NOVEMBER/DECEMBER 2014 | VOLUME 20 | NUMBER 6
NEW HEALTH LAWS FOR 2015 Also Inside: Achieving the Impossible (GPCI) Highlights From AMA's 2014 Interim Meeting
Member Benefit News: Open enrollment for the Santa Clara County Medical Association/ Monterey County Medical Society-sponsored dental plan has started!
You and your family are eligible to enroll in the SCCMA/MCMSsponsored dental plan only during open enrollment periods. Apply by December 31, 2014! To be eligible for coverage, applications must be received during the special open enrollment period ending on December 31, 2014.
For more information... Call a Client Advisor at 800-842-3761 for more information. Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.
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777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance.service@mercer.com 65621 (11/14) www.CountyCMAMemberInsurance.com • Copyright 2014 Mercer LLC. All rights reserved.
2 | THE BULLETIN | NOVEMBER / DECEMBER 2014
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
Feature Articles
Billing/Collections
10 New Health Laws for 2015
CME Tracking
16 POLST in 2014: What Health Care Professionals Need
Discounted Insurance
to Know
Financial Services
18 Achieving the Impossible
Health Information Technology
30 Highlights From AMA’s 2014 Interim Meeting
Resources House of Delegates Representation
34 Vote No on 46 Victory 40 California’s Unwitting Health Care Guinea Pigs
Human Resources Services Legal Services/On-Call Library
Departments
Legislative Advocacy/MICRA Membership Directory iAPP for the iPhone Physicians’ Confidential Line Practice Management
5 From the Editor’s Desk 6 Message From the SCCMA President 8 Message From the MCMS President
Resources and Education
26 Member Spotlight: Robert G. Aptekar, MD
Professional Development
28 Thank You to SCCMA SAC-PAC Contributors
Publications Referral Services With
32 SCCMA Award Nominations
Membership Directory/Website
36 Medical Times From the Past
Reimbursement Advocacy/
39 TPO Seminar: 11th Annual Employment Law &
Coding Services Verizon Discount
Leadership Conference 44 Classified Ads NOVEMBER / DECEMBER 2014 | 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: Arthur Basham, MD El Camino Hospital: Laura Cook, MD Good Samaritan Hospital: David Feldman, MD Kaiser Foundation Hospital - San Jose: Hemali Sudhalkar, MD Kaiser Permanente Hospital: Anh Nguyen, 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
AMA TRUSTEE - SCCMA James G. Hinsdale, MD
CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Martin L. Fishman, MD (District VII) 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 Jeffrey Keating, MD President-Elect James Hlavacek, MD Past President Kelly O'Keefe, 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 2014 by the Santa Clara County Medical Association.
4 | THE BULLETIN | NOVEMBER / DECEMBER 2014
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
AMA TRUSTEE - MCMS David Holley, MD
FROM THE EDITOR’S DESK
JOSEPH S. ANDRESEN, MD Editor, The Bulletin
A Time for Change... By Joseph Andresen, MD Physician Editor, The Bulletin November 4th, Election Day has come and gone! Certainly there was the posturing, speculation, and anticipation that accompany a national midterm election. And, in case you missed it, this was a record setting midterm with the largest amount of money ever donated. Despite the $3 billion dollars spent by candidates, only an estimated 36.6% of eligible voters showed up at the polls. On one hand, the economy appears to be heading in the right direction, unemployment has just fallen below 6% and the stock market is at an all time high. Yet the job approval rating for the President is well below 50%, Congress at 8%, and only 10% of voters believe that congressmen listen to their constituents. Ebola, ISIS, Ukraine, global warming, the growing income disparity and a shrinking middle class, new job creation, and rising college costs are just a few challenges that lie ahead for our nation. May we all promote a government that can meet these challenges. Well, how did we fare here in California? California’s Proposition 46, known as the Medical Malpractice Lawsuit Cap and Drug Testing of Doctors Initiative went down to defeat. The majority of Californians saw this as an attempt to promote trial lawyers interests in procuring large jury awards rather than getting an equitable settlement for patients harmed by medical negligence. The California Medical Association, with your crucial involvement, deserves special recognition for this important accomplishment. This is our November/December SCCMA Bulletin and fall is certainly in the air as I write these words. An engaging palate of seasonal oranges, yellow, and browns adorns the landscape with noticeably shorter days and cool, crisp mornings. With this in mind, highlighted below are several note-worthy articles included in this issue. You’ve probably heard the expression that passing legislation is kind of like making sausage. You really don’t want to see what’s in it until the final result is produced. Geographic Practice Cost Index (GPCI) has quite a story to tell when it comes to rectifying reasonable reimbursement to physicians caring for Medicare patients. For those who dare to look behind the curtain, read the 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.
story of Dr. Larry De Ghetaldi and many others, and their greater than a decade journey to achieve a solution to the perennial Medicare SGR patch dilemma. Dr. Robert Aptekar, a practicing orthopedic surgeon travels to Phnom Penh, Cambodia each year to provide care to patients at Children’s Surgical Centre. I’m warning you that reading about his adventures may inspire you to do something equally rewarding outside your normal life’s routine. Dr. Michael A. Shea shares a historical perspective on the origin of the Stanford Medical School. A must read for any and all of us who have spent some time on the “Farm.” May this time of change in seasons be one of new challenges, interests, and rewards in your personal and professional lives.
Who has the power to change the way you practice medicine? Legislators make critical decisions about the future of medicine. Help elect those legislators and candidates who understand the challenges of practicing medicine in California. Join with your colleagues to support the physicians' legislative and political policy agenda. Join CALPAC - the physicians' voice in California
1-800-CALPAC-9
CALPAC NOVEMBER / DECEMBER 2014 | THE BULLETIN | 5
MESSAGE FROM THE SCCMA PRESIDENT
JAMES R. CROTTY, MD, MBA President, Santa Clara County Medical Association
Ebola By James R. Crotty, MD, MBA President, Santa Clara County Medical Association I cannot think of another single word that carries so much weight, fear, and concern. I write about Ebola with the mission of the SCCMA in mind: to help the profession, to help physicians engaged in the practice of medicine, and to help the public health, particularly in Santa Clara County. The public health threat is real and tangible. Most of us have learned the basic facts: Ebola Virus Disease (EVD) is caused by one of five species of Ebolavirus, and Zaire Ebolavirus is the species responsible for the current outbreak. It was first discovered near the Ebola River in Zaire (now the Democratic Republic of Congo) in 1976. There is an animal reservoir in bats, primates, porcupines, and antelopes. The mean incubation is 11 days (2 to 21 days). There have been 8,399 confirmed cases in the West African countries of Guinea, Liberia, and Sierra Leone with 4,033 deaths. This outbreak started in December 2013 and has been different than outbreaks in the past because it is occurring in highly populated urban areas. On August 8, 2014 the World Health Organization (WHO) declared this outbreak to be a Public Health Emergency of International Concern. On September 15, Thomas Duncan, age 42, who lived in Monrovia, Liberia, helped his landlord’s daughter, who was stricken by Ebola, get to the hospital, but they were turned away for lack of space. Mr. Duncan then helped carry the woman back to the family home, where she died hours later. Mr. Duncan had made plans to visit family in Dallas. He showed no signs of fever or other symptoms of Ebola when he was screened on September 19 before boarding a flight from Monrovia to Brussels. He flew from Brussels to Washington Dulles, and then on to Dallas-Forth Worth. Mr. Duncan started showing symptoms on September 24 and sought medical care at Texas Health Presbyterian Hospital on September 25. His medical record shows that he had a fever to 103 that went down to 101.5 after Tylenol, and he was sent home. His condition worsened, and he was taken back to the hospital by ambulance on September 28. Officials confirmed on September 30 that his blood tested positive for Ebola. There have been concerns raised about the United States being unprepared. There have been concerns raised about physician leadership. The possibility that someone infected with this virus could travel anywhere in the world and thereby spread the virus into other countries seems not to have been translated into some action plan. Two nurses who cared for him have since been identified as being positive for EVD. I think most people realize that what happened in Texas could have happened anywhere, in any city, in the United States.
6 | THE BULLETIN | NOVEMBER / DECEMBER 2014
What are the take home messages from this event? 1. Hospitals and other health care settings need to be prepared. The Centers for Disease Control and Prevention (CDC) has now come out with instructions and recommendations about any patient who presents seeking care with fever, headache, and other symptoms with a recent travel from West Africa countries of Guinea, Sierra Leone, Liberia, Nigeria, or nearby countries. 2. The virus seems to be spread not by droplets as Influenza, but rather by direct contact with body fluids. Therefore, strict personal protection is required including face mask, nonpervious gowns, gloves, masks, and foot protection. The CDC has revised its initial recommendations. It seems that initially there was skin exposed, now the recommendation is that no skin be exposed, and that there should be oversight and a “buddy system.” 3. There is no specific therapy for treatment, and the care is supportive. 4. Efforts are focused on decreasing the spread of the disease. 5. There have been increased efforts to produce a vaccine and other anti-viral medications. 6. Medical science does not have an answer to every illness. 7. What happens in other countries does affect the health of Americans. Politically, the spread of this disease to the United States created a lost opportunity to demonstrate leadership for the profession. A Congressional hearing was called by the Chair of the House Committee on Energy and Commerce, Representative Tim Murphy R-Pa, examining the U.S. public health response to the Ebola outbreak on October 16. Dr. Tom Frieden, Director of the Centers for Disease Control and Prevention, Dr. Anthony Fauci, Director of The National Institute of Allergy and Infectious Diseases, and Dr. Robin Robinson, Director of the Biomedical Advanced Research and Development Authority at the U.S. Department of Health and Human Services gave sworn testimony. There was criticism that not enough had been done to prevent the spread of this disease. The aspect of people traveling who could be infected was constantly questioned. Screening for fever was discussed, with an estimate that 10%-15% of people infected would not have fever. Screening was implemented in five U.S. airports, and there is discussion that this should be expanded. The problems with screening are that many people, like Thomas E. Dunkin, would 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.
not likely manifest disease signs or symptoms. Screening will also find many people with low grade fever who do not have the disease. Screening people who are leaving the West African countries is problematic for the same reasons. On October 17, President Obama appointed Ron Klain, a lawyer and former Chief-of-Staff for Vice President Joe Biden and Al Gore, to the newly created post of “Ebola Response Coordinator.” He will report to both White House Homeland Security Adviser Lisa Monaco and National Securty Adviser Susan Rice. Respected physician leaders have not, as yet, been given any prominent leadership roles in this effort. In fact, there has been political posturing calling for the resignation of Dr. Thomas Frieden, head of CDC.
West Africa directly. Living for 21 days in quarantine is not something people would likely do voluntarily, and so depending on self-reporting for travel is problematic. Ebola is here to stay. The fact that a person can become infected with the Ebola virus globally, and the fact that this virus has a 50% or more fatality rate, that there is a high contagious rate, and that there are no therapies other than support, means that we must be prepared. I think we can thank Thomas Duncan for helping us to call the alarm. Being prepared does not mean causing undue worry or panic. Being prepared does take resources and commitment. The same can be said for Influenza and earthquake disasters.
More locally, the California Department of Health and Human Services has a Department of Public Health, whose Director, Dr. Ron Chapman, participated in a tele-conference on October 15. The department’s website has up-to-date information about Ebola. There is a link to local health officers, where Dr. Sara Cody is listed.
Kaiser Permanente has designated two hospitals, Oakland, and South Sacramento, as centers of excellence for treatment of patients who are suspected or who have been tested positive for Ebola Virus Disease (EVD). It may be wise for our county to discuss this strategy. It makes sense to designate centers where specialized training, equipment, and other resources can be focused.
There has been much in the press about quarantine. There are clear reasons for quarantine and Due process steps that are required. Since world-wide travel is relatively easy, someone would not have to come from
There is some good news: the nurses have not succumbed to the disease, and no other contacts have tested positive. Plan for the worse, hope for the best!
NOVEMBER / DECEMBER 2014 | THE BULLETIN | 7
MESSAGE FROM THE MCMS PRESIDENT
JEFFREY KEATING, MD President, Monterey County Medical Society
Proposition 46 By Jeffrey Keating, MD President, Monterey County Medical Society By the time this article is published, the election will have passed and we will know the outcome of Proposition 46. I have been speaking with friends and neighbors, basically anyone who will listen, about the issues at hand. Based on the reactions I have seen, Proposition 46’s increasing costs causes the most consternation and concern. Speaking of costs, my small group practice received a quote for health insurance for next year and there was only a “modest” 17% increase. This increase far outstrips the official inflation rate. This also includes a significant increase in the maximum out-of-pocket amount and other changes. In summary, we are paying more for less. I think this has not gone unnoticed by the public, how could it? So, once people learn that a family of four might expect an increase in medical costs of up to $1,000 per year, it definitely gets their attention. Being compassionate and caring people, Californians would likely choose to bear such an increase were it going to help the less fortunate in the community rather than the trial lawyers.
all you are left with is your local medical team, your doctor. A ballot initiative that would seriously undermine access to care and potentially drive physicians from the state is the last thing any reasonable voter would want, not now with so much uncertainty. We live in a world where everything increasingly appears to be run by MBAs and law-
yers, where people with real skills have been turned into commodities. Perhaps one positive outcome of the 46 campaign is that it provided an opportunity to rebuild community ties and remind the public about what we do and what we stand for, and what we all have to lose, because what is bad for the medical community is bad for the public.
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.
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Speaking of the authors and main potential beneficiaries of Proposition 46, probably the worst news for the trial lawyers is ebola. But then who could have predicted that a deadly viral illness seen in equatorial Africa would be seen here? And who could have predicted the perceived missteps by the Centers for Disease Control and Prevention (CDC) the feeling that there are mixed messages and changing policies? I have the utmost respect for the CDC and know that scientifically their reasoning is sound, but public relations are important in the face of such a terrible infectious disease. So when you can’t trust the politicians and bureaucrats then 8 | THE BULLETIN | NOVEMBER / DECEMBER 2014
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The California Legislature had an active year, passing many new laws affecting health care. Below are highlights of the new laws likely to impact physicians next year and beyond. For more details, see “Significant New California Laws of Interest to Physicians for 2015,” in the California Medical Association’s online resource library at www.cmanet.org/resource-library. 10 | THE BULLETIN | NOVEMBER / DECEMBER 2014
ALLIED HEALTH PROFESSIONALS AB 1841 (MULLIN) - MEDICAL ASSISTANTS Clarifies that medical assistants (MAs) may hand out properly labeled and prepackaged prescription drugs to patients as part of their existing authorization to provide “technical supportive services.” Permits MAs to hand out prescription drugs in non-state operated facilities licensed by the Board of Pharmacy. Requires that a licensed physician and surgeon, a licensed podiatrist, a physician assistant, a nurse practitioner, or a certified nurse-midwife provide the appropriate patient consultation regarding use of the drug.
CONFIDENTIAL INFORMATION AB 1755 (GOMEZ) - MEDICAL INFORMATION Revises provisions of law requiring licensed health facilities to prevent disclosure of patients’ medical information by extending the deadline for health facilities to report unauthorized disclosures from five to 15 business days after unlawful or unauthorized access, use, or disclosure has been detected. This bill also authorizes the report made to the patient or the patient’s representative to be made by alternative means, including email, as specified by the patient. This bill also extends the deadline when reporting is delayed for law enforcement purposes, as specified, from five to 15 business days after the end of the delay. This bill gives the Department of Public Health full discretion to consider all factors when determining whether to conduct investigations under these provisions.
DRUG PRESCRIBING AND DISPENSING AB 467 (STONE) - PRESCRIPTION DRUGS: COLLECTION AND DISTRIBUTION PROGRAM Establishes a license and regulatory framework for a “surplus medication collection and distribution intermediary” to facilitate the donation of surplus medications in California. Requires the Board of Pharmacy to license a surplus medication collection and distribution intermediary, established for the purpose of facilitating the donation or transfer of medications between entities under a specified unused medication repository and distribution program. Authorizes the intermediary to charge specified fees. Relates to license renewal. Requires the keeping and maintaining of complete records. Provides that fees collected would be deposited in the Pharmacy Board Contingent Fund.
AB 1535 (BLOOM) - PHARMACISTS: NALOXONE HYDROCHLORIDE Authorizes a pharmacist to furnish naloxone hydrochloride in accordance with standardized procedures or protocols developed and approved by both the Board of Pharmacy and the Medical Board. Requires 12 | THE BULLETIN | NOVEMBER / DECEMBER 2014
the development of protocols on the education of the person to whom the drug is furnished and notification of the patient’s primary care provider. Requires the pharmacists to complete related training. Prohibits furnishing the medication to the patient without consultation. Authorizes related regulations.
AB 1735 (HALL) - NITROUS OXIDE: DISPENSING AND DISTRIBUTING Makes it a misdemeanor for any person to dispense or distribute nitrous oxide to a person if it is known or should have been known that the nitrous oxide will be ingested or inhaled by the person for the purposes of causing intoxication, and that person proximately causes great bodily injury or death to himself, herself, or any other person. Requires each transaction to be recorded in a written or electronic document. Requires a signature and proper identification. Makes it a crime to misuse customer information.
AB 1743 (TING) - HYPODERMIC NEEDLES AND SYRINGES Deletes the limit on the number of syringes a pharmacist has the discretion to sell to an adult without a prescription and extends, until January 1, 2021, the statewide authorization for pharmacists to sell syringes without a prescription, as specified. Exempts the possession of a specified amount of hypodermic needles and syringes that are acquired from an authorized source.
HEALTH BENEFIT EXCHANGE AB 617 (NAZARIAN) - HEALTH BENEFIT EXCHANGE: APPEALS Establishes an appeals process for eligibility determinations for insurance affordability programs (including Medi-Cal and tax credits available through the California Health Benefit Exchange (Covered California) and requires Covered California to contract with the Department of Social Services to serve as the designated entity to hear appeals.
HEALTH CARE COVERAGE SB 959 (HERNANDEZ, E.) HEALTH CARE COVERAGE Prohibits a change in premium rate or
coverage for an individual plan contract or policy unless the plan or insurer delivers a written notice of the change at least 15 days prior to the start of the annual enrollment period applicable to the contract or 60 days prior to the effective date of renewal, whichever occurs earlier in the calendar year. Makes several corrections and clarifications to provisions of law governing individual and small group health insurance, including clarifying that health plans and insurers have a single risk pool for enrollees and insureds.
SB 964 (HERNANDEZ, E.) - HEALTH CARE COVERAGE Increases oversight of health care service plans with respect to compliance with timely access and provider network adequacy standards. Authorizes a health plan to include in its contracts with providers, provisions requiring compliance with timely access and network adequacy data reporting requirements.
Requires DMHC to annually review health plan compliance with timely access standards and to post its final findings from the review, and any waivers or alternative standards approved by DMHC, on its Web site. Authorizes DMHC to develop, and requires health plans to use, standardized methodologies for timely access reporting, and exempts the development and adoption of the standardized reporting methodologies from the AdmÂinistrative Procedures Act, the body of law governing state regulations, until January 1, 2020.
SB 1052 (TORRES) - HEALTH CARE COVERAGE Requires a health care service plan or insurer that provides prescription drug benefits or maintains drug formularies to post those formularies on its website and to update that posting with changes at specified times. Requires the development of a standard formulary template. Requires plans and insurers to use that template to display formularies. Requires the Covered California website provide a link to the formularies for each health plan through the Exchange.
SB 1053 (MITCHELL) - HEALTH CARE COVERAGE: CONTRACEPTIVES Requires, effective January 1, 2016, most health plans and insurers to cover a variety of Food and Drug Administration-approved contraceptive drugs, devices, and products for women, as well as related counseling and follow-up services and voluntary sterilization procedures. Prohibits costsharing, restrictions, or delays in the provision of covered services, but allows cost-sharing and utilization management procedures if a therapeutic equivalent drug or device is offered by the plan with no cost-sharing.
HEALTH CARE FACILITIES AND FINANCING AB 1570 (CHESBRO) - RESIDENTIAL CARE FACILITIES FOR THE ELDERLY Increases training requirements for licensees and staff of Residential Care Facilities for the Elderly (RCFE). Deletes the existing requirement of 40 hours of classroom instruction for RCFE licensee certification training programs and replaces it with 80 hours of required coursework, which shall include at least 60 hours of coursework that shall be attended in person. Adds personal rights, management of antipsychotic medication, managing Alzheimer’s disease and related dementias, and managing the physical environment, including maintenance and housekeeping to the list of items covered in the RCFE licensee certification training program.
AB 2044 (RODRIGUEZ) - RESIDENTIAL CARE FACILITIES FOR THE ELDERLY Relates to residential care facilities for the elderly. Requires that at least one administrator, facility manager, or designated substitute who has adequate qualifications be on the premises of a facility 24 hours per day. Requires a facility to employ, and an administrator to schedule, a sufficient NOVEMBER / DECEMBER 2014 | THE BULLETIN | 13
New Health Laws for 2015, from page 13 number of staff members. Requires certain training to include building and fire safety and the appropriate response to emergencies.
SB 1004 (HERNANDEZ, E.) - HEALTH CARE: PALLIATIVE CARE Requires the Department of Health Care Services (DHCS) to assist Medi-Cal managed care plans in delivering palliative care services, and requires DHCS to consult with stakeholders and directs DHCS to ensure the delivery of palliative care services in a manner that is cost-neutral to the General Fund, to the extent practicable. Authorizes implementation through all plan letters and similar instructions.
SB 1299 (PADILLA) WORKPLACE VIOLENCE PREVENTION PLANS: HOSPITALS Requires the Occupational Safety and Health Administration Standards Board, no later than July 1, 2016, to adopt standards that require specified hospitals to adopt a workplace violence prevention plan as part of their injury and illness prevention plan to protect health care workers and other facility personnel from aggressive and violent behavior. Requires the Division of Occupational Safety and Health to post a report on violent incidents at hospitals on its website. Exempts certain hospitals.
the business rules available to the System consortia to determine MediCal eligibility. Requires notices for the Medi-Cal and premium tax credit programs.
SB 1457 (EVANS) - MEDICAL CARE: ELECTRONIC TREATMENT AUTHORIZATION Requires requests for authorization for treatment or services in the Medi-Cal program, California Children’s Services (CCS) Program, and the Genetically Handicapped Persons Program (GHPP), excluding those submitted by dental providers enrolled in the Medi-Cal Dental Program, to be submitted in an electronic format determined by the Department of Health Care Services (DHCS) via DHCS’ website or other electronic means designated by DHCS. Requires DHCS to implement an alternate format for submission when DHCS’ website is unavailable due to a system disruption. Implements this requirement by July 1, 2015, or a subsequent date determined by DHCS. Authorizes all‑county letters, plan letters, or provider bulletins.
These are just a sampling of the new laws impacting health care in 2015 and beyond. For a complete list, see “Significant New California Laws of Interest to Physicians for 2015,” in the California Medical Association’s online resource library at www. cmanet.org/resource-library.
MEDI-CAL SB 396 (DE LEÓN) - PUBLIC SERVICES Repeals the unenforceable provisions of Proposition 187 relating to public social services, public health care services, public education and other activities of state and local agencies.
SB 1341 (MITCHELL) - MEDI-CAL: STATEWIDE AUTOMATED WELFARE SYSTEM Requires the Statewide Automated Welfare System to be the system of record for Medi-Cal and to contain all Medi-Cal eligibility rules and case management functionality. Authorizes the Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) to house the business rules necessary for an eligibility determination. Requires CalHEERS to make 14 | THE BULLETIN | NOVEMBER / DECEMBER 2014
MEDICAL EDUCATION AB 496 (GORDON) MEDICAL EVALUATION: SEXUAL ORIENTATION: GENDER IDENTITY
Amends existing law that requires continuing medical education accrediting associations to develop standards for compliance with the cultural competency requirement. Authorizes such associations to update these compliance standards in conjunction with an advisory group with expertise in such issues. Expands a recommendation regarding such care to include appropriate treatment and care of the lesbian, gay, bisexual, transgender, and intersex communities.
AB 2214 (FOX) - EMERGENCY ROOM PHYSICIANS AND SURGEONS Enacts the Dolores H. Fox Act to require the Medical Board of California to consider including a course in geriatric care for emergency room physicians and surgeons as part of its continuing education requirements.
MEDICAL PRACTICE AND ETHICS AB 1577 (ATKINS) - CERTIFICATES OF DEATH: GENDER IDENTITY Requires a person completing a certificate of death to record the decedent’s sex to reflect the decedent’s gender identity. Requires identity to be reported by the informant, unless the person completing the certificate is presented with a specified document, in which case the person would be required to record the decedent’s sex as that which corresponds with the gender identity as indicated in document. Provides the procedure in the absence of such document.
AB 2365 (PEREZ, J.) - CONTRACTS: UNLAWFUL CONTRACTS Seeks to make clear in California law that non-disparagement clauses in specified consumer contracts are void and unenforceable. Provides that a contract or proposed contract for the sale or lease of consumer goods or services may not include a provision waving the consumer’s right to make any statement regarding the seller or lessor or its employees or agents concerning the goods or services. Makes it unlawful to threaten or to seek to enforce a provision made unlawful under this bill, or to otherwise penalize a consumer for making any statement protected under the bill. Provides that a provision in violation of this bill is deemed unconscionable and against public policy. Relates to online reviews or comments.
PROFESSIONAL LICENSING AND DISCIPLINE SB 1159 (LARA) - LICENSE APPLICANTS: INDIVIDUAL TAX IDENTIFICATION Prohibits licensing boards under the Department of Consumer Affairs from denying licensure to an applicant based on his or her citizenship or immigration status, and requires a licensing board and the State Bar to require, by January 1, 2016, that an applicant for licensure provide his or her individual taxpayer identification number or a social security number for an initial or renewal license.
PUBLIC HEALTH AB 1559 (PAN) - NEWBORN SCREENING PROGRAM Requires the Department of Public Health to expand statewide screening of newborns to include screening for adrenoleukodystrophy as soon as the disease is adopted by the federal Recommended Uniform Screening Panel.
AB 1819 (HALL) - FAMILY DAY CARE HOME: SMOKING PROHIBITION Prohibits the smoking of tobacco in a private residence that is licensed as a family day care home without regard to whether the act occurs during the hours of operation of the home. Makes a conforming change.
AB 1898 (BROWN) - PUBLIC HEALTH RECORDS: REPORTING: HIV/AIDS Adds hepatitis B, hepatitis C, and meningococcal infection to the list of diseases that local health officer reports to the Department of Public Health (for the purpose of the investigation, control, or surveillance of human immunodeficiency virus/acquired immune deficiency syndrome and co-infection).
AB 2069 (MAIENSCHEIN) - IMMUNIZATIONS: INFLUENZA Requires the Department of Public Health to post specified educational information regarding influenza disease and the availability of influenza vaccinations on the department’s website. Authorizes the department to use additional available resources to educate the public regarding influenza, including, among other things, public service announcements.
AB 2217 (MELENDEZ) – PUPIL AND PERSONNEL HEALTH: AEDS Authorizes a public school to solicit and receive non-state funds to acquire and maintain an automated external defibrillator (AED). Provides that the employees of the school district are not liable for civil damages resulting from certain uses, attempted uses or non-uses of an AED. Exempts a public school or district, that is in compliance with AED requirements, from civil damage liability.
REPRODUCTIVE ISSUES SB 1135 (JACKSON) - INMATES: STERILIZATION Prohibits sterilization for the purpose of birth control of an individual under the control of the Department of Corrections and Rehabilitation or a county correctional facility. Prohibits any means of sterilization of an inmate, except when required for the immediate preservation of life in an emergency medical situation and when medically necessary to treat a diagnosed condition and certain requirements are satisfied. Requires reports of procedures. Relates to notification regarding sterilization.
NOVEMBER / DECEMBER 2014 | THE BULLETIN | 15
PRACTICE MANAGEMENT
POLST in 2014: What Health Care Professionals Need to Know By Judy Thomas, JD and Mark J Apfel, MD The new California POLST went into effect on October 1, 2014, and healthcare professionals must take note of key changes to the form. POLST (Physician Orders for Life-Sustaining Treatment) is a physician order signed by both a doctor and patient that specifies the types of medical treatment a patient wishes to receive toward the end of life. POLST is a tool that encourages conversation between providers and patients about their end-of-life treatment options, and helps patients make more informed decisions and communicate their wishes clearly. As a result, POLST can prevent unwanted or medically ineffective treatment, reduce patient and family suffering, and help ensure that patient wishes are followed. Most changes to POLST in 2014 are in
Sections B and C, where the order of treatment choices are reversed for consistency now starting with most aggressive treatment to least aggressive treatment. The POLST Documentation Committee and Task Force also developed goal statements for these sections in order to clarify and help patients better understand treatment options. All information relevant to the new POLST can be found at http://caPOLST.org/2014polst. There you will find downloadable versions of the new form in English, Armenian, Chinese, Farsi, Hmong, Japanese, Korean, Pashto, Russian, Spanish, Tagalog, and Vietnamese. POLST in braille can be ordered. A list of upcoming POLST education opportunities can be found at http://coalitionccc. org/training-events/polst-education. Previous versions of POLST will still be honored after the 2014 form goes into effect,
16 | THE BULLETIN | NOVEMBER / DECEMBER 2014
however, it is ideal to complete a 2014 version of POLST—and void older versions of the form— when a patient’s POLST is updated. Healthcare professionals with questions about POLST are encouraged to connect with their local POLST Coalition, see coalitionccc. org, or contact the Coalition for Compassionate Care of California at info@capolst.org. Judy Thomas, JD, is executive director of the Coalition for Compassionate Care of California (CCCC), an attorney who has worked in healthcare for more than 20 years, and is Chair of the National POLST Paradigm Task Force. Mark J Apfel, MD, is medical director of Anderson Valley Health Center in Boonville, CA, and serves on the California POLST Physician Leadership Council.
CAMPBELL LOCATION 3425 S. Bascom Avenue Suite I Campbell, CA 95008
ATHERTON LOCATION 3351 El Camino Real Suite 200 Atherton, CA 94027
appointments & referrals: 408-377-3331 online spine encyclopedia at: SanJoseNeurospine.com
Physician Profile Adebukola Onibokun, MD Board-certified Neurological Surgeon
Announcing a new Silicon Valley spine center option for those wanting freedom from back and neck pain We’re pleased to announce a new option for back and neck pain patients: San Jose Neurospine, which began seeing patients in early September through its offices in Campbell and Atherton. The spine center includes the expertise of Adebukola Onibokun, MD, a board-certified neurological surgeon who specializes in minimally invasive spine surgery. Over his career, he has done more than 2,000 successful surgeries. Dr. Adebukola Onibokun emphasizes a conservative approach to the care of his patients and encourages non-surgical treatment first. Some of these non-surgical treatment options for back and neck pain can include pain relieving spinal injections that reduce inflammation around a nerve root and spine-specialized therapy which increases the flexibility of the back, strengthens muscles and ligaments and reduces likelihood of future strain. In this regard, he works very closely and collaboratively with outside pain management specialists and therapists to coordinate non-surgical treatment options. If non-surgical options fail, or when symptoms progress to weakness/numbness in an arm or leg, the center uses minimally invasive spine surgery techniques that enable most patients to be home later the same day.
Minimally invasive spine surgeries performed MIS Lumbar Discectomy & Posterior Cervical Discectomy This procedure is done by making a small 1-inch incision over the herniated disc and inserting a tubular retractor. Then the surgeon removes a small amount of the lamina bone that allows the surgeon to view the spinal nerve and disc. Once the surgeon can view the spinal nerve and disc, the surgeon will retract the nerve, remove the damaged disc, and replaces it with bone graft material. MIS Lumbar Fusion A minimally invasive lumbar fusion can be performed the same way as traditional open lumbar fusion, either from the back, through the abdomen, or from the side. Lateral interbody fusion (LIF) A lateral interbody fusion, often used to treat spondylolysis, degenerative disc disease and herniated discs, is performed by removing a disc and replacing it with a spacer that will fuse with the surrounding vertebra. The procedure is completed on the side of the body in order to reduce the effect on the nerves and muscles.
Posterior cervical microforaminotomy (PCMF) A PCMF is performed to help relieve pressure and discomfort in the spine by making a small incision in the back of the neck and removing excess scar tissue and bone graft material. Anterior cervical discectomy An anterior cervical discectomy is used to reduce pressure or discomfort in the neck by removing a herniated disc through a small incision in the front of the neck. The space is then filled with bone graft material and plates or screws may be used to increase stability. Artificial Disc Replacement Artificial disc replacement is intended to be an alternative to spinal fusion surgery. Unlike a fusion that locks the two vertebrae in place, an artificial disc retains movement in the spine by simulating the natural rotational function of the disc.
San Jose Neurospine includes the expertise of Adebukola Onibokun, MD, a board-certified neurological surgeon who specializes in minimally invasive spine surgery. Dr. Onibokun (pronounced “Oh-kneebow-kun”) is Board Certified by the American Board of Neurological Surgery and is a fellow of the American Association of Neurological Surgeons. Dr. Onibokun received his medical degree from the prestigious Northwestern University Medical School, graduating with honors. He then completed 7 years of Neurosurgery Residency training at UCLA Medical Center, a program that consistently ranks as one of the top five neurosurgery programs in the country. Dr. Onibokun has previously served as Chief of Neurosurgery at Elmhurst Memorial Hospital in the Chicago area, where he established their Minimally Invasive Spine Surgery program. Prior to relocating to California, he was a Health System Clinician at the Northwestern Medicine Regional practice.
Home Remedy Book We provide a free 36-page Home Remedy Book that includes symptom charts that show when to see a doctor; home remedies; stretches that can relieve pain symptoms; and exercises that make the back stronger, more flexible and resistant to future strain. Call us, or email us at admin@ SanJoseNeurospine.com, and we’ll send 10 copies to your office for your patients. Our educational Internet presence at SanJoseNeurospine.com also has educational videos, medical illustrations, information on minimally invasive spine surgery options and a referral form.
View our video library to learn more about our practice online at: SanJoseNeurospine.com/videos
NOVEMBER / DECEMBER 2014 | THE BULLETIN | 17
How one “prick of conscience” launched a 12-year fight for fair geographic payments for Medicare physicians NOVEMBER / DECEMBER 2014 | THE BULLETIN | 19
By Elizabeth Zima, CMA Staff Writer In 2002, Larry De Ghetaldi, MD, met with his Congresswoman, Anna G. Eshoo (CA-18), to see if he could enlist her help in changing the way that Medicare reimbursed physicians in Santa Cruz County. Something was wrong with the Medicare geographic payment regions tied to the reimbursement formula known as the Geographic Practice Cost Index (GPCI). In his own Santa Cruz County, physicians were paid by Medicare approximately 20% less than in the next county north, Santa Clara, while the cost of providing care in both counties was essentially the same. The reason? Santa Cruz County was designated as “rural,” while Santa Clara County was not. In fact, the sixth largest city in the United States, San Diego, was also designated by Medicare as rural. Consequently, physicians seeing Medicare patients in San Diego were paid about 10% less than physicians in neighboring Orange County. Since the 1990s, hospitals have been paid according to the local costs in their Metropolitan Statistical Areas (MSAs). The MSAs are defined by the federal Office of Management and Budget and annually updated by the Centers for Medicare and Medicaid Services (CMS), so that reimbursement accurately reflects local costs to deliver care. But for physicians, CMS used county-based localities, and these localities have not been updated in 17 years. As a result, 14 recently urbanized California counties, such as San Diego, Santa Cruz, and Sacramento, were still designated as rural. This caused many California physicians to be paid up to 13% per year below what Medicare says they should be paid if they were correctly classified. Because physicians were paid less in Santa Cruz County, Dr. De Ghetaldi noted that many Medicare patients were having problems finding physicians to care for them. In fact, no physician group in Santa Cruz was accepting new Medicare patients. For this reason, he asked Congresswoman Eshoo to help him convince CMS to reconsider the payment regions it used to reimburse doctors. “This was a week after Congress voted to go to war in Iraq,” Dr. De Ghetaldi said. “We had already spent several hours with CMS trying to get them to change the formula, but they had little incentive to do so.” After explaining the issue to Eshoo, she told him: “Larry, it is easier to go to war, than to change this. We will leave Iraq before this fix is in place.” She said it with such certainty that Dr. De Ghetaldi was stunned – he didn’t want to believe that she was correct.
THE LONG HAUL
What followed was a 12-year odyssey that included divisive debates within the California Medical Association (CMA) House of Delegates (HOD); changes in administration from the Bush White
House to the Obama White House; several changes in leadership of key congressional committees and their staff; innumerable frustrating meetings between CMA and CMS; and countless rounds of relentless Congressional lobbying by CMA leadership. What began for Dr. De Ghetaldi as a “prick of conscience” about the lack of care for seniors in his county became an obsession. He, in turn, found a small cadre of activists who formed a team that could not look away from what turned out to be a problem for the whole country – the fact that many areas that CMS had judged as rural in 1997 had become more urbanized with changing costs and demographics, but had not been updated to accurately reimburse physicians. This, in turn, was stymieing seniors from getting the care they needed. It was a huge national problem, and unconscionable that CMS had not kept pace with physician payments. The team for the long haul was composed of physicians, lobbyists, and Members of Congress and their staff. The key players that took the issue from the CMA HOD floor to the national stage included Dr. De Ghetaldi; Edward Bentley, MD; Theodore Mazer, MD; Representative Sam Farr (D-Monterey, Santa Cruz) and his chief of staff, Rochelle Dornatt; and Elizabeth McNeil, CMA Vice President of Federal Government Relations. Dr. Bentley, an internist with a specialty in gastroenterology, was president-elect of the Santa Barbara Medical Society in 2002 when he became aware of the GPCI locality issue. “I had been in practice in Ventura County, so I knew that reimbursements were lower (in Santa Barbara County).” But, he didn’t know why. “I approached Dr. George Wolf [a CMA delegate] from Santa Cruz County and asked him to put forward a resolution asking CMA to do something about the problem,” said Dr. Bentley. This caused a ruckus the first time the motion was introduced at HOD. “It was a divisive resolution,” he said. Part of the problem was that CMS required that the fix be accomplished in a budget-neutral way. Unfortunately, this meant that in order to raise reimbursement levels for the underpaid counties, other counties would have to foot the bill. To get to some agreement on the issue, a CMA task force was formed. It was headed by current CMA President, Richard Thorp, MD. “He lived in a county that benefitted from the locality arrangement that had been established by CMS, so he was in a difficult position,” said Dr. Bentley. Trying to put together a compromise that would gain consensus from all counties turned out to be so contentious it took three years to pass through the HOD. When the task force looked at the issue, there were “clear winners and losers.” The other requirement CMS had for action on this issue was that there had to be 100% approval from the state medical association to make changes.
For McNeil, who says a substantial part of her job at CMA for the past 12 years has been focused on a solution to the locality problem, the CMS requirement for consensus was a tactic to discourage change. But, instead, she says, it served to galvanize the group to come up with a solution for the state that would promote unanimity and justice in payments. What CMS had wrought when it created the California localities in 1966, and further distorted them in 1997, was a mishmash of counties grouped together. In 1997, Locality 99 was comprised of 47 rural counties, but over the last decade at least 13 had become more urban. Payments for all counties within Locality 99 are averaged, which produces inaccurate payments not based on local costs to provide care. CMS had failed to keep pace with the changing demographics. “Our objective (in the task force) was to improve the accuracy of the payments,” said Dr. Bentley. It turned out to be very hard to do because Medicare is a budget-neutral program, where any payment change produces winners and losers. While the task force worked on a solution to the problem, the group had restarted talks with CMS to see if it would take into consideration some creative plans to refine the payment regions. CMA, Rep. Farr, and Dornatt started working with the powerful then-Chairman of the House Ways and Means Committee, Representative Bill Thomas (R-Bakersfield). He fully agreed with CMA about the problem and said he would help to fix it. Yet year after year, he stalled any action on a fix. In 2003, during markup of the Medicare Part D bill in the Ways and Means Committee, Rep. Farr tried to introduce language to fix the locality problem, but Rep. Thomas blocked the move. It was then that the “famous $100 bet” was struck on the House floor. Frustrated and ready to take a swing at Thomas, Farr instead bet Thomas that he would never permit a solution to the locality problem in California to pass. Thomas took the bet, telling him he would get it through. When Thomas retired in 2007, he made good on the bet, paying Farr $100. Meanwhile, the CMA task force had achieved near consensus across the state that all California physicians would take a one-time, 1% cut to pay for the update without harming the rural physicians. “We presented the idea to CMS and their lawyers were afraid they would get sued. So we proposed a pilot project that had to go through public hearings, but CMS wouldn’t budge,” said McNeil. In 2005, CMS proposed to update the payment regions and thus, the payments for the most harmed counties in California — Santa Cruz and Sonoma counties. The announcement disappointed doctors in other impacted counties and created angst throughout CMA membership because some physicians would see a small payment cut. The proposed regulation died because there wasn’t 100% consensus within CMA. “I thought CMA’s failure to reach consensus on this proposal was a real set-back, because we could have updated a few counties every two years until all were updated,” McNeil lamented. “We might have actually gotten it done before 2014!”
DEAD END
The group had reached a dead end. “We had tried the regulatory path and then realized the only way to solve it was through an act of Congress,” said Dr. Bentley. CMS can only change payments in a budget-neutral man-
ner with winners and losers, so any change that holds rural physicians harmless from cuts requires additional funding and Congressional action. Up to this point, CMS had been keeping private its cost inputs for the locality payments. In 2004, a staffer leaked the information to Dr. Bentley. He quickly went through the data and discovered that this problem was not confined to California. “The payment disparities were a national problem,” he said. Working with CMA, Rep. Farr introduced several bills over the coming years, some with his Republican counterpart Representative Brian Bilbray (R-San Diego), but nothing moved. CMA tried to educate the other negatively impacted state medical associations and get them on board. “It was like herding cats,” McNeil recalls. “It was an extremely difficult process. In the end, we were afraid it would take more time to bring on 10 medical associations than it would take to get the bill through Congress for California only.” In the 2014 legislation that ultimately passed, CMA attempted to insert a national study to help the other states. But in the end, Congress only chose to help California. Rep. Thomas did, however, do the group one favor. Before he retired, he asked the U.S. General Accounting Office (GAO) to study the problem. In 2006, Drs. Bentley and De Ghetaldi prepared a white paper for the Medicare Payment Advisory Commission (MedPAC), an independent body established to advise Congress on Medicare payment issues. “They acknowledged the problem,” said Dr. Bentley. The same paper was presented to the GAO who took up the problem and studied it. “The GAO issued a report that validated our white paper,” he added. In 2008, when California Representative Pete Stark (D-Fremont) became Chair of the House Ways and Means Subcommittee on Health, he (at the urging of Rep Farr, CMA, and other representatives) included a California GPCI solution in the Children’s Health and Medicare Protection (CHAMP) Act, which passed the House in 2008. He used the GAO report to justify its inclusion. Unfortunately, it did not pass the Senate. Another turning point came in 2009, when CMA hosted a Congressional “GPCI Summit” between the House, Senate, CMS, and MedPAC. All of the House and Senate committee leaders were in a neutral meeting place in the basement of the Capitol. This summit is where CMA started to gain general buy-in that the problem needed to be fixed, particularly from the Senate. In 2010, both Drs. Bentley and DeGhetaldi were invited to testify on behalf of CMA before the Institute of Medicine (IOM). “We presented the white paper,” said Dr. Bentley. “I presented the data that demonstrated the payment inaccuracies. The IOM took our presentation and NOVEMBER / DECEMBER 2014 | THE BULLETIN | 21
the white paper and refined it.” The IOM report confirmed the locality problem and recommended the CMA proposed solution to move localities to Metropolitan Statistical Areas consistent with the hospital payment regions. It was at this point that Congress began to really listen to the group. “When you have the backing of the IOM, the GAO, and MedPAC, they will listen,” Dr. Bentley said. In 2009-10, Chairman Stark inserted the California locality update into the House’s version of the Affordable Care Act (ACA). The House passed it, but the Senate version did not include the fix. Although the GPCI fix was adopted during the House-Senate Conference Committee on health care reform, when the Senate Democrats lost the majority, Congress was eventually forced to accept the Senate version of the bill without the California GPCI provision. “I felt like a beaten dog, at this point,” said Dornatt. But the problem was still there. “Doctors were still coming in the door [complaining]; and beneficiaries complained they could not find doctors to care for them.”
STARTING OVER
The group started over again looking for a solution that would pass both Houses of Congress. The Senate had been extremely critical of a Californiaonly solution. Some called it the “California gold rush.” CMA and Rep. Farr enlisted the help of Representative Darrell Issa (R-San Diego). Issa, the powerful Chairman of the House Oversight and Government Reform Committee, agreed to work with Farr to push their respective leaders to include the GPCI fix in any budget or Medicare legislative packages moving through Congress. At the same time, California Senator Dianne Feinstein found a California-only funding source for the locality legislation that would diminish the California “pork barrel” criticisms. Unfortunately, after the passage of the ACA, Congress became even more dysfunctional; the only Medicare bills moving through Congress were the last-minute Medi-
care sustainable growth rate (SGR) short-term patch bills. Congressional leadership told the CMA team that no new policy issues would be included in those patch bills, which once again nixed CMA’s chances to achieve California locality reform in 2011 and 2012. However, that didn’t stop Farr and CMA from trying. In early February of 2013, both the House and Senate began working on bills to solve the Medicare SGR issue. In 2012, the Republicans took control of the House with new leadership. Representative Kevin McCarthy (R-Bakersfield), who had replaced his mentor, Bill Thomas, became the House Majority Whip. Under his leadership, the House Republican Committee leaders renewed the call to fix the SGR. Their Democratic predecessors in the House had repealed the SGR twice, only to fail in the Senate. “We knew that both the House and the Senate wanted to fix the SGR because the cost of the fix had dropped dramatically,” Dornatt said. “The Medicare bill was intended to be a comprehensive payment reform bill, so we knew we had a shot at getting the California locality reform in,” said McNeil. Dornatt and McNeil began to push for the insertion of a GPCI fix for California. The proposal updated the California Medicare physician payment regions. It increased payments in the new urban areas and prevented payment reductions to California rural physicians, by using a hold harmless provision that was financed with administrative savings from the formation of a Medicaid County Organized Health System in Alameda County. But, said Dr. Bentley, “no one likes to do a onestate deal; it is considered pork. This was a sensitive issue, and we were trying to run under the radar.” Several committees in both the House and Senate were working on an unprecedented bipartisan, bicameral solution to the Medicare payment reform issue. With the help of Rep. Henry Waxman (D-Los Angeles), who was the Ranking Democrat on the House Energy Commerce Committee, and Com-
mittee Chair Fred Upton (R- Michigan), Dornatt and McNeil managed to insert language to update the California localities into the bipartisan Energy and Commerce Medicare SGR payment reform legislation (H.R. 2810), which unanimously passed the Committee on July 31, 2013. “We were frantically still negotiating language the morning of the mark-up,” recalled McNeil. “And we were literally one of the last amendments accepted into the bill. It was incredibly stressful. I knew we had to get GPCI into the first policy committee bill. Otherwise, we would be fighting an uphill battle the rest of the way, particularly going into the Senate.” This version of the locality update was a compromise between Reps. Upton and Waxman. It was based on legislation proposed by Reps. Farr and Issa. House Majority Whip Rep. McCarthy was key to the agreement, with CMS also stepping in to assist. California Energy Commerce Committee members Reps. Anna Eshoo, Lois Capps, and Doris Matsui, who all have impacted districts, also helped to push the solution.
DOING THE UNTHINKABLE
In the fall of 2013, it looked like Congress would do the unthinkable — solve the flawed Medicare SGR. Two other powerful committees were expected to introduce versions of the SGR bill: the House Ways and Means Committee and the Senate Finance Committee. “There was unprecedented unanimity in Congress that the time was now to fix the Medicare reimbursement problem,” said McNeil. While the SGR reform policy bill passed out of these committees before the winter holidays, there was no consensus on how to pay for it. The House Republicans and the Senate Democrats couldn’t agree on the funding sources, so they passed a policy-only bill. On February 7, 2014, the three congressional committees announced a final joint bipartisan, bicameral agreement on the Medicare SGR repeal and payment reform legislation, H.R. 4015/S. 2000. Now Congress just needed to marry the policy to the funding sources to the tune of $150 billion. The California GPCI fix had made it into the final compromise bill, and the group worked feverishly to get the bill passed. But as the SGR deadline grew closer, the group realized there would be no compromise on the funding sources, and that Congress would yet again — for the 17th time in a decade — pass a short-term patch to stop the double-digit SGR reimbursements cuts. McNeil and Dornatt swung into action to see if they could at least insert the California GPCI fix into the patch legislation. “When we knew there was the potential for a patch, we went to the top players in the House and Senate to get the California GPCI into it,” McNeil said. “Because of our lobbying efforts over the years, our relationships with the Congressional leadership and the committee staffers, they legitimately listened and were interested in helping.” “However, a special California provision would never make it into such a small bill, so we had to find a larger, more national argument,” said McNeil “When the Committee staff revealed to us that the SGR patch bill would include an extension of the national Medicare work GPCI payment floor, I knew we had an angle.” Nearly every other state in the country, except California, benefits from the work GPCI payment floor, so if physicians in other states were receiving an extension, McNeil and Dornatt argued that Congress should do something to help California physicians and patients. “California doesn’t benefit from the work GPCI floor because our localities are so out of whack,” said McNeil. “We urged GPCI payment parity for California and, incredibly, the
leaders agreed. It was incredible!” One day before the patch bill was up for a vote, McNeil was given a heads up that the California GPCI fix was in the legislation. “CMA didn’t want the SGR patch; we wanted comprehensive reform, but we wanted the GPCI fix to come through. CMA was incredibly conflicted,” she said. Dr. DeGhetaldi said he felt once again like the San Francisco Giants had won the World Series. “I felt chills when I watched the Senate vote,” he said. Then he went numb. He decided he couldn’t celebrate what had been a long, hard-fought battle, until President Obama signed the measure into law. Dr. Bentley felt the same way. “Every time we thought it was a done deal, something happened at the last minute to prevent its passage. After so many years, you somehow don’t believe it is actually happening. I was preparing myself for more work.” In the end, Dr. De Ghetaldi said, Eshoo was right. “It took us much longer than the Iraqi war to pass the fix.” The GPCI fix was ultimately signed by the president and requires the reimbursement formula to be calculated based on same Metropolitan Statistical Areas used to pay hospitals, which more accurately reflect the cost of practicing medicine. The higher payments will be phased in over a six year period starting in 2017. McNeil says, she has to take the long view on some of the issues she works on. “It takes at least five to 10 years to pass a bill through Congress. Especially if it is a new idea and only affects a subset of people, so I suppose we are on track. This is a particularly sweet victory because it was so difficult and achieved during one of the most contentious times in Congress. This was a hard-won geographic formula fight between physicians, involving an agency that never takes risk, a dysfunctional Congress, and a state unpopular in Congress that was singled out for assistance. The odds were definitely against us. But CMA was fortunate to have a team of wise and relentless physician leaders who never gave up.” “It is safe to say that everyone on Capitol Hill is grateful and relieved that they will never hear CMA utter the word ‘GPCI’ ever again,” laughs McNeil.
NOVEMBER / DECEMBER 2014 | THE BULLETIN | 23
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690 Saratoga Ave | Suite 200 | San Jose, CA 95129 408-217-6000 T | 408- 457-8803 F www.HealthMedRealty.com Lic. 01902032
NOVEMBER / DECEMBER 2014 | THE BULLETIN | 25
MEMBER SPOTLIGHT
Humanity in the Modern World
Robert G. Aptekar, MD in Phnom Penh, Cambodia By Susan Weiss Robert G. Aptekar, MD, a practicing orthopedic surgeon for more than 38 years in Los Gatos, CA, travels annually to Phnom Penh, Cambodia, to work at Children’s Surgical Centre, a charity hospital. I had the privilege of accompanying him in January 2013, the fourth trip, to document his work and the community in which he works. Currently, there is no health insurance system in Cambodia, one of the poorest countries in the world. The country suffered greatly for 30 years under the brutal regime of Pol Pot. By executing most health care workers, including physicians, he left a legacy of a greatly reduced medical system. The country is working to improve its standards and depends on the generosity and efforts of outside health care professionals. Children’s Surgical Centre (CSC), a nonprofit, non-governmental, and non-religious hospital was founded, in 1998, by Dr. Jim Gollogly, a British orthopedic surgeon. Dr. Gollogly originally came to Cambodia, in 1995, to work
with the American Red Cross to help land mine victims and returned three years later to establish the hospital to improve the quality of life for children and adults by providing free health care to the entire population. Dr. Aptekar met Dr. Gollogly on a trip with Health Volunteers Overseas at another hospital and was invited to work at CSC in the future. He saw it as an opportunity to treat conditions not usually seen in this country, provide service to the local population, and train the local surgeons to carry on the work in the future. CSC now offers medical services in orthopedics, opthalmology, plastic surgery, fistula repair, and other areas including affiliation with Cambodian Acid Survivors Charity. If CSC did not exist, most of the population would not get advanced medical and surgical treatment. Dr. Aptekar primarily performs total hip replacement surgery when at CSC. This work dramatically improves the lives of people who have severe hip conditions and limited mobility, whether from arthritis or trauma. He is there for one week and performs up to four surgeries
26 | THE BULLETIN | NOVEMBER / DECEMBER 2014
a day. This is the only opportunity for surgery of this type for patients who come from all over the country for the procedure. During the surgery, he is also training the medical staff who will be able to operate independently in the future, delivering these services to the previously underserved population. His surgical patients are prescreened throughout the year and those chosen wait for his arrival in January. Dr. Aptekar carries implants, donated through the organization Americares, with him for the surgeries, as those made in other Asian countries are inferior and the hospital cannot afford to purchase implants manufactured in western countries. The day begins at 8:00 a.m. at the open clinic, with the entire professional staff of about 50 in attendance, when patients arrive for a medical diagnosis and surgeries for the day are reviewed. The hospital treats a range of surgical problems. They have come from all parts of Cambodia with their families, who care for them during their hospital stay, living on the hospital grounds. The hospital provides free meals and clean drinking water for both the pa-
Examining patients in the medical ward tients and their caregivers. Once a diagnosis has been made, the patients are sent to the appropriate departments for their treatment. Dr. Aptekar’s pre-screened patients are prepped for surgery. The rest of his day is spent in surgery and postoperative care. Being a charity hospital, CSC looks for financial support from many sources in order to provide free services to the population. Patient surgi-
Dr. Aptekar in surgery cal profiles are posted on the website www.watsi.org to look for crowdsourced funding. Private donors also make contributions to the hospital foundation. The difficulty of obtaining funding impacts the availability of new equipment and replacement supplies. Shortly after our visit, the physical therapy building had a major fire and was completely destroyed.
A newborn in the pediatric ward
Evaluating a patient in the clinic At the time, they did not know if they would be able to rebuild the facility. The photographs in this article highlight moments during the week, including Dr. Aptekar in clinic, surgery, and rounds, plus other departments and patients with their families. The complete work will be on display at the Commonwealth Club in San Francisco in January, 2015. Dr. Aptekar and I will present the work in a lecture on January 14, 2015 at 6:00 p.m. Check with the Commonwealth Club for location. Dr. Aptekar is
Dr. Aptekar during a post operative examination now planning a volunteer trip to La Paz, Bolivia in 2015. I will be traveling with faculty from UNC dental school to Moldova, where they work with orphans and elderly patients. Dr. Robert Aptekar has been a practicing orthopedic surgeon for over 38 years. He attended John Hopkins for pre-medical training, University of Michigan for medical school, and Stanford for his internship and residency. He is a member of many medical societies and has won many awards throughout his career. Susan Weiss received a BA degree from the University of Michigan, has an MA degree from Mills College and a MFA degree from San Francisco Art Institute. She began her artistic career after retiring as a Vice President from First Interstate Bank. This will be her second show at the Commonwealth Club. “Service Unquestioned,” the first show, documented military families during a deployment to Iraq and Afghanistan. You can see more of her work at www.susanweissart.com. NOVEMBER / DECEMBER 2014 | THE BULLETIN | 27
Thank You to SCCMA SAC-PAC Contributors The SCCMA PAC is dedicated to advocating for policies and candidates who support the goals and ideals of the SCCMA and its physician community. SCCMA extends a huge thank you to the many members listed below who have made contributions to SACPAC (Santa Clara County Medical Association’s Political Action Committee) for the 2013-2014 fiscal year (as of September 29, 2014). SCCMA genuinely appreciates your commitment to defending and protecting MICRA.
$10,000 Randal Pham
$150 Peter Abaci Cameron Oba
$75 J Augusto Bastidas Scott Benninghoven Elwyn Cabebe Juan Carrillo Michael Charney Richard Cherlin Jeffrey Coe James Davilla Karen Devich Leonard Doberne Christine Doyle Martin Fishman Brandt Foreman David Francisco Peter Fung Michael Gold
28 | THE BULLETIN | NOVEMBER / DECEMBER 2014
John Heringer Kristina Hobson Daryl Hoffman Mark Kenter Francis Koch Stuart Krigel Andrew Lan Ami Laws Peter Levin William Lewis Edward Littlejohn John Longwell Eleanor Martinez Robert Marx Joseph Mason John Massey Jennifer Maw
William McCallum Andrew Menkes Prasanna Menon Michael Murray Michael Nagel Suresh Nayak Vinh Quy Nguyen F Richard Noodleman Lewis Osofsky Samuel Pearl Dennis Penner Mark Penner James Petros Bernard Recht Marshal Rosario Bassam Saffouri Hussein Samji
Randall Seago Vincent Seid Julia Shuleshko Neal Slatkin Mark Snyder Tanya Spirtos R Lawrence Sullivan Ernest Thomas Hugh Walsh William Waterfield Waldemar Wenner Byron Wilson Susan Wilturner Chi-Kwan Yen Takashi Yoshida Christo Zouves
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AMA INTERIM MEETING
Highlights From AMA’s 2014 Interim Meeting The nation’s physicians gathered at the 2014 American Medical Association (AMA) interim meeting in Dallas, Texas, this past month. The delegates debated a large number of resolutions, establishing new policies related to the worldwide Ebola epidemic, expanded network access for the Affordable Care Act, and electronic health records. A number of these resolutions were put forward by the California delegation. Below are highlights of some of the resolutions adopted as policy. Ebola: Resolution 925 put forth by the California delegation was incorporated into AMA policy that calls on AMA to strongly support U.S. and global efforts to fight the Ebola epidemic and support health care workers and volunteers that are fighting Ebola worldwide. The policy also supports the use of quarantine and isolation when it is based on science and asks AMA to make emergency recommendations on Ebola for the medical community and the general public. Adequate Networks for Patient Access, Choice: AMA adopted policy that calls for health insurers to make updates to their provider networks prior to the open enrollment period begins each year to avoid patient confusion. The policy also reiterates the need for health insurers to provide patients with an accurate, complete directory of participating physicians through multiple media outlets. These lists also should identify physicians who are not accepting new patients. Medicaid Enhanced Rates: The AMA delegates adopted policy (Report 7) that requires AMA to advocate for the Affordable Care Act’s Medicaid primary care payment increases to continue past 2014 in a manner that does not negatively impact payment for any other physicians. AMA Promotion of Improved Electronic Records: The delegates passed a resolution (210) that asks AMA to continue advocating with the Centers for Medical & Medicaid Services (CMS) for a halt to meaningful use penalties. Hospital Sponsored Electronic Health Records: The delegates referred for study a California resolution (825) that asked AMA continue to urge Congress and the CMS to mandate that all EHR systems be interoperable, and to require hospitals to protect physician rights to control and have access to their patients’ medical records. The resolution was referred so that current regulations, practices, and legal implications could be reviewed. Preventing Drug Manufacturers from Restricting their Distribution Networks: AMA reaffirmed policies D-110.993, H-110.992, and H-110.998 in lieu of California resolution 229 that asked the AMA to oppose attempts by drug manufacturers and distributors to increase profits by restricting the distribution of their medications. The resolution also 30 | THE BULLETIN | NOVEMBER / DECEMBER 2014
asked AMA partner with the American Hospital Association, the federal government, and other interested parties, to oppose Genentech’s plan to restrict the distribution of its products as a restraint of trade. Facilitating Multiple State Licensure: AMA delegates voted to support the Federation of State Medical Boards compact designed to facilitate a speedier medical licensure process with fewer administrative burdens for physicians seeking licensure in multiple states (Report 3). The compact includes model legislation to make it easier for physicians to obtain licenses in multiple states while providing access to safe, quality care. The California Medical Association will be working with the Medical Board of California to review the compact and determine the best course of action in our state. Cannabis: The delegates adopted a resolution (213) asking AMA to encourage model legislation to put a warning on all cannabis products not approved by the U.S. Food and Drug Administration that says: “Marijuana has a high potential for abuse. It has no scientifically proven, currently accepted medical use for preventing or treating any disease process in the United States.” The resolution also urges legislatures to delay full legalization of any cannabis product until further research is completed on the public health, medical, economic, and social consequences of chronic use of cannabis. More news from the AMA Interim Meeting is available on the AMA website at www.ama-assn.org.
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Santa Clara County Medical Association 700 Empey Way • San Jose, CA 95128 • 408/998-8850 • FAX 408/289-1064 November 2014 TO:
All Members, Santa Clara County Medical Association (SCCMA)
FROM:
Eleanor Martinez, MD, Chair, 2014-2015 Awards Committee
At the 2015 Medical Association’s annual banquet, the association will honor several individuals with its perpetual awards. These awards are significant honors which reflect the respect, recognition, and appreciation of our membership. The recipients are selected from among our outstanding members who have distinguished themselves with extraordinary service to medicine in general, to the association, to the community, or to medical education. Selections are made by the Awards Committee, with the aid of input from the membership at-large. Your suggestions for recipients for each of the awards, outlined on the next page of this memo, will be appreciated. Please complete the form below to submit suggestions, keeping in mind the requirements for each award as listed on the opposite page. If you would like to nominate more than one person, or for more than one award, please photocopy this form or send a letter. Suggestions must be received by February 16, 2015. Thank you for your recommendations. If you previously suggested a candidate who was not given an award, please feel free to resubmit that name. I THINK ______________________________________________________ WOULD BE A GOOD CANDIDATE FOR THE _____________________________________________________________________________________ . (Name of Award) PLEASE ATTACH ALL SUPPORTING INFORMATION, INCLUDING ACCOMPLISHMENTS AND CONTRIBUTIONS THAT WILL HELP THE AWARDS COMMITTEE EVALUATE THE CANDIDATE FOR THE AWARD SELECTED. YOU MAY MAIL, FAX, OR EMAIL THE INFORMATION TO PAM JENSEN AT SCCMA. SUBMITTED BY: __________________________________________________________________________________ MD (Please print) MAIL FORM TO: SCCMA Attn: Pam Jensen 700 Empey Way San Jose, CA 95128 EMAIL: pjensen@sccma.org FAX: 408/289-1064 DEADLINE: February 16, 2015 32 | THE BULLETIN | NOVEMBER / DECEMBER 2014
Santa Clara County Medical Association
ANNUAL AWARDS
ROBERT D. BURNETT, MD LEGACY AWARD
For a physician member of the Medical Association who has demonstrated extraordinary visionary leadership, tireless effort, selfless long-term commitment, and success in challenging and advancing the health care community, the well-being of patients, and the most exalted goals of the medical profession. The only four recipients of this award are Robert D. Burnett, MD, Philipp Lippe, MD, Robert Pearl, MD, and Sharon Levine, MD.
BENJAMIN J. CORY, MD AWARD
For a physician member of the Medical Association who has displayed forward-looking, pioneering ideas, enterprise, enthusiasm, and prolonged professional stature and ability.
AWARD FOR OUTSTANDING ACHIEVEMENT IN MEDICINE
For a physician member of the Medical Association who, during his/her medical career, has made unique contributions to the betterment of patient care, for which he/she has achieved widespread recognition. Consideration shall be given to research and/or the development of procedures, methods of treatment, pharmaceutical agents, or technological advances in the field of medicine.
AWARD FOR OUTSTANDING CONTRIBUTION TO THE MEDICAL ASSOCIATION
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the Association over and above that expected of the membership at-large.
AWARD FOR OUTSTANDING CONTRIBUTION IN MEDICAL EDUCATION
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more medical education activities over and above that expected of the membership at-large.
AWARD FOR OUTSTANDING CONTRIBUTION IN COMMUNITY SERVICE
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the community over and above that expected of the membership at-large.
CITIZEN’S AWARD
For an individual who is not a member of the Medical Association, who has achieved public recognition for a significant contribution in the health field. (This usually will be a non-physician, although physicians are not categorically excluded.) Benjamin J. Cory, MD Award
Outstanding Outstanding Contribution To The Contribution In Medical Association Medical Education
1994
Robert W. Jamplis
Richard M. O’Neill
John B. Shinn
Thomas J. Fogarty
1995 1996
---
Robert W. Andonian
Ronald L. Kaye
Norman E. Shumway
Christopher C. Chow
David M. Rosenthal
William C. Fowkes
Thomas A. Stamey
1997 1998 1999 2000 2001
Outstanding Achievement In Medicine
Outstanding Contribution In Community Service Arthur A. Basham / Arthur L. Messinger ---
Citizen’s Award Gary W. Steinke, MD / Mrs. Pamela Steinke Mr. Howard W. Pearce
Cindy Lee Russell / Minoru Yamate
Florene Poyadue, RN
---
Bernice S. Comfort
Robert J. Frascino
Michael R. Fischetti
Suzanne Jackson, RN
Mansfield F. W. Smith
Stanley D. Harmon
Howard R. Porter
Burton D. Brent
William A. Johnson
Judge Leonard Edwards
Donald J. Prolo
Steven S. Fountain
C. Michael Knauer
Jack S. Remington
M. Ellen Mahoney
Rigo Chacon
Sharon A. Bogerty ---
2002 2003
Robert M. Pearl
2004
Robert Wuerflein
2005 2006
Harvey J. Cohen
2007 2009 2010 2011 2012 2013 2014
---
Stephen H. Jackson
Theodore Fainstat
Richard P. Jobe
Barbara C. Erny
Janet Childs
Roger P. Kennedy
Bert Johnson
Nelson B. Powell / Robert W. Riley
Robert Michael Gould
Tony & Brandon Silveria
Elliot C. Lepler
Allen H. Johnson
Bruce A. Reitz
David Morgan
Tom Campbell / Ted Lempert
Joseph E. Mason, Jr.
Anthony S. Felsovanyi
David A. Stevens
Martin D. Fenstersheib
Michael E. & Mary Ellen Fox
Eugene W. Kansky
Barry Miller
D. Craig Miller
Elizabeth Menkin
Jayne Haberman Cohen, DNSc
Richard L. Miller
Gus M. Garmel
Rodney Perkins
Elouise Joseph
Doris Hawks, Esq.
Arthur A. Basham
Robert W. R. Archibald
G. David Adamson
Harmeet S. Sachdev
Edward A. Hinshaw, Esq.
Stephen H. Jackson
Cindy L. Russell
Catherine L. Albin
John R. Adler, Jr.
Madhur Bhatnagar
Debbi Ricks
Bernadette Loftus
Martin L. Fishman
George P. Kent
Thomas Krummel
Seham El-Diwany
Peggy Fleming-Jenkins
Melvin Britton
James G. Hinsdale
David Levin
Gary Steinberg
Leo Strutner
Judge Lawrence Terry
---
Tanya Spirtos
Dennis Siegler
Robert Armstrong
Gary Silver
Kathleen King
Steven S. Fountain
---
Robert Gould
William Jensen
Eleanor Levin
David Quincy
Assemblymember Jim Beall
James G. Hinsdale
Stephen C. Henry
Rosaline Vasquez
Diane E. Craig
Jeffrey D. Urman
Congresswoman Anna Eshoo
Martin L. Fishman
David H. Campen
Jonathan H. Blum
Gary E. Hartman
Keith A. Fabisiak
Gay Crawford
NOVEMBER / DECEMBER 2014 | THE BULLETIN | 33
VICT VICTORY On November 4, the voters of California spoke loudly
AND DEFINITIVELY, SENDING THE TRIAL LAWYERS’ PROPOSITION 46 TO DEFEAT BY A VOTE OF 67 TO 33. THE MESSAGE IS CLEAR – CALIFORNIANS SIMPLY DON’T WANT TO INCREASE HEALTH CARE COSTS AND REDUCE HEALTH ACCESS SO TRIAL ATTORNEYS CAN FILE MORE LAWSUITS. An increase in the Medical Injury Compensation Reform Act (MICRA) cap on non-economic damages has been rejected in California again and again: 10 times in court, 5 times in the Legislature and now overwhelmingly by voters. This idea now has its own dedicated spot in California’s political trash heap.
34 | THE BULLETIN | NOVEMBER / DECEMBER 2014
But this time, we energized the membership of CMA as a whole to fight the fight together, as one unified voice of medicine, representing the patients we so deeply care about and the care that we have committed to provide them.
includes labor, business, local government, health providers, community clinics, Planned Parenthood, ACLU, NAACP, taxpayers, teachers, firefighters and more – underscores just how important affordable, accessible health care is to every Californian.
Despite the trial attorney proponents’ attempt to sweeten the deal by adding provisions that polled well– physician drug testing and mandatory checking of a prescription database – voters said NO on Election Night. As people throughout the state heard from physicians and No on 46 coalition members about the real intentions of the measure’s proponents, there was resounding opposition.
In addition to the groups on the ground talking to voters about the deception and trickery behind Prop. 46, every major editorial board in California opposed the initiative.
TORY One of the secret weapons of this effort was the size and diversity of our coalition. We helped amass one of the largest and most diverse campaigns in California history. The breadth of the coalition — which SE PT EM BE
4
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The San Francisco Chronicle decried Prop. 46 saying that the measure, “overreached in a decidedly cynical way.”
The Orange County Register, UT San Diego, San Jose Mercury News, Monterey County Herald, Sacramento Bee and dozens of other newspapers echoed these sentiments.
R 13 , 20 14
re “…this measu cidedly de a in d he ac overre cynical way.”
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t h ey tely, m a n u t r do “ U n fo d t he ra n a use ad de s t i ng bec t ed te es d ru g or t ed l y t ou ps p r e g r s it t for n focu well i st suppor .” o t o bo measu re t he AUG
The Los Angeles Times said, “As worthwhile as [Proposition 46’s] goals may be, the methods the measure would use to achieve them are too flawed to be enacted into law.”
UST
The efforts of the California Medical Association and the county medical associations across the state is a tremendous showing of what we can do for the future of health care, 25 , 20 14 SE PT EM BE R the quality of medicine and the e trying “Proponents…ar raising dedication to patients everywhere. into to trick voters ards.” aw Working together to spread the e malpractic truth about Prop. 46, building coalitions across communities and standing strong as one united voice is what helped carry us to victory. 4 , 201 R 23
s’ w ye r a l l a i 46: Tr am” “ Prop a t he t ic sc p TE SEP
MBE
This was one of the most contentious and high-stakes ballot fights in California history and we rose to the occasion. We must use this unity moving forward and showcase to our colleagues the value the California Medical Association brings to our great profession and stay united for whatever comes our way next.
WINTER 2014
NOVEMBER / DECEMBER 2014 | THE BULLETIN | 35 SAN JOAQUIN PHYSICIAN 45
The Origin of Stanford Medical School By Michael A. Shea, MD Leon P. Fox Medical History Committee To discover the roots of Stanford Medical School, we must begin with Dr. Elias Samuel Cooper (1820-l862). Dr. Cooper was a controversial, yet able, surgeon in Peoria, Illinois, when in 1854 he elected to pursue postgraduate studies in Edinburgh, Scotland. It was here that he expressed his desire to open a medical college in San Francisco (discovered in a letter from Dr. Cooper to his traveling companion Hugh Keenan). His reasons for choosing an area of the country that he had not even been to seem to be found in his writings. He mentions climate and the predicted future growth of the area as some of his reasons. “Great empire to build! Brilliant destiny in future!” So it was, that in 1858, the Medical Department of the University of the Pacific was founded in San Francisco by Dr. Cooper, with 18 trustees – 36 | THE BULLETIN | NOVEMBER / DECEMBER 2014
ten of whom were clergymen and three were doctors (J. S. McClean, B. F. Hadden, and Henry Gibbons). The population of California, at that time, was under 380,000, and San Francisco about 56,000. Entrance requirements were one year’s apprenticeship with a respectable physician or graduation from high school. For medical graduation, two courses of 18 weeks were necessary, only one of which had to be taken in San Francisco. Tuition was set at $150. Providentially, there was soon the addition to the faculty of a new member who was ultimately, by his own efforts, to ensure the survival of the school. (The precursor to Stanford Medical School) This was Cooper’s nephew, Dr. Levi Cooper Lane (1828-1902), who was appointed Professor of Physiology in 1861. Elias Cooper died in 1862, succumbing at age 41 to an obscure neurological disorder. Without his leadership, the school’s momentum slack-
ened. It was about this time that Dr. Hugh Toland, a member of the current Cooper school faculty announced his plans to open a new medical school. The Toland Medical School (the future UCSF) opened in San Francisco in 1864. Outclassed and outflanked, the Medical School of the University of the Pacific suspended operation while Dr. Lane and several key faculty colleagues accepted the invitation of Dr. Toland to join the faculty of his new school. However, they later regretted their decision and, in 1870, withdrew from the Toland School. Under the leadership of Dr. Lane, they reactivated the Medical Department of the University of the Pacific, which had been suspended from 1865 through 1869. When their rejuvenated School reopened in 1870, it was located on Stockton Street, south of Geary in San Francisco, next to the laboratories of University (city) College, a Presbyterian School founded in 1860. In 1872, the school became known as The Medical College of the Pacific. After 1870, the faculty increased in size and competed successfully for students against the Medical Department of the University of California (formerly Toland Medical School). In 1876, each school awarded 20 diplomas. When the school was reorganized in 1870, Levi Cooper Lane was designated Professor of Surgery and Surgical Anatomy, a dual appointment formerly held by Elias Samuel Cooper. Lane also assumed the leadership role that Cooper had previously filled in the affairs of the school. Lane’s plan was divulged in 1882, when he donated to the school an impressive new building, constructed with his own private funds. It was located at the corner of SacraCooper Medical College, 1882 mento and Webster streets in San Francisco (see picture). That building, said to have no superior in the world for in September 1909. The last class of Cooper students graduated in May medical education at the time, was in continuous use as a medical school 1912 and Cooper Medical College ceased to exist. for the next 77 years (1882-1959). In 1959, the Stanford Hospital, the School of Medicine, and Stanford On moving to the new facility, the school was incorporated as an in- Clinics moved to the Stanford Campus in Palo Alto. dependent institution and the name changed from Medical College of the In 1968, Stanford University purchased the city of Palo Alto’s entire Pacific to Cooper Medical College in honor of Lane’s Uncle Elias. interest in the hospital’s properties and facilities. The hospital was reTwo additional structures were added to the medical school in the named the Stanford University Hospital. early 1890’s. The first was to enlarge the teaching facilities and the second Since its move to the campus, the School has grown steadily in nawas a 200-bed hospital, located at Clay and Webster Streets, adjacent to the tional status and now holds a respected place in the front ranks of medical medical school. From this, Dr. Lane established the Lane Hospital Traineducation, scientific achievement, and clinical medicine. ing School for Nurses, later to become The Stanford School of Nursing. The final detail in Lane’s grand design was in 1898 when the Doctor and Mrs. Lane announced a provision in their wills for the founding of the Lane Medical Library, which is open to the present day. Levi Cooper Lane died in 1902. Just before his death he made it possible for the Cooper Board of Directors to exercise their own judgment for the future of Cooper Medical College. This, they did by arranging, in 1908, for the transfer of Cooper Medical College and all its property in San Francisco as a gift to Stanford University for the purpose of establishing a medical department in the University. The first class of students entered The Stanford Medical Department NOVEMBER / DECEMBER 2014 | THE BULLETIN | 37
Legacy Wealth Advisors Managing the reserve investment accounts of the Santa Clara County Medical Association (SCCMA) and the Bureau of Medical Economics (BME) since 2000 1900 The Alameda Suite 510 San Jose, CA 95126 P: (408) 452-7700 F: (408) 452-7470 Email: Info@lwallc.com
Planning Topics to Consider As We Approach Year-End: • Roth IRA Conversions – we assist our clients with analyzing the suitability of converting some or all of their IRA assets to a Roth IRA. Retiring physicians should particularly consider the benefits of a Roth IRA conversion which could be done in connection with the rollover of other retirement strategies. • IRA Beneficiary Designations – it is a good idea to periodically review your beneficiary designations to ensure they are still current and consistent with your wishes. • Estate Planning – if your estate planning documents have not been updated in the last five years, it may make sense to have your estate planning attorney review them for any potential revisions. These are just a sample of the wealth management services that we provide to SCCMA and MCMS physician members and their families. Please contact us if you would like further information.
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11 th Annual Employment Law & Leadership Conference HOT TOPICS IN LABOR & EMPLOYMENT LAW The SAQUI LAW GROUP
AM GENERAL SESSION
An Enlivened Look at What’s Coming At You in 2015! If you haven’t seen Mike Saqui in action, get ready for a dynamic powerhouse of knowledge, energy and edge of your seat learning! With the Governor signing more new legislation since 2008, Mike will take you through the latest labor and employment law twists and turns and give you jargon-free advice about what you need to do to get your HR practices in line for compliance in 2015. Can listening to an authoritative lawyer about new laws be exciting? One word…YES!
AFTERNOON BREAK-OUT SESSIONS
12:45pm – 4:00pm
UP TO & INCLUDING TERMINATION: The Cornerstones of Disciplinary Action and Termination of Employment
Robert Russell, SPHR, TPO Principal & Kimberley Worley Esq., The Saqui Law Group Attend this “get to the point” program to learn how to plan and implement termination policies and practices that respect the dignity of your employees, while avoiding regulatory traps you may not be aware of. Not just what to do or not, but how to do it with best HR practices. You’ll be glad you did!
HR Q&A – Balancing both Legal and Leadership Perspectives!
Michael Saqui, Esq., The Saqui Law Group & Melissa Irwin, SPHR-CA,TPO Senior Consultant/Training Specialist Talk about brain power – a whole session with Mike Saqui & Melissa sharing both legal and HR answers and advice about the most critical questions on the minds of our conference participants – questions from General Session? Get your answers here. This fun and fast-paced session is back by popular demand!
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40 | THE BULLETIN | NOVEMBER / DECEMBER 2014
By Craig H. Kliger This article is reprinted with the permission of Real Clear Policy (www.realclearpolicy.com)
Imagine waking up to find, as Dorothy famously did in The Wizard of Oz, that you’re not in Kansas anymore, having been transported somewhere else without your volition or consent. The people you trust are nowhere to be found, and the ones you encounter range from “good” to not-so-“wonderful” to even “wicked.” This has become reality for thousands of Californians who are eligible for both Medicare (available to the elderly and disabled) and Medicaid (available to the poor), called “dual eligibles,” many of whom have complex medical problems. Unless they actively opt out of pilot programs authorized in 2010 by the Golden State – now called “Cal MediConnect” (www.calduals.org) – they are automatically (magically?) enrolled in managed-care plans. Unlike traditional Medicare, which allows enrollees to see any provider willing to accept it, these plans typically limit the doctors patients can see, potentially disrupting long-established care relationships with providers should they not participate. Of course, California isn’t in this alone. The Medicare-Medicaid Coordination Office (MMCO) within the Centers for Medicare and Medicaid Services (CMS) approved the state proposal that permitted the optout in early 2013, ostensibly consistent with the MMCO’s statutory goal of “making sure [dual eligibles] have full access to seamless, high quality health care and to make the system as cost-effective as possible.” Yet because many of these patients don’t have English as a first language and/or have limited educational backgrounds, navigating the complexity of the opt-out process may be challenging despite the state’s promise to send “multiple notices” prior to automatically enrolling patients. As a result, untold numbers have been or will be enrolled in these plans without their knowledge and likely against their wills. About two-thirds of those eligible require a 30-day notice after receiving 60- and 90-day ones, suggesting they haven’t responded. So it seems reasonable to presume the ultimate number will be very high. More disturbing, it seems the process is relying on these questionable-at-best circumstances to maximize participation and potential savings. The state of California and CMS will almost certainly counter that these demonstration projects are an attempt to improve care (by coordinating the services offered through the two programs) while reducing its cost to the state and the federal government. Certainly both are noble goals. And I am confident those involved are well-intentioned. But a careful read of the authorizing state statutes and federal documents strongly suggests that improving quality is not the priority. While there are nebulous provisions that might allow CMS to request modifications to address quality issues, the agency’s only hard requirements for modification or termination have to do with cost overruns. California has similar provisions: The program will become “inoperative,” for example, if the director of finance determines there are no “cost savings.” In fact, because CMS’s directive from Congress (see §1115A(b)(3)(B)) envisions only three acceptable outcomes – improving the quality of care
without increasing spending, reducing spending without reducing the quality of care, or improving the quality of care and reducing spending – the demonstration would be deemed a failure and shut down if it substantially improved quality while only slightly increasing costs. Further, a program truly dedicated to quality improvements would not use auto-enrollment, because changing someone’s health insurance – and, as suggested earlier, the set of providers he or she has access to – can have serious consequences. The unwitting enrollment of a California man in a regular Medicare Advantage (managed care) program in 2012 disrupted his planned treatment for age-related “wet” macular degeneration and resulted in legal blindness in the affected eye while things were sorted out. His case and others may have inspired CMS to give those that might be passively enrolled the opportunity to disenroll from or reenroll in the program monthly. Aside from the chaos this might cause, this provision does little to help those like this man, who need urgent or emergency care and have no idea where they can seek it. The irony is that California saves very little on the provider services that are most disrupted by this process. The details are complicated, but essentially this happens because California’s Medicaid fees are low and services already must be administered through managed care wherever possible regardless. Where the state might save money is in the coordination of long-term-care services. But these almost certainly could have been addressed separately. MMCO has as a statutory goal of “increasing dual eligible individuals’ understanding of and satisfaction with coverage under the Medicare and Medicaid programs.” So, how can it possibly defend what amounts to legitimized duping of huge numbers of the very people it is charged with protecting? It’s not as if efforts haven’t been made to stop this. Aside from the hundreds of comments filed with CMS that did result in some revisions, the Los Angeles County Medical Association and others recently sought an injunction – denied to date – largely based on technicalities. And it shouldn’t take a lawsuit for CMS to realize it is creating two classes of Medicare recipients by discriminating solely on the basis of economic disadvantage. Those with Medicare alone – an entitlement earned by working and paying payroll taxes over many years – retain their ability to choose managed care, not be forced into it, while those who happen to have Medicaid in addition become subject to this grand experiment. Don’t get me wrong. This is not an indictment of all managed care, and I am clearly in favor of saving money if we can. But how we do that is important, and as well-intentioned as this might have been, it’s time for the man (or woman) behind the curtain at CMS – who, having government insurance, almost certainly doesn’t face the threat of waking up one morning locked into a health plan he or she had no say in picking – to demonstrate respect and concern for these vulnerable patients. There’s still time: CMS’s Memorandum of Understanding with California allows the agency to terminate the program “without cause” with 90 days’ notice. For the sake of the welfare of the patients CMS is charged with protecting, this option should be exercised. Craig H. Kliger is an ophthalmologist and executive vice president of the California Academy of Eye Physicians and Surgeons.
NOVEMBER / DECEMBER 2014 | THE BULLETIN | 41
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Classifieds OFFICE SPACE FOR RENT/LEASE WHY ENRICH YOUR LANDLORD? • MEDICAL OFFICE SPACE – MTN VIEW
Rent/Buy/or Option to purchase 2,000 sq. ft. office with minor surgical suite in first class building within walking distance of El Camino Hospital. Full service lease, with or without furnishings. Call 650/961-2652.
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.
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
JOIN SAMARITAN INTERNAL MEDICINE
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.
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.
PREMIER COMMUNITY HEALTHCARE PROVIDERS LOCATED IN NORTHERN CALIFORNIA An exceptional practice opportunity awaits you at Samaritan Internal Medicine. Our group has been meeting patients’ needs for more than 30 years in the Silicon Valley. We believe that excellent communication leads to excellent care and we are dedicated to the health and well-being of our patients and their families.
Opportunity - Position Details
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.
We are seeking a full time Internal Medicine physician to begin work fall of 2014. Our office is located in San Jose, CA and we currently utilize Epic EHR. We are a 5 person medical group with 4 MDs and 1 NP/PA providing internal medicine services to our community.
MEDICAL OFFICE SPACE TO SUBLET • MTN VIEW
Join our team and enjoy:
Mountain View medical office space to sublet. 1,100 sq. ft. Available three days a week. In large medical complex, behind El Camino Hospital. Basement storage, untilities included. Large treatment rooms, small lab space, BR, private office, etc. Call Dr. Klein at cell 650/269-1030.
MEDICAL OFFICE SUITE FOR LEASE • SAN JOSE
900 sq. ft. suite near Regional Medical Center of San Jose. Four treatment rooms, doctor’s office, and Reception area inside McKee Medical Center. Call 408/466-9178.
MEDICAL/DENTAL/PROFESSIONAL OFFICE SUITE • SALINAS
Second story of professional building across from Salinas Valley Memorial Hospital. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $0.963/sq. ft. Rent is $1,190/month. Contact Steven Gordon at 831/757-5246.
PRIME MEDICAL OFFICE FOR LEASE • SANTA CLARA
Ideal for medical, dental, physical therapy, optometry, office use. Approximately 1,700 sq. ft., near Santana Row. Excellent parking. Call owner at 408/858-9687. 44 | THE BULLETIN | NOVEMBER / DECEMBER 2014
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Professional and personal life balance Income guarantee and comprehensive benefits package Infrastructure that supports practice growth Providing the most advanced care possible with enhanced quality and service • Contributing to SHC’s research, health education, and community service mission
CONTACT
Angela Van Ginkel, MBA Manager, Provider Recruitment & Relations 650-725-1501 UHAProvider@stanfordmed.org Samaritan Internal Medicine is partnered with University HealthCare Alliance, Stanford Hospital & Clinic’s medical foundation. The structure allows for the preservation of a private practice environment while providing access to one of the world’s leading medical institutions.
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.
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.
URGENT CARE PHYSICIAN
Palo Alto Medical Foundation is growing and is looking for a BC/BE Emergency Medicine or Family Medicine Physician to join our Medical Group in the Urgent Care Department in Santa Cruz. For more information or to submit your CV directly, please contact: Rinky Dhamija, Physician Recruiter, mdcareers@pamf.org.
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METRO MEDICAL BILLING, INC. • • • • • •
Full Service Billing 25 years in business Book Keeping ClinixMIS web based software Training and Consulting Client References
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2015: A Healthcare/ Medical Mission to the Philippines Dr. Tanya Spirtos and Dr. Toby Frescholtz of Women’s Care Medical Group are delighted to inform you that they are joining a medical mission team in January 2015! We would like to ask for your support of the team organized through the Philippine Medical Society of Northern California. This medical and surgical mission team will be traveling to Bohol, Philippines, from January 16-25, 2015. As you may recall, in 2013, the Bohol province was deeply impacted with the deadliest earthquake to hit the Philippines in 23 years followed three weeks later by a devastating typhoon. The PMSNC mission team includes a mix of physicians, dentists, optometrists, nurses, prosthetists, students and other allied health professionals. Medical services are composed of primary care, various surgical specialties, ophthalmology and dentistry. Health education for patients and continuing medical education for practitioners are also provided during these missions. Many of the patients we will serve in Bohol have never seen a doctor in their lives and often will travel 3-4 days to receive care from this mission team. There are over 120 volunteers participating with this medical mission and for many, it is our first mission trip! Due to the volunteer efforts and your donations, we are able to serve thousands of patients each year and make a difference in their lives. We are trying to raise $50,000 to cover the supply and equipment costs to transport all the necessary medical items to Bohol which will allow us to appropriately care for these patients. Your contribution of $100, or whatever you can give, will greatly help! Peter Bretan MD, the organizer of this mission, was recently presented with the 2014 Benjamin Rush Award for Citizenship & Community Service by the American Medical Association. Dr. Bretan was presented the award “for his exceptional work as an innovator in renal transplant surgery and urology as well as for his unwavering disaster relief efforts around the globe”. You can make a contribution online through PMSNC at: http://www.pmsnc. com/pages/donate.php. If you wish to make a contribution, please click on the “Donate” button under Medical Missions and you will be securely directed to PMSNC’s PayPal account. All contributions are 100% tax-deductible, and will be acknowledged by PMSNC. Thank you so much! With thankfulness and anticipation, Dr. Tanya W. Spirtos
Dr. Toby Frescholtz
PS - I welcome you to watch the highlights of the medical mission in 2014 to Tarlac, Philippines at: http://www.pmsnc.com/pages/volunteer.php
NOVEMBER / DECEMBER 2014 | THE BULLETIN | 45
NOW AVAILABLE
From Medicine Man to Medical Doctor The Medical History of Early Santa Clara Valley
31 Chapters covering 110 pages of the local medical history from the Ohlone Period to the American Period • Origin of major Bay Area hospitals (SCVMC, O’Connor Hospital, San Jose Hospital, Agnews State Hospital, and more) • History of UCSF and Stanford medical schools and founders • Biographies of pioneer physicians (e.g., Benjamin Cory, John Townsend, John Marsh, Euthanasia Meade, Henry Warburton, and more) • Topics of interest (e.g., Trephination, Bloodletting, Gold Rush Medicine, Orificial Surgery, Cholera Epidemic of 1850, Famous Grizzly Bear Attack of 1854)
46 | THE BULLETIN | NOVEMBER / DECEMBER 2014
Authors: Michael A. Shea, MD; Gerald E. Trobough, MD; Elizabeth Ahrens-Kley
$19.95 incl. S&H FOR INQUIRIES/ORDERS – SEND CHECK TO: Michael A. Shea, MD 6807 Leyland Park Drive San Jose, California 95120 Email: md6996@sbcglobal.net Phone: 408/268-5820 All profits will be donated to the construction of the new medical museum at Santa Clara Valley Medical Center.
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