2018 March/April

MARCH / APRIL 2018 VOLUME 24 | NUMBER 2

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BULLETIN THE

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

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

MEMBER BENEFITS Billing/Collections CME Tracking Discounted Insurance Financial Services

Feature Articles 10 Frequently Asked Questions and CMA’s Medical-Legal Library: One of Your Most Valuable Benefits 14 Physician Burnout

Health Information Technology

Departments

Resources

5 Awards Banquets – Save the Dates

6 Message From the SCCMA President

7 Message From the MCMS President

House of Delegates Representation Human Resources Services Legal Services/On-Call Library

17 Welcome New Members

Legislative Advocacy/MICRA

18 Classified Ads

Membership Directory APP for

20 Medical Times From the Past

the iPhone Physicians’ Confidential Line Practice Management Resources and Education

24 Hospital News 28 MEDICO News 34 Physicians News Network

Professional Development Publications Referral Services With Membership Directory/Website Reimbursement Advocacy/ Coding Services Verizon Discount MARCH / APRIL 2018 | THE BULLETIN | 3

The Santa Clara County Medical Association OFFICERS

CHIEF EXECUTIVE OFFICER

COUNCILORS

President Seham El-Diwany, MD President-Elect Kenneth Blumenfeld, MD Past President Scott Benninghoven, MD VP-Community Health Cindy Russell, MD VP-External Affairs Erica McEnery, MD VP-Member Services Ryan Basham, MD VP-Professional Conduct Faith Protsman, MD Secretary Seema Sidhu, MD Treasurer Anh Nguyen, MD

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Lewis Osofsky, MD El Camino Hospital: Gloria Wu, MD Good Samaritan Hospital: Vinit Madhvani, MD Kaiser Foundation Hospital - San Jose: Hemali Sudhalkar, MD Kaiser Permanente Hospital: Martin Wong, MD O’Connor Hospital: Cathy Angell, MD Regional Medical Center: Heather Taher, MD Saint Louise Regional Hospital: Vacant Stanford Health Care / Children's Health: John Brock-Utne, MD Santa Clara Valley Medical Center: Clifford Wang, MD

CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Kenneth Blumenfeld, MD (District VII)

BULLETIN THE

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

THE MONTEREY COUNTY MEDICAL SOCIETY

Printed in U.S.A.

OFFICERS

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 2018 by the Santa Clara County Medical Association.

4 | THE BULLETIN | MARCH / APRIL 2018

President Maximiliano Cuevas, MD President-Elect David Ramos, MD Past-President Craig Walls, MD PhD Secretary Alfred Sadler, MD Treasurer Steven Harrison, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Valerie Barnes, MD Christopher Burke, MD David Holley, MD William Khieu, MD Eliot Light, MD

Phillip Miller, MD Walter Mills, MD James Ramseur, MD Stephen Saglio, MD Diane Sanchez, MD

SCCMA Annual Awards Banquet and Installation Tuesday, June 5, 2018 6:15 pm Social | 7:00 pm Dinner & Program The Fairmont Hotel, San Jose Installation Kenneth Blumenfeld, MD, SCCMA President 2018-19 Honoring Seham El-Diwany, MD, SCCMA President 2017-18 Award Honorees Martin Fishman, MD – Robert D. Burnett, MD Legacy Award Sameer Awsare, MD – Benjamin Cory, MD Award William Parrish – William C. Parrish, Jr. Leadership in Healthcare Award Ruma Kumar, MD – Outstanding Achievement in Medicine John Tatman, MD – Contribution in Medical Education Thomas Dailey, MD – Contribution to the Medical Association Suchada Nopachai, MD – Contribution to the Community John & Gini Mitchem – Citizen’s Award SCCMA Alliance & Foundation – Special Recognition Award Formal invitations will be mailed by end of April

JUNE 5, 2018 JUNE 7, 2018

MCMS Annual Physician of the Year Banquet and lnstallation Thursday, June 7, 2018 6:30 pm Social | Dinner & Program to follow Bayonet and Black Horse, Seaside Installation David Ramos, MD, MCMS President 2018-19 Honoring Maximiliano Cuevas, MD, MCMS President 2017-18 Physician of the Year To Be Announced Formal invitations will be mailed by end of April

MARCH / APRIL 2018 | THE BULLETIN | 5

President, Santa Clara County Medical Association

SEHAM EL-DIWANY, MD, FAAP

MESSAGE FROM THE

SCCMA PRESIDENT

Are There Safeguards Against Opioid Overdose?

Seham El-Diwany, MD, FAAP is the 2017-2018 president of the Santa Clara County Medical Association. She is a board certified pediatrician with The Permanente Medical Group and is currently practicing with Kaiser Permanente San Jose.

T

he CDC in February 2017 reported that from 1999 to 2015 more than 183,000 Americans died from overdoses related to prescription opioids. Also, the NCHS (National Center for Health Statistics) detailed some striking changes in two areas: the specific drugs involved and the age groups of the people most affected. In 2010, 29% of fatal overdoses involved so-called “natural” and “semisynthetic” opioids (morphine, oxycodone), while only about 12% involved methadone, a “synthetic” opioid. Five years later, the percentage of fatal overdoses involving these drugs fell to 24% and 6%, respectively.

In contrast, fatal overdoses involving heroin skyrocketed from 8% in 2010 to 25% in 2015, essentially tripling. Different age groups were also hit far harder by fatal opioid overdose than others. While overdose death rates increased for all age groups, the greatest increase was in adults aged 55-64.

Still, the group with the highest overall rates of fatal overdose was in the 45-54 age group.

Heroin and opioid analgesics have a problematic relationship: Research suggests that since they act similarly in the brain, taking prescription opioids even “as directed” can increase one’s susceptibility to becoming hooked to the other.

So, while the overdose death rate for illicitlyobtained opioids like fentanyl is skyrocketing (it jumped 73% from 2014 to 2015,) the overdose death rate from many other legal prescription opioids is rising far more slowly (4% over the same period).

That suggests that recent efforts aimed at curbing widespread over-prescribing practices could be starting to have a positive impact.

Fentanyl is a tricky drug: It’s 50 times stronger than pure heroin and is readily available in the pharmacy and on the black market.

The opioid antagonist Naloxone has been used to reverse illicit and anesthetic overdose of opioids for decades and has recently become readily available in easy to use injection kits and nasal sprays. In Baltimore, Maryland the health commissioner has made it essentially an over-the-counter medication.

6 | THE BULLETIN | MARCH / APRIL 2018

Despite these reduced technical barriers, cost and supply varies depending on where and how it can be obtained. Cost assistance programs for patients with financial difficulties and no insurance are also available but all too often the drug isn’t available when it’s most needed.

The first provision of take-home naloxone in the United States occurred in Chicago, Illinois in 1996. Following the death of one of its founding members in May 1996, the Chicago Recovery Alliance began providing training and dispensing naloxone kits as early as autumn 1996. Because of the demand arising from a four-fold increase in druginduced deaths reported by the Medical Examiner’s Office from 1996 to 2000, naloxone distribution was converted into a formal program with a standardized training curriculum in 2001. The first state program was enacted that same year in New Mexico.

In California, AB 2760 (Wood) is currently being introduced and has not passed the house of origin yet – it requires that, for certain categories of high-risk patients, prescriptions for opioids must also include a co-prescription for naloxone. The bill describes a high-risk patient as one who fits in one of these three categories: 1. The prescription dosage for a patient is between 50 and 100 morphine milligram equivalents of an opioid medication per day.

2. An opioid medication is prescribed concurrently with a prescription for benzodiazepine.

3. The patient presents with an increased risk for overdose, including a patient with a history of overdose, a patient with a history of substance use disorder, or a patient at risk for returning to a high dose of opioid medication to which the patient is no

Continued on page 8

President, Monterey County Medical Society

MAXIMILIANO CUEVAS, MD, FACOG

it back into the electronic health record; without the information, the differential diagnosis remains unchanged and the care of the patient remains as previously managed. Another scenario to consider is one that arises when we interface with another medical office to arrange a referral for specialty consultation; without accurate and timely information, delays in the care of the patient will happen. And another scenario occurs when our patient is evaluated in the emergency department or admitted to the hospital under the care of a hospitalist; often, the information about the patient does not get back to the primary care physician in a timely manner.

The solutions require an understanding of the desired outcome and knowing what it is that we will measure.

Medical care is error-prone even when care is provided by a single provider; opportunities for serious error increase when multiple providers are involved. The scenarios described are examples of fragmented care involving a number of physicians who are not communicating and sharing information. Reduction in the fragmentation of care can occur by making sure that all providers share clinical information with each other and by making sure that all providers have clear shared expectations about their role in the care of the patient. Strategies for reduction of fragmentation must also include ways to make sure that patients and their families are informed and that their care experience is a “perfect” one when we transition their care from the ER or hospital back to our office.

The reasons for fragmentation of care can be found by taking a look at how our delivery of care is organized. First, most medical practices are independent, so office policy and procedures for patient management are different between the practices.

Second, not all offices are using electronic health records. Third, existing payment methodology does not cover care coordination. Finally, health plan physician networks and the separation of primary care from hospital care have affected the personal relationships between primary care physicians and their specialist consultants and the institutions where patients get care.

How many times have we or our staff been involved in non-beneficial exchanges with other specialists about the poor quality of information sent by referring physicians and the inappropriateness of the referral? Do we hear complaints from our primary care colleagues that they often do not get information back from their consultants or are not notified

MESSAGE FROM THE

H

ealthcare is fragmented across the United States and Monterey County is no different. A patient and their physician must interact with medical specialists, community service agencies, and hospital and emergency facilities. Our patients are required to navigate through a landscape to get from Point A to Point F, but there is no map or directions on how to get there in order to receive their healthcare services. Often, physician offices are busy and might not provide sufficient guidance. What strategies can we develop to assist our patients to successfully reach each point in the healthcare landscape and receive needed care in a timely manner? We can start by reforming our local delivery system to create coordination of care that first addresses who is responsible for making that system work for both our patients and our physicians; who is accountable for making it work well?

I posit that it is the primary care physician. Later we can discuss strategies for providing patient support and guidance for navigating the process, then we will discuss strategies for building relationships and agreements among providers (including community agencies) that lead to shared expectations for better communication and care, and finally we will discuss strategies for developing connectivity via information pathways that encourage timely and effective communication flow between providers (including community agencies).

The daily care of our patients requires that we are current in regards to information about our patients’ health. After all, it is the physician that has caused that information to be made available as part of the process used to develop a differential diagnosis prior to reaching a final diagnosis. And it is the physician who uses the information to make a decision regarding our patients’ health or related conditions.

What happens when the “flow” of information is interrupted and does not get back to the physician? If we can manage and coordinate the flow of information regarding our patients as they traverse the many silos that currently exist in our medical delivery system, we can expedite the care of our patients, saving time and money for our patients and the delivery system that we use to “navigate” the care we provide to those people.

The delays in diagnosis and care are avoidable but require an understanding of the various factors that cause the “waste of time.” Not having the medical information on our patient can create a number of issues. Consider the common scenario in which our patient may have returned to the office for a followup on laboratory testing, but the results did not make

MCMS PRESIDENT

Care Coordination

Maximiliano Cuevas, MD, FACOG is the 2017-2018 president of the Monterey County Medical Society.

He is currently the Chief Executive Officer at Clinica de Salud del Valle de Salinas.

Continued on page 8 MARCH / APRIL 2018 | THE BULLETIN | 7

Message From the MCMS President, from page 7 when their patients are seen in the ER or are admitted to the hospital?

In 2001, the Institute of Medicine published its aims for high-quality health care: 1. Timely: Patients receive needed transitions and consultative services without unnecessary delays.

2. Safe: Referrals and transitions are planned and managed to prevent harm to patients from medical or administrative errors.

3. Effective: Referrals and transitions are based on scientific knowledge, and executed well to maximize their benefits.

4. Patient-centered: Referrals and transitions are responsive to patient and family needs and preferences.

5. Efficient: Referrals and transitions are limited to those that are likely to benefit patients, and avoid unnecessary duplication of services.

6. Equitable: The availability and quality of referrals and transitions does not vary by the personal characteristics of patients.

These aims define high-quality health care from the patient’s perspective. From the perspective of the various physicians involved in the care of the patient, high-quality health care must meet their needs and expectations as well. Successful coordination of care and transitions of care must insure that the primary care physician sends relevant information to the specialist and the specialist must communicate with the referring physician.

Establishing the conditions and infrastructure for assuring quality referrals and transitions is a core responsibility of the primary care physician. Or is it? Physicians that assume responsibility and make an effort to coordinate care try to develop the relationships, infrastructure, and processes that support successful referrals and transitions; we are accountable for the care of our patients. A referral is more likely to be successful if referring and consulting physicians understand each other’s expectations and if they have the information infrastructure to assist patients and their information get to where they need to go. This information must be shared and made clear to the patient and to their family to get their buy-in to play an active role in this process. We can begin by having groups of primary care physicians review expectations for communication about patients with their consultant partners. Draft

agreements regarding these expectations are available.

Physicians must work with hospitals and hospitalists, emergency rooms and emergency physicians, to make them accountable for assuring quality transitions when our patients are discharged back to the office. Let’s have our various hospital medical staffs work on agreements regarding the expectation on information exchange from the hospital and ER back to the office.

Receiving relevant patient information must be a priority and strategies to increase the likelihood that this information makes it to where it is needed must be identified. One approach is to develop the ability to track referrals and transitions to make sure that they are completed.

Referral tracking can be facilitated by a system (electronic health records or paper records) that document when the referral appointment was made, when patient information was received, when the appointment was completed, and when the consultation note was received. A useful referral tracking system will include: 1. Patient name; 2. Patient ID number; 3. Diagnosis; 4. Brief reason for referral; 5. Consultant name; Insurance status; 6. Referral request status (sent, received); 7. Appointment date; 8. Required pre-appointment tests; 9. Appointment completion; 10. Consultant note received; 11. Post-consultation care (consultant follow-up visits, specialistto-specialist referral, return to primary care).

The practice will have to regularly receive information regarding its patients’ admissions and discharges from hospitals and emergency rooms so that it can set up a system for tracking transitions. Tracking this information daily to get early contact with a recently hospitalized patient or their family improves post-discharge care and prevents readmission. To get this done, consider assigning one staff member to check on this each day in the morning to find out if any of our patients have been admitted. We can discuss this strategy with our local hospital administrators.

Message From the SCCMA President, from page 6 longer tolerant.

Does supplying the high-risk patient for opioid overdose with a co-prescription of Naloxone prevent future overdoses?

In fact, while Naloxone has the capacity to prevent an eminent death, it has not shown to be effective in preventing further overdose episodes. As the addiction cycle continues, patients remain just as likely to overdose again.

Preventing opioid overdose requires preventing more than just one episode in a series of overdoses. It requires a multipronged strategy to eliminate and prevent future overdoses.

STRATEGY 1: Encourage providers, persons at elevated risk, family members, and others to learn how to prevent and manage opioid overdose.

STRATEGY 2: Ensure access to treatment for individuals who are misusing or addicted to opioids or who have other substance use disorders.

STRATEGY 3: Ensure ready access to naloxone.

8 | THE BULLETIN | MARCH / APRIL 2018

STRATEGY 4: Encourage the public to call 911.

STRATEGY 5: Encourage prescribers to use state Prescription Drug Monitoring Programs.

Therefore, it is imperative that we strive to achieve a balanced approach to ensure that people suffering from pain can get the relief they need while minimizing the potential for negative consequences. This can be achieved through the development and implementation of multidisciplinary, evidence-based strategies that would not only prevent over prescribing but would also improve access to chemical dependency treatment programs together with a targeted strategy to prevent over dose death in those at elevated risk.

I’m still hopeful, even with the current shift in health care coverage from a mandate to a personal choice that we continue to address the epidemic strategically and improve access to treatment programs.

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CMA’s Medical-Legal Library: One of Your Most Valuable Benefits

C

MA On-Call, the California Medical Association (CMA) online health law library, contains nearly 5,000 pages of upto-date legal information on a variety of subjects of everyday importance to practicing physicians. One of CMA’s most valuable member benefits, the searchable online library contains all the information available in the California Physician’s Legal Handbook (CPLH), an annual publication from CMA’s Center for Legal Affairs.

CMA members can access On-Call documents free at www.cmanet. org/cma-on-call. Nonmembers can purchase On-Call documents for $2 per page. CPLH, the complete health law library, is also available for purchase in a multi-volume print set or annual online subscription service. To order a copy, visit www.cplh.org or call (800) 882-1262.

The following are some examples of frequently asked questions and

10 | THE BULLETIN | MARCH / APRIL 2018

the CMA On-Call documents that can help answer your questions.

FAQ: CAN I PROVIDE TREATMENT FOR MY FRIENDS, FAMILY MEMBERS AND COLLEAGUES? Physicians are often called upon to treat or write prescriptions for friends, family members, or colleagues. Although California law does not specifically prohibit treating oneself or one’s family members, American Medical Association (AMA) policy and the California Medical Board strongly discourage the practice. California law does prohibit prescribing or administering controlled substances to oneself.

AMA policy points out that treating a family member may cause the physician to lose objectivity and allow personal feelings to unduly affect his or her professional medical judgment. Patients may feel uncomfortable disclosing sensitive information or undergoing an intimate examination if

they have a familial or personal relationship with the physician. Physicians may also feel obligated to provide treatment even if they are not comfortable doing so.

Physicians should also be aware that some payors limit their obligation to reimburse physicians who treat themselves or their relatives. Medicare, for example, expressly excludes coverage for treatment of a physician’s immediate relatives.

For more information on treating oneself, friends or family, see CMA On-Call document #7655, “Treatment of Relatives (or Oneself).” For information on treating colleagues, see CMA On-Call document #3500 “Establishment of the Physician-Patient Relationship.”

FAQ: IS IT OK TO CHARGE PATIENTS FOR MISSED APPOINTMENTS? The California Medical Association (CMA) often receives questions from members as to appropriate billing policy when a patient repeatedly “no-shows” or misses a scheduled appointment. What you may not know is that unless a physician has entered into a contract with a payor that prohibits such charges, a physician may charge a patient when he or she misses an appointment or does not cancel in adequate time to allow another patient to fill the appointment slot – if advance notice of such a billing policy is given. Specific billing rules may also apply with regard to certain payors (e.g., Medi-Cal and Medicare).

For more information about your rights when it comes to billing patients for missed appointments, see CMA medical-legal document #7600, “Billing Patients.”

This document includes a detailed discussion about noncovered services, discounts for the uninsured, and discounts for prompt payment and stresses the importance of receiving and maintaining accurate patient financial information. It also contains a sample patient financial responsibility form.

FAQ: DO SERVICE DOGS HAVE TO BE ACCOMMODATED IN A PHYSICIAN’S OFFICE? Physicians are asked to accommodate service dogs in their offices

with increasing frequency. The law generally requires a place of public accommodation, like a physician’s office, to permit service dogs where customers would normally be allowed so long as providing the accommodation is reasonable and necessary. However, what constitutes a service dog is not always obvious as many people also have companion animals or emotional support animals they wish to bring.

The law does not require companion animals to be accommodated in the same way as service animals. To help distinguish, a service animal must be one that is individually trained to provide assistance to a person with a disability. Although service animals are required to have identification tags identifying them as service animals, the law does not require a service animal to have completed a certain requisite training or examination.

A person with a mental disability may have either a psychiatric service animal or a companion animal. A psychiatric service animal must be accommodated by law, whereas the companion animal need not be. To qualify as a psychiatric service animal, the animal must not only recognize a problem, but must be trained to respond to that problem.

To determine whether an animal is truly a service animal, physicians may ask what task the animal is trained to perform and whether it is required for a disability. But physicians should avoid asking about the nature and extent of the person’s disability and may not request further documentation of the dog’s certification or training. Determining whether an animal is truly a service animal can be a blurry line. Physicians should exercise extreme caution and consult with a personal attorney or their professional liability carriers where appropriate.

To learn more about the intricacies of the Americans with Disabilities Act and the accommodation of service animals see CMA On-Call document #6002, “Disabled Patients: Health Care Services.”

FAQ: HOW MUCH CAN I CHARGE FOR COPYING MEDICAL RECORDS? As the health care system moves in a direction of transparency and

Continued on page 12 MARCH / APRIL 2018 | THE BULLETIN | 11

increased access to medical information, physicians are often put in the position of deciding if and how much they should charge patients and patient representatives who request copies of medical records.

Physicians and office staff should be aware that there are several statutes that specify how much can be charged for copies of medical records in certain circumstances.

CMA medical-legal document #4002, “Medical Records: Allowable Copying Charges,” details how much a physician can charge based on the type and source of the request, including requests from patients, patients’ attorneys and insurers, as well as subpoenas for medical records. The document also includes a discussion of specific limitations for HIPAAcovered entities when responding to patient access requests, as well as the rules that apply to physicians who use electronic health records.

FAQ: RECORD RETENTION UNDER CALIFORNIA LAW Statutory authorities that specifically regulate the retention of medical records in a physician’s office are found broadly in California law. These include the Medi-Cal Act, the law governing the Emergency Medical Services Fund, the California Uniform Controlled Substances Act, the KnoxKeene Act, OSHA rules and the laws governing workers’ compensation.

The California Medical Association’s (CMA) ON-CALL document #4005, “Retention of Medical Records,” discusses the major issues raised by the retention, abandonment, theft and destruction of medical or health insurance information and physician practice business records, including: statutory record retention requirements, the rules applicable to records abandoned in bankruptcy or otherwise, recommended retention periods, options for record management on the sale or closing of a medical practice, record destruction requirements, and obligations for safeguarding patients personal information and for responding when records containing identifying information are stolen or otherwise breached.

FAQ: ELECTRONIC COMMUNICATION WITH PATIENTS: PATIENT PORTALS, E-MAIL AND ONLINE ADVICE As physicians and patients embrace the use of technology in health, physicians are increasingly using various forms of electronic communication to interact with their patients. In fact, many patients prefer having the option to communicate with their physicians via email, text, or electronic messaging through a patient portal to receive test results, refill prescriptions, and obtain medical advice for non-emergent care. Physicians, however, must be mindful of liability risks when communicating with patients electronically. CMA offers medical-legal document #0405 “Electronic Communication with Patients: Patient Portals, E-mail and Online Advice,” which discusses the major issues that arise when physicians engage in electronic communications with their patients. For information on physician practice websites, see CMA ON-CALL document #0402, “Physician Practice Websites.” For information on the use of social media by physicians and their staff, see CMA ON-CALL document #0403, “Physicians and the Use of Social Media.” For information on online physician review and rating websites, see CMA ON-CALL document #0401, “Online Consumer Review and Rating Sites.” For information on electronic medical records, see CMA ON-CALL document #4300, “Electronic Health Records.”

FAQ: MEDI-SPAS: LEGAL CONCERNS FOR PHYSICIANS Have you been asked by a layperson to serve as a “medical director” for a “medi-spa” that provides laser and other cosmetic medical services?

If you agree to, you could be in violation of California law. A physician 12 | THE BULLETIN | MARCH / APRIL 2018

contracting with or acting as an employee of a lay-owned business offering cosmetic medical services would be aiding and abetting the unlicensed practice of medicine. Only individuals who are licensed to practice medicine in the State of California can legally offer or provide medical services.

To assist you in understanding the laws that regulate the provision of cosmetic medical services in California, the California Medical Association (CMA) has published medical-legal document #3701, “Cosmetic Procedures.”

In addition to the discussion of medi-spas, the document includes information on who can legally perform procedures including laser treatments, Botox injections and microdermabrasion. The document also discusses the rules for hiring estheticians or cosmetologists in your medical office.

Physicians are encouraged to review the laws that govern the provision of cosmetic medical services. Using unlicensed individuals to perform medical treatments can subject you to serious penalties, ranging from medical board disciplinary action to criminal prosecution.

FAQ: PATIENT RETENTION/RESTRICTIVE COVENANTS Physicians who leave a medical practice often have questions concerning restrictions that may prohibit them from continuing to treat patients they have seen during their former practice.

Although it must be emphasized that the facts specific to each case may completely change the legal analysis, CMA On-Call document #3501, “Patient Retention/Restrictive Covenants,” provides general answers to commonly asked questions regarding these two issues.

Under “Covenants Not to Compete,” the document begins by addressing the following question: “My contract with the group I just left contains a provision that says that I am prohibited from setting up a medical practice in my county for three years after I leave the group. Is this lawful?”

The answer provides a legal analysis of restrictive covenants for physicians who are: • employees of a medical group, • independent contractors, • partners in a medical group, or • owners of, or shareholders in, a medical practice.

Included in the answer is the opinion discouraging restrictive covenants issued by the Council on Ethical and Judicial Affairs of the American Medical Association. Additionally, the document addresses the legality of requiring residents and fellows to sign a covenant not to compete as a condition of enrollment in a teaching institution.

The document also deals with the scope of restrictive covenants and notification of patients when a physician’s employment contract with a medical group or managed care plan is not renewed.

FAQ: HAVE YOU BEEN ASKED TO PROVIDE EXPERT WITNESS TESTIMONY? Quite often, the California Medical Association (CMA) receives inquiries from physicians who have been issued a subpoena or have been retained to provide expert witness testimony in a civil or criminal case.

CMA medical-legal document #0501, “Expert Witness Issues,” answers the most common questions that arise in these instances.

The document covers issues such as expert witness fees and depositions, expert witness testimony, the general status of treating physicians, ethical issues, and HIPAA implications. The document also includes a sample expert witness retention agreement for use in civil cases.

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Burnou

Physician Burnout

CMA Doc: Edward Ellison, M.D. Southern California physician sets out to teach physicians that their wellness matters

“Physicians are ailing,” says Edward Ellison, M.D. He wants the public to know about it and to thank their physicians, he wants governing bodies to understand the toll their reporting and oversight requirements are taking on physicians, and he wants the physicians who lead medical schools, residency programs and medical groups to change the nature of being a physician from one of suffering to one of health and well-being.

Dr. Ellison is in a position—or more accurately, many positions—to effect that change. Since 2012, he has been Executive Medical Director and board chair of the Southern California Permanente Medical Group. He is also board chair and CEO of the Southeast Permanente Medical Group, comprised of 500 physicians in the cities of Atlanta and Athens, GA, and surrounding areas. >>

14 | THE | MARCH / APRIL 2018 24BULLETIN CENTRAL VALLEY PHYSICIANS

Winter 2018

Dr. Ellison is so concerned about physicians’ unhappiness in a profession they once loved that he presented the grim picture to a public, nonmedical forum, the 2017 TEDxNaperville conference in the Chicago area this November.”

He is co-CEO of the nationwide Permanente Federation. And he is a member of the board of directors of the soon-to-be Kaiser Permanente School of Medicine, under construction in Pasadena.

He was also part of an AMA consortium of 10 physician leaders of major medical groups, including the Mayo and Cleveland clinics and several academic medical centers, drawn together in 2016 to propose solutions to the physician burnout crisis, which jeopardizes the quality of care and is pushing more and more physicians to leave the profession.

Dr. Ellison is so concerned about physicians’ unhappiness in a profession they once loved that he presented the grim picture to a public, nonmedical forum, the 2017 TEDxNaperville conference in the Chicago area this November. Among the causes of burnout, Dr. Ellison, said are that physicians, who are by nature perfectionists, feel they have lost control over their work and are “being measured on everything they do.” The electronic health care records and reporting requirements have created inefficient workf lows and less time for patients, which “feel like a gigantic pile-on.” He noted that surveys of physicians conducted in 2011 and again in 2014 showed that numbers of physicians experiencing at least one symptom of burnout rose to 54.4 percent from 45.5 percent.

“But it gets darker,” Dr. Ellison said. “In the last two years data show that the rate of suicide among male physicians is 40 percent higher than that of the general public,” with female physicians’ suicide rate “130 percent greater than the general public.” In fact, he said, “The rate of suicide among physicians is similar to that of combat veterans.”

Much of the problem, too, begins in medical school with many physicians entering practice after residency training already “broken and beaten,” Dr. Ellison said. He noted that two of his medical school classmates killed themselves before beginning their internships. He described his early career within the traditional “lockstep” regimen of American medical education: “I did the

Winter 2018

In a first for U.S. academic medical center, Stanford Medicine hires chief physician wellness officer

BY RUTHANN RICHTER, STANFORD UNIVERSITY

Tait Shanafelt, M.D., a pioneer and nationally recognized expert in physician burnout, recently joined Stanford Medicine as its first chief wellness officer, leading the medical center’s pioneering physician wellness program.

His appointment makes Stanford the first academic medical center in the country to create a position of chief wellness officer at a time when physician burnout nationally has reached an all-time high. Dr. Shanafelt, whose clinical work and research focus on the treatment of patients with chronic lymphocytic leukemia, will direct the WellMD Center at Stanford Medicine and serve as associate dean of the School of Medicine.

Leading the way Since 2008, Dr. Shanafelt has overseen multiple national surveys that included more than 30,000 U.S. physicians and about 9,000 U.S. workers in other fields. These found increasing rates of burnout among doctors; in 2014, more than half of those surveyed were suffering from emotional exhaustion, loss of meaning in work or a sense of ineffectiveness and a lack of engagement with patients. Moreover, his studies have found that as physicians suffer, so do patients: Burnout has been found to contribute to physician errors, higher mortality among hospitalized patients and less compassionate care.

“I think most health care leaders now realize this is a threat to their organization, but there is also uncertainty that they can do anything effective to address it,” Dr. Shanafelt said. “They say, ‘It’s a national

MARCHVALLEY / APRIL 2018 | THE BULLETIN | 15 CENTRAL PHYSICIANS 25

epidemic, what can we do?’ My experience has shown that an individual organization that is committed to this at the highest level of leadership and that invests in well-designed interventions can move the needle and run counter to the national trend of physician distress and burnout. I hope that the Stanford WellMD Center becomes a paragon that other medical centers want to emulate.”

Declining burnout rates at Mayo In 2008, Dr. Shanafelt became the Mayo Clinic’s director of the Department of Medicine Program on Physician Well-Being and launched an effort to address physician distress through programs promoting physician autonomy, efficiency, collegiality and a sense of community. While many were focused on strategies to make individual physicians more resilient, Dr. Shanafelt and his team focused on systems, the practice environment, organizational culture, and leadership.

As a result, the absolute burnout rates among Mayo physicians declined 7 percent over two years, despite an 11 percent rise in the rate among physicians nationally.

Dr. Shanafelt will work in collaboration with his new colleagues at Stanford in building on its innovative WellMD Center, which was established in 2016. The center has engaged more than 200 physicians through programs focusing on peer support, stress reduction and ways to cultivate compassion and resilience, as well as a literature and a dinner series in which physicians explore the challenges and rewards of being a doctor.

Bryan Bohman, M.D., who served as WellMD’s interim director, said the WellMD team has worked closely with Dr. Shanafelt over the past year on projects of mutual interest.

“All of us at the center have been struck by Tait’s collaborative nature, his integrity, his warmth, his generosity of spirit and his work ethic,” said Dr. Bohman, who also serves as chief medical officer for Stanford’s University Healthcare Alliance. “Both at Mayo and nationally — in the physician wellness community — Tait is seen as an inspiring and strong leader. We couldn’t be happier that he will be guiding our future wellness work at Stanford.”

This article was excerpted with permission from Stanford Medicine News. Ruthann Richter is the director of media relations for the Stanford University School of Medicine Office of Communication & Public Affairs.

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I have gained perspective. I have heard the cries. it is time that society recognize and care about the lives of those who save lives.”

training. I went without sleep. I ate junk. And I learned and I suffered. But I was also inspired by the gratitude of my patients and the satisfaction of knowing I was making a difference in people’s lives. So I did more and I asked for more and took on more, as my colleagues do.”

Now, however, having been “called to leadership,” and being a “co-leader of one of the largest groups of physicians in the world—21,000 doctors taking care of almost 12 million patients,” he said, “I have gained perspective. I have heard the cries.” He said it is time that society “recognize and care about the lives of those who save lives.”

Within SCPMG, he spearheaded a physician wellness program focusing on physicians’ health and on burnout prevention. For the physicians of the future he wants a total transformation of the American medical culture.

“We need to change our thinking,” Dr. Ellison says, “and change our culture inside and outside of the medical profession across society…We have to declare our physicians’ humanity.”

Permanente, he says, has a “path forward” beginning with its new medical school. As well as teaching students to be exceptional physicians, which is “nonnegotiable,” he says, “We are going to teach them that their wellness matters. We are going to provide support for them and connect them with each other and resources. We are going to teach them how to set healthy boundaries for their own wellness and about how prevention and nutrition work not just for their patients but for themselves.”

For whatever kind of medical system—small practice, large practice, academic institutions—that the students set their sights on, he says, ““We’re going to teach them how to work within theses systems to change these systems so they’re not buffeted about [and] they can be advocates for change.”

“I still love my profession,” Dr. Ellison says, and he hopes young people, “those bright shining stars,” will continue to seek it out.

Winter 2018

MEMBERSHIP

Welcome 114 New Members Santa Clara County Medical Association Name City Specialty Emily Adams-Piper San Jose OBG Sirtaz Adatya Santa Clara IC Tayyeba Ali Santa Clara OPH Charlene An Santa Clara EM Robert Atienza San Jose PTH Nagehan Ayakta Menlo Park STU Kristin Berona Santa Clara EM Isabel Beshar Palo Alto STU Hriday Bhambhvani Stanford STU Punam Bhullar Mountain View UC Drew Birrenkott Stanford STU Jonathan Bradley Palo Alto AN Siqi Cao Stanford STU Kiersten Carter Santa Clara EM Carla Carvalho Palo Alto CCS Leon Carlos Castaneda San Jose HOS David Chang Los Gatos VS Helen Chang Millbrae PD Faraaz Chekeni Palo Alto PD Garrett Chinn Santa Clara IM Lauren Conti Santa Clara PD Amy Couturier San Jose PD Courtney Cunningham Santa Clara IM Susannah Daniel Palo Alto FP Linh Dao San Jose IM Marissa Darling San Jose PM Kimberly DeBruler STU Roberto Diaz Mountain View OSM Monica Eneriz Wiemer Mountain View PD Kathryn Erickson-Ridout San Jose P Michael Fahmy Palo Alto AN Thomas Gaffey Palo Alto AN Stephanie Gancarczyk San Jose ORS Amy Gin Santa Clara IM Juliana Gomez-Arostegui Sunnyvale PD Monica Goodstein San Jose GS Camilla Guitarte San Jose OBG Liv Harmon San Jose GS

Name Kathryn Hawrylyshyn Jared Herr Rwo-Wen Huang Michael Hung Deborah Ikhena-Abel Eric Imoto Shiv Jain Maris Jones Paula Jossan Shanthala Keshavacharya Faeza Khan Yonitte Kinsella Seul (Kathy) Ku Monique Kuo Jerry Lai Melissa Larsen Giang Le Stephen Lee Christopher Lim Lei Yuan Lim Shirley Liu Tiffany Lo Devin Lonergan Becky Luo Kyaw Lwin Zeshaan Maan Suneetha Maddineni John Mark Michael Marques Wasi Mohamed Edward Moon Heather Narciso Aaron Nayfack Elaine Nguyen Kim-Son Nguyen Julia Nordgren Katharine O'Malley Heena Panchal

City Specialty Palo Alto AN Palo Alto CDS Santa Clara EM Palo Alto AN Santa Clara OBG San Jose IM Mountain View FP Santa Clara GS Los Gatos PE Palo Alto AN Santa Clara PD San Jose EM Palo Alto STU Santa Clara PLM Sunnyvale OPH Salinas OBG Santa Clara AN San Jose U San Jose EM San Jose IM Palo Alto AN Mountain View PD Palo Alto OTO Mountain View UC Palo Alto AN Menlo Park RST Mountain View IM Palo Alto PD Palo Alto AN Cupertino P Palo Alto ORS Santa Clara IM Los Altos PD Santa Clara AN Sunnyvale HO Portola Valley PD Santa Clara OBG San Jose P

Name David Parris Brandon Pham Brendan Pierce Jordan Piluek Ehsan Rahimy Kirtee Raparia Samuel Ridout Daniel Rosenbaum Daniele Rottkamp Beth Ellen Ruben Jubin Ryu Mark Saleh Bryan Santiago Heidi Schmidt Marisa Scofield Bronwyn Scott Vinita Shastri Sara Slatkin William Tate Elaine Tran Van Tran Ilana Traynis Sphoorti Umarjee Peter Uong Jennifer Varghese Brandon Varr Gurunadh Vemulakonda Julie Verdi George Whang Daetwan Williams Sandy Wong Chunying Xu Allandale Yap Kevin Yee Esther Yun Kelly Zhang

City Specialty Palo Alto AN Stanford STU Palo Alto OTO Palo Alto OPH Palo Alto OPH Santa Clara PTH San Jose P Santa Clara HOS Palo Alto END Palo Alto D Palo Alto D Palo Alto N Gilroy IM Palo Alto IM San Jose EM Stanford STU Santa Clara IM Campbell IM Stanford STU San Jose STU Palo Alto AN Santa Clara OPH San Jose PD Santa Clara A Gilroy PD Santa Clara IM Palo Alto OPH Santa Clara OBG Mountain View EM Palo Alto AN Stanford STU Santa Clara P San Jose FP San Francisco IM San Jose OBG Menlo Park STU

Monterey County Medical Society Name Gary Garcia

City Specialty Salinas FP

Name Terrence Hack

City Specialty Salinas IM

US - Unspecified | STU - Student | RST - Resident MARCH / APRIL 2018 | THE BULLETIN | 17

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MEDICAL OFFICE SPACE TO SUBLET • GILROY Medical Suite available next to Saint Louise Hospital in Gilroy. Please call today and get in tomorrow. Can share staff, phone, Internet. Contact Mil at (650) 618-1661.

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OFFICE SPACE FOR LEASE AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building. Please call 408/926-2182 or 408/315-4680.

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Breaking News...

We’re all under pressure to lower blood pressure

Target: BP is our commitment to

reducing the number of Americans living with uncontrolled high blood pressure.

Along with the American Medical Association, we have a mission: getting the control rate for hypertension to 70 percent and preventing 14,000 deaths a year.

Here’s how to get involved. It’s easy and it’s free.

• Make lowering blood pressure a priority within your practice. You will have access to American Heart Association and American Medical Association evidence-based tools, patient support and resources.

• Measure improvement and report the results you’re seeing. It’s the key to making necessary modifications.

AHA staff members are available to assist. To learn more about Target: BP and how to submit data, go to https://targetbp.org/home/contact-us/ • Strive for recognition. The Target: BP Recognition Program provides national recognition yearly to practices that join and a Gold-level achievement award to those that reach the 70 percent BP control among their adult patients.

Together, we can save lives and make a difference.

To sign-up or learn more, please visit www.targetbp.org or contact: Mike Gonzalez Senior Director of Health Initiatives American Heart Association Silicon Valley Mike.Gonzalez@heart.org 408.606.5948

MARCH / APRIL 2018 | THE BULLETIN | 19

Great Moments in Medical History The Birth of American Gynecology and Gynecological Surgery — Part l

By Gerald E. Trobough, MD Leon P. Fox Medical History Committee In the seventeenth and early eighteenth century, the care of women’s health issues was largely neglected by male physicians. The idea that certain women’s health problems deserved separate and distinct medical and surgical care did not occur to the physicians at that time. Most doctors received little or no training in the anatomy or physiology of the female reproductive system. As a result, women were treated for common ailments but pelvic conditions were ignored and women suffered in silence and seclusion.

American physicians often looked to their European counterparts for consultation and guidance in their medical and surgical practices. The conservative practices of the sophisticated physician leaders in the Medical Centers of Europe were not helpful to the doctors in the American frontiers. The Americans were forced to improvise, invent, experiment and take chances in treating medical conditions.

Most gynecologic health care was provided by midwives. For centuries, midwives attended birthing of children and they had more knowledge of reproductive physiology than physicians. Although most had no formal training, midwives had years of experience and a wealth of knowledge that was passed down over the years. They had a wide array of herbs 20 | THE BULLETIN | MARCH / APRIL 2018

they could prescribe to treat minor pelvic issues. Since anesthesia and antisepsis was not understood by the medical profession until the 1860’s, abdominal and major pelvic surgery was rarely done as most patients died of overwhelming infection.

Two pioneer American physicians in the nineteenth century were responsible for developing gynecology and gynecologic surgery. Both doctors came from similar backgrounds. Dr. Ephraim Mc Dowell and Dr. James Marion Sims were raised in small towns in the Deep-South and came from large families. They had good medical education for their time and both men had creative minds.

In Part 1, Ephraim McDowell, MD is highlighted. He is often referred to as the Father of Abdominal Surgery because he was the first person to successfully remove an ovarian tumor. Part 2 will reference the life of J. Marion Sims MD who developed the first successful vesico-vaginal fistula repair, and started the first women’s hospital. Sims is considered the Father of Modern Gynecology.

Dr. Ephraim Mc Dowell (1771-1830), was born in Virginia. He later moved with his family to Kentucky in 1784 settling in the small frontier town of Danville. He was the ninth child born into his family. After his early education in Danville, Ephraim decided to study medicine in Stanton, Virginia for three years under the preceptorship of Dr. Alexander Humphreys. He went on to attend medical lectures at the University of Edinburgh from 1793-1794 and he studied privately with one of the out-

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standing professors in Great Britain named Dr. John Bell. McDowell never received a medical diploma. In 1825, the University of Maryland conferred an honorary MD degree to this exceptional man.

In 1795, McDowell returned to Danville and established a surgical practice. He quickly earned a reputation as the best surgeon west of Philadelphia. In 1809, two physicians requested him to evaluate a young woman they thought was slow in delivering twins. After his examination, McDowell determined she had a large ovarian tumor.

The patient was Mrs. Jane Todd Crawford who begged Mc Dowell to save her from a slow, painful death. He told her that an operation as a cure had never been performed. He also related to her that the four top surgeons in England and Scotland felt that opening the abdomen to remove a tumor would lead to inevitable death due to” peritoneal inflammation.” If she was prepared to die and willing to travel to Danville, a 60 mile horseback ride, he would remove the tumor. Without hesitation, Mrs. Crawford traveled to Danville in the middle of winter with the “tumor resting on the pommel of the saddle.”

On Christmas morning, 1809, McDowell performed the operation assisted by his nephew, who had studied medicine in Philadelphia and was a young apprentice to McDowell. No anesthesia or antisepsis was used.

Mrs. Crawford recited psalms during the surgery. When the incision was made, the intestines fell on the table and remained there for the entire procedure. McDowell successfully removed the 22.5-pound tumor in 25 minutes. He wrote in his journal “the bowel became so cold that I thought proper to bathe them in tepid water previous to my replacement.” He then replaced the intestines into the abdomen, sutured the incision and put the patient to bed. He saw the patient 5 days post-operatively and found her making her own bed. Twenty-five days after the surgery, she rode her horse

back to her home and lived another 31 years.

In 1813 and 1816, McDowell removed other ovarian tumors.

He published an article describing the three cases, but the medical profession expressed disbelief and discounted them. In 1817, he sent a letter to his friend and mentor, Professor John Bell who had the Ephraim McDowell, MD article published in the Edinburgh Medical and Surgical Journal in 1824. Finally, McDowell achieved the recognition he deserved. By the end of his career, he had removed tumors in twelve women with the loss of only one patient. This was a remarkable record for that date.

In 1830, McDowell died of “inflammatory fever.” Ironically, the pioneer of abdominal surgery died of acute appendicitis without the benefit of surgery.

MARCH / APRIL 2018 | THE BULLETIN | 21

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Do you have an office EMERGENCY? Call us at (408) 217-6000 22 | THE BULLETIN | MARCH / APRIL 2018

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MARCH / APRIL 2018 | THE BULLETIN | 23

Carmel Woman Gives $106M for Mental Health Care in Monterey County

Natividad Medical Center Expands Medical Services With New Care Center Monterey County residents will have better access to specialized medical services with the opening of the new Natividad Care Center in Salinas. The new center, located in a building at Natividad Medical Center (NMC), opened in February and expands access to medical services that Monterey County residents previously sought outside the area, said Julie Edgcomb, Natividad Medical Center ambulatory services administrator.

“We had run out of space for women’s imaging. We had run out of space to expand cardiology and cardiopulmonary services,” said Edgcomb. “We had reached a point where we were able to take this one space that we had available and create a shared clinic so that the services could be quickly provided.” Gary Gray, physician and Natividad CEO, said the new care center includes three main areas: an outgoing patient cardiology clinic, a cardiopulmonary department and women’s diagnostic imaging. The new care center includes six cardiology rooms that offer mammography services, women’s diagnostics, bone density exams and ultrasound scans.

A cardiopulmonary area will include an echocardiogram, stress testing, electrocardiogram and pulmonary testing, according to a press release from NMC. “We’re the only ones, I believe, in Salinas that offer 3-D mammography services to women,” said Andrea Rosenberg, assistant administrator of operations and support services for NMC. “We have offered that in the main hospital, but now we have a designated space that has a very comfortable environment.”

24 | THE BULLETIN | MARCH / APRIL 2018

A Carmel woman has donated $105.8 million to create specialized behavioral health services to children and teens in Monterey County. Roberta “Bertie” Bialak Elliott made the donation to Montage Health Foundation, the parent company of Community Hospital of the Monterey Peninsula. The gift will be entirely devoted to child and adolescent behavioral health services to be housed in what will be called the Ohana House and include early intervention resources and comprehensive support for young people and their families. It will have between 18 and 24 psychiatric hospital beds for youths experiencing a psychological crisis as well as a mental health clinic to treat issues before they turn into crises, said Steven Packer, president and CEO of Montage Health. Currently, no such acute emergency facility exists in Monterey County, said Eric Jacobson, MD, medical director at the Community Hospital of the Monterey Peninsula. When a behavioral crisis, such as suicidal thoughts, strikes a young person and their family, they may spend days in an emergency room while waiting for a bed to be found in a county two or more hours away, he said. Recently, one youth waited several days at CHOMP (Community Hospital of the Monterey Peninsula), which can hold juveniles temporarily but cannot treat them at its adult unit, until a bed opened up in San Diego, Jacobson said. “There’s nothing between Fremont and LA (for youths with a mental health emergency),” he said. It’s not the first time that Elliott has made a nine-figure donation. She previously donated $100 million to her alma mater, Northwestern University. She also was an early investor in Berkshire Hathaway, founded by her brother Warren Buffett.

Salinas Valley Memorial Celebrates Grand Opening of Pediatric Diabetes Center The Salinas Valley Memorial Healthcare System recently celebrated the grand opening of its Pediatric Diabetes Clinic, the only one of its kind in Monterey County offering specialized care for children with diabetes. The new clinic, now part of the Salinas Valley Medical Clinic’s Diabetes and Endocrine Center, is the result of a partnership with UC San Francisco Medical Center and is designed to address the growing needs of children living with type 1 and type 2 diabetes. “Trying to navigate care for a child with diabetes in Monterey County is unbelievably challenging,” said Allen Radner, MD, chief medical officer of Salinas Valley Memorial, during the grand opening and ribbon-cutting ceremony that hosted about 100 people. “Our institute made a commitment to take care of those with diabetes with education and treatment – This is taking care of kids with diabetes and providing really great care, which is difficult to do and usually found at universities.” In March, Dana Armstrong, a registered dietician and director of diabetes services at the Salinas Valley Medical Clinic Diabetes and Endocrine Center, announced the expanded center on the second floor of the Abbott Street building. The expansion is part of a county-wide initiative to reverse the growing trend of the disease in Monterey County. Initially, the center will include two providers, one nurse practitioner and one attending physician but is expected to expand from there.

Surgical Affiliates and Regional Medical Center of San Jose, an HCA Hospital, Announce Their Partnership to Enhance Quality of Care to Patients Surgical Affiliates, a provider of emergency surgical services for hospitals and healthcare systems, and Regional Medical Center of San Jose, a Level II Trauma Center, announce their partnership to enhance care and expand surgical services. Surgical Affiliates and Regional Medical Center are two qualityfocused, data-driven organizations that focus on providing excellent quality of care for their patients. Through this partnership, Regional Medical Center gains access to Surgical Affiliates’ around-the-clock surgery services and expertise in trauma care to support local providers and enhance the current standards offered by each organization. “We are very excited to partner with Regional Medical Center of San Jose and work hand in hand with their team of local surgeons to provide excellent trauma and emergency surgical services to the community,” said the chief medical officer of Surgical Affiliates, Lynette Scherer, MD, FACS. “Together with Surgical Affiliates’ processes and Regional’s exceptional providers, we will be providing a standard in which all patients will have 24/7 access to the highest quality of emergency surgical care.”

MARCH / APRIL 2018 | THE BULLETIN | 25

El Camino Hospital Joins the Fight Against Opioid Crisis Tracking and tight controls on pain meds will ease addiction, hospital officials say As the death toll for opioid-related deaths climbs throughout the United States, El Camino Hospital officials say they’re doubling down on ways to control the problem on a local level by keeping a close watch on prescription painkillers and offering more services for patients suffering from chronic pain.

Opioid addiction and overdoses have turned into a leading cause of accidental deaths in the United States, surpassing car accidents in 2008, with a staggering 91 Americans dying every day from overdose, said Dr. William Faber, El Camino’s chief medical officer. Speaking at a hospital board meeting last week, Faber said that while the over-prescribing of opiates is seen as the biggest cause for the epidemic, street drugs like heroin are cheaper than they used to be, and can be more lethal when laced with the synthetic narcotic Fentanyl.

While Santa Clara County’s opioid-related death rates have been fairly low compared to the rest of the country and the state, it’s still a local problem worth addressing, he said. State data tracking the opioid epidemic shows that 66 people died of opioid overdose in Santa Clara County in 2016, slightly higher than neighboring San Mateo and Alameda counties when adjusted for population. That same year, the number of opioid prescriptions in the county surpassed 700,000, more than one for every three residents.

Although local death rates change dramatically each year, the 94041 zip code region that encompasses Old Mountain View had the highest death rate in the county in 2015, with just over 19 opioid deaths per 100,000 residents.

Given the region’s small population, that amounts to three deaths.

El Camino Hospital’s plans center around strong accountability and tracking of narcotic drugs. Faber said the hospital has an in-house system that keeps track of every dose of painkillers that doctors and nurses administer to patients, giving El Camino an effective way of catching any staffer who may be misappropriating opioid drugs. This is particularly important for substances like Fentanyl, he said, which can be processed into dangerous street drugs.

The hospital also hired a so-called pain pharmacist over the summer, whose role is to help doctors address pain through non-narcotic drugs and methods like physical therapy that are more safe and just as effective. For example, the pharmacist might recommend a drug like Toradol in lieu of opioids for a patient with a kidney stone, Faber said.

Although the pain pharmacist plays an important advisory role in the way the hospital handles chronic and acute pain during patient visits, as well as over prescriptions for discharged patients, it’s ultimately up to each physician to decide what drugs to prescribe.

Hospitals aren’t the primary culprit for the opioid problem, which admittedly limits the role they play in reducing the problem, Faber said. Most of the painkillers being prescribed are from outpatient care providers for people suffering from chronic pain, whereas patients in the hospital often rely on strong narcotics – appropriately – for recovery from surgery and other major procedures. It’s once patients leave the hospital and continue to seek out the drugs that an addiction problem arises.

“When people go out into the outpatient realm, we’ve got some doctors who are loosely prescribing inordinate amount of drugs for people with back pain or a headache when it’s inappropriate,” he said. “Despite the fact that it’s mainly an outpatient problem, there are a number of things we do here at the hospital to do our part.”

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One of the ways narcotics can make it out of the hospital and onto the streets is through the emergency department, prompting El Camino to adopt strict policies for giving out drugs to patients who might be feigning an illness in order to get their hands on drugs like Vicodin. Faber said the emergency department does not prescribe strong narcotics just because patients ask for them, and the default is to give people no more than 15 tablets of Norco, a relatively mild opioid.

In order to cut out the middle man and reduce the chances of a forged prescription, hospital officials are planning to open El Camino’s own outpatient pharmacy off of the main lobby in May which would allow patients to get their prescriptions filled on the spot before leaving. It won’t be a money-making venture and would likely break even, Faber said, but it does mean fewer people will be in the “chain of custody” for each prescription that leaves the hospital.

“Mischief happens when people leave the building with a prescription or it’s electronically sent off premises,” he said. “Sometimes people play games with that or alter the prescription. When I was prescribing narcotics if I said ‘10 Vicodin,’ on numerous occasions someone would try to put another zero on it and turn it into 100.”

Board member Peter Fung, a neurologist, said the hospital needs to change the mentality of the physicians at El Camino and encourage them not to spring for opioids whenever a patient is feeling pain. In many cases, overthe-counter drugs like Tylenol are often just as effective as the opioid Percocet.

At the same time, he said, the hospital needs to improve its addiction and behavioral health services for the patients who are already addicted to narcotics and need help.

The hospital currently provides addiction services including weeks-long outpatient program for adults struggling with drug abuse. One of the two outpatient programs, the Dual-Diagnosis Program, is an intensive program for patients suffering from severe addiction to drugs including opiates and stimulants as well as “co-occurring” mental health disorders, according to Dr. Evan Garner, director of the hospital’s addiction services programs.

Garner said the Dual-Diagnosis Program runs five days a week for six hours a day, and is considered one step down from 24-hour in-patient care or an acute psychiatric setting.

Rebecca Fazilat, chief of staff at El Camino’s Mountain View campus, told board members that addressing the opioid crisis means suspension of judgment against people who are suffering from addiction, many of whom are struggling from real pain and didn’t choose to get addicted to painkillers.

“They are seeking the only help they know that they can get,” she said. “It behooves us not to judge them and kick them out the door.”

At the same time, Fazilat urged against vilifying all of the outpatient physicians who prescribe painkillers. There are few pain specialists and other pain management resources available in the area, and primary care doctors are often inundated with so many other obligations that it becomes tempting to just hand out a prescription.

“As much as we like to judge folks for dishing out a prescription, if they know their patient is in pain and it’s an easy thing to do, that’s often why it happens,” she said.

Source: Kevin Forestieri / Mountain View Voice

Dear Members: Please read this very important message from the California Department of Public Health (CDPH).

Here in California, the Zika virus remains a serious public health concern to people traveling to areas with Zika. Zika is a virus that is spread through the bite of an infected mosquito or through unprotected sex with an infected partner. Those who travel to areas where Zika is circulating are most at risk of contracting the virus.

So far in California, Zika virus infections have only been documented in people who were infected while traveling to areas with ongoing Zika transmission, through sexual contact with an infected traveler, or through maternal-fetal transmission during pregnancy. At this time, there has been no known local transmission of Zika in California.

The mosquitoes that can carry the Zika virus (Aedes aegypti and Aedes albopictus) have been detected in an increasing number of counties throughout California, including the California-Baja and California-border region (San Diego and Imperial Counties).

We recently released a PSA on the subject: you can view it by visiting www.zikafreeca.com.

HERE ARE A FEW THINGS EVERYONE NEEDS TO KNOW ABOUT ZIKA. Zika is mosquito-borne virus that can infect both men and women. Most concerning of all, the virus can have detrimental effects on a pregnant woman’s developing baby. This is why it is up to all of us to stay vigilant.

There are three main ways to contract the virus:Â (1) from mosquitoes in affected areas, (2) through unprotected sex, and (3) from an infected mother to her developing baby.

First and foremost, CDPH advises pregnant women not to go to areas with Zika. As you make travel plans, you can find out where Zika is present by visiting the following site: https://wwwnc.cdc.gov/travel/page/zika-information.

If you or your partner must travel to an area with Zika, it is important to know that the virus is spread through sex and can persist in men for up to six months, and women, for eight weeks. The only way to avoid getting the virus through sex is to abstain from sex entirely. Otherwise, safe sex with condom use should be practiced.

When traveling, be sure to use EPA-registered insect repellent consistently and correctly to protect against mosquito bites. Continue to use repellent for three weeks after you return to prevent the spread of Zika back home. See your doctor right away if you have been to an area with Zika and have Zika symptoms like fever, rash, red eyes or joint pain.

Couples planning pregnancy when either has been exposed to the Zika virus should speak with their health care provider about a safe time to try to get pregnant.

For more information visit ZikafreeCA.com.

MARCH / APRIL 2018 | THE BULLETIN | 27

(CMA Newswire, March 19, 2018 issue)

New Universal Access Proposal Introduced in CA Legislature A sweeping package of legislation was introduced in the California Legislature last month that sets a clear and realistic path forward to achieve universal access and improve affordability to health care in California. Sponsored by SEIU CA, Health Access and NextGen America, key components of the legislative package will help increase access to care and expand access to undocumented patients.

“The key bills address fundamental challenges with California’s current health care system and seek to achieve universal access by improving affordability for all patients, expanding access for undocumented adults and focusing on the behavior of for-profit insurers,” said CMA President Theodore M. Mazer, MD. “CMA has long supported key elements of this legislation, including the expansion of Medi-Cal to income-eligible undocumented adults. CMA fully supports the inclusion of these proposals as a fundamental step towards universal access.”

While the proposed legislation represents a significant step forward, a truly successful universal access plan cannot be achieved without addressing the health care workforce shortage facing a majority of counties. As the recent University of California, San Francisco report commissioned by the California State Assembly recommended, any successful legislative proposal to achieve universal health care must ensure that California has a strong physician workforce.

The bill package contains provisions that CMA supports: • State Individual Mandate. The loss of the Affordable Care Act’s (ACA) individual mandate could increase premiums by 10 percent as many people, especially the young and healthy, will forgo purchasing health insurance. To ensure a healthy risk pool that provides the most certainty, California needs a mechanism to compel all its citizens to participate in the insurance market to keep costs down.

• Subsidy Relief for Individuals Purchasing Insurance on the Exchange/Individual Market. Increase subsidy relief for individuals purchasing insurance on the individual market to ensure affordability.

• Allow Income-Eligible Undocumented Immigrants to Enroll in Medi-Cal. Estimates suggest that 1.8-2 million undocumented immigrants could qualify for Medi-Cal coverage – this would require state-only funds; there would be no federal 28 | THE BULLETIN | MARCH / APRIL 2018

Medicaid match.

CMA also recommends the legislative package to be expanded to include the following: • Increase Physician Workforce and Encourage Physicians to Practice in Primary Care. California should increase funds available for loan repayment and increase residency slots, as well as institute policies that encourage physicians to work in primary care and under-served settings.

• Strengthen State Laws Regarding Oversight of Mergers of Health Insurance Plans. Consolidation leads to higher prices, and California should take a more robust oversight role in this area.

• Administrative Simplification. Standardize quality measures and institute a single process for provider credentialing that applies to all health plans, hospitals, etc., as well as establish electronic authorization policies for payers.

• Increase Medi-Cal Reimbursement Rates to Medicare Levels to help increase access for the nearly 14 million Californians currently covered by Medi-Cal.

(CMA Newswire, March 19, 2018 issue)

CMA Asks DMHC to Require Anthem to Publish Effective Dates for Clinical Policies Unlike all other major payors in California, Anthem Blue Cross does not disclose on its website the effective dates for its 241 different medical and clinical utilization management policies, which dictate the medical services Anthem will cover for its enrollees. Physicians and their patients, therefore, have no timely or effective method to determine which of Anthem’s published policies are effective or what medical services are covered for purposes of providing clinical care, determining cost sharing arrangements, and evaluating the breadth of Anthem’s coverage.

This issue came to light when Anthem published a concerning clinical guideline that restricts the use of intravenous anesthesia to sedate patients during cataract surgery. In a complaint to the Department of Managed Health Care (DMHC), the California Medical Association (CMA) expressed concern that the drastic

change in policy would cause significant patient safety concerns and put patients at risk of serious complications, including blindness. CMA asked DMHC to investigate Anthem’s policy restricting use of sedation during cataract surgery.

In response to CMA’s complaint on the new policy, Anthem clarified that while the policy was published on December 27, 2017, and then revised and re-published on February 1, 2018, the policy has not been implemented and is not yet in effect for California.

CMA has now asked DMHC to require that Anthem, on a prospective basis, add an easily identifiable effective date to its policies to clearly indicate whether a posted policy is in effect in California.

Without the effective date, the published policies cause confusion and misinform patients, consumers and all providers. CMA also believes that Anthem’s practice of not disclosing

the effective dates violates Health & Safety Code §1363.5(a), which requires plans to disclose to DMHC and to network providers the process the plan uses to authorize, modify or deny health care services under the benefits provided by the plan. Plans must also disclose this information to enrollees upon request.

“Anthem’s method of publishing all of its national medical policies on its California website without identifying whether they are effective for its California products is not only confusing but makes it nearly impossible for providers, enrollees and regulators to effectively monitor or assess what medical services it does cover in California,” wrote CMA President Theodore M. Mazer, MD, in a letter to DMHC. CMA has asked DMHC to look into this issue, and we will publish an update when additional details are available.

(CMA Newswire, March 19, 2018 issue)

New Parkinson’s Reporting Requirements Take Effect July 1 Health care providers diagnosing or providing treatment to Parkinson’s disease patients will be required to report each case of Parkinson’s disease to the California Department of Public Health (CDPH) beginning July 1, 2018.

The data will be used to measure the incidence and prevalence of Parkinson’s disease. California’s large and diverse population makes it ideal for expanding the understanding of this disease to improve the lives of Parkinson’s patients.

CDPH is currently developing a California Parkinson’s Disease Reg-

istry Implementation Guide that will detail how health care providers can comply with the reporting mandate. The guide will be released in April 2018 and will be available at www.cdph.ca.gov/parkinsons. The guide will provide the necessary information for reporting Parkinson’s disease data, and outline who is required to report, the timeline for reporting, and the electronic methods for transmitting data to the California Parkinson’s Disease Registry.

For more information, see CDPH’s fact sheet, which provides more details related to the new law.

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(CMA Newswire, April 2, 2018 issue)

Patient Outcomes Shortchanged by Prior Authorization More than nine in 10 physicians (92 percent) say that prior authorizations programs have a negative impact on patient clinical outcomes, according to a new physician survey by the American Medical Association (AMA). The survey results further bolster a growing recognition across the entire health sector that prior authorization programs must be reformed.

According to the AMA survey, which examined the experiences of 1,000 patient care physicians, nearly two-thirds (64 percent) report waiting at least one business day for prior authorization decisions from insurers—and nearly a third (30 percent) said they wait three business days or longer.

“Under prior authorization programs, health insurance companies make it harder to prescribe an increasing number of medications or medical services until the treating doctor has submitted documentation justifying the recommended treatment,” said AMA Chair-elect Jack Resneck Jr, MD, a dermatologist and health policy expert from the San Francisco Bay Area. “In practice, insurers eventually authorize most requests, but the process can be a lengthy administrative nightmare of recurring paperwork, multiple phone calls and bureaucratic battles that can delay or disrupt a patient’s access to vital care. In my own practice, insurers are now requiring prior authorization even for generic medications, which has exponentially increased the daily paperwork burden.”

High wait times for preauthorized medical care have consequences for patients. More than nine in 10 physicians (92 percent) said that the prior authorization process delays patient access to necessary care; and nearly four in five physicians (78 percent) report that prior authorization can sometimes, often or always lead to patients abandoning a recommended course of treatment.

In addition, a significant majority of physicians (84 percent) said the burdens associated with prior authorization were high or extremely high, and a vast majority of physicians (86 percent) believe burdens associated

with prior authorization have increased during the past five years.

The survey findings show that every week a medical practice completes an average of 29.1 prior authorization requirements per physician, which takes an average of 14.6 hours to process—the equivalent of nearly two business days. To keep up with the administrative burden, about a third of physicians (34 percent) rely on staff members who work exclusively on the data entry and other manual tasks associated with prior authorization.

“The AMA survey illustrates a critical need to help patients have access to safe, timely, and affordable care, while reducing administrative burdens that take resources away from patient care,” said Dr. Resneck. “In response, the AMA has taken a leading role in convening organizations representing, pharmacists, medical groups, hospitals, and health insurers to take positive collaborative steps aimed at improving prior authorization processes for patients’ medical treatments.”

In January 2017, AMA, with 16 other associations, urged an industrywide reassessment of prior authorization programs to align with a newly created set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. More than 100 other health care organizations have supported those principles.

In January 2018, AMA joined the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association in a Consensus Statement outlining a shared commitment to industry-wide improvements to prior authorization processes and patientcentered care.

Please visit the AMA website to learn more about the organization’s ongoing efforts on prior authorization reform.

(CMA Newswire, April 2, 2018 issue)

Get Ready for the New Medicare Beneficiary Cards and ID Numbers The Centers for Medicare and Medicaid Services (CMS) will begin mailing new identification cards to California Medicare beneficiaries between April and June 2018, as required under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The new cards will contain a unique, randomly assigned Medicare Beneficiary Identification (MBI) number replacing the current Social Security-based number.

CMS will allow a 21-month transition period beginning April 2018, where health care providers will be able to use either the patient’s current Medicare number or the patient’s new 30 | THE BULLETIN | MARCH / APRIL 2018

Medicare number.

CMS has developed a web page (https:// www.cms.gov/Medicare/New-Medicare-Card/ Providers/Providers.html) to help physicians navigate the transition to the new Medicare beneficiary identifier (MBI) number, including slides from the most recent CMS Open Door Forum on the transition. Physicians will be able to look up their Medicare patients’ new Medicare numbers through Noridian, the Medicare Administrative Contractor’s secure web portal starting in June 2018. Physicians should also talk to their practice managers and health IT

vendors now to ensure their systems will be ready to accept the MBI.

NEW MEDICARE CARD: VIDEO FOR YOUR WAITING ROOM To help inform Medicare patients the new Medicare Cards are coming, CMS has created a video for your waiting room (https://www. youtube.com/watch?v=DusRmgzQnLY&featur e=youtu.be). The video tells patients when and how they will receive the new card.

For more information, please visit www. cms.gov/newcard.

(CMA Newswire, April 2, 2018 issue)

CMA Survey Finds Rampant Health Plan Payment Abuses Despite a California law passed in 2000 to address widespread payment abuses by health care service plans, many payors continue to flout the law. A recent survey by the California Medical Association (CMA) confirms that health plans regularly engage in unfair payment practices, with two-thirds of physician practices reporting routine payment abuses in violation of state law.

The Department of Managed Health Care (DMHC) has been slow to address provider complaints and has taken few enforcement actions against health plans that unlawfully underpay providers. When DMHC has acted, the penalty amounts have been small in relation to the economic injury to consumers and providers. Because of this, some health care service plans make economic decisions to violate the law, knowing that any penalty amount that may be imposed will be outweighed by the extra revenue the health plans will generate by, for example, underpaying medical care.

Last month, CMA, along with its county medical societies and several specialty societies, surveyed physicians to obtain feedback on the health plans that are routinely engaging in unfair payment patterns, the types of violations and the results of physician efforts to resolve the issues both through internal plan processes as well as through DMHC. In a period of nine days, 741 physician practices representing thousands of physicians responded to the survey.

Key survey results include: • Two-thirds of physician practice respondents report routine problems with plans engaging in various unfair payment patterns, defined as a practice, policy or procedure that results in repeated delays in the adjudication and correct reimbursement of provider claims, as outlined in 28 C.C.R. §1300.71.

• More than half of practices report that health plans attempt to rescind or modify authorizations after the physician renders the service in good faith.

• Sixty-two percent report that Anthem Blue Cross is the most problematic when it comes to unfair payment practices; Blue Shield of California was second most problematic (52 percent).

• The health plan provider dispute resolution processes are largely ineffective, with 32 percent of practices indicating disputes are resolved only half of the time, and 29 percent indicating disputes are rarely resolved through the plans’ internal processes.

• Though most practices do utilize the health plans’ internal processes to attempt to resolve issues, 63 percent report that plans routinely fail to respond to their appeals within 45 business days of receipt, as required by California law. Anthem Blue Cross is identified as the most problematic (66 percent), with Blue Shield the second most problematic (61 percent).

• When health plans do respond to physician appeals, 74 percent of practices state the health plan responses do not include a clear explanation for the plans’ determination.

These survey results confirm that health plans overwhelmingly continue to engage in unfair payment practices, despite the legislation that passed 18 years ago attempting to stop these abuses. It further demonstrates that, although plans are required to maintain fast, fair and costeffective provider dispute processes, their processes are largely ineffective.

To address this issue, CMA is sponsoring AB 2674 (Aguiar-Curry), which would require DMHC to investigate provider complaints that a health care service plan has underpaid or failed to pay the provider in violation of the Knox-Keene Act. If DMHC finds that a health plan has unlawfully underpaid a provider, AB 2674 would require the penalty amount to, at a minimum, equal the amount of the underpayment plus interest.

Furthermore, AB 2674 would protect the health care delivery system by ensuring providers are made whole when health care service plans violate the law. The bill would also deter future violations of the law, thereby saving providers and the state vital resources that should be invested in patient care.

CMA CAN HELP YOU GET PAID Physicians are reminded that members have access to CMA’s practice management experts for free one-on-one help with contracting, billing and payment problems. Need assistance? Contact CMA’s reimbursement helpline, at (888) 401-5911 or economicservices@cmanet.org.

MARCH / APRIL 2018 | THE BULLETIN | 31

(CMA Newswire, April 2, 2018 issue)

U.S. Supreme Court Hears Arguments in Challenge to California’s Reproductive FACT Act A California law that requires specified facilities providing pregnancy-related services and counseling to disclose information about the availability of comprehensive reproductive health care services is currently being challenged before the United States Supreme Court.

At issue in this case—NIFLA v. Becerra—are efforts by the State of California to ensure that patients receive accurate information about the availability and accessibility of free and low-cost comprehensive reproductive health services.

Passed in 2015, the California’s Reproductive Freedom, Accountability, Comprehensive Care and Transparency (FACT) Act requires licensed health-care centers to notify patients of the availability of free or low-cost health care services, including contraception, prenatal care, and abortions, through state programs. The law additionally requires that unlicensed health care centers—for example facilities that provide primarily counseling services—to inform women that there are no licensed medical providers on staff.

The issue before the U.S. Supreme Court is whether the disclosures required by the FACT Act violate the Free Speech Clause of the First Amendment.

The California Medical Association (CMA) joined the American College of Obstetricians and Gynecologists, American Academy of Pe-

diatrics – California, American Society for Reproductive Medicine and other health care provider organizations to file an amicus brief in support of California’s FACT Act. CMA’s brief explained that requiring licensed facilities to inform women of the availability of comprehensive free or lowcost reproductive health care reduces delays in care that can pose significant risks to maternal and fetal health.

“Women’s pregnancy-related health care services are highly timesensitive, and unnecessary delay can pose significant risks to maternal and fetal health,” CMA’s brief said.

Additionally, the brief argues that requiring unlicensed medical facilities to inform women that there are no licensed medical providers on staff allows women to make informed decisions about the pregnancy-related services that they receive and prevents such facilities from misleading women into believing that the services being offered are medically necessary or beneficial.

CMA’s brief explains that “patients can neither fully consent nor make fully informed decisions about their health care if they are not meaningfully informed about the care they are receiving or the qualifications and expertise of the individual who will be providing the care.”

Oral arguments in this case were heard in the U.S. Supreme Court on March 20, 2018, and a decision is expected by the end of June.

(CMA Newswire, April 2, 2018 issue)

CMA Comments on Proposed Protections for Conscience Rights and Religious Freedom In January, the U.S. Department of Health and Human Services (HHS) released a proposed rule that would expand protections for physicians and other health care providers who object to performing certain procedures. The proposal covers a wide array of existing federal laws that provide “conscience” protections, including those related to abortion, sterilization, assisted suicide and the performance of advance directives.

While the California Medical Association (CMA) is a strong advocate for the conscience rights of physicians, we do not believe this proposed rule accomplishes its purported aims. We are concerned that it may lead to discrimination that is prohibited under both federal and California law, adversely impact patient access to comprehensive care, and inappropriately insert politics into the patient-physician relationship.

Moreover, current federal and California law 32 | THE BULLETIN | MARCH / APRIL 2018

provide extensive protections for the conscience rights of health care providers, and the supplemental administrative burdens imposed by this rule do not add any meaningful benefit.

CMA is also concerned that the overly broad language in the proposed rule would allow any entity involved in a patient’s care—from a hospital board of directors to the receptionist that schedules procedures—to use their personal beliefs to dictate a patient’s access to care.

CMA policy has always sought to balance the rights of patients to access needed health care with the rights of physicians to exercise their conscience. CMA believes that the proposed rule would undermine anti-discrimination protections, especially regarding reproductive health, sexual orientation and gender identity.

California law explicitly prohibits discrimination based on sex, sexual orientation or gender identity. The proposal lays the groundwork to

preempt California laws that have been put into place to ensure that patients in the state have access to comprehensive health care.

Existing federal and state laws protect the rights of physicians by allowing states to take nuanced positions on protecting the conscience rights of health care workers, particularly with regard to abortion, sterilization and aid-in-dying.

“The Proposed Rule’s provisions are not only redundant but will have a chilling effect on the enforcement of and passage of state laws that protect access to health care,” CMA wrote in comments submitted to HHS on the proposed regulations. “California law already properly balances the rights of physicians and their patients…Adding a confusing and unnecessary layer of federal regulations may prevent [other] states from successfully passing and implementing their own conscience protections.”

(CMA Newswire, April 2, 2018 issue)

$1.3 Trillion Federal Appropriations Bill Loaded With New Health Care Spending Last month, President Trump signed a massive $1.3 trillion federal spending bill—the Omnibus Consolidated Appropriations Act of 2018. It is loaded with new spending for health care programs that were supported by the California Medical Association (CMA). Unfortunately, it did not include two bills that CMA was strongly promoting – the Affordable Care Act (ACA) market stabilization bill and a permanent solution for the nearly 700,000 Deferred Action for Childhood Arrivals program recipients.

A brief summary of the federal spending bill is below.

Bipartisan ACA Market Stabilization: CMA, the American Medical Association (AMA) and other physician groups strongly advocated to include the bipartisan ACA market stabilization bill in the omnibus spending package. Unfortunately, lawmakers could not reach a compromise. It would have funded for two-years the cost-sharing assistance that helps low-income families afford copayments and deductibles that President Trump eliminated in 2017. It would have also provided state waiver flexibility and reinsurance funding to cover high-cost, catastrophic cases. The Congressional Budget Office estimated that the bill would have reduced premiums by 20 percent in 2020. A compromise could not be reached because the Freedom Caucus insisted on placing abortion restrictions on the ACA plans in exchange for the two-year ACA stabilization bill.

Opioids: The bill includes nearly $4 billion in new funding for prevention, treatment and law enforcement to address the opioid crisis. With the $6 billion in the Budget Act enacted by Congress in February, new 2018-2019 opioid funding totals $10 billion. The breakdown is as follows: • $500 million for National Institutes of Health research on opioid addiction, development of opioid alternatives, pain management and addiction treatment.

• $27 million for Mental and Behavioral Health Education Training to recruit and train professionals in psychiatry, psychology, social work, marriage and family therapy, substance abuse prevention and treatment, and other areas.

• $105 million for the National Health Service Corps to expand access to opioid and substance use disorder treatment in rural and underserved areas.

• $100 million for a new Rural Communities Opioids Response Program to support prevention and treatment of substance use disorder in 220 counties and other rural communities identified by the Centers for Disease Control and Prevention (CDC) as being at high risk.

• $350 million (for a total of $475 million) to support CDC’s Opioid Prescription Drug Overdose Prevention activities. $10 million must be used to conduct a nationwide opioid education campaign to increase understanding of the epidemic and to increase prevention activities. Also requires CDC to promote

the use of prescription drug monitoring programs (PDMP) and expand efforts to enhance the utility of state PDMPs to make them more interconnected, in real-time, and usable for public health surveillance and clinical decision making. CMA aggressively advocated for this provision to ensure that the federal government work with electronic health record (EHR) vendors to link EHRs to state PDMPs. • $1 billion in new funding for State Opioid Response Grants.

• $94 million for law enforcement and grants to combat opioid, heroin and other drug trafficking.

• $94 million to strengthen Food and Drug Administration (FDA) presence at international mail facilities and to fund equipment and technology to increase FDA capacity to inspect more incoming packages to detect illicit fentanyl.

Gun Violence: The bill included $2.3 billion in funding associated with the STOP School Violence Act of 2018 to cover mental health services, security training and school safety programs to prevent gun violence. It also fully funds the FBI National Instant Criminal Background Check System. While CDC research promoting gun control is still prohibited, the Omnibus spending bill included a general clarification that there are no restrictions on general research related to gun violence. However, there was no funding appropriated for such research. Finally, it increased funding for the National Violent Death Reporting System to all 50 states to assist researchers and lawmakers.

CMA continues to support California Senator Dianne Feinstein’s legislation that would ban assault weapons and high-capacity magazines, as well as efforts to require more extensive background checks and waiting periods.

Mental Health Programs: Provides more than $2.3 billion in new funding for various mental health programs.

Drug-Related Provisions: Physicians will continue to receive enhanced payments for the first few years a drug/biological is on the market to assist in the costs of adopting new drugs and technology.

Graduate Medical Education: The Children’s Hospitals graduate medical education program received a $15 million funding increase, for a total of $315 million. Congress also provided an additional $15 million for the Rural Residency Program to expand the number of rural residency training programs with a focus on developing programs that can be selfsustainable.

Other Notable Health Care Spending Increases: The National Institutes of Health received a significant increase in funding to support research into Alzheimer’s disease, the Brain Initiative, the universal flu vaccine and antibiotic-resistance efforts. The CDC also received additional funding for diabetes programs.

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Local Counties Taking Steps to Address Mental Health Issues Because one in five adults suffers from some kind of mental illness, according to the National Alliance on Mental Illness, healthcare providers and organizations in Monterey and Santa Clara counties are stepping up with a variety of programs to support residents struggling with mental illness.

In Santa Clara County, the county Board of Supervisors approved the Pay for Success project in an effort to improve stability and wellness of some of the county’s most severely mentally ill individuals. The county will partner with Telecare to offer intensive outpatient treatment, case management, and supportive services to the patients in most need. Pay for Success is a funding model under which governments pay for services only if and when a service provider achieves clearly defined, measurable results. The project will serve individuals who have frequent or extended stays in the county’s psychiatric emergency and inpatient facilities and in other institutional settings, and will ensure these individuals are stabilized in less restrictive, community-based environments, according to a county statement.

“Improving the stability and wellness of members of our community who suffer from acute mental illness is a high priority for the county,” said Dave Cortese, president of Santa Clara County Board of Supervisors. “We are hopeful that through this project, we’ll be able to offer more effective services in community-based settings.”

In August, the Children’s Health Council in Palo Alto launched a teen mental health initiative that includes expanded counseling, community mental health education and community partnerships to reduce teen anxiety, depression, and suicide. The Children’s Health Council accepts referrals from professionals and provides training for current and future professionals who work with children.

“We feel a very strong calling to do our part to address the significant teen anxiety, depression and suicide that is affecting our local communities,” said Rosalie Whitlock, PhD, executive director at CHC. “Many of us live in this community or have raised kids here, so it is our personal call to action as well as a professional one to open our doors and serve more teens and families in the community in a very actionable way.”

CHC and Stanford University Medical Center, which CHC is affiliated with, plan to lead and engage the community in some of the following ways: • Convene a community-wide and multi-constituent team on a regular basis to drive community-based efforts and accountability to action on teen mental health including break-out task groups.

• Develop a yearly symposium on teen mental health and 34 | THE BULLETIN | MARCH / APRIL 2018

wellness for teens, parents, educators, and professionals to bring people together and develop cohesive, communitybased education.

• Partner with like-minded community engagement task forces such as Project Safety Net and Partnering for Healthy Minds to ensure consistent messaging and communication about community progress, resources and goals.

In Monterey County, the Central California Alliance for Health recently granted $2.5 million to Interim Inc. and Mid-Peninsula Housing Corporation respectively. Interim Inc. will build New Bridge House at Shelter Cove in Marina to offer transitional residential treatment for adults with serious mental illness and substance abuse, while Mid-Peninsula Housing Corporation will develop permanent supportive housing in Salinas for Medi-Cal beneficiaries who are homeless and have chronic conditions. These grants are part of $20 million awarded by the Alliance to organizations in Monterey, Santa Cruz and Merced counties for the expansion of services needed by more than 350,000 residents enrolled in the state Medi-Cal program.

Stanford Medicine Hosts Teach-in on Gun Violence and Public Health On March 14, Stanford Medicine held a teach-in on campus that focused on gun violence. The forum included presentations on a variety of topics related to guns and public health including gun laws and regulations, the financial cost from gun violence, and a trauma surgeon’s perspective on gun injuries.

“Physicians and medical schools can work to provide a healthy environment for all patients by helping to decrease gun violence,” said Daniel Bernstein, MD, the associate dean for education at Stanford Medicine, in his opening remarks at the forum. Stanford Medicine identified some key highlights from the teach-in: Understanding the U.S. gun-violence epidemic requires defining which piece of the problem you intend to address, said Jahan Fahimi, MD, PhD, assistant clinical professor of emergency medicine at the University of California, San Francisco. Dr. Fahimi presented data demonstrating the link between homicides and assaults driving non-fatal gun injuries and the homicide vs. suicide rate between African-Americans and whites. “Are we talking injury or death? Homicides or suicides? Black or white? These three [categories], at the very minimum, are needed to get us to a place of understanding the scope of the problem in a more nuanced way.”

Stanford trauma surgeon Lisa Knowlton, MD, spoke about her experiences caring for gunshot victims. “As trauma surgeons we like to think we are prepared for anything, but there are few injuries as violent as those from firearms,” she said. Dr. Knowlton described the process of assessing and caring for a gunshot victim and the priorities in trauma surgery for treating gunshot wounds. Patients who survive the initial surgery face “multiple surgeries, prolonged stays in the hospital, complications, loss of work, depression, mental health issues, PTSD; the impact can really be very devastating even if they do manage to leave the hospital alive,” Dr. Knowlton said.

Financial costs of firearm injuries can be measured many different ways, with the annual total cost in the U.S. estimated at $174 billion to $229 billion, Stanford medical student Sarabeth Spitzer told the audience. Last year, Spitzer was lead author of a study of the costs of initial hospitalizations for gun injuries, which totaled $734.6 million per year nationwide. Other costs, such as lost wages or the toll on quality of life following a gunshot injury, as well as who bears the costs, are harder to measure, she said. “The more reliable and transparent the data, the more informed public health decisions can be,” Spitzer said.

The United States has a smorgasbord of gun laws that are not easy to explain or navigate, medical and legal scholar David Studdert, LLB, ScD, told

the audience. “Most of these laws do not exist at a federal level,” he said.

“A state like California is a national leader in implementing and formulating such laws, while others such as Virginia and Wyoming have virtually none.” He also described 2017 Pew Research Center data that shows widespread agreement between gun owners and non-owners on several proposed gun control measures, such as expanding background checks to include private gun sales and banning concealed carry without a gun license.

Pediatrician Michelle Sandberg, MD, of Santa Clara Valley Medical Center, explained how physicians can advocate for gun safety with their patients. Doctors should broach the subject of gun safety from a health perspective, Dr. Sandberg said. “Firearm counseling should be non-ambiguous and non-judgmental, like counseling about medication safety or storing poisons,” she said. She also encouraged physicians to promote the ASK campaign, in which parents ask anyone who might be supervising their children “Is there an unlocked gun where my child plays?”

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EHRs Can Advance Good Medicine – If Doctors Are Aware of the Risks Historically, the doctor-patient relationship has been at the heart of medical practice, with administrative tasks and recordkeeping at the border.

Today, that critical balance is at risk. Nearly all hospitals and 80% of medical practices use electronic health records (EHRs), presumably to help improve access to health information and increase productivity. The problem is that none of these digital tools were designed specifically to advance the practice of good medicine.

Consider these stark statistics: Every hour doctors spend with patients, they dedicate nearly two more hours to maintaining EHRs and clerical work. Yet even when physicians are with patients, they’re spending approximately 37% of their time interacting with EHRs or other desk work.

We are now witnessing the highest levels of physician burnout on record. Indeed, the rise of documentation demands and decrease of meaningful patient interactions has led to major physician frustrations — while making it harder for physicians to deliver quality care.

For these reasons and more, the EHR has introduced patient safety risks and unanticipated medical liability risks. According to a new study from The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, the number of EHRrelated medical malpractice claims has risen over the past 10 years.

FACTORS BEHIND EHR ERRORS For the most part, the EHR is a contributing factor in an EHRrelated claim and not the primary cause. This and their low frequency (0.9% of all claims) suggest that EHRs infrequently result in adverse events of sufficient severity to develop into a malpractice claim.

When EHRs are a factor in a claim, the study showed that user factors (such as data entry errors, copy-and-paste issues, alert fatigue, and EHR conversion issues) contributed to nearly 60% of claims. As computer users, we all copy and paste; therefore, it’s no surprise that time-pressured physicians embrace the same habits when using EHRs. In fact, the University of California San Francisco Medical Center — today considered a top-five medical center in the United States — reviewed more than 23,000 of their own progress notes over an eight-month period and found that, on average, clinicians manually entered just 18% of the text in each note, while 46% was copied and 36% was imported.

System factors (such as data routing problems, EHR fragmentation and inappropriate drop-down menu responses) contributed to 50% of claims. EHR fragmentation was among the most prominent system factors, contributing to 12% of errors. This factor means that different components of a single patient encounter might not be located together in the EHR. Consequently, doctors must check in different places to find laboratory and X-ray results, histories and physicals, etc., resulting in important information being overlooked or unidentified.

RECLAIMING THE DOCTOR-PATIENT RELATIONSHIP One overwhelming response to adjust to burdens introduced 36 | THE BULLETIN | MARCH / APRIL 2018

by EHRs has been the rapid growth of medical scribes. Nearly 20% of medical practices are using scribes to help untether physicians from the EHR, with many doctors citing improved efficiency and satisfaction. Yet while scribes can offer great advantages, they can be a double-edged sword. According to a survey of hundreds of physicians from The Doctors Company, the lack of standardized training and variability in experience among scribes poses risks to data accuracy and delivery of care — which could increase liability for the patient and physician alike.

With or without scribes, lowering risk begins with each patient visit. At the beginning of each new session, doctors should inform patients of the purpose of the EHR and emphasize they are listening closely even though they might be typing during the appointment.

Practices can set up treatment rooms so the patient can watch the screen and see what is being typed. It is also helpful to summarize or read the note to the patient to demonstrate that you have listened, and ask, “Do I have it right?” If the doctor is using a medical scribe to untether them from their EHR, the same principle applies.

Patients must also become their own advocates. They can ask their doctor to read back the EHR notes or review what has been written. Patients can interact with their health record online through patient portals and review their medical record as well as disease-specific educational materials and drug safety information.

It is important that they communicate any errors they find as well as personal information updates to the physician.

WHAT THE FUTURE HOLDS As with any challenge of major proportions, progress will take time. But I’m optimistic that the EHR will evolve over the next 5 to 10 years and improve both the quality of medical care and patient safety.

OPTIMIZING THE EHR WILL INVOLVE:

• Redesigning EHR workflows to reflect clinical practice workflows in hospital, clinic and office environments. It is essential that physicians and other healthcare providers be involved in this endeavor.

• Developing standardized diagnostic and treatment protocols.

• Researching medical artificial intelligence (AI). This is under way and will doubtless play a significant role in future medical practice.

• Making EHR interoperability a high priority.

• Applying “big data” techniques to healthcare. This is under way and, like AI, will lead to new knowledge insights that will change the practice of medicine.

Today, what I hear from The Doctors Company’s 80,000 member physicians is encouraging. Doctors are eager to “reclaim” their profession and refocus patient relationships amidst the new demands of today’s digital age. Into the future, new protocols, policies and training programs must take these small successes to a large scale.

SOURCE: By David B. Troxel, MD, Medical Director | The Doctors Company

CMS Announces Plans to Overhaul Meaningful Use, Launch of New EHR Initiative In a speech focused on value-based and patient-centric care, Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma announced plans to overhaul meaningful-use requirements and electronic health record (EHR) incentive programs at HIMSS18 in Las Vegas last month.

MYHEALTHEDATA CMS is launching a new initiative called MyHealthEData, according to Verma, intended to give patients more control of their own EHR data and share their personal health data with anyone they choose.

“We cannot effectively transition to a value-based system unless we provide to both the doctor and the patient all of the clinical and payment data required at the point of care, to help them mutually make a different and better decision than they could have today,” Verma said leading into the announcement.

“To this end,” she continued, “the administration is launching the MyHealthEData Initiative. MyHealthEData is a government-wide initiative that will break down the barriers that contribute to preventing patients from being able to access and control their medical records.

MyHealthEData makes it clear that patients should have access and control to share their data with whomever they want, making the patient the center of our healthcare system. Patients need to be able to control their information and know that it’s secure and private. Having access to their medical information will help them make decisions about their care, and have a better understanding of their health. MyHealthEData will unleash data to trigger innovation and advance research to cure diseases and provide more evidence-based treatment guidelines that ultimately will drive down costs and improve health outcomes.”

“It is extremely rare for different provider systems to be able to share data. In most cases there is not yet a business case for doing that – it’s in the financial interest of the provider systems to hold on to the data for their patients,” she said.

The plans will require providers to update

their systems to ensure data-sharing and to allow a patient’s data to follow them after they are discharged from the hospital.

MEANINGFUL USE After years of complaints from providers that the meaningful use program was too burdensome and hard to implement, Verma provided few details but indicated an intention to reduce time and compliance costs associated with the program.

“CMS will be announcing a complete overhaul of the Meaningful Use program for hospitals, and the Advancing Care Information performance category of the Quality Payment Program. Ensuring the security of healthcare data will be an absolute requirement in order to avoid negative payment adjustments or to receive an incentive payment. Our new direction will not only reduce time and costs, but will also be laser-focused on increased interoperability and giving patients access to their data across all of our programs,” Verma said.

The announcement comes just weeks after President Donald Trump signed a funding bill that included measures to ease meaningfuluse requirements and expand telehealth access for Medicare beneficiaries.

BLUE BUTTON 2.0 Verma also unveiled Medicare’s Blue Button 2.0, a web application that will allow patients to access and share their healthcare information, previous prescriptions, treatments and procedures with a new doctor; such sharing can reduce duplication in testing and provide continuity of care.

“The possibilities for better care through Blue Button 2.0 data are exciting, and may include enabling the creation of health dashboards for Medicare beneficiaries to view their health information in a single portal, or allowing beneficiaries to share complete medication lists with their doctor to prevent dangerous drug interactions,” Verma said. “So far, over 100 organizations, including some of the most notable names in technological innovation, have joined the CMS developer preview program.

And we expect more to join once Blue Button

Following the announcements at HIMSS18, Health and Human Services Secretary Alex Azar outlined a four-point plan to accelerate shift toward a valuebased system: • Giving consumers greater control over health information through interoperable and accessible health information technology • Encouraging transparency from payers and providers • Using experimental models in Medicare and Medicaid to drive value and quality throughout the entire system • Removing government burdens that impede this transformation.

2.0 is launched to consumers.”

“Today,” Verma concluded, “I challenge the entire healthcare industry to join us in achieving the goals of the MyHealthEData initiative. Let’s empower patients to access their records so that they may seek treatment whenever and wherever they choose. We cannot do this alone, but together we can accomplish wonderful things.

Ten years from now let’s look back on this conference and the launch of MyHealthEData as the beginning of a new era in patient care and empowerment, and celebrate the advances that we can’t even imagine today.”

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REPORT: Gender Wage Gap Widens With Female Physicians Making 28% Less Than Male Peers Female doctors earned 28% less than their male colleagues from 2016 to 2017. There is no medical specialty in which female doctors earn more than male doctors, according to the second annual Physician Compensation Report from Doximity. The study found that while doctors saw an average 4% wage increase nationally from 2016 to 2017, compensation varied significantly across metropolitan areas, medical specialties and between genders.

PHYSICIAN GENDER WAGE GAP The report, which is based on more than 65,000 verified U.S. physician respondents, making it one of the largest studies available on physician pay in the United States, found that the national gender gap for physicians increased as female doctors earned 27.7% less than their male counterparts, an average of $105,000 less a year. The disparity in 2016 was 26.5%, when female doctors earned $91,284 less.

While women were more likely to practice medicine in lowerpaying specialties like primary care, even in more lucrative fields like orthopedic surgery or plastic surgery they were also paid substantially less than men. The report also found: • Similar to 2016 findings, there remains no medical specialty in which female doctors earn more than male doctors.

• Women earn less than men in all of the top 50 metro areas.

• From 2016 to 2017, the metro areas with the largest increase in gender wage gaps were Charleston, SC (8.6% increase); Ann Arbor, MI (8.2% increase); Riverside, CA (8.0% increase); Providence, RI (6.4% increase); and Indianapolis (6.1% increase).

• In 2017, the metro areas with the largest gender wage gaps were Charleston, SC (female physicians earn 37% or $134,499 less); Kansas City, MO (32% or $131,996 less); Nashville, TN (32% or $118,706 less); Providence, RI (31% or $108,796 less); and Riverside, CA (31% or $115,991 less).

• In 2017, the medical specialties with the largest gender wage gaps were hematology (female physicians earn 20% or $78,753 less); occupational medicine (20% or $59,174 less); urology (20% or $84,799 less); orthopedic surgery (19% or $101,291 less); and gastroenterology (19% or $86,447 less).

“All healthcare stakeholders should be aware of the differences in compensation for men and women across the country,” said Christopher Whaley, PhD, the report’s lead author and adjunct assistant professor at the University of California, Berkeley School of Public Health. “Compensation inequity can directly affect where and what physicians choose to practice, which could ultimately affect patient access.”

“The gender pay disparity is disappointing, and it’s a serious issue that we want to rectify,” said Amit Phull, MD, Doximity’s vice president of strategy and insights. “Unlike other industries, the 38 | THE BULLETIN | MARCH / APRIL 2018

medical profession doesn’t openly reveal or discuss salaries. If physicians know how much their peers are making, it will give them better leverage to negotiate their pay. We want this report to provide some transparency.”

“Medical students aren’t taught how to negotiate salaries. But it’s vital for them, especially for women, to learn this skill,” Fatima Stanford, MD, who specializes in obesity medicine and nutrition at the Massachusetts General Hospital and is on faculty at Harvard Medical School, told CNN. While men are getting paid more, women have surpassed them in one critical measure that may have a longer-term impact. Last year marked the first time that more women than men enrolled in U.S. medical schools.

OTHER FINDINGS IN THE REPORT INCLUDE: • The five medical specialties with the highest average annual salary in 2017 were neurosurgery ($662,755); thoracic surgery ($602,745); orthopedic surgery ($537,568); vascular surgery ($476,300); and plastic surgery ($473,212).

• The five medical specialties with the lowest average annual salary in 2017 were pediatric infectious disease ($191,735); pediatric hematology and oncology ($208,524); pediatric endocrinology ($214,911); pediatrics ($221,900); and preventive medicine ($231,838).

• The five metro areas with the highest average annual salary in 2017 were Charlotte, NC ($402,273); Milwaukee ($398,431); Jacksonville, FL ($379,820); Indianapolis, IN ($378,011); and San Jose, CA ($376,585).

• From 2016 to 2017, the metro areas with the largest increase in physician compensation were Charleston, SC (11.6% or $33,182 more); Milwaukee (7.3% or $52,601 more); Austin, Texas (7.2% or $45,605 more); San Francisco (6.9% or $58,184 more); and Las Vegas (6.7% or $47,256 more).

Why Does the U.S. Spend More on Healthcare Than Other High-Income Countries?

A new study published by the Journal of the American Medical Association investigated the reasons why the United States spends more on healthcare than other high-income countries. The findings reveal higher administration expenses, particularly for doctors and pharmaceuticals, are the cause.

The data is primarily from 2013-2016, provided by the Organisation for Economic Co-operation and Development and the Commonwealth Fund, and analyzed by researchers from Harvard and the London School of Economics and Political Science. The focus was comparing the U.S. to 10 countries with high income, high health spending, and “populations with similar demographic characteristics that have similar burdens of illness,” the researchers explained. Countries included Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, Sweden, Switzerland and the United Kingdom. Some key findings include: 1. The U.S. continues to spend more on healthcare. In 2016, the U.S. spent 17.8% of its gross domestic product (GDP) on healthcare, while the average spending level among all high-income countries was 11.5% of GDP. 2. The U.S. has lower rates of insurance coverage. U.S. health coverage has risen to 90% since the Affordable Care Act, while other high-income countries achieved coverage for at least 99% of its population.

3. The U.S. has mixed levels of population health. Americans have higher rates of obesity and infant mortality. Life expectancy in

the U.S. is 78.8 years, nearly three years less than the average life expectancy in other high-income countries.

4. Except for diagnostic tests, the U.S. uses healthcare services at rates similar to those of other countries. Numbers of hospital visits and surgeries performed in the U.S. are similar to those in other countries. However, the U.S. performs 118 MRI scans per 1,000 people, compared to an average of 82 MRIs per 1,000, and a CT scan rate of 245 per 1,000 people, compared to 151 per 1,000 people among all high-income countries.

5. The U.S. pays more for: a. Doctors. The average salary for a general practitioner in the U.S. is nearly double the average salary across all highincome countries at $218,173. b. Pharmaceuticals. The U.S. spends double on pharmaceuticals: $1,443 per person, compared to the average of $749. c. Healthcare administration. The U.S. spends 5% more (8%) of national health expenditures on activities related to planning, regulating and managing health systems and services, compared to an average 3% spent among all high-income countries.

The study concludes that the United States medical-care utilization was similar to the other countries it was compared to, but spent nearly twice as much on labor and goods, including pharmaceuticals, and administrative costs.

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Both Uber, Lyft Announce Partnerships With Providers to Transport Patients to Appointments Healthcare is on the move. Ride-hailing services Uber and Lyft are both moving aggressively into the healthcare transportation space, according to recent dual announcements.

Uber announced Uber Health, a desktop platform for healthcare providers that allows doctors to provide rides for patients who might otherwise miss their appointments because they can’t get to them. Uber will be teaming up with a variety of healthcare organizations to provide rides. Lyft is expanding its partnerships with healthcare providers to provide the service to doctors and hospitals who want to arrange transportation for patients who can’t get to appointments and is partnering with Allscript, an electronic health records company, to give hospitals a platform to request rides for its patients.

Uber will also be launching an Uber API, enabling easy integrations into existing healthcare products, featuring: • Flexible ride scheduling for patients, caregivers and staff. Coordinators can schedule rides on behalf of patients, caregivers and staff to take place immediately, within a few hours, or up to 30 days in advance. This allows for transportation to be scheduled for follow-up appointments while still at the healthcare facility. Multiple rides can be scheduled and managed at the same time, all from a single dashboard.

• Access for patients without a smartphone. Riders don’t need the Uber app, or even a smartphone, to get a ride with Uber Health because it’s all done through text message. An option is even going to be introduced for riders to receive a call with trip details to their mobile phone or landline instead. For many, their first-ever

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Uber ride will be through Uber Health, so Uber says it is committed to providing the necessary education tools that ensure every patient feels comfortable and at ease during their journey.

• Simple billing, reporting, and management. Organizations can easily keep track of what they’re spending on rides.

Reporting on requested rides and viewing monthly billing statements, appointments, and scheduling reports is simple.

• HIPAA Compliance. To ensure Uber Health meets HIPAA standards, Uber has been working hard to develop, implement and customize numerous safeguards.

It has also worked with Clearwater Compliance, a leading HIPAA compliance company, to conduct comprehensive risk and compliance assessments and has signed business associate agreements (BAAs) with its healthcare partners.

Over 100 U.S. healthcare organizations are currently a part of the Uber Health beta program with healthcare technology companies exploring ways that Uber Health can work with their offerings.

Lyft is working with Allscripts to integrate its platform into the daily routines of 2,500 hospitals, 45,000 physician practices and 180,000 physicians, reaching an estimated 7 million patients, according to Lyft. A desktop application will allow medical facilities to call multiple cars at once, and sends patients ride details via text messages. Healthcare providers cover the cost of the ride unless otherwise specified.

“Through a seamless integration of Lyft’s API and Allscripts’ EHR system, we’re empowering clinicians to eliminate transportation barriers for millions of people across the country by making it easier to get to and from medical appointments with Lyft,” said Gyre Renwick, VP of Lyft Business. “Our partnership with Allscripts is an important next step towards reaching our goal of cutting in half the number of Americans that face transportation issues to medical appointments by 2020, as we work to ultimately improve people’s lives with the world’s best transportation.”

Blue Cross Blue Shield, Sutter and CareLinx, among other healthcare organizations, already use Lyft to bring patients in for appointments and say the company’s missed appointment rate has dropped 20% since partnering with Lyft.

Supes Approve Plans For Gun Violence, Mental Health Summit The Santa Clara County Board of Supervisors unanimously approved the beginning of plans for a summit on gun violence and its relation to mental health.

The motion came as a result of the February 14 mass shooting in Parkland, Florida, which killed 17 people, including students and faculty at Stoneman Douglas High School.

The board directed the County Executive’s Office and the county’s Behavioral Health Department to work with the supervisors to convene a “Gun Violence and Mental Health Summit” within the next 60 days.

The summit would be modeled after that of the 2011 Older Adult Summit, which is now held bi-annually as a part of the Seniors’ Agenda plan to address the growing population of seniors in the county.

Supervisor Dave Cortese, who introduced the motion, said the summit will be just one of many recommendations, such as the formal endorsement of the March For Our Lives, an event being organized by high school students across the country on March 24, including San Jose.

Along with the march endorsement and proposed summit, the motion called for the County Counsel to provide further legal analysis on how the county could possibly use police power and land use authority to require that mental health information be flagged in background checks for firearm purchases and transfers.

The idea of the summit garnered both positive and negative reactions from community members and advocates.

Cortese said he wanted to clarify that the county does not want to risk stigmatizing those with mental illness as violent, but some experts from around the county felt as though the suggested title of the summit had the potential to do just that.

Two representatives from National Alliance on Mental Illness Santa Clara County discussed, with data, how people with mental health issues have more violent acts perpetrated toward them rather than perpetrating violent acts themselves.

Executive director Kathy Forward said NAMI was not opposed to the summit itself, but the name of it, and suggested changing it to “Addressing Gun Violence” or “How to Stop Gun Violence,” among other titles.

Forward said that according to NAMI’s national office, people with mental illness only account for 4 percent of violent acts in the U.S. Only 2 percent of those acts are committed with guns, she said.

“There is no evidence that prohibitions against those with mental illness will reduce gun violence,” Forward said. “However, expanding these prohibitions could enforce stigma and discrimination toward mental illness and further discourage people from seeking help when needed.”

Erin O’Brien, president of the nonprofit Community Solutions, said she was grateful for the attention gun violence was getting after the Parkland shooting and for Cortese’s desire to end gun violence, but she was concerned the summit established a clear association between that and mental illness.

“If we want to look at what data shows is tied to gun violence, particularly mass shootings, we need to look into domestic violence,” O’Brien said. “Fifty women a month are killed by their partner with a gun.”

Kathleen King, CEO of the non-profit organization Healthier Kids Foundation, and Santa Clara County Superintendent of Schools Mary Ann Dewan both spoke in support of the summit, offering their agencies’ resources in collaboration to enable the dialogue’s existence.

Dewan said that the county Office of Education will be announcing its own plans for gun violence prevention and safety at schools at its next board meeting.

After the public comments concluded, Cortese thanked the mental health advocates for speaking and said that he agrees the summit title should be different than that of the subject line of his attached memo.

Cortese said he would work with partici-

pating departments to come up with an appropriate name.

“I am sensitive to what has been brought up by public speakers today,” Cortese said. “Sometimes titles aren’t important, but in this case it does matter so that we don’t forever today in the county archives have something that might be misunderstood.”

Cortese said he intended only for the summit to be an open dialogue about the problem of gun violence, as “that is the Santa Clara County way.”

SOURCE: Bay City News Service | www.sfgate.com/news/bayarea

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Palo Alto Looks to Become a ‘Dementia-Friendly City’ Push to create better support services gains momentum After living with a diagnosis of “mild cognitive impairment” for the past three years, Kitty Lynch has a few things she’d like people to know.

The 70-year-old cringes when her friends say “Don’t you remember?” or “I already told you that.”

“When people say that, it feels like you’re getting stabbed,” said Lynch, who expects her condition will lead to Alzheimer’s disease. “It highlights cognitive loss, and it’s totally demoralizing.”

Lynch and others will share their stories of living with dementia during a public forum on Wednesday, March 28, sponsored by the City of Palo Alto, Avenidas, Age-Friendly Silicon Valley and the Alzheimer’s Association to explore how Palo Alto can become a “dementia-friendly city” that is inclusive and supportive of people living with dementia.

Palo Alto is among a growing number of communities around the world that have begun to look at how government, businesses and residents can work together to provide better resources — like training for first responders, community support networks and policies that better aid employees who are also caregivers — for the expanding population of aging adults who are being diagnosed with dementia.

In Santa Clara County, more than 31,000 residents currently have Alzheimer’s disease or other forms of dementia, and that number is projected to increase to 56,000 by 2030, said Jessica Rothhaar, policy and advocacy manager for the Alzheimer’s Association of Northern California and Northern Nevada.

Rothhaar said most people with dementia can remain active in the community and, with appropriate support, will have a better quality of life at lower costs than if they are isolated or institutionalized.

By changing the way people think, act and talk about dementia, Rothhaar said she believes the community can play a key role in helping those afflicted with memory loss remain independent and socially engaged.

“Dementia is something we usually don’t talk about, and people avoid someone who has it,” said Palo Alto Mayor Liz Kniss, who will speak at the event. Kniss, who helped care for a relative with Alzheimer’s living in her home, said the isolation that comes along with the disease can be unnerving.

“I’d certainly be happy if people began to look at somebody with dementia as a person who can use their help, support and especially their understanding,” she said. “I’d like people to become aware of it, not fear it and be aware of it among your group of friends because maybe you can help.”

Families usually have a hard time acknowledging a dementia diagnosis to friends and relatives, said Paula Wolfson, a social worker at the nonprofit Avenidas senior services agency who for many years has operated support groups for caregivers. They feel stigmatized for being in a “sad, depressing and shameful situation, especially if the person with dementia was well-known and very accomplished in research, academia or Silicon Valley tech,” she said.

A typical dynamic is that the caregiver family does not wish to be a burden to their neighbors and the neighbors are reluctant to ask questions or ask if they can help for fear of seeming intrusive, Wolfson said.

“There needs to be a way that everyone has ‘permission’ to reach out to the other,” she added.

42 | THE BULLETIN | MARCH / APRIL 2018

Lynch said she initially felt devastated by her diagnosis.

“I was literally in hysterics, and I didn’t know what to do,” she said.

Eventually she found help, including a weekly support group, through the Alzheimer’s Association.

“Having this disease is a journey that can be scary, sad and lonely, but for many of us, there’s still a lot left,” she said. “I sing in four choirs; I tutor an English learner. I’m great in the present tense, but I often forget things I’ve said or done. That’s hard. It’s embarrassing and it takes a while to adjust to the losses.”

Lynch remains in her longtime book group despite having lost her ability to read books. She urges neighbors to include people in social engagement activities even if they can’t fully participate any more.

Her advice to people wishing to support friends or neighbors with dementia: “Stay in the present tense because that’s where they operate. Help them contribute and stay active in the community, maybe by taking them to church, concerts, art shows, parks or garden tours. Your friendship and acceptance and support is the greatest gift you can give.”

Menlo Park resident Karen Berman, who has cared for her husband since 2009, identifies her main problems as “social isolation and lack of emotional and practical support.”

She has hired caregivers to stay with her husband a few hours a day so she can get out for activities of her own, including a caregiver support group and long walks with her dog.

The support group “has just been essential for my mental health,” she said. And during the dog walks, “It means a lot to me when somebody smiles at me. I’m kind of isolated and lonely, and it’s really nice that people speak or say hello or smile.”

Berman, who moved to Menlo Park four years ago after 25 years in Los Angeles, said she would welcome closer relationships with neighbors.

“My husband really can’t be left alone, and a lot of times I have to cut short what I’m doing to rush home before my help leaves,” she said. “It would really be nice to know my neighbors well enough to call and say, ‘Could you stay with him until I get there,’ a little exchange for things like that.”

Practical things people can do that can help, Wolfson said, are assisting with transportation for things like groceries or medical appointments; making friendly visits with pets or children; being on the lookout in case the person with dementia wanders off; inviting the caregiver for a coffee breaks and including people with dementia in social gatherings.

As part of its broader push for an “age-friendly Silicon Valley,” Santa Clara County last year joined Dementia Friends, a global movement begun by the Alzheimer’s Society in the United Kingdom to change the way people think about dementia.

Diana Miller, the county’s senior agenda project manager, said a 2016 survey that the county conducted found that few people have a clue about where to find resources for someone with dementia.

“When we asked people where they would go ... it was almost like a blank,” Miller said. “Either people don’t think about it, or they’re not talking about it.”

SOURCE: By Chris Kenrick | www.paloaltoonline.com

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