2015 May/June

MAY/JUNE 2015 | VOLUME 21 | NUMBER 3

CYBERSECURITY

Time to go shopping... ...for a better deal on workers’ compensation.

There has never been a better time to shop the sponsored workers’ compensation plans offered through the Santa Clara County Medical Association/Monterey County Medical Society/CMA. That’s because workers’ compensation insurance rates in California continue to move upward. The Insurance Commissioner recommended an increase of 6.7% in pure premium rates for 2015 compared to the average premiums charged as of July 20141. Your plan may experience a higher or lower rate increase than recommended by the Department of Insurance.

Don’t just sit back and accept higher rates! Call Mercer to see if you can get a better deal through the Santa Clara County Medical Association/Monterey County Medical Society/CMA. Working with Mercer as the program administrator, the Association/Society sponsors best-in-class insurance plans at competitive premiums.

By becoming involved with the sponsored plans you will receive valuable protection for your practice and employees while supporting the good work of your Association/Society!

Take control of your workers’ compensation costs. Call 800-842-3761 now for your free, no-obligation quote. Or visit www.CountyCMAMemberInsurance.com for more information and to download an application or premium indication form.

Sponsored by:

Scan for more info!

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 Copyright 2015 Mercer LLC. All rights reserved. • 777 South Figueroa Street, Los Angeles, CA 90017 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com 800-842-3761 • 71374 (5/15)

Source: Workers Compensation Insurance Rating Bureau of California, http://www.wcirb.com/sites/default/files/documents/insurance-commissioners-decision-01012015_1.pdf 1

2 | THE BULLETIN | MAY / JUNE 2015

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 Representation Human Resources Services

Feature Articles 8 Cybersecurity 14 How to Beat Burnout: 7 Signs Physicians Should Know 16 Doctors and Weight: Helping Without Harming

Departments 5 From the Editor’s Desk 6 Message From the SCCMA President 7 Message From the MCMS President

Legal Services/On-Call Library

22 Medical Times From the Past

Legislative Advocacy/MICRA

24 MEDICO News

Membership Directory iAPP for

28 In Memoriam

the iPhone Physicians’ Confidential Line Practice Management

29 2015-2016 SCCMA Committee Response Form 30 Discount Ticket Program

Resources and Education

31 Member Spotlight: James Hinsdale, MD

Professional Development

32 2015 Global Medical Brigade

Publications

34 Practice Management Tools and Resources

Referral Services With

35 Wireless Symposium October 10, 2015

Membership Directory/Website

38 Classified Ads

Reimbursement Advocacy/ Coding Services Verizon Discount MAY / JUNE 2015 | THE BULLETIN | 3

THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President James Crotty, MD President-Elect Eleanor Martinez, MD Past President Sameer Awsare, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Peter Cassini, MD VP-Professional Conduct Seema Sidhu, MD Secretary Seham El-Diwany, MD Treasurer Scott Benninghoven, MD

CHIEF EXECUTIVE OFFICER

COUNCILORS

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Ryan Basham, MD El Camino Hospital: Joshua Sickle, MD Good Samaritan Hospital: David Feldman, MD Kaiser Foundation Hospital - San Jose: Hemali Sudhalkar, MD Kaiser Permanente Hospital: Martin Wong, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Erica McEnery, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Vanila Singh, MD Santa Clara Valley Medical Center: Richard Kramer, MD

CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Tanya Spirtos, MD (District VII)

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Printed in U.S.A.

OFFICERS

Editor

President Jeffrey Keating, MD President-Elect James Hlavacek, 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 2015 by the Santa Clara County Medical Association.

4 | THE BULLETIN | MAY / JUNE 2015

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD Valerie Barnes, MD Ronald Fuerstner, MD Gary Gray, DO Steven Harrison, MD David Holley, MD John Jameson, MD

William Khieu, MD Eliot Light, MD Edward Moreno, MD Marc Tunzi, MD Craig Walls, MD Cary Yeh, MD

Editor, The Bulletin

A tear came to my eye as my son walked across the University stage to accept his diploma. His mother sat beaming in the audience with all the other parents and relatives in attendance for this momentous occasion in their son, daughter, or family member’s lives. Of course this all happened in my mind’s eye since I was 3,000 miles away, working and on-call in the hospital. My hug and congratulations would come later. David had already completed his undergraduate degree, majoring in Philosophy. However, after a summer internship in our hospital and volunteering as an EMT in his local college town, medicine has become his chosen path.

Two more years of chemistry, physics, biology, and math were now under his belt as he faced the long journey ahead.

I never encouraged, nor discouraged, either my son or daughter to become physicians, but to find their own paths. They certainly experienced medicine second hand as I shared stories of triumphs and tragedies, as well as my irritability, after many a sleepless call night.

When talking with colleagues, many say they would discourage their children or family members from becoming doctors. Loss of autonomy, more paperwork, less time with patients, and decreasing income are all factors in our profession’s malaise. Sadly, recent surveys reveal that 30%–40% of practicing physicians wouldn’t choose to enter the medical profession again, and even a larger number wouldn’t encourage their children to pursue medicine.

Dr. Sandeep Jauhar explores this in detail in his article, “Why Doctors Are Sick of Their Profession,” printed August 29, 2014, in the WSJ Saturday Essay. We’ve gone from Marcus Welby, the almost heroic portrayal of physicians in the 1970’s, to ER and Grey’s Anatomy, emphasizing personal and professional fallibility. The change in reimbursement has also led to a decline in how the public views our profession, with reports of unnecessary procedures, Medicare fraud, and the perception of doctors bilking the system as health care costs rise.

From HMO’s to managed care to increased specialization, the doctor-patient relationship has suffered with more distance and less time.

How can we overcome this professional malaise? Certainly, when doctors aren’t happy, it is not good for their patients. Strong advocacy for

JOSEPH S. ANDRESEN, MD

Physician Editor, The Bulletin

professional autonomy and reasonable reimbursement continues to be at the forefront of our medical organization’s mission. Recognizing the many measures of success in medicine by creating attachments with our patients and taking credit for their improved health and well-being often with more limited resources. There are many measures of excellent care including reporting of surgeon mortality rates, readmission rates, and patient satisfaction to name just a few. Recognition and prevention of physician burnout should be an integral part of our medical staff activities.

The recent and continual transformation of health care has been most unsettling for those of us in the middle and near the end of our careers. Yet, if we revisit our motivation, perhaps recalling our personal statements from our medical school applications and asking ourselves why did we choose medicine in the first place? It undoubtedly is condensed down to wanting to help others. Understanding that and acknowledging our personal resilience in accomplishing this journey is a worthy endeavor.

Our young generation of medical students will have the idealism and ambition to see that the medical profession retains the high standards that we envision. They will be able to see beyond “regulations” and find greater efficacy in the practice of evidence-based medicine exemplified by lowering infection rates, reducing medication errors among many other objective measures. With our mentoring and support, they will seek to become physician leaders, health care and hospital administrators that will shape the future for our profession and most importantly, for our patients.

In the past 24 hours I placed a large bore intravascular catheter in the neck of a hemorrhaging postpartum patient, initiating the massive transfusion protocol helping to save her life; reassured the parents that their 10-year-old daughter would be fine and got her to smile as she told me that her favorite school subjects were math and art, as we wheeled her into the operating room for an emergency appendectomy; held the hand of an anxious 80-year-old patient awaiting surgery for her hip fracture.

I know no other profession where our actions can touch the lives of others so profoundly. These rewards have been and will continue to be priceless for those who choose to pursue the profession of medicine.

FROM THE

By Joseph Andresen, MD

EDITOR'S DESK

To Be A Doctor?

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.

MAY / JUNE 2015 | THE BULLETIN | 5

SCCMA Membership: Return on Investment

By James R. Crotty, MD, MBA

President, Santa Clara County Medical Association

JAMES R. CROTTY, MD, MBA

MESSAGE FROM THE

SCCMA PRESIDENT

President, Santa Clara County Medical Association

James R. Crotty, MD, MBA, is the 2014-2015 president of the Santa Clara County Medical Association.

He is a urologist and is currently practicing with The Permanente Medical Group/Kaiser in San Jose.

The mission of CMA is to: promote the science and art of medicine, the care and well-being of patients, the protection of public health, and the betterment of the medical profession. The primary goal of CMA and SCCMA is to provide value to its members.

Does CMA/SCCMA membership provide return on investment? I will gladly pay my membership dues in order that California physicians can act together as force for change. Last year, CMA led a coalition to defeat Proposition 46. If this had passed, California physicians would have seen a huge increase in their malpractice premiums. The increase costs to physicians would have been tens of thousands of dollars per year. Membership dues pay for the salaries of CMA staff who work to help the organization accomplish its aims. They are a dedicated and hard-working lot.

CMA successfully advocated for passage of a fix to the Medicare California geographic practice cost index (GPCI), providing substantial payment increases to California physicians. CMA and AMA, also this year, finally celebrated the elimination of the Sustained Growth Rate (SGR) that would have implemented a 21% decrease in Medicare reimbursements, after many years of lobbying efforts. Again, these actions have directly resulted in preserving and increasing physician revenues. The $1K individual membership dues investment has returned tens of thousands of dollars.

What better investment can you find than this? Why aren’t all California physicians members of CMA? As President of SCCMA, I have been surprised that CMA did not see a huge increase in membership this year with Prop 46 being so prominent in the news. Talking with other physicians, I have come to the conclusion that physicians who choose not to be members of CMA do so mostly because they do not want to pay the membership dues, but that they are happy that this work is being done. Physicians feel that they should be paid for their services, commensurate with their training, abilities, and risk responsibilities. What has CMA done for me lately? One area that CMA has great concerns is Medi-Cal. We know that Med-Cal eligibility will grow to 12 million next year. Medi-Cal will cover 60% of children in California. Medi-Cal rates in California are ranked 47th of all states. CMA has been lobbying to have California increase their Medi-Cal rates and is supporting SB 243. Unfortunately, even though California has a budget surplus, much of it will

6 | THE BULLETIN | MAY / JUNE 2015

go to education because of previous California legislative actions. Increasing Medi-Cal rates will require a long term strategy, and having more physicians in the legislature is a huge step in that direction. CMA called for the state to conduct an independent, third-party assessment on reimbursement rates, stating that such an assessment is a critical component in determining both the baseline rates and the level of incentive payments required. Dr. Richard Pan was helped by CMA to win his senate seat, and Dr. Pan will continue to champion California physicians causes. CMA has plans to make sure that California physicians can take advantage of whatever payment arrangement Medicare will devise. CMA, also successfully, convinced the Centers for Medicare and Medicaid Services (CMS) to reverse their mandate on California to retroactively recoup a 10% Medi-Cal reimbursement rate cut from 2011, retaining $218 million in payments. The current “Hot List” of legislative proposals include economic issues such as expansion of scope of practice, insurance company practices, payments for telephone and electronic encounters, and rules for worker compensation that have direct impact for physicians in practice.

The CMA/SCCMA dues pay for themselves, and are a great investment for California physicians. Increasing membership also increases political muscle.

The public looks to physicians for opinions regarding health issues. Physicians are, in general, thought of as good people looking to keep the population healthy.

CMA has weighed in on issues such as vaccinations, end of life care, drug affordability, opiate drug prescribing practices, tobacco, e-cigarette, marijuana and alcohol regulation, and Ebola. CMA is constantly in the news media. The question: what does the California Medical Association think of this? The practice of medicine is changing with more focus on keeping patients healthy. This is a good thing for CMA, because if we are working to improve the health of our patients, Californians will support California physicians. There is much work to be done to accomplish what the Institute for Healthcare Improvement has called the Triple Aim: improving population health, improving the patient care experience, and decreasing costs. AMA has also called for increasing physician leadership in team-based care as a top priority.

So, encourage your physician friends to be active members of CMA/SCCMA and not free riders. Health care reform will be with us for the next decade, and if we are not at the table we are probably on the menu.

President, Monterey County Medical Society

One of the members of the society, Dr. Jan Belza, was kind enough to share a book outlining the medical history of Monterey County from 1770-1970. Medicine in Monterey County has an interesting history. In 1770, Father Serra and Portola arrived, beginning European life in Monterey.

At that time, the first surgeon general of the Royal Presidio of Monterey and first resident doctor in California was Don Pedro Prat from the University of Barcelona, who was paid approximately $1,000 per year. Of course, before then the Indians/native people had their own form of medicine with witch doctors/Shamans who used devices of dance, incantation or magic, herbs, bleeding, and sweat houses.

The payment for services rendered was with strands of beads, and if the treatment failed no payment was made. During the Mexican Period there were not enough surgeons to cover the practice which required pressing into service individuals who had only a small amount of medical knowledge. This included drug clerks, dentists, phlebotomists, and even barber surgeons. A man (note gender) wishing to become a physician bound himself to some recognized medical man in his community for a term of years or until he considered his course complete.

There were so many occupying such prominent positions in California communities that they broke up the first State Medical Society meeting when that organization tried to enforce a law that no doctor could join the society unless he had an M.D. from a recognized Medical College. One interesting account of a self-styled physician is one Joe Meeks who came from Oregon, where he stated that as soon as he could wagon to California “I’m going to palm myself off as a doctor;” he subsequently became known as Dr. Meeks. He could neither read nor write. With his very first case, he attained not only success but renown – A boy had a toe cut off, and luckily, Dr. Meeks happened to be near and stuck the toe in its rightful place, bound and poulticed it on, and tradition says it grew on again. He had a habit of looking and acting very wise, especially when people talked about things of which he was ignorant. Unfortunately for him, his career was cut short when a surgeon on a visiting American man-of-war discovered his deficiencies. With California becoming a state in 1850, the first California Medical Society meet-

JEFFREY KEATING, MD

President, Monterey County Medical Society

ing was held in Los Angeles. In 1870, the Monterey County Medical Society was said to be formed and was listed as being represented at the AMA meeting in San Francisco in 1871. Established medicine progressed slowly in the county, with the gradual development of several “home hospitals.” It is interesting to see a “Schedule of Fees of the Monterey County Medical Society” from 1924, with fee for normal labor with analgesics of $50 and minor operation from $5 to $50. I will leave it to the current members of the Society to fill in the gaps from 1970 until now. And, it will be future members to decide the future of the Society in what promises to be challenging times.

It was an honor to have been the Monterey County Medical Society President for the 2014-15 term. The highlight of the year for me as President was the successful defeat of Prop 46. (And, no, I do not take personal credit for that.) For me, the “No on 46” campaign highlighted how much we need the California Medical Association to provide logistics, legal advice, and expertise on media relations and political action; I have no doubt that without CMA, the Proposition would have passed. The biggest lesson was that we were advised to follow the script and not go off on our own and make statements or behave in a way which would be used against us.

This goes against the grain for most physicians, but it highlighted the need to work together to prevail on a strategic level, and to follow the advice of the professionals in their respective domains, just as we would have patients follow our advice.

Convincing people to join the Society is a continued challenge. In the age of instant messaging and social media, actually meeting in person is becoming anachronistic. Convincing doctors to join, and then to actually pay membership fees is an even greater challenge. And that is not because we are cheap – we are all facing decreased reimbursement and increased overhead costs squeezing the bottom line. Of course, this means that the less who join, the more the remaining need to contribute. Organized medicine (e.g. MCMS, CMA, and even AMA) is the only legal way we are allowed to be heard and the best way to change government policy. If Prop 46 had passed, the value of the Society would then have been made apparent, but then it would have been too late. Let there be no doubt – the trial lawyers, government bureaucrats, insurance compa-

MESSAGE FROM THE

By Jeffrey Keating, MD

MCMS PRESIDENT

Monterey County Medical History

Jeffrey Keating, MD, is the 2014-2015 president of the Monterey County Medical Society. He is a Pathologist and is currently practicing with Community Hospital of Monterey Peninsula in Monterey.

Continued on page 28 MAY / JUNE 2015 | THE BULLETIN | 7

COVER STORY

By Marion Webb 8 | THE BULLETIN | MAY / JUNE 2015

COVER STORY

In the wake of recent events, in particular the monumental data breach at health insurer Anthem, cybersecurity is on the mind of every physician, administrator and patient. In this timely issue of The Bulletin, we will provide you with the latest news and legislative information, as well as tips to help protect your practice and patient information from cyber attacks.

MAY / JUNE 2015 | THE BULLETIN | 9

COVER STORY RECENT BREACHES AND SENATE ACTION Insurers aren’t required to encrypt consumers’ data under the main health privacy law—the Health Insurance Portability and Accountability Act, or HIPAA—or under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, although the latter offers incentives, according to Medical Economics reports.

The data breaches at Anthem, the nation’s second-largest health insurer, made public in February, and the just revealed Premera Blue Cross breach has spurred a bipartisan congressional effort to reexamine HIPAA, possibly adding a costly and cumbersome requirement to encrypt health records.

The Anthem breach is the largest HIPAA violation to date and affected some 80 million people whose names, dates of birth, member ID and Social Security numbers, addresses, phone numbers, email addresses, and employment information were stolen. The Premera Blue Cross breach is the second largest cyber attack in industry history, exposing the personal, financial, and medical information of more than 11 million customers.

Anthem says it encrypts data it exports, but the data was stolen at the company level and was unencrypted. But even if it had been encrypted, Medical Economics reported, the system administrator credentials that were stolen could have been used to access encrypted client data.

Since the Anthem incident, the Senate Health, Education, Labor & Pensions Committee announced that it is planning to examine the security of all health information technology and the health care industry’s preparedness against cyber attacks.

OBAMA’S CYBERSECURITY PROPOSAL In light of massive cyber attacks across several industries in 2014, which included JP Morgan Chase, Sony Pictures 10 | THE BULLETIN | MAY / JUNE 2015

Entertainment, Target, and The Home Depot, cybersecurity is now also a priority of the Obama administration.

The administration’s recently released cybersecurity proposal outlines the obligations it believes companies have to notify customers of breaches. It includes a 30-day notification requirement, the creation of a national notification standard, improving information sharing between private sector and the government, and bolstering law enforcement’s ability to combat cybercrime.

Some health care experts believe, however, that the cybersecurity wish list offers few specifics for the health care industry, which is expected to see more phishing and malware attacks this year, iHealthBeat forecasted.

Angela Rose, director of health information management practice excellence at the American Health Information Management Association, told iHealthBeat it’s too early to predict the proposal’s effect on health care organizations.

She noted, however, that the administration’s data sharing plan, which encourages sharing information between private entities and the Department of Homeland Security, requires private companies to remove “unnecessary personal information” from shared data.

This, she said, raises the question whether such information will map the HIPAA definition of protected health information or include other elements such as credit card information.

Another part of the legislative package that needs sorting out is the health care breach notification standard, which currently is governed by differing state laws and also differs from HIPAA’s requirement for covered entities, iHealthBeat reported.

The White House proposal states that businesses must notify individuals affected by a data breach within 30 days; HIPAA requires businesses to notify individuals within 60 days of the discovery of a breach.

The proposal wouldn’t immediately impact health care organizations covered under HIPAA, the experts said.

Lynn Sessions, a partner with the law firm BakerHostetler who specializes in health care data security and breach response, noted that a few states have breach notification laws on the books that are more restrictive than HIPAA and its 60day standard.

Some offer an exemption for HIPAAcovered entities, while others include health care data within the scope of their notification laws, he said.

The Florida Information Protection Act, effective since 2014, includes medical history, treatment and diagnosis information, health insurance policy numbers, and subscriber identification numbers as “protected information” subject to its breach notification requirement, which is within 30 days.

Sessions is a proponent of a single breach notification law, pre-empting other directives.

Another unresolved issue the experts noted is the treatment of business associates, such as vendors, who often have little health care experience.

The financial services industry has had a data sharing mechanism in place for more than a decade. The Financial Services Information Sharing and Analysis Center provides a global cybersecurity resource. Healthcare is moving in that direction as well with the creation of the National Health Information Sharing and Analysis Center in 2014, iHealthBeat reported.

THREATS ON THE RISE; CONSUMER CONFIDENCE LOW One issue that all experts can agree on is that the threat of data breaches is higher than ever before.

According to a recent study by the Ponemon Institute, as reported by Clinical Innovation & Technology, 20% more medical identity thefts occurred in fiscal year 2014 compared to the year prior.

COVER STORY In the annual study of 49,000 adults, which aims to determine the effects and pervasiveness of identity theft in the U.S., 79% said they felt it was important for providers to ensure the privacy of their medical data, and 68% said that they did not have confidence in their providers’ security measures.

Researchers also noted that 35% of consumers were “not familiar” with HIPAA and privacy standards related to security data.

To reduce medical identity theft, the study authors recommended that “health care providers and insurance providers help consumers gain more control over their medical records,” according to published reports.

Some people believe that organizations should do more to protect patients’ data, which would help raise consumer confidence and also help thwart off cyber attacks.

Indeed, the Ponemon Institute also found that, on average, provider organizations spend about 3% of an organization’s IT budget on security issues, which is low compared to other regulated industries such as banking.

MOBILE HEALTH PRIVACY TOP CONCERN FOR ADOPTION A global survey of 144 health care leaders working in public and private health care sectors, including life sciences, found that the adoption of potentially lifesaving mobile health devices is also hampered by consumers’ privacy concerns, HealthIT Security recently reported.

The majority of health executives, 64%, said that new mobile technologies that provide greater patient access to medical information would “dramatically improve health outcomes,” with 63% reporting that they could help patients make better health decisions on their own.

But barriers prevail. Half of the respondents in the public sector raised concerns about patients misinterpreting their own data and then making poor decisions

The data breaches at Anthem, the nation’s second-largest health insurer, made public in February, and the just revealed Premera Blue Cross breach has spurred a bipartisan congressional effort to reexamine HIPAA, possibly adding a costly and cumbersome requirement to encrypt health records. and recognized that privacy is a major concern for consumers.

“In addition, companies worry that regulators will struggle to keep up with the fast pace of technological innovation, leading to long delays before new devices are approved,” the report’s authors noted, according to hitconsultant.net.

Yet, of the respondents that use mobile features, the majority, or 58%, said they use email, text messages, and social media to communicate with medical providers, 44% to access and manage their personal health records and 44% to locate, buy, and manage health care services and products.

The respondents expect patients’ ability to access and manage health records via mobile devices to remain the same.

Half of the respondents were confident that five years from now, mHealth infrastructure will remove reimbursement and revenue barriers and be able to increase patient contact.

CONCLUSION Health care security experts predict that in the new electronics world, breaches will be found on many fronts, and medical identity theft will become big business.

The New York Times, in a recent article, cited one security expert who noted that in one black market auction, a patient medical record sold for $251, which com-

pared to credit cards selling for only 33 cents.

Last year, 18 health care providers reported data breaches due to hacking, the article said. Among the companies and organizations that had data breaches were Centura Health and a student health center at the University of California, Irvine.

The Anthem breach has become the subject of intense regulatory scrutiny.

And the National Association of Insurance Commissioners, a group of state insurance regulators, planned a multistate examination of the insurer, according to reports.

But security experts said that doctor practices and organizations need to become more proactive in protecting their systems from cyber attacks.

A 2014 report by Forrester Research estimated that only 59% of health care organizations have implemented any type of data encryption.

Implementing defense strategies, monitoring Internet-connected devices, training employees on the importance of security and notifying patients of how their data will be used are all critical steps to safeguarding your practice and instilling consumer confidence.

This article is reprinted with the permission of Los Angeles County Medical Association’s Physician Magazine.

MAY / JUNE 2015 | THE BULLETIN | 11

COVER STORY

13 Strategies to Safeguard Your Cyber Data To help you protect your organization from evolving threats, here are 13 expert-recommended strategies to safeguard your information:

6. If an employee is terminated, human resources should follow up with IT staff to make sure that the individual’s network access has been terminated.

1. Having strong internal and external firewalls, access control measures, antivirus solutions, and phishing filters are important IT measures to prevent attacks, but policies and procedures and employee education are just as important and often cheaper.

7. Also, companies that have access to patient data should spell out how the contractor will protect the information and respond in the event of an attack.

2. Start by assessing your risk for a cyber attack. Have solid processes in place to identify your risk with new systems, devices, services, and partners, and determine how to best use their power as purchases and weed out those that don’t meet your best security practices.

3. Everyone needs to play a role in information security systems, said Kamal Govindaswamy from the RisknCompliance Consulting Group. But he believes that health IT managers and leaders are key to making security programs effective. He said accurate inventory of data and how to protect it is a problem for many health care organizations. He proposes that businesses assign ownership and accountability of the health IT leadership and insist on independence for the chief information security officer or equivalent. Smaller organizations may have one owner who is accountable and responsible for the IT assets, regardless of whether they are leased or owned or subscribed, and that person needs to be proactive at all times. Every physical and virtual asset (network device, server, storage, app, database) must have an assigned owner at a manager/ director/VIP level.

4. Organizations should conduct “mock scenarios” with a clear roadmap for where it should divert resources to eliminate tech vulnerabilities.

5. Employees are vulnerable too and as such should be given adequate training to recognize when hackers have breached their network or are casing it to find a way in.

They should also be educated on how to take precautions when traveling with a work computer that has sensitive data.

12 | THE BULLETIN | MAY / JUNE 2015

8. Make incident response management a priority.

Organizations should make use of smart and purposebuilt software automation for assessing incidents and managing responses to better mitigate risks to their patients, reputation and bottom line, according to Government Health IT. 9. Control your workflow and minimize workforce access.

This includes safeguarding it from impermissible uses and disclosures.

10. Smaller companies need to be particularly cautious because they often don’t have the resources to devote to security and compliance, Government Health IT reported. They should turn to third-party vendor management to strengthen oversight and review processes.

11. Both the health care industry and its technology service providers need to dramatically improve how they take advantage of existing technologies as well as how they design, construct and deliver new tools. This is also key when it comes to health-related mobile apps, which are being introduced at a phenomenal pace, but often without enough consideration for privacy.

12. The government says that health care industries need to get better at determining key metrics to continuously measure and improve security.

13. Voicemail systems, customer service call recording systems, and closed-circuit television systems could all potentially be storing protected health information data that may not be as carefully protected as traditional IT systems.

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PHYSICIAN WELLNESS

Reprinted from AMA Wire

HOW TO BEAT BURNOUT: 7 SIGNS PHYSICIANS SHOULD KNOW

If constant stress has you feeling exhausted, detached from patients, or cynical, take notice. You may be in danger of burnout, which studies show is more prevalent among physicians than other professionals. But how can you avoid it? Learn the signs of physician burnout and what you can do to stay motivated on the job.

1. YOU HAVE A HIGH TOLERANCE TO STRESS.

Stress consistently ranks as the number one predictor for burnout among physicians. Dr. Linzer said, “Please don’t ignore the stress, even if you can take it,” he said. Physicians who consistently operate under high stress are at least 15 times more likely to burn out, according to his research.

2. YOUR PRACTICE IS EXCEPTIONALLY CHAOTIC.

A quick glance around your practice will let you know if you or your colleagues may cave to stress. “People tend to think it’s the patients that always stress doctors out, but actually, it’s the opposite,” Dr. Linzer said. “Caring for patients keeps doctors motivated. What bums them out is caring for patients in a high-stress environment. Change the environment and you’ll change the overall quality of care.”

3. YOU DON’T AGREE WITH YOUR BOSS’ VALUES OR LEADERSHIP.

This one is particularly tricky to identify but “necessary to prevent burnout,” Dr. Linzer said. Whether at a large hospital or private practice, physicians need to feel as if the people leading them also share their values for medicine and patient care. Otherwise, their motivation can slowly wane.

4. YOU’RE THE EMOTIONAL BUFFER.

Working with patients requires more than medical expertise. “Often, the doctor acts as an emotional buffer,” Dr. Linzer said. “We will buffer the patient from our own stressful environment until we can’t take it anymore.”

5. YOUR JOB CONSTANTLY INTERFERES WITH FAMILY EVENTS.

Spending quality time with loved ones helps physicians perform bet-

14 | THE BULLETIN | MAY / JUNE 2015

ter. “When they can’t do those things, it’s all they think about during the day and the patient suffers.” Dr. Linzer said, citing work-life interference as one of the most common predictors for burnout among physicians in his studies.

6. YOU LACK CONTROL OVER YOUR WORK SCHEDULE AND FREE TIME.

When work demands increase, but control over your schedule doesn’t, stress can kick in and spark burnout. That’s why Dr. Linzer often tells practices, “If you standardize, customize” – a medical mantra to suggest that if physicians must work a long standardized set of hours each week, practices should at least customize their schedules to flexibility fit changes or needs in their daily lives.

7. YOU DON’T TAKE CARE OF YOURSELF.

When was the last time you enjoyed a nice bubble bath or morning run? If you continually neglect yourself, you may neglect your patients, too. “As physicians, we want to be altruistic but one of the keys to altruism is self-care,” Dr. Linzer said.

DID YOU FIT MOST OF THESE SIGNS?

If you think you or your fellow physicians are suffering from excessive stress, check out these tips from residents who have conquered burnout (http://www.ama-assn.org/ama/pub/ama-wire/ama-wire/post/ways-residents-found-conquer-burnout). Find more on maintaining a happy medical family in Physician Family, (http://www.physicianfamilymedia.org/) the AMA Alliance’s magazine.

Also download a copy of Dr. Linzer’s clinical study on burnout (http://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/advances-in-patient-safety/vol1/Linzer.pdf) for tips and recommendations that may fit your practice. Preventing physician burnout is a priority for the AMA’s Professional Satisfaction and Practice Sustainability (http://www.ama-assn.org/ama/pub/about-ama/strategicfocus/enhancing-professional-satisfaction-and-practice-sustainability. page?) initiative, which partners with physicians, leaders, and policymakers to reduce the complexity and costs of practicing medicine so physicians can continue to put patients first.

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1(888) 543-7497 www.bmesc.org MAY / JUNE 2015 | THE BULLETIN | 15

By Ellyn Satter Registered Dietitian and Family Therapist

STANDARD FOOD ADVICE IS NEGATIVE

For the policy makers and consensus-arrivers, child obesity prevention is about eating the right food and avoiding the wrong food, with a bit of “restrict portion size” and “move more” thrown in.

• Limit sugar-sweetened beverages1-5 • Encourage fruits and vegetables1-5 • Encourage low-fat dairy foods and whole grains4 • Limit portion sizes1-3,5

NEGATIVE FOOD ADVICE DOES HARM

Less than 10% of adults can follow this drab and negative advice6 for themselves, let alone for their children, and they feel bad about it. Imposing food rules makes it harder for parents to get a meal on the table, even when you try to soft-pedal by saying “watch what he eats,” or “follow the food pyramid,” or “follow MyPlate,” or “don’t let him eat so much starch— so many sweets—so many fried foods.” You know by the dread and consternation on a parent’s face. Parents want to nurture. This advice makes them food cops. No more relaxed and enjoyable family meals, holidays, and birthday parties. Parents brace themselves to get their child to eat vegetables, to eat less, to stay away from high-fat, high-sugar food. At the next appointment, the parent won’t meet your eyes and the child’s weight gain has accelerated. Or they simply don’t show up.

Some parents tell you: “ just don’t mention weight!” Parents’ intuitive Reprinted from www.ellynsatterinstitute.org

16 | THE BULLETIN | MAY / JUNE 2015

wisdom is backed by evidence: children who are labeled overweight feel flawed in every way—not smart, not physically capable, and not worthy.7 Five to nine year olds characterized as being at risk for overweight ( ≥85th BMI percentile) say they eat only a little bit on purpose so they don’t get fat.8 That’s pretty sad, isn’t it? Children are entitled to be free from worry about eating, moving, and weight.

PUT A POSITIVE SPIN ON THE STANDARD ADVICE

You can do what the policy-makers say, just do it so it helps. In the midst of its own negative food selection advice, the American Academy of Pediatrics (AAP) puts forth this possibility: “Empower parents to promote children’s ability to self-regulate energy intake while providing appropriate structure and boundaries around eating.”4 Essentially, AAP recommends sDOR (Satter Devision of Responsibility in feeding). To translate, consider this advice from the handout, Your Child’s Weight: Helping without Harming (http://ellynsatterinstitute.org/cms-assets/documents/99505-225954. helpingwithoutharming.pdf) and the book of the same name: • Have regular, reliable, and rewarding sit-down family meals and sit-down snacks. This would be AAP’s “appropriate structure and boundaries around eating.” The rewarding part is important.

Consistently providing family meals is a lot of work. Parents who are freed to provide food the family enjoys get intrinsic reinforcement for making meals a priority.

• Include a variety of good-tasting, wholesome foods. Families who eat regular meals get around to including fruits, vegetables, and other wholesome foods. And they eat them because they enjoy them, not because they have to.

• Include “ forbidden foods” in meals and snacks. Making sugarsweetened beverages a sit-down, rather than a carry-around beverage limits consumption. A lot. Giving a time and place to enjoy high-sugar, high-fat snack foods also limits consumption.

More importantly, children come to regard high-calorie, low nutrient foods and beverages as everyday food that they consume the same as other food: sometimes a little, sometimes a lot.

• Trust the child to decide what and how much to eat from the food parents provide. The food cops emphasize limiting portion sizes, which is, of course, a form of restriction. Children whose food intake is restricted become food preoccupied and are prone to overeat when they get the chance. Children whose parents follow sDOR do a good job of managing their own portion sizes.

• Forget about encouraging “slimming” foods. The evidence doesn’t support recommending low-fat dairy foods.9 Whole grains are nutritious, but they aren’t slimming.

FOCUS ON THE PARENTS’ FEEDING, NOT THE CHILD’S EATING

Encourage parents to do a good job with feeding, not to try to fix their child’s eating. Be persistent in your encouragement, and keep your nerve.

It takes parents time to establish family meals and more time to stop interfering with what and how much their child eats. sDOR is working when family meals are pleasant and the child is relaxed and positive about eating. Keep your nerve about weight as well. Until the middle grades, children have a greater than even chance of slimming down.10,11 In the process of making change on behalf of their child, many parents will improve their own eating competence. Parents who are eating competent follow sDOR12 and their children show better nutrition profiles.13 The Joy of Eating (http://

ellynsatterinstitute.org/hte/the-joy-of-eating.php) translates sDOR in feeding children into guidelines for adults’ feeding themselves.

THE 15 MINUTE INTERVENTION

• Assess weight in an sDOR consistent fashion (http:// ellynsatterinstitute.org/cms-assets/documents/207309-56529. primintgrow.pdf). Support consistent growth, even if it is high or low enough to be “diagnosable.” Identify weight acceleration or faltering early and address it by restoring sDOR. • Give the handout, Your Child’s Weight: Helping without Harming (http://ellynsatterinstitute.org/cms-assets/ documents/99505-225954.helpingwithoutharming.pdf) also available in Spanish (http://ellynsatterinstitute.org/cms-assets/ documents/99506-828981.helpingwithoutharmingspanish.pdf).

• Encourage parents to follow a division of responsibility in activity (http://ellynsatterinstitute.org/dor/ divisionofresponsibilityinactivity.php).

• Encourage parents who read books to read Your Child’s Weight (http://www.ellynsatterinstitute.org/store/index. php?route=product/product&product_id=51).

• Incorporate feeding dynamics education into your anticipatory guidance handout routine. Articles on the ESI website (http:// ellynsatterinstitute.org/htf/agesandstagesindex.php) are free.

Feeding in Primary Care (http://www.ellynsatterinstitute.org/ store/index.php?route=product/product&path=63&product_ id=71) handout masters are in English and Spanish and cost about $.01 each.

• Show the Feeding with Love and Good Sense DVD (also in

Continued on page 18 MAY / JUNE 2015 | THE BULLETIN | 17

Doctors and Weight: Helping without Harming, from page 17 English/Spanish) (http://www.ellynsatterinstitute.org/store/ index.php?route=product/product&path=76&product_id=62) in your waiting room.

REFERENCES

1. CDC. Overweight and Obesity: Strategies and Solutions. http:// www.cdc.gov/obesity/childhood/solutions.html. Accessed March 22 2015.

2. Barlow SE, and the Expert C. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007;120 (Supplement 4):S164-192.

3. USDA, FNS. Maximizing the message: Helping moms and kids make healthier food choices. FNS-409. 2012 http://www.fns. usda.gov/core-nutrition/maximizing-message. Accessed May 8, 2015.

4. American Academy of Pediatrics Committee on N. Prevention of pediatric overweight and obesity. Pediatrics. 2003/2007;112:424430.

5. USDA, USHHS. Dietary Guidelines for Americans. 2010 U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines for Americans, 2010 http:// www.cnpp.usda.gov/DietaryGuidelines. Accessed May 8 2015.

6. Laster LE, Lovelady CA, West DG, et al. Diet quality of overweight and obese mothers and their preschool children. Journal of the Academy of Nutrition and Dietetics.

2013;113(11):1476-1483.

7. Davison KK, Birch LL. Weight status, parent reaction, and selfconcept in five-year-old girls. Pediatrics. 2001;107:46-53.

8. Shunk JA, Birch LL. Girls at risk for overweight at age 5 are at risk for dietary restraint, disinhibited overeating, weight concerns, and greater weight gain from 5 to 9 years. J Am Diet Assoc. 2004;104(7):1120-1126.

9. Satter E. Family Meals Focus #98. Should you put your child on skim milk? . 2015; http://www.ellynsatterinstitute.org/fmf/ familymealsfocus.php.

10. Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the US preventive services task force.

Pediatrics. 2005;116:e125-e144.

11. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Preventive Medicine. 1993;22:167-177.

12. Tylka TL, Eneli IU, Kroon Van Diest AM, Lumeng JC. Which adaptive maternal eating behaviors predict child feeding practices? An examination with mothers of 2- to 5-year-old children. Eat Behav. 2013;14:57-63.

13. Lohse B, Satter E, Arnold K. Development of a tool to assess adherence to a model of the division of responsibility in feeding young children: using response mapping to capacitate validation measures. Child Obes. 2014;10(2):153-168.

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Medical Challenges on the California Trail ~ Part 1 ~

By Michael A. Shea, MD Leon P. Fox Medical History Committee The California Trail is a 2,000 mile trek from the northwest border of Missouri to Sutter’s Fort in present day Sacramento. It crossed over plains, mountains, and deserts. Five to six months were required to complete the journey by wagon train. In the trail’s history (1841-1857), 165,000 hardy souls took the challenge, the majority of whom came during the gold rush years of 1849 and later. It is estimated that 5% or approximately 8,250 emigrants died during the attempt. Their story will be the subject of this two-part essay.

There were about 1,500 “doctors,” who came west on the trail, some real, some not. They ranged from no training to bona fide MD’s, educated in the East or in European medical schools.

Even the best trained doctors were handicapped by the current deficit of 22 | THE BULLETIN | MAY / JUNE 2015

scientific knowledge. Bacteria and viruses were unknown and surgery suffered from lack of anesthesia and asepsis. Treatment regimens consisted of purging, bloodletting, and poulticing.

The following is a partial list of medications that would be found in a mid nineteenth century black bag: • Quinine – treatment for malaria, fever, and pain. It was expensive. One lot sold for four times its weight in gold.

• Laudanum – a form of morphine useful in treating pain and diarrhea.

• Calamel – a mercury salt used for purging.

• Smallpox vaccine – a crude preparation, but effective.

• Tartar Emetic – to induce vomiting.

• Doveri Pulvules – contained one grain of calamel.

• Potassium Iodide – Mucolytic agent.

• Bloodletting lancet – used to bleed patients for almost any medical ailment.

Total mortality rates on the Trail for the years 1841 to 1857 were: Infectious Disease

Percent

Total

Cholera

39%

3,200

Fevers

6%

492

Other

4%

328

Indian Related

13%

1,066

Starvation/Freezing

12%

984

Drowning

7%

574

Accidents Murder/Hanging

7%

574

4.5%

369

By far, the leading cause of death was cholera. It is estimated that 2%, or 3,200 of the total migration, died of the disease. Cholera is caused by the bacteria Vibrio Cholerae, and is transmitted by contaminated food and water. Once in the intestines, a toxin is released, leading to profuse watery diarrhea (up to 15 liters a day). In severe infections, death from

hypovolemia can occur in 12-24 hours. Treatment is hydration with an oral sugar salt solution or IV infusion of physiologic fluids. Antibiotics are sometimes used but are more helpful in containing the spread of the disease than in treating the acute phase. On the trail, they had no IV solutions and there does not seem to be any record of oral fluid treatment.

Since vomiting can also accompany the diarrhea, this may have prohibited widespread use of oral fluids.

Cholera met the travelers at the Missouri River where many arrived by riverboat. Some boats reported losing nearly half of the passengers on board. The disease had started in New Orleans and came up the Mississippi to the Missouri.

Once on the Trail, it followed the immigrants to Fort Laramie and South Pass, where it mysteriously abated. The reason for this is not clear.

It may have been that at this halfway point the Cholera may have simply expended itself on those who died and those who survived.

Treatment on the Trail consisted of oral medications, such as Laudanum, Calamel, Dover’s capsules, brandy, and camphor balls. One poultice listed in a diary was made up of cornmeal covered with mustard, and sprinkled with cayenne pepper, and applied to the abdomen. These treatments would have little effect on severe cases, and mortality rates as high as 25%-50% were reported.

The Indians were not immune to Cholera either. Exact numbers are not available, but diary entries list significant numbers of them dying of the disease. They may have drunk from some of the pioneer wells or dug up contaminated graves to obtain the clothing.

The Indians did have an interesting treatment. They would carry the victim down to the river, immerse him, leaving him there until he could no longer bear it. They would then place the individual in the sun. The process was repeated until the patient died or recovered.

Part 2 of this article will be printed in the July/August 2015 Bulletin issue.

MAY / JUNE 2015 | THE BULLETIN | 23

(CMA Alert, June 15, 2015 issue)

President’s Message: A critical year for health care We haven’t quite hit the halfway mark, but 2015 is already shaping up to be an important year for health care.

In just these past few months, legislators have repealed the Medicare sustainable growth rate (SGR), saving physicians from an imminent 21% payment cut, and have considered an abundance of new bills aimed at solving several major health issues across the state.

The topic of health has been filling front-page headlines at every leading newspaper in California recently, reaffirming my belief that this is truly an exciting time to be practicing medicine.

The aforementioned repeal of the SGR was an enormous win not only for the California Medical Association (CMA) and our county medical societies, which fought alongside the American Medical Association in their advocacy efforts, but also for some of the country’s most vulnerable patients, who would have dealt with decreased access to care if not for Congress’ intervention. It took years of persistence and teamwork to eliminate the SGR, and I’m happy to report that that fortitude has finally paid off.

Now, we look to maintain that momentum through the remainder of the year, as we push for new laws that could change our profession and the future of health care.

Senate Bill 277, for example, would eliminate the personal belief exemption (PBE) from school vaccination requirements, ensuring our children’s safety by boosting immunization rates across California. The CMAsponsored bill would play a vital role in protecting public health and stop the spread of preventable diseases. The bill, authored by CMA member Dr. Richard Pan and his colleague Senator Ben Allen, passed through the state Senate in May and is currently working its way through the Assembly.

I am optimistic that SB 277 will be met with the same positive response from legislators in the Assembly as it did in the Senate, but we must rise to the occasion and let our representatives know how important the bill is to the perseverance of public health. The tremendous amount of support the measure has received from both health and education organizations alike will undoubtedly help in that regard. News outlets big and small across the state have endorsed SB 277, as have local governments, elected officials, health care groups, education organizations, and dozens more.

Just last month, many of CMA’s medical students and physicians joined forces at the California State Democratic Party convention in Anaheim to inform delegates there about the importance of removing the PBE option in favor of only medical exemptions. That work paid off, as the CDP 24 | THE BULLETIN | MAY / JUNE 2015

took an official position to support the removal of PBEs. With so many things, collaboration is often the key to finding success. Forging allies makes us stronger, which is why we must continue to pursue cooperative efforts with those who share our vision.

Earlier this year, we did just that by joining the Save Lives California Coalition to fight the dangers of tobacco use by advocating for a variety of bills. One of them, SB 591, would raise the tax on tobacco products by $2 per pack in California. Another, Assembly Bill 1396, would use the funds generated from SB 591 to create better access to health care by funding the state’s Medi-Cal program.

The coalition, composed of the American Heart Association, American Lung Association, American Cancer Society Cancer Action Network, CMA, SEIU California, the California Dental Association, Tobacco Free Kids, and Health Access California, also filed two ballot initiatives last month that would let California voters decide for themselves if the tobacco tax should be raised. While the legislation remains a priority, CMA and the coalition are keeping all options open as we move toward a solution to reduce tobacco use among our youth and fully fund Medi-Cal. If you haven’t had a chance to check out the campaign website or sign up to follow on social media, visit SaveLivesCalifornia.org today.

You may have also seen or heard ads on TV and radio that highlight the need to fully fund Medi-Cal. The We Care for California coalition, of which CMA is a member, has joined efforts with SEIU United Healthcare Workers West and the California Hospital Association in a campaign to spread the word about who is impacted by cuts made to Medi-Cal in recent years. You can see more at the new website Medi-Calmatters.org. The coalition hosted a 5,000-person rally earlier this month to raise awareness about the need to fully fund Medi-Cal through a series of patient and provider stories. As emcee of the rally, I was honored to represent CMA on this important effort.

Thank you all for your hard work and continued support. Working together as a united body will undoubtedly result in huge advances for the medical profession and the patients we see each day.

Luther F. Cobb, MD CMA President

(CMA Alert, June 15, 2015 issue)

Vaccination bill clears Assembly Health Committee after nearly five hours of discussion, testimony Senate Bill 277, which would bar parents from skipping school vaccination requirements due to personal philosophies, passed its first test in the state Assembly last Tuesday. Policymakers in the Assembly Health Committee approved the bill on a 12-6 vote.

SB 277 would allow only medical exemptions for children entering public school by removing the option to file a personal belief exemption (PBE). The bill would not pertain to families who homeschool or utilize independent study.

As in previous hearings, both proponents and opponents of SB 277 filled up the room to listen to the highly debated bill, which was the only item on the committee’s agenda and spurred nearly five hours of discussion and testimony.

“A [Public Policy Institute of California] poll last week reported two-thirds of Californians say children should not be allowed to attend public school unless they are vaccinated,” said SB 277 co-author Senator Richard Pan, MD, to committee members. “This majority will not be silent. When more people are hospitalized or die of preventable contagious diseases, they will hold us accountable for denying the science of vaccination if we refuse to act.”

A back-and-forth discussion between Assemblymembers and witnesses on both sides of the issue took up the bulk of the hearing, as the committee did its best to separate the facts about immunizations from the profusion of myths.

Hannah Henry, co-founder of Vaccinate California, assisted in that regard.

“SB 277 is a common sense measure,” she told Assemblymembers. “A basic protection we need to restore in our society so all schools are equally safe for our kids and our communities.”

Others who voiced their support on Tuesday included representatives

from the California Medical Association, California Children’s Hospital Association, American Academy of Pediatrics, and California State PTA. But many other cities, counties, community groups, and health and education organizations have also endorsed the bill.

The American Medical Association on Monday announced that it also supports stiffer limitations on non-medical vaccination exemptions — a goal of SB 277.

Vaccinations have prevented more than 21 million hospitalizations and 732,000 deaths among children born in the last 20 years. For reducing the burden of infectious diseases, only clean water has performed better, according to the World Health Organization.

However, a reduction in the number of vaccinated children, combined with a rise in the number of outbreaks of vaccine-preventable diseases, has led to a need for the legislation, according to health experts. “The consequences [of increased exposure] are disease among those who choose not to be vaccinated, but also in those who are vaccinated because, remember, vaccines don’t work 100% of the time,” said Dean Blumberg, MD, chief of pediatric infectious diseases at UC Davis Children’s Hospital. “And, in addition, there are those who are too young to be vaccinated, and they may be infected.”

It is estimated that more than 13,500 kindergartners in California are currently unvaccinated due to the personal belief exemption. A rising number of unvaccinated children for non-medical reasons are a potential threat to the rest of the population, particularly to those who are immunocompromised, such as pregnant women, chemotherapy patients, and those with chronic diseases.

SB 277 now moves to the Assembly floor for consideration. For more information, go to www.cmanet.org/sb277.

MAY / JUNE 2015 | THE BULLETIN | 25

(CMA Alert, June 15, 2015 issue)

(CMA Alert, June 15, 2015 issue)

What is commercial risk adjustment?

Senate passes bills e-cigarettes, raise s

Over the past few months, CMA has received several calls from practices who had received requests for medical records from various payors stating the records are needed for “risk adjustment.” The records requests are a result of the commercial risk adjustment program created

by Section 1343 of the Affordable Care Act. The primary goal of the risk adjustment program is to spread the financial risk borne by payors more evenly in order to stabilize premiums and provide issuers the ability to offer a variety of plans to meet the needs of a diverse population.

Similar to Medicare risk adjustment audits, the commercial risk adjustment program is designed to identify the health status and demographic characteristics of enrollees in nongrandfathered plans in the individual and small group markets to determine a risk score average.

The risk score is a relative measure of how costly an individual is anticipated to be. If at the end of the annual risk adjustment assessment, Plan A has a lower-risk average score than Plan B, then Plan A has to issue a payment to Plan B. In a nutshell, the program is intended to prevent payors from cherry picking only healthy enrollees.

Because the information reported by physicians and other providers is at the heart of payment adjustments, health plans must engage providers by requesting copies of medical records that accurately reflect diagnoses and/ or underlying health conditions to comply with risk adjustment program requirements. [77 Fed. Reg. 17220, 17241 (March 23, 2012)] The risk adjustment program is a requirement on the payor; however, through managed care contracts, payors typically require their contracting physicians to comply with the risk adjustment medical record requests. Non-contracted physicians are under no obligation to comply with the request. Most payors appear to be contracting with a third-party vendor to handle the record requests and collection.

A frequently asked question by physicians about the requests is whether the records can be released without written authorization from the

Two bills aimed at making it harder for California’s youth to use tobacco products passed in the state Senate. Senate Bill 151 (Hernandez) would raise the minimum age for buying cigarettes from 18 to 21. SB 140 (Leno) would regulate e-cigarettes similar to combustible cigarettes, including banning their use in the usual “smoke-free” locations, such as schools, restaurants, and hospitals. SB 151 was the first of the two bills heard on the Senate floor. It passed on a 26-8 vote.

“We will not sit on the sidelines while big tobacco markets to our kids and gets another generation of young people hooked on a product that will ultimately kill them,” said Senator Ed Hernandez (D-West Covina), author of SB 151, in a statement after the vote. “Tobacco companies know that people are more likely to become addicted to smoking if they start at a young age.”

It is estimated that tobacco kills about 480,000 people in the United States each year.

It is the leading cause of preventable death, with more fatalities than motor vehicle accidents, drugs, murders, suicides, alcohol, and AIDS combined.

However, a recent study by the Institute of Medicine found that about 200,000 fewer deaths would occur for those born between 2000 and 2019 if the minimum age to purchase tobacco was raised to 21. “We need to wake up and stop

26 | THE BULLETIN | MAY / JUNE 2015

patient under HIPAA. Both HIPAA and California’s Confidentiality of Medical Information Act permit disclosures of protected health information to third-party payors for treatment and payment purposes without patient authorization, including to plans for risk adjustment purposes. However, when dealing with sensitive medical information such as mental health records or psychotherapy notes, the circumstances in which disclosures may be made to third-party payors absent the patient’s signed authorization are limited. Given the sensitivity of this information, provisions allowing for permissive disclosure of these records should be interpreted narrowly and physicians should err on the side of caution with regards to disclosures absent patient authorization. For more information, see CMA On-Call document #4250, “Confidentiality of Sensitive Medical Information,” available at http://www.cmanet.org/resource-library.

At least one payor appears to be offering to provide a scanner technician upon request, paid for by the plan, who will come to the practice to retrieve the needed records; others are requiring the practice to handle the copying/scanning and submission either by fax or mail. Additionally, the commercial risk adjustment audits usually involve only a handful of patients per practice, but if the request is voluminous, practices may wish to contact the payor and request that it send a copy/scanner service out to the practice.

For more information on the commercial risk adjustment program, go to http://www.cms. gov/CCIIO/Resources/Files/Downloads/ppfmrisk-adj-bul.pdf.

SCCMA leadership met with Assemblywom annual Legislative Leadership Conference pertaining to the practice of medicine in C

(CMA Alert, June 2, 2015 issue)

to regulate smoking age making it so easy for tobacco companies to poison generation after generation of Californians,” Sen. Hernandez said.

SB 140, which would also place e-cigarettes under the Stop Tobacco Access to Kids Enforcement Act, a law to reduce illegal sales of cigarettes to minors, passed the Senate on a 24-12 vote.

“E-cigarettes are addicting a new generation of smokers to nicotine, which contains toxic chemicals and is highly addictive,” said the bill’s author, Sen. Mark Leno (D-San Francisco), in a statement. “We must take action now in order to protect our youth and Californians of every age from harmful firsthand and secondhand ecigarette emissions.”

Of great concern to Leno is the number of middle and high school students who have never smoked traditional cigarettes, but are now smoking e-cigarettes — products that contain nicotine, he said at the hearing. Those students comprise the fastest growth segment of new ecigarette users.

“One hundred and twenty three cities and counties in California have already done what this bill proposes to do today,” he said Tuesday.

“It’s time for the entire state to move in this direction.” Both bills now move to the state Assembly.

man Nora Campos, during CMA’s 41st e, to discuss important legislation California.

CMA changes stance on physician aid in dying, takes neutral position on End of Life Option Act

The California Medical Association (CMA) has changed its long-standing position on the issue of physician aid in dying, and has taken a neutral position on Senate Bill 128 (Monning/ Wolk), the End of Life Option Act. The organization’s physician leadership decided to change CMA’s decades-old policy after several committee hearings and an extensive amount of discussion by members. A final vote was taken by the CMA Board of Trustees in April, making CMA the first state medical association in the nation to change its stance on physician aid in dying.

“The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options,” CMA President Luther Cobb, MD, said in a statement. “We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage.”

Following the change, CMA has now taken a neutral position on SB 128. While the influential organization is not endorsing the bill, many expect its new unopposed stance will now give the legislation a better chance of passing in the state legislature. Senator Lois Wolk (D-Davis), a co-author of the bill, called CMA’s decision a “game-changer.”

SB 128 would allow physicians to prescribe

a lethal dose of drugs to terminally ill patients with less than six months to live. The bill ensures that participation in the act would be completely voluntary for patients, physicians, pharmacists, and other health care providers.

Its authors, Senators Bill Monning (D-Monterey) and Wolk, have been meeting with CMA to answer questions about physician protections since before the bill’s introduction in January.

“I am pleased that CMA has made a historic shift from its prior position on this issue, after engaging in a rigorous debate and discussion with its members,” said Senator Monning in a statement, adding, “This change in policy respects the importance of the doctor-patient relationship when a terminally ill patient is faced with making end of life decisions.”

Collaborative conversations that enhance safeguards for both physicians and patients were possible because of CMA’s shift in policy. Since 1987, CMA has opposed the enactment of any law that would require a physician to aid in the death of a patient. In the 1990s, it condemned voluntary active euthanasia by physicians and opposed physician-assisted suicide clinics.

However, a CMA resolution to remain open to the multiple views and perspectives of various participants on the topic of physician aid in dying was also passed during that time.

Dr. Cobb said protecting the physician-patient relationship is essential. “CMA’s focus has historically been on improving end of life options and enhancing palliative care and hospice for patients who are terminally ill,” he said. “Ultimately, however, it’s up to the patient and their physician to choose the course of treatment best suited for the situation – and CMA’s new position on physician aid in dying allows for that.”

SB 128 will be heard next on the Senate floor.

MAY / JUNE 2015 | THE BULLETIN | 27

Monterey County

In Memoriam

Medical History,

Leo V. English, Jr, MD

Martin B. Levitt, MD

Family Medicine 12/31/19 – 2/25/15 SCCMA member since 1955

*Pediatrics 1/1/32 – 2/27/15 SCCMA member since 1963

page 7

Robert Q. Lee, MD

Francis Stephen San Filippo, MD

General Practice 12/31/28 – 1/15/15 SCCMA member since 1962

General Practice 1/1/24 – 3/8/15 SCCMA member since 1954

Online CME

continued from nies, and hospitals will continue to try to erode the autonomy of physicians and disrupt the physician-patient relationship. They will continue to seize even bigger slices of the health care financial pie. They would be content to relegate us to the role of interchangeable providers following pre-determined scripts/practice protocols. The knowledge base seems to be increasing exponentially and just keeping up on the science is a challenge. On top of that, things are becoming increasingly difficult for us: endless new regulations, maintenance of certification, ICD-10, are examples. This is, of course, by design; being busy physicians, we do not have time to fight and they know that. But that is why we need robust organized medicine, to fight for us.

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2015-2016 SCCMA COMMITTEE RESPONSE FORM

Listed below are the current SCCMA committees—all meet at the Medical Association building. Omitted are those where membership is by election (e.g., Council and Executive Committee), bylaw consideration, and/or existing protocol (e.g., Awards, Membership, Physicians’ Well-Being, and Professional Standards/Conduct).

SCCMA committees help recommend policies for the Association, standards for practice in Santa Clara County, and aid in the development of important relationships with governmental and public service organizations. Committee service commences on July 1, 2015. The majority of the committees will not meet during July and August, however.

In accordance with SCCMA bylaws, committee appointments are made each year by the President and state that, “The terms of office of the chairs and members of all committees shall be at the discretion of the President, and, in any event, shall end with the term of office of the President by whom they were appointed…” Therefore, the terms of fiscal 14-15 committee members and chairs, having been appointed

by James Crotty, MD, will officially end with his term of office — June 30, 2015.

Name:

(Please Print)

Specialty:

Phone:

Fax:

Members interested in serving on any of the following Committees are asked to return this form.

❏

Bioethics (Bi-monthly, dinner) To educate its

❏ ❏

members regarding bioethical decision making, discuss bioethical issues and develop guidelines, and advise government and industry leaders regarding the ethical aspects of health care policy.

Leon P. Fox Medical History (Bi-monthly, 3rd Thursday, dinner) To identify, collect, and preserve archival material, memorabilia, and artifacts representing the medical history of Santa Clara County.

❏

Environmental Health (Bi-monthly, dinner) To study and address environmental and occupational health concerns.

❏

High School Outreach Program (Yearly) To speak about your specialty before local high school students at the annual program, which is designed to pique the students’ interest in becoming a physician in our community.

Medical Student Mentor Program (Yearly) To volunteer as a mentor to a Stanford medical student. Students can “shadow” practicing physicians to learn about their specialties and modes of practice.

FAX form to 408/289-1064 or mail to SCCMA by 7/15/15.

06/12

MAY / JUNE 2015 | THE BULLETIN | 29

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Jim Hinsdale, MD has been re-elected to the prestigious and important AMA Council on Medical Services. Through its reports, the Council on Medical Service recommends AMA policies and actions for consideration by the AMA House of Delegates on the socioeconomic factors that influence the practice of medicine. Council reports cover a wide range of topics, including: • • • • • • • • • • • •

Allied health professionals Consumer-driven health care Covering the uninsured and expanding choice Delivery reform e-Health Health care costs Health insurance Hospitals & hospital-based services Medicare & Medicaid Pharmaceutical coverage & spending Physician payment reform Other CMS topics

The Santa Clara County Medical Association and the California Medical Association are very proud of Jim and appreciate his dedication and willingness to serve on this national council, representing all physicians and patients of the United States.

Congratulations Jim and God speed.

MEMBER SPOTLIGHT

James Hinsdale, MD

MAY / JUNE 2015 | THE BULLETIN | 31

Santa Clara University

2015 Global Medical Brigade

By Julia Puchi This year, the SCU Global Medical Brigades chapter traveled to Nicaragua for nine days during Spring Break to facilitate a temporary medical and dental clinic in two communities, and helped two families build sanitary units and concrete floors for their homes in a third community. The team was made up of 35 students and one doctor who is the father of one of the students on the trip. Leading up to the trip, the team was responsible for raising $15,000 to buy all the medications and supplies necessary for the clinic. This included medications that were needed in the community, from antihistamines to anti-parasitics, gauze, and novocaine for the dental clinic, and plenty of multivitamins for both children and adults.

Raising the money seemed intimidating at first, but with the whole team actively involved in the effort our goal was reached sooner than we had expected. We relied on each team member raising money at home over the Christmas break, reaching out to the Santa Clara community, doing fundraisers on campus, and our volunteer alumni committee, to raise the funds. We also received generous donations of non-medication supplies that made a huge impact on reaching our goals. Each team member was also responsible for paying their own way on the trip.

32 | THE BULLETIN | MAY / JUNE 2015

Global Brigades is one of the largest student-led organizations in the world, with chapters at Universities all over the United States, as well as in Europe. They have brigades for everything from medical and dental to microfinance. The organization works on a holistic model, and their goal is to create sustainable communities. During the first part of our trip, we saw patients at a medical and dental clinic. Stations at the clinic included triage, doctor consult, dental, public health, pharmacy, and OBGYN. Patients were able to receive medications for a variety of different ailments, and doctors were able to refer patients to in-country medical services if their medical issue was more serious. At the public health station, patients were educated on how to prevent disease through sanitation and clean drinking water.

For the last three days of our trip, we did a public health project in the community. We built a sanitary station, consisting of a shower, sink, toilet, and concrete floors for two families. The families were responsible for paying for 10% of the project, and this money went into a community fund from which community members would be able to take out loans for future public health, business, or educational projects. Having a share in the cost of the project also makes it more likely that the family will main-

tain upkeep of their new facilities. During the time of our trip, most families in the community that we worked in had already participated in this initiative and were happy that they had a new and clean sanitary station and a concrete floor in their home to avoid insect-borne diseases. It was clear that Global Brigades had made a very positive impact in the community and the work of the students was an essential resource to getting these projects done.

Not only were we able to help the people of Nicaragua in a positive way, but the trip was an invaluable experience for our team members.

All of the students were genuinely invested in bettering the lives of the people in the communities we worked in, and they worked tirelessly the whole time we were in Nicaragua. For some, the experience solidified what they wanted to do in their future, whether it was being a doctor, or working in the field of public health. For others, it influenced them to choose a new path. Shannon Breslin, a Freshman from Chicago said, “Nicaragua changed my viewpoint on life and I never thought nine days could ever do that. Before college, all college was about was getting the right major, to get the right degree, to get loads of cash. After Nicaragua, the money wasn’t as prominent in my college experience or why I was going to college. After

Nicaragua, I realized that the experiences I will have and the people I will meet throughout my life are worth more than money could ever pay for.

Also, I realized that I want to do non-profit work with my life and live a life geared towards helping those less privileged than I am.”

The success of Global Medical Brigades at SCU can also be credited to the values that SCU instills in its students, namely the emphasis that is put on helping others. Many of our team members are involved in other clubs on campus, such as SCAAP, that focus on helping marginalized communities in the San Jose area. There are also various immersion trips and programs that allow students to travel outside of the state and to foreign countries for the purpose of helping others in need. Global Medical Brigades has the honor of being one of those programs that can offer students the opportunity to foster their longing to better the lives of others and to gain a better understanding of what it means to be a global citizen.

We hope that next year’s team will have an equally fulfilling experience as we did in Nicaragua this year, and that they will continue to receive the support of the Santa Clara community.

MAY / JUNE 2015 | THE BULLETIN | 33

PRACTICE MANAGEMENT

Practice Management Tools and Resources One of CMA’s many goals is to empower physicians by providing resources and guidance to improve the success of your practices. Whether it’s identifying and fighting unfair payment practices, improving the efficiency of your practice, or negotiating payor contracts, we have tools and resources to help. (http://wwwcmanet.org/resources/reimbursementassistance/practice-management-tools-and-resources/)

TOOLKITS • • • • • • • • • • • • • • • • • •

2015 PQRS and Value-Based Modifier Getting Started Guide ICD-10 Transition Guide – What physicians need to know Updating Provider Demographic Information with Payors Surviving Covered California: Preparing for changes in 2015 Medicare Incentive and Penalty Programs: What physicians need to know Cal MediConnect Physician FAQ: What you need to know about keeping your patients and billing for the dual eligible population A Physician’s Guide to Implementation of SB 866: The new standardized prescription drug prior authorization form Medi-Cal Survival Guide: Important Changes and What they Mean to Your Practice Medicare Transition Guide: What physicians need to know Medi-Cal Primary Care Physician Rate Increase FAQs CMA’s Got You Covered: A physician’s guide to Covered California, the state’s health benefit exchange TRICARE Transition Guide: What physicians need to know Aetna Termination Resource Guide Taking Charge: A step by step guide to evaluate and prepare for negotiations with managed care payors Best Practices: A Guide for Improving the Efficiency and Quality of Your Practice CMA Balance Billing Advocacy Tool Kit Medicare Enrollment Guide for Individual Physicians Publications CMA Practice Resources (CPR)

KNOW YOUR RIGHTS • • • • •

Know Your Rights: Timely Filing Limitations Know Your Rights: Timely Payment Know Your Rights: Timeframes to Appeal Know Your Rights: Quick Guide for Appeals Know Your Rights: Identify and Report Unfair Payment Practices • Know Your Rights: Filing a formal complaint with the regulator

34 | THE BULLETIN | MAY / JUNE 2015

PAYOR CONTRACTING / CONTRACT ANALYSIS BILLING/CODING • New CMS 1500 Implementation Reference Guide • CMA Medicare Consultation Code Billing Guide • CMA Managed Care Consultation Code Quick Reference Guide, Updated October 2011

SAMPLE LETTERS, CHECKLISTS, AND WORKSHEETS • Financial Impact Worksheet • Payor Solvency Checklist • Sample Tracking Sheet: Health Plan Acknowledgement of Receipt of Claim • Sample Termination Letter – Patient • Sample Termination Letter – Material Modification to Contract • Sample Letter – Request for Complete Fee Schedule and Detailed Payment Rules • Sample Letter – Request for Copy of Signed & Executed Contract, Complete Fee Schedule & Detailed Payment Rules • A/R Phone Call Follow up Log Template

OTHER RESOURCES • • • •

Special Investigations Unit Audit Guide CMA Timely Access Guide Medicare Electronic Prescribing (eRx) Overview Medicare Part B 2012 Important Changes: What they Mean to Your Practice • Patient Handout: FAQ About Accountable Care Organizations (ACOs) • Heritage California Accountable Care Organization (ACO) Physician Frequently Asked Questions • Medicare Audit Guide for Physicians

Wireless Technology and Public Health:

Health and Environmental Hazards in A Wireless World

Are wireless devices making us ill? Join Dr. Joel Moskowitz, Director of the Center for Family and Community Health, along with other experts to learn about the current scientific research regarding electromagnetic frequencies and their impact on biological systems. We will hear why 200 international scientists recently called for safer wireless radiation standards. Panelists will discuss links to autism, cancer, infertility, effects on wildlife, as well as best practices with cell phone safety and wi-fi precautions.

Refreshments served.

Saturday, October 10, 2015 9AM - 1PM Mountain View Center for Performing Arts 500 Castro Street Mountain View, CA 94039 Sponsor: Santa Clara County Medical Alliance Foundation Tickets - $12 each www.mvcpa.com MAY / JUNE 2015 | THE BULLETIN | 35

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PRIMARY CARE PHYSICIAN (FAMILY MEDICINE / INTERNAL MEDICINE)

Asian American for Community Involvement (AACI), a federally qualified health center, is looking for a full-time, bi-lingual (Cantonese, Mandarin, or Vietnamese) Primary Care Physician for our East/West San Jose locations. For consideration, please apply at http://aaci.org/ contact/career-opportunities/.

INTERNAL MEDICINE PHYSICIAN NEEDED

We are looking for an internal medicine physician for our multi-specialty group. Please email your CV to kaajhealthcare@gmail.com.

PRIVATE, INDEPENDENT, MEDICAL PRACTICE IN REDWOOD CITY

A qualified, energetic MD is needed to help a large established and still growing general practice with a broad range of medical services.

This is an opportunity for a family practitioner, internist, or general physician to join a group of five other MD’s in a busy urban environment, in comfortable old world office space. Negotiable contractor agreement. Opportunity for partnership. Email: angelineom.asma@gmail.com and send CV.

MEDICAL BILLER NEEDED

Person must be experienced in: EclinicalWorks, Medicare-Medi-Cal, HMO, SCCIPA, Affinity, PPO. Salary negotiable. Full-time 35 hours. Generous pension plan. One MD office. Call 408/356-5553, Email: gloria_wumd@sbcglobal.net.

PEDIATRIC OPPORTUNITY

Private practice in Mountain View has opening for BC/BE primary care pediatrician. Successful candidate will desire a long-term relationship with patients/families. This is a part-time position (2.5 – 3 days/week, large call group with nurse triage at night, newborn rounds at El Camino Hospital). Please call 650/968-6033, or email: kimberlyhdp@sbcglobal.net.

FOR SALE INTERNAL MEDICINE OFFICE CLOSING SALE

All equipment including 2 Ritter 104 exam tables, Philips Page Writer 300 pi EKG, Easy One Spirometry lamps, supplies, furniture for waiting room and office. Please call 408/705-7773.

FAMILY PRACTICE FOR SALE

Family Practice for Sale. East San Francisco Bay, CA. Multi-location, multi-discipline practice for the Asian community’s established residents and newcomers. Revenue over $1 million. The languages spoken by physicians and staff include Cantonese, Mandarin, Punjabi, and Spanish; buyer doctor must be fluent in at least one Chinese dialect. The office also performs sleep studies. EMR in place. High profit margin, and seller will stay to train buyer in proprietary systems. Independent appraisal available. Offered at only $682,000. Real estate also available. Contact Practice Consultants at info@PracticeConsultants.com or 800/5766935. www.PracticeConsultants.com.

A Successful Medical Practice It’s what California’s finest physicians strive for... and what CAP can help you achieve.

Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT).

As a physician-directed organization, we understand the realities of running a medical practice these days, and are committed to supporting you with a range of programs and services that no other professional liability company offers. These include a 24-hour early intervention program, HR support, EHR consultation, a HIPAA hotline, and a robust group purchasing program, to name a few.

Are You ICD-10 Ready? Get Your “ICD-10 Action Guide” FREE! On October 15, 2015, all medical practices must comply with new, expanded ICD-10 codes. CAP’s ICD-10 Action Guide for Medical Practices has the answers you need to successfully make the transition.

Request your free electronic or hard copy today!

800-356-5672 CAPphysicians.com/icd10now MAY / JUNE 2015 | THE BULLETIN | 39

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