is subject to change, and therefore you may want to verify the data by searching for current medical reporting requirements on your particular state’s department of transportation website.

The AMA publication lists the web address for each state’s transportation department, which may make your search easier. The decision about whether or not to report can be very fact-specific. You may want to consult your attorney to advise you in complicated situations.

Reporting and Confidentiality In some states, information about a patient’s condition may be released to the transportation department without the patient’s consent, and no civil or criminal action may be brought against a physician for providing the information required under the state’s system.

The federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules require physicians and other covered entities to protect the confidentiality of patient’s health information. However, HIPAA does not prevent physicians and other health care providers from disclosing patient information that is required by law.1 Therefore, if your state has mandatory reporting of medical conditions that impede safe driving, you should submit the information your state calls for to identify the person and describe the problem limiting driving ability.

If your state allows or authorizes (but does not mandate) reporting of patients whose conditions create driving hazards, your report will be affected by the HIPAA “minimum necessary” rule. To comply with the rule, you will need to consider the situation and then release only the minimum necessary patient information required to make a reasonable and comprehensible report.2 Before making a report, you should discuss with the patient your examination and your conclusion that the patient’s driving ability is impaired. You should advise the patient that you will be reporting the circumstances to the appropriate state department or agency. After recommending that a patient stop driving, having a conversation to get the patient’s feedback and to explore the patient’s ideas for alternate transportation can help the patient anticipate and adjust to coming changes. Discussion can contribute to the patient’s acceptance of a nondriving status. You should document in the patient’s medical record about the substance of your discussion.

Conclusion In the case that opened this article, the diabetic patient’s situation did not match the reporting criteria established by his state’s law.

Although the physician was sued, he was able to show he was in compliance with his state’s requirements. As a physician, you should be aware that if you have a patient who, in your clinical opinion, meets the state’s reporting threshold, you have a duty to notify the transportation department about that patient. Two potential con-

sequences, depending on the laws of your state, might result from neglecting your reporting duty: you could be held responsible as a proximate cause of a patient’s motor vehicle accident and/or you could face a challenge to your medical license. Both possibilities are best avoided through knowledge of and compliance with

your state’s statutes on transportation-department reporting.

1 45 CFR §164.512 (a)(1).

2 45 CFR §164.514 (d)(3)(iii)(A).

Department of Motor Vehicles Reporting – California How to report:

When to report: What to report: Must be reported:

Report in writing to the local health officer the name, date of birth, and address of the person.1 The report can be made on a Confidential Morbidity reporting form, which can be found online at: www.cdph.ca.gov/pubsforms/forms/CtrldForms/pm110.pdf.

The local health officer will notify the DMV, and the DMV will decide if: • Driving privilege should be immediately suspended.

• Reexamination is necessary.

• No action should be taken.2 Within seven days of diagnosing the reportable condition.3 Disorders “characterized by lapses of consciousness,...[including] Alzheimer’s disease and those related disorders that are severe enough to be likely to impair a person’s ability to operate a motor vehicle.”1 “Disorders characterized by lapses of consciousness" are defined in regulations as medical conditions that involve: • A loss of consciousness or a marked reduction of alertness or responsiveness to external stimuli.

• The inability to perform one or more activities of daily living.

• Impairment of the sensory motor functions used to operate a motor vehicle.4

May be reported:

Visual standards:

For more information:

References:

Types of medical conditions that may evolve to a severity level that would make driving unsafe are Alzheimer's disease, dementia, seizure disorders, brain tumors, narcolepsy, sleep apnea, and abnormal metabolic states (including diabetes).4 Any condition that in the physician’s opinion would affect a person’s ability to safely operate a motor vehicle.1 Form for reporting unsafe driving conditions available at: http://apps.dmv.ca.gov/forms/ds/ds699.pdf.

A patient falls outside the allowed standards and may not drive if he or she does not have visual acuity of at least 20/200 best corrected vision in at least one eye.5 Applicants for drivers’ licenses must pass a screening test with a standard of: • 20/40 with or without correction with both eyes tested together.

• 20/40 in one eye and 20/70 or better in the other eye with or without correction.

Those who don’t meet the screening standard must submit an eye examination report form signed by an ophthalmologist and must take and pass a driving test.5 This chart presents excerpts from the law to give an overview of reporting requirements. For more information, see: www.dmv.ca.gov/dl/driversafety/dsmedcontraffic.htm.

For complicated situations, you may want to contact your attorney for advice.

1 California Health and Safety Code § 103900.

2 DMV’s Reexamination Process, www.dmv.ca.gov/pubs/brochures/fast_facts/ffdl27.htm. Accessed April 4, 2013.

3 17 CCR § 2810(a).

4 17 CCR § 2806.

5 California Department of Motor Vehicles. Vision Conditions. http://www.dmv.ca.gov/dl/driversafety/vision_cond.htm. Accessed April 2, 2013.

MAY / JUNE 2013 | THE BULLETIN | 17

18 | THE BULLETIN | MAY / JUNE 2013

Balance / Lifestyle & Wellness

By AMA Staff This article is reprinted with the permission of Physician Magazine For physicians, these are challenging times, with studies suggesting – and physicians reporting – that they are under tremendous stress to see more patients in less time, and with less support, than in the past. Written for physicians by physicians, the AMA has provided these practical steps for resilience to remind physicians of two important points: (1) that mental health is the cornerstone to a healthy and productive life, and (2) recognizing periods of difficulty with mental health issues and seeking help can truly make a difference personally and professionally. If you identify a particular emotional health challenge in yourself or a colleague, let this information help you take steps toward assistance and resilience.

ANXIETY

Physicians have anxiety disorders with the same frequency as nonphysicians, characterized by uneasiness and worry without relief. If you or a colleague are experiencing anxiety on a regular basis, here are options to explore: • Treatment with psychotherapy, primarily cognitive behavior therapy (CBT), is the cornerstone of treatment for anxiety disorders such as generalized anxiety disorder, social phobia, and post-traumatic stress disorder, with or without medication.

• Medications for anxiety disorders often are used in conjunction with psychotherapy in order to achieve the best results.

BURNOUT

Experienced by approximately 50% of physicians at some point in their career; characterized by fatigue, depersonalization, and mental exhaustion. Burnout can happen to anyone in any specialty. To distinguish between burnout and depression, consider that burnout symptoms are almost always relieved after adequate rest, vacation time, and positive changes made in the work environment and/or work and life balance.

These changes do not alleviate symptoms of depression. In fact, depressed physicians often take time off with the hope their symptoms will remit—but the symptoms remain, or even worsen, on the vacation. A hallmark of burnout is feeling detached and distant from one’s work and patients. It is best to prevent burnout, however, to combat it, taking time off and changing work priorities can help. Consider the following:

• • • • •

Get at least eight hours of sleep per night Practice good nutrition Regular mobility and/or mindfullness or yoga Cultivate close relationships Take regular breaks and/or vacations

DEPRESSION

Three times more prevalent in physicians than with age-matched cohorts, depression can be mistaken for burnout; however, one difference is the length of symptoms. Burnout symptoms can be relieved by time away from work, whereas depression symptoms persist beyond a vacation or break from work. The good news is that depression, even recurrent depression, is usually very responsive to treatment.

There are many effective treatments for depression, including various psychotherapies.

• Mild to moderate depression: cognitive behavioral therapy (CBT) or supportive psychotherapy.

• Moderate to severe depression: there is a wide range of effective antidepressant medications with different modes of action and side effect profiles.

• For severe and life-threatening depressions, electroconvulsive therapy (ECT) may be indicated. Transcranial magnetic stimulation (TMS) is another effective therapy for treatmentresistant depression.

SUICIDE

• Physicians who are referred, or self-refer, for suicidal thoughts, should be seen by a psychiatrist immediately—the same day, if possible.

• Most importantly, the suicidal physician must receive the same standard of care as any other suicidal patient. Physician patients tend to understate and minimize their symptoms and suicidal intent, and their treating physicians are often influenced by their own reluctance to insist on an inpatient hospitalization, more intensive treatment, or a mandatory leave from practice for their patient.

This companion piece to the Physician’s Guide to Personal Health is designed to provide information and resources on mental and emotional health, particularly anxiety, burnout, depression, and suicide. 0.50 AMA PRA Category 1 Credit™ available. http://www.ama-assn.org

MAY / JUNE 2013 | THE BULLETIN | 19

Transitions / Career Management

Opportunities for Retired Physicians

By Marion Webb This article is reprinted with the permission of Physician Magazine Many doctors who are nearing retirement age, but are not quite ready to hang up their stethoscopes, will find that their medical training makes them ideal candidates for other careers. Here are nine jobs for doctors to consider—whether they are already in retirement or looking to reinvent themselves post-retirement.

Reentry Program For doctors who let their license expire and have been inactive for an extended period of time, reentering as a physician in the United States may involve continuing education and passing the Special Purpose Examination (SPEX). With the changing emphasis on technology, doctors also need to be prepared to brush up on such know-how as electronic medical records. Several reentry programs nationwide can help doctors get up to speed. The cost, however, could be upward of $20,000.

Locum Tenens For doctors with an active license and looking to work part-time and through a staffing agency, being a substitute doctor for others is a great opportunity to work on your own terms. This often requires travel and working off-hours.

Health Care Administrator Knowing how medicine is delivered and having clinical experience can work in your favor as a health care administrator. The real challenge, however, is being trained in business.

According to the U.S. Department of Labor, the demand for health care administrators is on the rise.

Consultant Consulting is a great way for doctors to create income. Medical consultants have many options, including at companies that make medical devices, law firms looking for expertise or testimony in cases, and publications.

Writer and Editor Providing medical expertise for magazines, online publications, and websites can be a great freelance opportunity for doctors, which can be done from home. With health news exploding on the Internet, there is no shortage of websites looking for scientifically backed information on health issues.

Hospitalist A hospitalist, or doctor who specializes in the care of hospitalized patients, is seeing rising demand. Some studies have shown that hospitalists reduce the length of a patient’s stay and the likelihood of readmission. A large majority of hospitalists (about 78%) had their training in general internal medicine. Internists make excellent candidates for hospitalists.

Telemedicine Often meaning simply treating patients by talking to

them over the phone or via Internet, telemedicine can often be done parttime from home. Services like AmeriDoc.com even suggest that the majority of doctors’ visits can be done via phone.

Teacher Retired doctors often enjoy teaching undergraduate health sciences like biology, anatomy, and physiology as a low-stress alternative to clinical work. The University of Texas Health Science Center at Houston has gained attention and praise for its nursing program, which brings in retired doctors to help train nurses.

Volunteer For doctors who simply want to give back to the community, volunteering their time in free clinics can be personally rewarding and refreshing. This allows doctors to stay in the medical loop without having to deal with red tape. However, they may need to buy malpractice insurance.

Another opportunity is to volunteer your services in underprivileged countries. Health Volunteers Overseas (HVO) is one nonprofit organization dedicated to bringing health care volunteers to developing countries. Some doctors say that these opportunities are often easier for more experienced doctors who remember life without technologies vs. younger doctors who rely on computers to assist them.

As we move forward with health care reform, there will be even more opportunities for physicians to explore, retired or not, including a wide variety of new business ventures.

With all the changes that will come with health care reform, there will be even more opportunities for physicians – retired or not – to explore, including a wide variety of new business ventures.

20 | THE BULLETIN | MAY / JUNE 2013

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Food and Drug Administration April 17, 2013 Docket FDA-2011-N-0899 Dear FDA Staff: We are writing during the public comment period regarding pending FDA approval of AquAdvantage® Salmon, which adds a growth hormone gene from Chinook salmon into Atlantic salmon, and urge you not to approve this genetically altered animal for human consumption.

The Santa Clara County Medical Association represents about 4,000 doctors in California. As a physician group concerned with both the shortterm and long-term public health and environmental consequences of genetically modified organisms, we are writing to ask that you do not approve genetically engineered (GE) salmon for commercial use or consumption.

The AquAdvantage® Salmon was generated by micro-injecting a DNA combination of a promoter gene from an ocean pout antifreeze protein and a protein-coding sequence from a Chinook salmon growth hormone gene into the fertilized eggs of wild Atlantic salmon. These eggs would be produced in a facility on Prince Edward Island in Canada and then shipped to a facility in Panama, where they would be reared to market size.

The USFDA’s draft assessment of genetically engineered salmon does not adequately address the potential long-term environmental effects or food safety risks associated with genetically modified salmon.

At the very least, if approved, labeling of GE salmon needs to be mandatory, accurate, and subject to appropriate monitoring, fines, and enforcement.

Considering this is the first request for approval of a GE animal, the consequences are far reaching. It is expected that a flood of requests will soon follow and salmon eggs will be transferred to and raised in less secure and unmonitored environments despite assurances. There are many uncertainties noted in your FDA Briefing Packet September 20, 2010. After review of your May 4, 2012, Briefing Packet, uncertainties still exist. Many scientists, including geneticists, have concerns with regards to potential adverse outcomes regarding all genetically modified foods and animals. They understand that there is not a one gene, one trait interaction, as biological systems are extremely complicated. Over expression, under expression, or silencing of some genes in different environments could cause unpredictable changes in proteins or nutrients with unintended consequences. Processes other than amino acid sequencing in DNA can alter protein synthesis to produce toxins, as was seen in a detailed study of GM pea plants in Australia. (10) Although in your report it is stated to be “unlikely” that AE eggs 22 | THE BULLETIN | MAY / JUNE 2013

would escape, if they did, harmful intermixing of genes would likely result and would be permanent. There can be no recall after genetic pollution is unleashed. After reviewing scientific research and your briefing packet, we found there were technical flaws and inadequate data in several of the tests. Our concerns are as follows: 1. Lack of rigorous independent, peer reviewed, long-term, multigenerational testing for human health effects. One major area of concern is allergenic potential. Testing was done via analysis of structural similarity of gene product to known allergens and through various immune globulin testing. While important, these tests do not address novel proteins created in the GE salmon that when consumed by an individual causes an immediate or delayed allergic reaction.

Indeed the combination of ocean pout promoter gene and growth hormone could produce novel proteins. In vivo animal testing is the most rigorous method of determining allergenic potential. In addition, no pepsin resistance test was performed, as it was assumed that only growth hormone protein and no other protein would be produced.

Pepsin resistance is an important indicator for allergenicity.

2. Pre-market testing indicated changes in nutritional value with the growth hormone gene causing an increase in IGF1, which stimulates the growth of prostate, breast, and colon cancer. Although we consume a variety of foods with varying levels of IGF1, a general increase in this hormone could be significant if consumed in larger quantities. In addition, with certain in vivo environmental changes such as temperature, over expression of growth hormone may result with a substantial increase in IGF1 and cause significant public health concerns. In addition, there were significant alternations in vitamin and lipid content.

3. Lack of transparency in pre-market approval process due to Trade Secret Laws. Biotechnology causes new and powerful molecular changes that affect all life forms, thus requires complete transparency to allow independent tests to be done over a reasonable time to assure safety of the product. In addition, adequate public input is much needed throughout the process of approval.

4. Environmental impact with serious threats to wild salmon populations in North America. No consideration of environmental harm or environmental impact report was performed in Prince Edward Island, Canada, where the eggs would be produced, or in Panama, where the eggs would be reared. Mandates in the National Environmental Policy Act of 1969 (NEPA) do not require an analysis of environmental effects in foreign sovereign countries for New Animal Drugs approved in the U.S. (9) Wild salmon are a critical natural and cultural resource for California. Wild salmon runs are currently threatened to extinction.

There is an increasing body of science indicating that the inevitable escape of even regular hatchery raised salmon, either in tanks or in open pens, can adversely effect wild populations and reduce their survival. Captive traits are passed on to wild salmon that don’t compete as well for mates and are less able to avoid predators. It is estimated that up to 4% of the AquAdvantage salmon are not sterile, thus are a threat to wild salmon populations if even a few salmon escape. Fish and fish eggs regularly escape both tanks during water exchange and farm pens. There is no assurance that the GE salmon cannot survive outside controlled rearing tanks. This could lead to negative impacts on the entire ecosystem. There are many examples in river systems where non-native species were introduced to the detriment of the entire ecosystem. There are indications from the studies provided that GE salmon may have a broader appetite and compete for food other fish depend on, as well as salmon.

5. Lack of coordinated framework for regulating biotechnology.

Currently, biotechnology falls under existing federal mandates and agencies. In your 2009 “Final Guidance Document,” GE animals

are considered a New Animal Drug. The Center for Veterinary Medicine evaluates the safety and efficacy of the animal product. Since biotechnology including genetic engineering spans many disciplines, it seems reasonable that a separate multidisciplinary entity be created to oversee this industry, which could include geneticists, biologists, toxicologists, and physicians.

6. Lack of adequate labeling to protect individuals who may have health effects or wish to know for religious, ethical, or cultural reasons.

7. From an economical standpoint there is no market for it. Farm and wild salmon already exist. Grocery stores and much of the public have already indicated they would not sell or buy GE salmon.

In conclusion, the industry testing performed indicates many uncertainties and gaps in data that cannot lead to a conclusion that genetically engineered salmon is safe for humans or the environment. Indeed, the approval and release of GE salmon are likely to do more harm to an already fragile wild salmon population and may have other unintended consequences over time as has been found with GM plants, i.e. insecticide resistance, creation of toxins, and genetic pollution in organic crops. More importantly, there is no need to produce this GE fish. Scientists are urging lawmakers to put more energy and resources into protecting and rehabilitating natural habitat, removing dams, and reducing toxins to promote a robust wild salmon population that generations can enjoy without a patented fish that will undermine, not solve, a global seafood demand.

As physicians, we have an obligation to protect individual health as well as public health and thus urge you not to approve this GE salmon.

Respectfully submitted, William Parrish, Jr. CEO, Santa Clara County Medical Association

References 1. FDA Briefing Packet for GE Salmon Sept 20, 2010. http://www.fda. gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/ VeterinaryMedicineAdvisoryCommittee/UCM224762.pdf 2. Oregon Fisheries Lawsuit. http://www.oregonlive.com/environment/ index.ssf/2013/03/judge_to_rule_wednesday_on_sto.html 3. Hatchery Salmon May Threaten Wild Populations. http://www. conservationmagazine.org/2008/07/hatchery-salmon-may-threatenwild-populations/ 4. Environmental rearing conditions produce forebrain differences in wild Chinook salmon Oncorhynchus tshawytscha. http://www.ncbi. nlm.nih.gov/pubmed/16890467 5. The road to extinction is paved with good intentions: negative association of fish hatcheries with threatened salmon. http://www. ncbi.nlm.nih.gov/pubmed/11375103 6. An evaluation of the effects of conservation and fishery enhancement hatcheries on wild populations of salmon. http://www.ncbi.nlm.nih. gov/pubmed/17936136 7. Migration and growth potential of coho salmon smolts: implications for ecological impacts from growth-enhanced fish. http://www.ncbi. nlm.nih.gov/pubmed/20666255 8. Population effects of growth hormone transgenic coho salmon depend on food availability and genotype by environment interactions. http://www.ncbi.nlm.nih.gov/pubmed/20666255 9. FDA AquAdvantage® Salmon Draft Environmental Assessment.

May 4, 2012. http://www.fda.gov/downloads/AnimalVeterinary/ DevelopmentApprovalProcess/GeneticEngineering/ GeneticallyEngineeredAnimals/UCM333102.pdf?source=govdelivery 10. CSIRO abandons research into GM peas. http://www.abc.net.au/pm/ content/2005/s1510290.htm

MAY / JUNE 2013 | THE BULLETIN | 23

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membership

Welcome 77 SCCMA Members Santa Clara County Medical Association Name Radha Achalu Katrina Barnett Madeleine Blaurock Suzanne Bovone Jeffrey Bui Casey Buitenhuys Jaret Butler Jin Chang Runi Chattopadhyay Lay Cheah Clement Cheng Karunasree Cherukuri Sheila Chyu Shekar Davarya John Duncan Lindsey Dyson Susan Fong Michael Fu Shadan Ghaemian Orchid Ghaffari Sarah Griffin Isiah Harris Harrison Hines Dana Hoch Edward Huang Pamela Ison Paul Jackson Diana Johns Lynn Johnson Noelle Johnstone Varsha Joshi Amy Kane Laurie Karl Nicole Ketterman Fahd Khan Brian Kim Julian Kim Samira Kirmiz

City Specialty Santa Clara IM San Jose EM San Jose IM Los Gatos OBG Santa Clara ORS San Jose EM Mtn View ORS Mtn View PCCM Palo Alto GS Santa Clara IM Milpitas IM Mtn View D Milpitas IM Santa Clara OBG Santa Clara NS Santa Clara OBG Santa Clara PD Palo Alto US San Jose *IM Los Altos PD Santa Clara PD Santa Clara GYN Menlo Park US Campbell IM San Jose GE Palo Alto PD Palo Alto NS San Jose AN DR, ADMD Palo Alto Palo Alto IM Santa Clara IM Menlo Park OBG Los Altos OBG Sunnyvale PD Los Gatos NS Santa Clara R Palo Alto PD Mtn View EDM

Name Liza Kunz Jeffrey Kwan Albert Lam Amanda Lam John Lannin Amy Lee Jennifer Lee Keith Lee Kimberly Lee Topaz Levenberg Ryan Lum Sarah MacMahon Domenico Manzone Amy Mao Natalie Marino Kavitha Mehra Sofia Moreno Katharine Nelson Richard Nguyen Grace Jane No Jacqueline Pelavin Thao Pham Gail Pyle Catherine Rose Gordon Sakamoto Shivani Sethi Eugene Shek Anupama Shetty Brett Spitnale Aldous “Dennis” Sumaylo Salli Tazuke Richard VanWoerkom Laine Watanabe Eric Wilson Angela Wong Ryan Woods Anapurna Yarlagada Young Yoon Yu Zhao

* - Board Certified | US - Unspecified 26 | THE BULLETIN | MAY / JUNE 2013

City Specialty Mtn View OBG San Jose GE Palo Alto GER Mtn View D Palo Alto ORS Mtn View N Milpitas IM Palo Alto U Santa Clara OBG Santa Clara PD Mtn View IM Santa Clara PD Los Gatos INF Santa Clara PD Campbell FP Santa Clara PD Santa Clara PD San Jose AI San Jose GS Santa Clara IM Santa Clara *U Milpitas IM Palo Alto IM San Jose PD Palo Alto NS Santa Clara US Santa Clara PD Santa Clara NPM Palo Alto FP Mtn View PD Palo Alto OBG Santa Clara NPM Cupertino PMR Santa Clara IM Palo Alto FP Santa Clara IM Santa Clara PD Santa Clara EM Milpitas OM

Welcome 3 New MCMS Members Monterey County Medical Society Name Kevin Leahy Amish Shah

City Specialty Salinas AN Salinas AN

Name Stephanie Taylor

City Specialty Carmel OBG

* - Board Certified | US - Unspecified

In Memoriam Robert Avery, MD

Dennis G. Gillett, MD

Kenneth Hayes, MD

Charles L. Rennell, MD

Internal Medicine 12/17/20 – 2/9/13 SCCMA member since 1951

*Pulmonary Disease *Internal Medicine 5/8/47 – 2/16/13 SCCMA member since 1979

*Internal Medicine 8/3/20 – 5/28/13 SCCMA member since 1957

*Radiology 10/3/24 – 4/30/13 SCCMA member since 1959

Roger B. Goodfriend, MD

Ralph Pietrobono, MD

Donald M. Scanlon, MD

*Orthopaedic Surgery 11/12/22 – 3/23/13 SCCMA member since 1957

Cardiovascular Disease *Internal Medicine 1/16/30 – 5/13 MCMS member since 1961

Joseph M. Badame, MD *General Surgery 4/24/28 – 2/18/13 SCCMA member since 1960

Ronald R. Clarke, MD *Pediatrics 3/17/31 – 4/25/13 SCCMA member since 1973

*Urology 5/1/29 – 1/4/13 SCCMA member since 1965

William J. Hawes, MD *Neurology *Pediatrics 4/23/30 – 5/9/13 SCCMA member since 1978

Donald Posthumus, MD *Pulmonary Disease *Internal Medicine 7/10/42 – 2/25/13 SCCMA member since 1978

THANK YOU TO THE FOLLOWING THIRD-OF-A-CENTURY MEMBER In the process of recognizing SCCMA physicians who have been members for more than a third of a century, we managed to slight the following physician in the March/April issue of The Bulletin. Please

accept our apologies Dr. Herbert M. Vogler, and thank you for your 43 years of membership! We appreciate your long-term support of SCCMA and CMA!

MAY / JUNE 2013 | THE BULLETIN | 27

2013 Education Series JUNE 26

June 26: Meaningful Use – What You Need to Know for This Year and Stage 2 David Ginsberg • 12:15 – 1:15 p.m.

Many changes are in order for the 2014 edition (Stage 2) of Meaningful Use. This informative webinar will assist you in understanding these changes and how they impact your workflows and use of electronic health records (EHR).

JULY 24

July 24: Protect and Preserve Your Patient Relationships Nancy Heard, M.D. • 12:15 – 1:15 p.m.

Presented by the Department of Health Care Services (DHCS), this webinar will help you increase understanding and awareness of the impact of fraud, waste and abuse on patient care, and discuss methods to prevent abuse and ways to preserve the integrity of the physician/patient relationship.

AUG 21

Aug. 21: HIPAA Compliance: The Final HITECH Rule David Ginsberg • 12:15 – 1:15 p.m.

The HITECH Act created the extensive funding incentives and standards for adopting electronic health records; it also created new HIPAA rules or modified existing ones. This webinar will provide an overview of the changes to HIPAA and key steps medical practices can take to comply with these changes.

AUG 28

Aug. 28: Medicare: Proposed Changes for 2014 Michele Kelly • 12:15 – 1:15 p.m.

This webinar will focus on proposed policy changes to the physician fee schedule for the year 2014 (excluding any discussion on the SGR, or revised payment methodology). This discussion will provide an opportunity for physicians to hear how new or revised policies may impact their practice, and allow them to provide input to CMA during the Notice and Comment period.

SEPT 4

Sept. 4: Appropriate Prescribing and Dispensing: New Measures Medical Board • 12:15 – 1:15 p.m.

Representatives from the Medical Board of California will discuss outcomes from the Forum to Promote Appropriate Prescribing and Dispensing, held February 2013, including what the Board is proposing/supporting; what the legislature is proposing, and how these measures will be implemented if adopted.

SEPT 11

Sept. 11: California’s Health Benefit Exchange: The Positives and Perils of Contracting Brett Johnson • 12:15 – 1:45 p.m.

Beginning in 2014, California’s private health insurance market will never look the same – individuals and small employers will be able to purchase health insurance coverage through the state’s health insurance exchange, named Covered California. It is estimated that by the end of 2016, over one in five Californians will get their health insurance through the Exchange. In October of 2013, Californians will be able to access the Covered California website and begin enrolling in plans for the 2014 benefit year. Depending on health plans’ distribution of enrollees, a surge of physician contracting efforts may occur as these plans attempt to ensure adequate networks are in place prior to January 1, 2014. In this presentation, you will learn more about California’s exchange and what it will mean for physicians. You will also gain an understanding of some of the risks and benefits of being contracted to provide services to exchange enrollees.

28 | THE BULLETIN | MAY / JUNE 2013

SEPT 12

Sept. 12: ICD-10 Documentation for Physicians: Part 1 AAPC • 12:15 – 1:15 p.m.

Continued on Sept. 19 and 26.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

SEPT 18

Sept. 18: Recipe for Financial Success: Key Steps to Increasing Your Net Income Debra Phairas • 12:15 – 1:15 p.m.

Physicians and office managers need business management skills, particularly in the financial area. This workshop will teach critical skills in analyzing the practice profit/loss statement, accounts receivable ratios and staffing patterns and how to access specialty comparison norms.

At least one source of comparison data specific to your medical specialty will be given to each participant.

SEPT 19

Sept. 19: ICD-10 Documentation for Physicians: Part 2 AAPC • 12:15 – 1:15 p.m.

Continued from Sept. 12 and ends Sept. 26.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

SEPT 26

Sept. 26: ICD-10 Documentation for Physicians: Part 3 AAPC • 12:15 – 1:15 p.m.

Continued from Sept. 12 and 19.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

OCT 30

Oct. 30: CMS Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties CMS • 12:15 – 1:45 p.m.

Presented by the Centers for Medicare & Medicaid Services (CMS), webinar attendees will understand the background and rationale for CMS incentives and payment adjustments that affect physicians, including the Physician Quality Reporting System (PQRS), the ePrescribing (eRx) Incentive Program, the Electronic Health Record (EHR) Incentive Program, and the new Value Modifier (VM) program; be able to define what actions they need to take to receive each incentive and avoid payment adjustments; and know where to go to obtain further information about CMS quality programs and stay abreast of future developments.

NOV 6

Nov. 6: External Auditors and You: Medi-Cal Recovery Audit Contract Process DHCS • 12:15 – 1:15 p.m.

Presented by the Department of Health Care Services (DHCS), this webinar will help you gain information on the current status of the Medi-Cal external audit contract process, understand rules and timelines for implementation, and understand how to work with external auditors.

NOV 13

Nov. 13: Managing Difficult Employees and Reducing Conflicts Debra Phairas • 12:15 – 1:45 p.m.

Very few medical or business schools teach hands-on human resources management skills and techniques. This information-packed workshop will teach you the secrets of how to lead, coach and manage difficult employees; set practice values; and reduce conflict in the practice.

DEC 4

Dec. 4: Medicare: 2014 New Rules Michele Kelly • 12:15 – 1:15 p.m.

This webinar will focus on final rules from the Medicare Physician Fee Schedule that will affect physician practices during 2014 and beyond.

This will help you prepare for any continuing or new programs that may negatively impact payments, as well as prepare you for revisions to policies that may impact your billing and reimbursement.

DEC 5

Dec. 5: ICD-10 Documentation for Physicians: Part 1 AAPC • 12:15 – 1:15 p.m.

Continued on Dec. 12 and 19.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

The above webinars are being hosted by the California Medical Association. Please register at www.cmanet.org/events. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar. Questions? Call the CMA Member Help Line at (800)786-4262.

Please note that this calendar does not include CMA’s ICD-10 training courses to be offered in 2013.

MAY / JUNE 2013 | THE BULLETIN | 29

MEMBER BENEFIT NEWS

Employment Practices Liability Insurance (EPLI) Many members think they have coverage for wrongful termination, harassment, discrimination claims by employees or patients (third party).

However, most policies exclude coverage for these types of actions or only provide limited coverage (a contribution to defense costs).

The SCCMA/MCMS/CMA sponsored Employment Practices Liability program includes a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the program are: • Special First Time Buyers program.

• A Helpline staffed by experienced employment defense attorneys.

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

• If a member seeks Helpline advice on an employee termination, which later results in a claim, there is a 50% reduction of the member’s EPLI deductible for that claim.

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

• EEO compliance training for managers/supervisors. An Internet-based training program, compliant with California law, provides supervisors with sexual harassment training.

• Wage and Hour Defense Coverage.

This valuable member program is available to members through Marsh/Seabury & Smith Insurance Program Management, our sponsored insurance program administrator, and in conjunction with the Employment Practices Risk Management Association (EPRMA).

For more information on these important benefits, please contact Marsh at 800/842-3761 or email CMACounty.Insurance@marsh.com.

Want More Than $1,000,000?

Travel assistance** and funeral planning and concierge services*** included at no additional charge to you.

When SCCMA/MCMS/CMA members apply for up to $1,000,000 of 10- or 20-year Term Life insurance coverage underwritten by ReliaStar Life Insurance Company, a member of the ING family of companies, they get a few things non-members don’t.

• Access to special member-only rates.

• Premium savings since rates remain level for the first 10 or 20 years of coverage*.

• Each plan also includes a travel

assistance service for medical emergencies when you are traveling away from home ** and a funeral planning and concierge service*** at no additional charge to you.

You may also insure your spouse or domestic partner, and your eligible employees, for up to $1,000,000.

Call Marsh/Seabury & Smith Insurance Program Management for more information at 800/842-3761, email CMACounty.Insurance@ marsh.com, or visit www.CountyCMAMemberInsurance.com to download a brochure and application.

*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the policy with 60 days advance written notice. Underwritten by ReliaStar Life Insurance Company. Home Office: Mpls, MN Policy form LP08GP. **ING Travel Assistance Services provided

by Europ Assistance USA, Bethesda, MD 20814.

This product is not available in all states. ***Funeral Planning and Concierge Services provided by Everest Funeral Package, LLC, Houston, TX 77056. This product is not available in all states.

See What You Could Be Saving!

“When I found out how much money I could save ($1,650) on the sponsored workers’ compensation program, I joined CMA. The savings paid for my membership and then some. Now I have access to everything CMA offers.”

– Nicholas Thanos, MD, CMA Member Did you know that CMA/SCCMA/MCMS members can save 5% on their workers’ compensation insurance? And, they may save up to 15%, depending upon where they place their group medical insurance.

It’s true. CMA/SCCMA/MCMS members receive a discount on workers’ compensation insurance policies provided through Employers Compensation Insurance Company. This discount is available exclusively through Marsh/Seabury & Smith Insurance Program Management, the sponsored broker and administrator.

30 | THE BULLETIN | MAY / JUNE 2013

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•

TA CLARA SAN

C AL

IAT SSOC ION • LA

Y MEDIC UNT A O C

IF O R N IA Serving Physicians Since 1876

“My Membership provides me a Voice in Sacramento and Washington DC.” William S. Lewis, MD

Santa Clara County Medical Association, Monterey County Medical Society, and CMA Members Enjoy: Vast CMA Resources: • • • • • • •

Contract Analysis Reimbursement Hotline Legal Hotline Legislative Hotline HIPAA Compliance Free Monthly Webinars on various topics Extensive Online Resources including over 200 letters, agreements, forms, etc.

• Plus - Free Legal Advice with CMA ON-CALL Documents!

Santa Clara County Medical Association and Monterey County Medical Society Resources: • • • • • • • • • • • •

Annual Directory CMA Member Seminars Cost-Saving Benefits Bi-Monthly Publication Website/Online Resources Insurance Savings Alliance Membership Annual Social Events Patient Referrals Practice Resources Reimbursement Advocacy DocBookMD phone app

Federal, State, and Local Advocacy:

Your dues are an investment which supports our efforts in protecting your rights.

If We Don’t Fight for You… Who Will?

Phone: (408) 998-8850 or (831) 455-1008 www.sccma-mcms.org MAY / JUNE 2013 | THE BULLETIN | 31

MEDICAL TIMES FROM THE PAST

The Cholera Epidemic in San Jose, California, 1850

By Elizabeth Ahrens-Kley SCCMA Leon P. Fox Medical History Committee

Dr. Cory

As cholera swept across Europe and the eastern U.S. in the mid-1800s, thousands perished from the so-called “noxious vapors,” a dangerous miasma, or “bad air” thought to be the deadly and unavoidable source of the illness. Death struck with terrifying suddenness, killing a random few to hundreds at one time. Those infected could perish within a few hours. Every sort of cure was proposed, but none worked with any notable success. Thousands are thought to have died while crossing the plains to California. The doctors in San Jose who actively fought the disease in 1850, Dr. Benjamin Cory, Dr. John Townsend, and Dr. Louis Bascom, were no more successful in their fight against it than the most famed doctors in London.

It was not known that bacterially-contaminated water, from ponds, wells, rivers, or, as most certainly was the case in San Jose, a large ditch known as the Acequia Madre, was the likely culprit. In earlier times, a dam had been built above the pueblo to collect water in a pond supplied by the Canoas Creek. The pond fed water into the Acequia, which meandered through the town, providing irrigation for agriculture, as well as being the source of domestic water. The tributaries functioned as collectors for runoff and collection of sewage.

As thousands of gold seekers streamed into town in 1849, as well as politicians and legislators (San Jose being designated the new capital of California), a violent outbreak of the disease was preordained. No sanitation infrastructure existed and the serious lack of hygienic conditions allowed the disease to spread with vicious rapidity in November and December of 1850. Residents fled the town en masse and as suddenly as it began, by mid December, the brutal crisis had ended.

Of the three doctors who worked day and night tending to those in need, only Dr. Cory continued practicing medicine in the long-term. Dr. John Townsend and wife Elizabeth, famed as members of the Murphy party, which crossed the plains in 1844, both contracted the disease while treating patients and Prevention of cholera, poster succumbed. Dr. Louis Bascom and Dr. Cory continued their partnership (having worked together durpublished in NYC, 1849 ing the epidemic) for a short time, but only two years later, Dr. Bascom bought 135 acres of farm land, thereafter registering himself as “farmer” instead of “physician.” Dr. Bascom is mainly remembered nowadays for having sold a strip of his land to the town, which is presently known as Bascom Avenue. He lived until 1881, and Dr. Cory continued his practice for another 46 years, until his death in 1896.

32 | THE BULLETIN | MAY / JUNE 2013

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MAY / JUNE 2013 | THE BULLETIN | 33

2013 Legislative Leadership Day Physician Leaders Converge on the Capitol for CMA’s 39th Annual Lobby Day Over 400 California Medical Association (CMA) member physicians, medical students, and physician supporters gathered in Sacramento on April 16, to bring the voice of medicine to legislators. During CMA’s 39th annual Legislative Leadership Conference, physicians discussed the many threats – and opportunities – facing the practice of medicine in California.

CMA President Paul Phinney, MD, greeted attendees, saying “Today is the house of medicine coming together. It takes a little bit of help from a lot of people to make things happen.”

Assemblymember Richard Pan, MD, also addressed the attendees, telling them how critical it is for legislators to hear the voice of organized medicine. But, he noted, “That voice is only as strong as all of your voices.” Dr. Pan emphasized that physicians bring a unique viewpoint to the Capitol, advising them when visiting with legislators later in the afternoon to “talk about what you do every day, in your practice – taking care of patients.”

Lieutena nt Governor Gavin Newsom, one of the keynote speakers, told the crowd that “the issue of health care is the dominant challenge we face as it relates to balancing our [state] budget.” With the challenges posed by the Affordable Care Act, he said, “this is an interesting and enlivening time.”

Peter Lee, the executive director of Covered California, urged attendees to look broadly at the good the state health care ex34 | THE BULLETIN | MAY / JUNE 2013

change program will do for California and for the nation, rather than getting “trapped” in the day-to-day problems that might arise in the beginning.

“Think of January 2014 as a starting point,” said Lee. “When we look back 50 years to [the passage of] Medicare, we don’t look at the first months or at enrollment issues of that time, [instead] we say, ‘this was the right thing to do.’ ” After lunch, attendees were witness to the witticisms of former speaker of the California Assembly Fabian Núñez and newly-elected chair of the California Republicans, Jim Brulte, as they both talked about the future of politics in California and the nation.

When both were asked how physicians can influence the decisions of the state legislators, Núñez urged CMA members to visit their representatives in their districts rather than at the Capitol. “They are more relaxed in their district audiences. They will be able to listen” in the calm outside of the Capitol. Brulte suggested that phy-

sicians should talk with legislators in their treatment rooms. “Invite them to surgery and show them what you do.” Brulte talked about doing just such a thing and how it gave him a greater understanding of what physicians did and how they navigated the health care system.

After a morning of legislative briefings and guest speakers, the group headed to the Capitol to speak to their legislators about critical legislative issues affecting the practice of medicine in California.

“The political process is dynamic, rapidly changing, and often enigmatic,” Ruth Haskins, MD, the chair of CMA’s Council on Legislation, told attendees before they headed off to meet with their legislative leaders as champions for medicine and their patients. “Today you can influence medicine as it’s practiced in California.”

Among the issues discussed with legislators were physician workforce, scope of practice, and the state budget, including the 10% cut to Medi-Cal payment rates.

SCCMA leadership met with Assemblywoman Nora Campos to discuss scope of practice issues and protecting MICRA.

NEED HELP WITH CLAIMS?

TRY SCCMA/MCMS’s SPECIAL MEMBER BENEFIT: REIMBURSEMENT ADVOCACY PROGRAM If you need help in evaluating disputes between insurance companies and patients concerning fees and medical services, and need assistance in resolving disputes directly with the involved parties, contact Sandie Becker, CMC, Coding/Reimbursement Specialist.

Phone: 408/998-8850 or 831/455-1008 or Email: sandie@sccma.org.

MAY / JUNE 2013 | THE BULLETIN | 35

medico news

Trial lawyers’ money grab threatens to overturn MICRA California’s trial attorneys, last week, launched an all-out assault on California’s historic tort reform law, which since 1975 has helped keep malpractice premiums in-check and ensured that California’s patients have access to affordable health care.

On Wednesday, May 2, 2013, a coalition—including the Consumer Attorneys of California and the trial lawyer-funded Consumer Watchdog group—announced intentions to seek to overturn California’s landmark Medical Injury Compensation Reform Act (MICRA) through a ballot initiative. The group has until September to submit a proposed initiative to qualify for the November 2014 general election ballot.

If successful, the trial attorney’s efforts will cause malpractice rates to skyrocket, and recreate the same conditions that threatened to throw California’s health care system into crisis during the early 1970s. Prior to MICRA, out-of-control medical liability costs were forcing community clinics, health centers, physicians, and other health care providers out of practice.

California’s MICRA has been a national success story with broad public support and has safeguarded both patients and our health care delivery system for decades. Risky reforms like the ones being threatened by the trial lawyers would severely impede our state’s ability to provide health care to the poorest and most vulnerable patients. At a time when we are trying to implement federal health care reform and provide access to health care to all Californians, this is the worst possible overreach at the worst possible time.

“The threat of a ballot measure is nothing more than a money grab by trial lawyers,” says CMA President Paul R. Phinney, MD. “And one

that will come at the expense of higher health costs for all patients and decreased access for patients and clinics already struggling to keep their doors open. We cannot and will not let that happen.”

Physicians will be victorious in this fight, but in order to do so, we need your help.

DONATE: A fight of this magnitude will be extremely costly. The California Medical Association (CMA) is urging all physicians to consider a donation to CMA’s political action committee (CALPAC), which for the last 38 years has served as the first line of defense for California’s historic physician protections. DONATE TODAY. JOIN: And if you are not already a member of CMA, please consider joining today. By joining CMA, you will help to ensure that the voice of California physicians is heard loud and clear in the Capitol and beyond.

Together, our unified voice can move mountains. JOIN TODAY. SPEAK OUT: Sign up to be a CMA Key Contact. As a Key Contact, we will provide you with all the tools you need to quickly and effectively deliver your message to legislators, from talking points to sample letters.

CMA has some of the best lobbyists, lawyers, and other advocates in the Capitol, but the most powerful weapon in advancing the cause of physicians and their patients is you. Hearing from a physician with experience from the frontlines of medicine can make all the difference for a legislator facing a complicated health care issue such as MICRA. SIGN UP TODAY. For more information on MICRA, and what you can do to help in the fight, visit www.cmanet.org/micra.

(CMA Alert, May 6, 2013 issue)

Action is required to avoid the 2% e-prescribing penalty in 2014 If you haven’t started e-prescribing yet, the time is now. To avoid a 2% penalty on all Medicare Part B claims in 2014, physicians must,

by June 30, 2013, report e-prescribing activity using measure code G8553 with at least 10 fee schedule services between January 1 and June 30, 2013. This is true even for physicians who are already reporting through an electronic health record (EHR) system. Please note: There is no incentive payment for e-prescribing in 2014.

June 30 is also the deadline to apply for an e-prescribing exemption for 2014, if you fall into one of the following hardship exemption categories: • The physician is unable to electronically prescribe due to local, state, or federal law or regulation 36 | THE BULLETIN | MAY / JUNE 2013

• The physician has or will prescribe fewer than 100 prescriptions for all patients during a 6-month reporting period (January 1 through June 30, 2013) • The physician practices in a rural area without sufficient high-speed Internet access • The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing CMA strongly recommends that physicians submit more than 10 claims during the reporting period to ensure the minimum threshold is met. Exemptions must be requested through the Quality Net Portal at https://www.qualitynet.

org/portal/server.pt/community/communications_support_system/234.

Physicians may also avoid the penalty if they have demonstrated meaningful use of a certified EHR between January 1, 2012, and June 30, 2013, or have registered to participate in the EHR Incentive Program.

For more information, see the CMA e-prescribing guide, “Medicare Electronic Prescribing Overview: Payment Incentives and Payment Reductions,” available at http://www.cmanet. org/resource-library.

Contact: Michele Kelly, 213/226-0338 or mkelly@cmanet.org.

(CMA Alert, May 6, 2013 issue)

medico news

President’s budget addresses physician payment issues With the release of President Obama’s 2014 budget in April, the administration showed its support for repealing the Medicare sustainable growth rate (SGR). Not only does the budget build-in the cost of repealing the SGR, it calls for “the continued development of scalable payment models” to promote affordable quality care. The budget also eliminates the 2% Medicare sequestration cuts.

The price tag to repeal the SGR is estimated at $138 billion. Under the president’s proposal, the wealthiest Americans would be asked to pay higher Medicare copayments and deductibles. Pharmaceutical companies would be required to increase the rebates given to low-income Medicare recipients by treating them similarly to Medicaid patients. The rebates would mean a major loss for big pharma.

The California Medical Association (CMA) is pleased that Obama’s budget recognizes the need to eliminate the broken Medicare SGR and move toward new ways of delivering and paying for care that reward quality and reduce costs.

Additionally, the budget gives the Independent Medicare Payment Advisory Board (IPAB) ability to trigger cuts sooner. IPAB, established by the Affordable Care Act (ACA), will mandate arbitrary spending cuts if Medicare spending exceeds certain targets.

CMA has been lobbying long and hard for the board’s elimination and has offered other ways to control health care costs. This budget would allow the IPAB to make cuts to Medicare when spending hits GDP + 0.5%, versus the original ACA target of GDP + 1%. CMA sees this as a step backwards and supports bipartisan proposals to eliminate this unaccountable panel. However the congressional budget office estimates that the IPAB won’t likely be convened until 2020 because of the slower growth to Medicare spending in recent years.

CMA also has concerns with other items in the budget including an $11 billion cut to indirect medical education payments to hospitals.

While the president’s budget does not represent a change in law and is not expected to be introduced as legislation, it does provide options for Congress to consider as it develops legislation to address the nation’s fiscal issues this year. The proposal also offers insight into the Obama administration’s budget priorities, which could play a role in the debate on government spending.

Below is a summary of the proposed Medicare changes in the president’s budget: • Eliminates the 2% budget sequestration cuts to Medicare • Supports elimination of the SGR and development of a new payment system with a stable transition period • Expands the data available to physicians to make medical decisions for patients • Requires wealthier Medicare beneficiaries to pay higher premiums, copayments, and deductibles • Closes the Part D donut hole and requires patients to pay more • Requires pharmaceutical manufacturers to pay higher rebates to low income beneficiaries • Establishes a 15% surcharge on MediGap supplemental insurance premiums to discourage overutilization • Cuts Indirect Medical Education payments to hospitals by $11 billion • Reduces Medicare payments to hospitals to cover bad debt • Allows IPAB cuts when Medicare spending hits GDP + 0.5% vs. the ACA target of GDP + 1% • Reduces reimbursement for physician-administered drugs from 106% to 103% of Average Sales Price • Allows physician self-referral if certain accountability standards are met (CMA Alert, April 22, 2013 issue)

Regulation changes for emergency contraception Proposed amendments to section 1746 of Division 17 of Title 16 of the California Code of Regulations regarding emergency contraception have been approved. Among the changes is

an update to the information that is to be communicated to the patient when a patient requests emergency contraception. The operative date for the changes to go into effect is July 1, 2013. To

read the adopted text, use this link: http://www. pharmacy.ca.gov/laws_regs/1746_adopted.pdf.

(MBC Newsletter, Spring 2013 issue)

MAY / JUNE 2013 | THE BULLETIN | 37

medico news

California’s exchange adopts model contract The Board of Directors for Covered California, the state’s health benefit exchange, recently approved its model contract for health plans earlier.

The contract was the result of several rounds of stakeholder engagement following adoption of the exchange board’s plan policy and strategy recommendations last August, said Peter Lee, executive director of Covered California. While exchange staff has approved the final draft of the contract, minor changes will be allowed moving forward on an “as needed basis,” Lee added.

“We don’t think this contract is perfect,” he said. “We think it’s very good and we will improve upon it in time.”

Multiple stakeholders took time to comment on the final adopted document at the Covered California board meeting last month, with most noting that, while they still had concerns regarding the final contract, it had come a long way since the contract outline was released in January.

The process, however, moved at a frenetic pace, stakeholders receiving six versions of the nearly 150-page contract, rarely getting more than five business days to review and comment on each successive draft.

From the standpoint of the California Medical Association (CMA), one area of concern that received attention in the final draft was the presence of the 90-day grace period allowed for under the Affordable Care Act (ACA).

Under the law, subsidized patients would be given a total of 90 days of nonpayment of health insurance premiums before coverage was terminated. Once the patient entered the second month of the grace period, a health plan could begin pending any claims submitted by providers on that patient. In the event that suspension occurred, plans would be able

to deny payment for all claims submitted in the last 60 days of the grace period. This provision, CMA repeatedly said, would leave physicians, and ultimately patients, on the hook for roughly two months of claims with no notice that they were exposing themselves to such financial risk.

In the final contract, a provision was included that would require a physician to receive a 15 calendar day notice prior to a subsidized patient entering the 60-day pend and deny period. However, only physicians who had submitted claims on the patient within the previous two months or who were the patient’s assigned primary care provider would get the notice.

CMA was also successful in getting the exchange to delete terms harmful to patients and physicians. For instance, prior drafts of the model contract defined “medical necessity” as primarily a health plan determination and stated that a service could only be “medically appropriate” if it was more cost-effective than alternatives.

With the contract now adopted, the exchange is expected to release the names of plans selected to offer contracts on Covered California’s new online marketplace during its May 23 meeting. Those plans will also be submitting proposed rates for review by state regulators on that date.

Under California’s “active purchaser” model, only plans selected by Covered California’s Board of Directors as “qualified health plans” can offer products on the new marketplace.

Pre-enrollment for the state’s exchange is still expected to begin on October 1, 2013, while the marketplace and coverage will go live on January 1, 2014.

(CMA Alert, May 21, 2013 issue)

CMA offers Congress several solutions to the outdated Medicare physician payment localities The California Medical Association (CMA) is urging Congress to fix Medicare’s outdated geographic payment localities as part of any effort to repeal the sustainable growth rate (SGR) payment formula. In a recent letter to Dave Camp (R-MI), chairman of the House Committee on Ways and Means, and Fred Upton (R-MI), chairman of the House Committee on Energy Commerce, CMA proposed two solutions to this long standing problem that has underpaid physicians in a number of recently urbanized areas. Reps. Camp and Upton are authoring legislation to repeal and replace the SGR. The first solution proposed by CMA is a pilot project limited to California that would update the California Medicare physician payment localities by changing them to follow the same Metropolitan Statistical Areas (MSAs) used to pay hospitals.

The MSAs used to determine payment rates 38 | THE BULLETIN | MAY / JUNE 2013

for hospitals are continuously updated, so that reimbursement accurately reflects local costs to deliver care. The physician payment localities, on the other hand, have not been updated in 15 years. As a result, 14 urban California counties, such as San Diego, Monterey, and Sacramento, are still designated as rural. This has caused many California physicians to be paid up to 14% per year below what Medicare says they should be paid if they were in the correct region.

The pilot would be a temporary, budgetneutral solution that would raise payment levels for urban counties misclassified as rural, while holding remaining rural counties harmless from cuts.

Although the payment discrepancies are most egregious in our state, with California accounting for half of all payment anomalies in the country, a number of other states are experiencing similar problems. According to the

Government Accountability Office (GAO), the three states with the worst payment accuracy are California, Virginia, and Maryland. The second approach proposed by CMA would be a similar multi-state pilot for these three most impacted states.

In both instances, CMA is urging that the remaining rural counties be “held harmless” from cuts that would otherwise result as the result of budget neutrality requirements.

CMA also suggested that another larger approach could be to develop a supplemental rural payment rate to offset the rate reductions that would be experienced by physicians in the locality reconfiguration regions and to help attract physicians to rural areas across the country.

Contact: Elizabeth McNeil, 800/786-4262 or emcneil@cmanet.org.

(CMA Alert, May 21, 2013 issue)

medico news

Walgreens refuses to fill some controlled substance prescriptions without additional information from prescriber The California Medical Association (CMA) has received reports from physicians that Walgreens pharmacists are refusing to fill controlled substances prescriptions without additional information from the prescriber. Physicians are being asked to provide information on diagnosis, ICD-9 codes, expected length of therapy, and previous medications tried and failed.

Walgreens has also sent letters to prescribers that provide an overview of its newly revised policy on good faith dispensing of controlled substances and cites a pharmacist’s corresponding responsibility to ensure that every prescription for controlled substances is “issued for a legitimate medical purpose.”

This new policy appears to be in response to recent investigations and actions by the Drug Enforcement Agency (DEA) related to prescription drug abuse. While proper prescribing and

dispensing of controlled substances must be encouraged, CMA is concerned with issues related to patient privacy, administrative burdens, and re-diagnosing by pharmacists arising from the inconsistent application and implementation of this policy.

CMA has confirmed with the Medical Board of California, other California-based health professional associations and other state medical societies that this policy is being implemented throughout California and nationwide.

In some states, other large chain retail pharmacies are also implementing similar policies and it is likely that other pharmacy chains in California will follow suit.

CMA will be working with the American Medical Association, other state medical societies, and California-based groups to ensure that disruption of legitimate patient care and physi-

cian time is minimized. CMA remains committed to addressing concerns about prescription drug abuse in California and is working with the legislature, regulatory bodies, and law enforcement to find effective solutions.

For more information on this emerging issue, please see “Fact Sheet on Changes to Walgreens Policy on Filling Prescriptions for Controlled Substances,” available in the CMA resource library at www.cmanet.org/resourcelibrary.

If you or your patients have difficulties filling prescriptions for controlled substances at any pharmacy in California, please report problems to CMA’s Center for Legal Affairs at legalinfo@cmanet.org or 800/786-4262.

(CMA Alert, May 21, 2013 issue)

CMA files brief in support of MICRA’s cap on noneconomic damages The California Medical Association (CMA) filed an amicus brief defending the constitutionality of our state’s landmark Medical Injury Compensation Reform Act (MICRA), which caps noneconomic damage awards at $250,000. This case is just the latest in many legal challenges to MICRA that have been funded by trial lawyer groups from across the country.

In this case, Gavello v. Millman, MD, the jury awarded the plaintiffs $2.9 million for lost wages and $1 million for pain and suffering (noneconomic damages). In accordance with MICRA’s noneconomic damages provision (Civil Code Sec. 3333.2), the court adjusted the $1 million dollar award to $250,000 and then apportioned the award to reflect the jury’s finding that Dr. Millman was 20% responsible for the plaintiff’s injuries.

The plaintiffs have appealed, asserting that MICRA’s cap on noneconomic damages violates the Equal Protection clause of the Constitution and their right to a jury trial.

CMA’s amicus brief emphasizes the constitutionality and importance of MICRA’s cap on noneconomic damages. It explains that “[t]he Supreme Court and Court of Appeal have held repeatedly that MICRA, generally, and Section 3333.2, specifically, are rationally related to legitimate state interest,” and that the plaintiffs’ arguments do not change that analysis or provide any legitimate basis to question the constitutionality of MICRA.

Today, MICRA is still working to restrain premium rates in California, while states without liability reform are seeing dramatically higher premiums. Because of MICRA, California has a system that is affordable, pays patients for their full medical and economic losses, and promotes patient safety and improved patient care.

MICRA allows patients with justifiable medical negligence claims to receive the following forms of compensation: • Unlimited economic damages for past and future medical costs • Unlimited damages for lost wages, lifetime earning potential, or any other economic losses • Unlimited punitive damages • Up to $250,000 for noneconomic damages (pain and suffering) MICRA also includes a sliding pay scale to control attorney contingency fees, ensuring that more money goes to patients, not lawyers. MICRA’s $250,000 cap on noneconomic damages has proven to be an effective way of limiting meritless lawsuits and keeping health care costs lower, but has been targeted by the trial lawyers because it restricts the amount of money they can collect in attorney’s fees.

This case is currently before the California Court of Appeal, First Appellate District.

(CMA Alert, May 21, 2013 issue) MAY / JUNE 2013 | THE BULLETIN | 39

medico news

As cases of valley fever increase, CDPH urges physician education, reporting According to the Centers for Disease Control and Prevention (CDC), coccidiodomycosis, a potentially lethal but often misdiagnosed disease, is infecting more and more people in California. Most often prevalent in arid regions of the United States, coccidiodomycosis (also known as “valley fever”) can be contracted by simply breathing in fungus-laced spores from dust disturbed by wind.

Reported cases of valley fever cases have continued to increase in California from about 700 in 1998 to more than 5,500 cases reported in 2011. The disease has seen the sharpest rise in Kern County, followed by Kings and Fresno counties. Out of the 18,776 California cases between 2001 and 2008, 265 people died, according to the California Department of Public Health (CDPH). According to state public health officials, the reasons for the increase is still unclear.

With the reemergence of coccidiodomycosis, CDPH is urging California physicians to refresh their knowledge and understanding of the disease and to report suspected cases to their local health departments.

Concerns about increases in reported cases of valley fever were heightened during the first week of May when a federal health official ordered the transfer of more than 3,000 inmates

from two San Joaquin Valley prisons where several dozen have died of the disease in recent years. A day later, state officials began investigating an outbreak in February that sickened 28 workers at two solar power plants under construction in San Luis Obispo County.

Although most individuals infected with coccidiodomycosis will not have any symptoms, approximately 40% of patients will present with symptoms that range from pneumonia to skin lesions.

Symptoms arise at one to three weeks following infection. Most symptomatic persons will present with a mild, self-limited influenzalike illness or community-acquired pneumonia and may complain of fever, cough, chest discomfort, malaise, and fatigue. Infected individuals may also develop diffuse or progressive pneumonia, mediastinitis or pulmonary nodules or cavities. About 5% of symptomatic per-

sons will develop disseminated disease, which most often presents as skin lesions, osteomylitis, or meningitis.

While anyone in the endemic area is at risk, persons working in occupations involving dirt and dust exposure may be at increased risk of developing valley fever. African Americans, Filipinos, persons aged 65 and older, pregnant women in their third trimester, and persons with diabetes or immunocompromising conditions are at increased risk of severe pulmonary or disseminated disease when infected.

Several diagnostic methods for coccidioidomycosis are available including serology, culture and histopathology and several antifungal medications are available for treatment.

For more information, visit http://www. cmanet.org/news.

(CMA Alert, May 21, 2013 issue)

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Our special home financing program is designed specifically to meet your needs as a busy physician for the purchase of your primary residence.

For information on how you can take advantage of this special home financing program from BBVA Compass, give us a call today.

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All loans subject to approval, including credit approval. Eligible properties must be located in Alabama, Arizona, California, Colorado, Central Florida, North Florida, New Mexico or Texas where BBVA Compass has a market presence. BBVA Compass is a trade name of Compass Bank, Member FDIC.

40 | THE BULLETIN | MAY / JUNE 2013

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New TRICARE Contract Might Create Gap in Medical Malpractice Coverage The California Medical Association (CMA) has recently become aware of a broad “indemnification” clause in the UnitedHealth Military & Veterans Services (UMVS) TRICARE provider contracts that is causing concern. The indemnification clause stems, at least in part, from a requirement of federal regulation 32 C.F.R. 199.17(p)(1), which relates to the Civilian Preferred Provider Network of the TRICARE program. Exact language of the contractual indemnity clause in question does vary from the regulatory language, is subject to interpretation and, depending on insurance policy language, may result in liability that is excluded from coverage under a physician’s medical professional liability insurance policy.

Contractual indemnity obligations are typically excluded from coverage under a medical professional liability insurance policy. However, such an exclusion would usually not be invoked for liability that the insured would have under the law in the absence of a contract or agreement. Because medical professional liability insurance policies are typically written to cover liability for negligent acts or omissions of the insured physician in providing professional medical services, the contractual indemnity provi-

sion in the TRICARE contract would typically NOT result in an exclusion from coverage of claims brought against the insured physician by a TRICARE beneficiary. Hence, although the amount of any uncovered liability could be significant, it would likely be a low probability event.

CMA is working directly with the medical professional liability carriers and UVMS on this issue. CMA strongly recommends that physicians contact their medical professional liability carriers directly regarding the indemnification provision in the TRICARE contract and obtain information from them on what the clause means in terms of liability insurance coverage and exclusions from coverage.

As with all contracts, physicians should read the new TRICARE contract carefully and thoroughly and should consider obtaining legal advice from their personal attorney before deciding whether to sign the TRICARE contract.

Contact: California Medical Association: 888/401-5911 or economicservices@cmanet.org.

MAY / JUNE 2013 | THE BULLETIN | 41

Classifieds office space for rent/ lease MEDICAL SUITES • LOS GATOS – SARATOGA

Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking. Located next door to Los Gatos Community Hospital.

Both units currently available. Call 408/3551519.

MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA

Medical space available in medical building.

Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft.

Call Rick at 408/228-0454.

MEDICAL SUITES • GILROY

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

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE

Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/644-9800.

2,300 SQ FEET MEDICAL SPACE

2,300 sq. ft. surgicenter; eligible for Medicare approval. Or Medical-Dental office space by Good Samaritan Hospital. Rent negotiable. Call Gloria Wu, MD at 408/356-5553 or Jeff Petulla at 408/888-4859.

PRIME MEDICAL OFFICE FOR LEASE • SAN JOSE

Dermatologist, Rheumatologist, Orthopedic Surgeon, or an Endocrinologist. 5 newly remodeled treatment rooms equipped with brand new ADA compliant chairs and in-office digital x-ray, access to state of the art minor procedure room, utility room, storage, cabinets, and break room. Call 408/358-2250 or email: losgatospodiatrygroup@gmail.com.

OFFICE FOR RENT • SAN JOSE

2395 Montpelier Dr #5, San Jose 95116. Rent $2,000 per month. Lease required. Owner pays triple net and monthly H/O dues. Two doctors set up. Three examination rooms. Approximately 1,100 sq. ft., furnished or unfurnished, adequate parking, walk to Regional Med Ctr. Close to X-Ray and lab. Previous tenant doctor retired. Call Marie at 408/268-2040.

MEDICAL/DENTAL/PROFESSIONAL OFFICE SUITE • SALINAS

Second story of professional building across from SVMH. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $1.25/sq. ft. Rent is $1,544/month. Contact Steven Gordon at 831/757-5246.

MEDICAL OFFICE SPACE TO SHARE • SUNNYVALE

Convenient location. One large private office plus one exam room, shared waiting room and front office. Newly built, total 1,280 sq. ft. Available now. Please call 408/438-1593.

MEDICAL OFFICE/EXAM ROOM FOR LEASE IN DIAGNOSTIC IMAGING FACILITY • SAN JOSE NEAR O’CONNOR HOSPITAL

Excellent location. Westgate area. 1,584 sq. ft.

West Valley Professional Center, 5150 Graves Ave. Suite 2/stand-alone unit. Private office, reception area, exam rooms with sinks. Available 2/1/11. Call owner at 408/867-1815 or 408/2217821.

Perfect for Orthopedics & Chiropractors. Immediate access to MRI, CT, X-Ray, US & DEXA. Includes great amenities: shared reception desk, large lobby/waiting room & kitchen. Includes all utilities, phones, computers. Great visibility on Winchester Blvd. Available Monday-Saturday.

Call Khoi, 408/984-7226.

MEDICAL OFFICE TO SHARE • LOS GATOS

MEDICAL OFFICE SPACE FOR LEASE/ SALE • SAN JOSE

Available now! 1,800 sq. ft. to share with a newly established Podiatry Practice near Good Samaritan Hospital with after hours Health Care Urgent Care facility and Health Diagnostics (MRI/CT) imaging center downstairs. Excellent for a Primary Care Physician, Cardiologist, 42 | THE BULLETIN | MAY / JUNE 2013

Luxury modern 1,300 sq. ft. turn-key office with minor surgery OR. Prime Good Samaritan/Bascom Avenue at Highway 85 location in multispecialty building. Interior amenities and terms negotiable. Call 408/559-8658.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY

Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage.

We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or email riflovin@allianceoccmed.com for additional information.

EMPLOYMENT OPPORTUNITY

Physician/Locum tenens for Family/Internal Medicine. Office based practice only. Coverage mostly needed during vacation. Part-time, must have excellent communication, interpersonal and clinical skills. Please fax CV to 408/3566676.

SUPERVISING PHYSICIAN POSITION

GENERAL NATURE OF POSITION: Provides primary care services to patients and supervises the activity and performance of the medical residents. Collaborates with the Catholic Charities integrated Behavioral Health team (Consulting psychiatrist, LCSW, etc), Division/ Clinic Administrator and Directors of the partnering educational institutions to implement the

METRO MEDICAL BILLING, INC. • • • • • •

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integrated clinic and to achieve primary care service goals. Provides consultation and training for the clinical team composed of residents, and the clinical operations staff members.

Position is part-time, 12 hours per week. Job posting: http://catholiccharitiesscc.org/im/jobs/ job_1128.html. Please submit resume to jobs@ catholiccharitiesscc.org or via fax to 408/9440276 attn: TM.

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Office is 11 years old. PPO, Medicare, and cash. Take over very low rate payment on office loan plus a small amount of cash. Call 408/8716800.

MEDICAL OFFICE SPACE FOR LEASE/ SALE • SAN JOSE

Luxury modern 1,300 sq. ft. turn-key office with minor surgery OR. Prime Good Samaritan/Bascom Avenue at Highway 85 location in multispecialty building. Interior amenities and terms negotiable. Call 408/559-8658.

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2013 Physician Membership Resource Directory NOWS.C.C.M.A. AVAILABLE! 8-12-08 ORDER YOUR COPIES TODAY There are a lot of updates and changes in the new 2013 edition. Make sure to order enough copies for you and your staff!

Contact Maureen Yrigoyen at 408/998-8850 today!

MAY / JUNE 2013 | THE BULLETIN | 43

SAC-PAC

Santa Clara County Physicians’ Political Action Committee

AND 1559 Meridian, San Jose, CA 95125

700 Empey Way, San Jose, CA 95128

PRESENT

6:00 PM – First Sip True connoisseurs will want to join us for this wine and food pairing led by

Bert George

CEO/President/Wine Educator, From the Joseph George Winery and Wine Shop In Addition to Tasting Bodacious Wines, Come Join the Fun and Meet

Senator William Monning, SD 17 (17th Senate District, 2016 Primary) Brush up on your wine trivia and be prepared to enter the “Wine Fun-Fact Contest.”

The winner of this contest will receive a very special bottle of wine!

Please join the SAC-PAC Board in Hosting This Very Special Evening!

Please join the SAC-PAC Board in Hosting This Very Special Evening!

Wine Tasting and Meet & Greet Event With Senator William Monning, SD 17

Thursday, June 27, 2013 6:00 to 7:30 PM Joseph George Wine Shop Wine Educator, Bert George 1559 Meridian Avenue, San Jose, CA 95125 Please RSVP by June 24, 2013, to Jean Cassetta, jean@sccma.org or call, 408/998-8850 Ext. 3010, or Fax 408/289-1064 Present your contribution for Senator Monning’s Senate campaign at the door.

(A minimum of $50 per person is appreciated!)

If you can not attend but would still like to contribute, mail check to: 1127 11th Street, Suite 331, Sacramento, CA 95814

Donor Name Contact Name Address City/State/Zip Office Phone

Fax

Employer

Occupation

The CA Political Reform Act (Prop. 34) places limits on contributions to candidates for state office and imposes certain prohibitions. This request does not seek a contribution in excess of applicable limits or from prohibited sources. An individual, union, PAC, and other entities may contribute a maximum of $4,100 per election period. A registered Small Contributor Committee may contribute a maximum of $8,200 per election period. Contributions are not deductible for tax purposes. Produced in-house by laser printer.

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We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of “Books for Botox®” community outreach program, benefitting the libraries of underfunded public schools

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

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MAY / JUNE 2013 | THE BULLETIN | 47

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