2017 September/October

SEPTEMBER / OCTOBER 2017

VOLUME 23 | NUMBER 5

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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

Feature Articles 12 Physicians are Getting Burned Out

Billing/Collections

14 When You Feel Overwhelmed, Do a “Stress Scan”

CME Tracking

16 AMA Alliance Efforts to Reduce Physician Burnout

Discounted Insurance

18 New Medical School

Financial Services

26 No End in Sight for California’s Skyrocketing STD Rates

Health Information Technology

32 The Importance of Keeping Adequate and Accurate Medical Records

Resources House of Delegates Representation

Departments

Human Resources Services

6 Message From the SCCMA President

7 Message From the MCMS President

Legal Services/On-Call Library Legislative Advocacy/MICRA Membership Directory APP for the iPhone

10 CMA President’s Message 17 CMA On-Demand Education 20 Hospital News 23 Medico News

Physicians’ Confidential Line

28 Physicians News Network

Practice Management Resources and Education

33 New Resources: For Treating Alzheimer’s and Opioid Guideline

Professional Development

34 3 Steps to Responding to Negative Online Comments

Publications Referral Services With Membership Directory/Website Reimbursement Advocacy/ Coding Services

36 Welcome New Members 38 Case Law Update: HIPAA 40 Medical Times From the Past 42 Classified Ads 43 CMA Summary of the Board of Trustees Meeting

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THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President Seham El-Diwany, MD President-Elect Kenneth Blumenfeld, MD Past President Scott Benninghoven, MD VP-Community Health Cindy Russell, MD VP-External Affairs Vanila Singh, MD VP-Member Services Ryan Basham, MD VP-Professional Conduct Faith Protsman, MD Secretary Seema Sidhu, MD Treasurer Anh Nguyen, MD

CHIEF EXECUTIVE OFFICER

COUNCILORS

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Lewis Osofsky, MD El Camino Hospital: Vacant 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: Erica McEnery, 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 2017 by the Santa Clara County Medical Association.

4 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

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

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The Physicians’ and Dentists’ Confidential Line is a project of the California Medical Association and the CMA Alliance, with additional support from the California Dental Association.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 5

Is “Single Payer” a Viable Option?

President, Santa Clara County Medical Association

SEHAM EL-DIWANY, MD

MESSAGE FROM THE

SCCMA PRESIDENT

T

Seham El-Diwany, MD 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.

he California State Senate introduced The Healthy California Act (SB 562) as amended on April 17, 2017 to establish a Single Payer Health Care System in California.

Although shelved by the Assembly, it provided a glimpse into what such system entails and it initiated an important discussion.

SB 562 is highly ambitious. It aims to cover every person regardless of their immigration status with no copay, deductible or coinsurance (e.g. separate billing). Benefits include all medically appropriate care and services covered by Medi-Cal, Medicare, and ACA essential benefits and coverage mandates including prescription drugs, dental, vision chiropractic, acupuncture, skilled nursing facility care as well as all forms of therapy that are shown to be safe and effective.

The cost of such a universal coverage is astronomical. One analysis by the Senate Appropriations Committee estimated SB 562 would cost $400 billion per year (more than triple the state governor’s current annual budget) and a second analysis by the National Nurses United , estimated it would cost a mere $331 billion per year.

As with any monumental government run program, oversight and administration of this plan underlies many of its obstacles. SB 562 proposed that it would be run as an independent program within the state government (not be affiliated with any existing agency or department) with an unpaid executive board of nine members with demonstrated and acknowledged expertise in health care that would oversee the program.

The reality is that any health care debate boils down to cost and who pays for it. California, even with its high per capita income, cannot afford it. And even if it does by some miracle, it cannot go it alone.

While a single payer plan has to be administered at the state level, it is clear that a single payer plan must be in partnership with the Federal government. In short, California cannot devise its own “Single Payer” in isolation as SB 562 suggests. Finally, the reality of the current national healthcare debate has proved beyond reasonable doubt that a single payer system is so untenable that we should probably consider its mention purely an academic exercise for the time being.

As healthcare providers and advocates for patients, physicians believe that “All people have a right

6 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

to quality health care. “ Being at the frontlines of the healthcare delivery system, physicians also carry the vital responsibility of guiding the required changes in healthcare based on today’s reality and not experimentation in social engineering.

In my opinion, I believe that a single payer healthcare system (similar to the Canadian system) ignores realities of American society. Past and current debates around healthcare have proved we need an evolutionary process with time allowed for adjustments and corrections with each incremental change. Quantum leaps such as the “universal coverage” or “slash and burn” approaches feed on the hope that a better system would emerge as in “Repeal [now] and Replace [later]” and ignore that they would likely create severe and potentially irreversible dislocations in our healthcare system.

I believe that a path towards single payer or universal coverage can be achieved through incremental changes to existing programs. For example, expanding Medicare to gradually include more groups such as those between the age of 60 and 65 and the unemployed (the least desirable demographics in Health Insurance) can effectively make it more affordable to young adults. As a Social Security benefit, it is an earned right for a continually increasing number of people, paid for through payroll deductions throughout their working career. It takes the lifetime of a career to build this benefit. Similarly, a generation of incremental changes must be made into Medicaid/Medi-Cal and other existing social welfare programs for any collaboration between federal and state welfare programs to produce the scale of change being discussed.

President, Monterey County Medical Society

MAXIMILIANO CUEVAS, MD, FACOG

specialists in the clear majority of rural and agricultural producing regions in California and the nation have been more a “talking point” than a policy point.

In California, there are currently 607 federally designated Health Professional Shortage Areas (HPSA).

The preferred ratio of primary care physicians to population is 1,041 to 1. The only counties in California that meet this ratio are Orange, Sacramento, and the Greater Bay Area region! When we examine this ratio in counties in California’s central and coastal valleys and in the north, the ratios often are twice the preferred ratio. Access to medical specialists is significantly greater in these regions. While there is no doubt having more individuals covered under MediCal and the ACA is a great improvement, we cannot ignore the reality that many of these new patients to insurance continue to function without a primary care doctor and appropriate access to specialists.

Not only has the challenge of access to preventive primary health care services become worse, we must also confront that little, if anything, is on the drawing boards of policy makers or medical schools to address the failure to develop doctors to work in rural communities and to address the cultural and linguistic realities of a significant percentage of the California patients that has been growing since the mid-1990’s. These realities have been ignored for decades and, as doctors, we have had to endure concerns around the failure to communicate well with our patients. This challenge is not relegated only to patients from outside of U.S. with different language

MCMS PRESIDENT

I

t is still safe to say that doctors are indispensable to the delivery of health care regardless of the health plan one may have and especially if one does not have a health plan or health insurance. Over the last 20 years we have read and heard of how this irreplaceable workforce in health care is getting older and retiring earlier than many had expected. This is depleting the physician workforce at a time when health care coverage has expanded, has become a higher priority in the lives of a significant majority of Americans, and includes a much more linguistically and culturally diverse population. Predating these issues has been the ever-constant challenge and structural problem of the doctor shortage in rural areas throughout the nation.

These factors and trends were present decades before the debate on the Affordable Care Act (ACA) began. The ACA has now brought even more light on these problems, which have only gotten worse.

While some in the media and in academia have given attention to serious barriers to health access, these realities have largely been ignored on a substantive basis during the ACA’s operation. They have not even been part of any substantive policy discussions neither in the California legislature nor in the one-sided deliberations in both houses of the U.S. Congress throughout the high drama on the repeal and replace of the ACA. A February 17, 2015, San Jose Mercury News story reported that new Medi-Cal enrollees in the Bay Area were having trouble finding a physician or waiting months for an appointment.

The lack of primary care providers and medical

MESSAGE FROM THE

50 Years of Physician Shortages and Other Medical Workforce Challenges Require Bold and Creative Initiatives

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 SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 7

Message From the MCMS President, from page 7 and culture. We must recognize that advocates for gay, disabled, and transgender communities have underscored this concern of poor communication and a disconnect with many in the medical profession.

These serious structural problems have been recognized for several decades and they have had a profound impact on the health delivery system of California and the nation. The most recent study that acknowledges the consequences of these problems was just issued by the Commonwealth Fund “From Last to First – Could the U.S. Health Care System Become the Best in the World?,” published in the New England Journal of Medicine on July 17, 2017. It compared the health care delivery systems in 11 nations. The key finding was that “… U.S. ranked last on performance overall, and ranked last or near last on the Access, Administrative Efficiency, Equity, and Health Care Outcomes domains.”

Those of us located and practicing in a rural/agricultural producing community have known of these barriers and problems for a very long

year medical students, an estimated 34.3% had an intention to practice among the underserved.” The reality is we have not seen over the last 20 years anything close to 34.3% of fourth year medical students making the decision to practice in medically underserved communities, especially in rural areas.

Speaking to the lack of diversity in culture and language in our physician workforce, was a research paper published in Academic Medicine Vol. 90, No. 7/July 2015 entitled “Latino Physicians in the United States, 1980-2010: A Thirty-Year Overview From the Census.”This paper pointed out a growing trend that has been ignored over the last 30 years that the Association of American Medical Colleges discussed in their “Recent Studies and Reports on the Physician Shortage in the U.S.” that “…nearly every state is facing a physician shortage. Absent from these published concerns regarding the overall physician workforce has been any discussion of the Latino physician supply – even though the Latino

time. While we cannot argue against the newly created access to health care brought about by the Affordable Care Act (ACA) and Medi-Caid expansion, many of our patients and others are still afflicted by the lack of primary care doctors and specialists in these communities. As I stated above, California only has three counties in the state that have the preferred population to primary care provider ratio of 1,041 to 1.

Reinforcing the poor access is the study, “A National Longitudinal Survey of Medical Students’ Intentions to Practice Among the Underserved,” published in American Medicine in July 2017 found that “…lack of formative education experiences may dissuade students from considering underserved practice.” The study found that “…among fourth-

population is projected to increase from $51 million in 2010 to $129 million by 2060.”

This paper found that non-Hispanic white physicians rate per 100,000 of the non-Hispanic white population increased from 211 in 1980 to 315 in 2010. In the case of Latino population to Latino physicians, the rate dropped significantly from 135 to 105 per 100,000 Hispanics. It concluded that “The Latino physician shortage has worsened over the past 30 years. The authors recommend immediate action on the national and local level to increase the supply of Latino physicians.” This lack of cultural and linguistic connection appears to manifest itself in the data that tells us that Latino patients who are limited English pro-

8 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

ficient make less office visits, while having a language connection has found that patients are less confused, frustrated, and “…language related poor quality rating.”

The growth of the health care industry has been a constant over the last seven years due to the ACA and the expansion of persons securing private and public health insurance. In March 2017, Goldman Sachs reported that because of the ACA 500,000 jobs were added to the health care sector since 2012. Many of those jobs, unfortunately, did not include the appropriate increase in medical school admissions, the necessary residency slots in hospitals, new criteria for insuring that federally designated Health Professional Shortage Areas (HPSA) would be targeted for placement of more doctors, connecting the need for specific medical specialties to admission and training programs, curriculums that integrate cultural and linguistic competency because of the growing diversity in the patient population and creating initiatives that have medical schools be more inclusive of the students they recruit for admission to their institutions.

Certain aspects of these issues receive some public attention through discussion of workforce development in the health sector. There are many articles that appear in various medical publications and policy arenas but they do not and have not resulted in meaningful results that have improved access to primary and specialty care in rural and agriculturally producing regions in California and throughout the nation.

Based on the personal experiences I had in deciding to become a doctor, in selecting obstetrics and gynecology as my specialty, in working in a community health center, serving as the CEO of the largest primary health care system in the County of Monterey, and constant never-ending challenge of confronting the serious doctor shortage in the service areas our clinics target and having to recruit doctors to practice in our system, I believe it is time that we seriously begin a policy discussion to create institutional initiatives that will bring short and long-term efforts to reducing the doctor shortage in rural and agricultural communities in California.

Specifically, I believe we must: 1. Increase the number of students being admitted to medical school and base that increase on the specific number of the medical specialties necessary to meet the accepted population to provider ratios in urban and rural communities in the state.

2. Identify the cultural and linguistic profile of the patient populations that need having appropriate levels of access to primary and specialty care.

3. Require medical schools to add to their curriculums requirements language acquisition and knowledge of cultural beliefs and practices that would enhance the communication between doctors and their patients. These changes should not be limited to cultures of patients whose country of origin is outside the U.S. only but deals with sub-culture of patients who are California and U.S. born such as disabled, gay, and transgender patients.

4. Identify the specific number of primary care and specialty doctors that are needed in rural and urban communities in the state of California that have been designated as shortage and medically underserved census tracts by the federal government.

5. Create a track for medical school admissions of candidates who will be accepted based on their commitment and legal agreement to work in these specific medically underserved

communities for no less than twelve years. Those candidates agreeing to be admitted to medical school under this “track” will have a portion (to be determined) of their medical school education costs covered by outside sources including private and public funds.

6. Students choosing this track will all be required to have one of their school years designated “social service” where they will be assigned to work in a private practice, hospital or community health center that is in a federally designated Medically Underserved Community, Medically Underserved Population, or Health Professional Shortage Area.

7. Extending the life of the Licensed Physicians and Dentists from Mexico Pilot Program (AB 1045/Chapter 1157) passed by the state legislature in August 2002 and signed by then Governor Gray Davis September 2002. This pilot program allows board certified doctors from Mexico who meet other criteria and have various levels of oversight, to receive a California medical license to practice in community health centers located in medically underserved and health professional shortage areas in rural/agricultural producing counties in California. This pilot program is for three years and will have an evaluation conducted to determine if it should continue beyond this time.

Based on more than 50 years of analysis, research and policy discussions on doctor shortages in rural areas, I am convinced that we have largely failed to develop concrete policy and programmatic paths to institutionally reduce and correct this shortage. In the process, the medical profession and academia are now confronted by challenges that have made the doctor shortage even more complex to address. We now must confront and overcome the barriers to health care access that have been created by the lack of cultural and linguistic competency to effectively deal with the patient population diversity that has developed over these years. We must integrate the medical profession in a responsible manner that does not compromise the required standards for providing the highest level of care, and recognizes that our patients and their expectations and needs have changed on many levels. The expansion of the private insurance market by the ACA and Medi-Cal (Medicaid) has brought into systems of care populations that have not had a doctor or on-going access in communities that have long been underserved and unserved.

We cannot afford to respond to these challenges in the defensive manner we have heard all too often for decades. The data over these 50 years keeps telling us the same thing – little, if any, progress has been made by medical schools, our profession, and health care policy makers.

We have no choice but to be bold, creative and disciplined in having a short and long-term approach for resolving these serious and life-threatening barriers. Being a doctor requires us to lead on these issues and that is the role we must take.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 9

MESSAGE FROM THE CMA PRESIDENT

Together, We Can Move Mountains

By Ruth Haskins, MD President, California Medical Association Over the past year, I’ve had the privilege to serve as your California Medical Association (CMA) president, and I’ve had the pleasure of discussing the future of medicine with countless physicians across the state.

You’ve shared your experiences, perspectives and challenges, and one thing remains clear – serving as a physician isn’t something we do, it’s something we are.

It’s a calling. And it can be an unforgiving profession. The responsibility of life and death decisions, compounded by administrative burdens often feels overwhelming and isolating.

As a solo practicing ob-gyn, I’ve felt helpless plenty of times, faced with seemingly insurmountable obstacles to getting my patients the care they need.

Perhaps the most important thing I have learned in my 24 years as a CMA member is that the camaraderie of working with other physicians to fight legislative and regulatory battles for both my patients and my profession is invigorating. It’s revitalizing. It gives me the renewed energy I need to go back to my practice and give my patients the best of my time and talents.

CMA has a track record of “fighting the big fights” for physicians so that we can focus on and care for our patients. One such battle took on a personal tenor for me that began with one patient.

Many years ago, I discovered one of my pregnant patients had an abnormal heart condition. She had Medi-Cal insurance, which because of low reimbursement makes it harder to see specialists. She needed immediate access to a cardiac specialist to protect herself and her child.

But of the two cardiologists in her area — one wasn’t accepting new Medi-Cal patients,

and the other had a three-month waiting list.

Her options were to travel 60 miles to a cardiologist out of the area or to rely on the emergency room for care. When I heard her options, I was angered. Fortunately, I was able to pull some strings to get her into a cardiologist immediately, and her issue was controlled. But this incident really drove home the fact that having insurance doesn’t always mean having access to care, and I was determined to do something about it.

And through my CMA membership, I have.

I’ve spoken to legislators about the fact that low Medi-Cal reimbursement rates means physicians who see Medi-Cal patients often do so at a financial loss to their practices. I’ve testified in committee hearings about the fact that physicians have to make heart wrenching decisions to turn away Medi-Cal patients because increasing our Medi-Cal patient load would mean putting the financial viability of our practices at risk.

I’ve spoken at rallies on the Capitol steps, so that our elected officials could see the faces of the patients who are suffering because of an empty promise of coverage, without real access to care.

CMA also rightly made this issue one of its top priorities over the past decade. They’ve worked on both the legislative and the legal level – even taking the issue to the Supreme Court.

But after these efforts failed and we faced a wall of reluctance to solve the problem in the legislature, we pivoted and mounted a statewide initiative campaign to provide the funds to increase reimbursement to get these patients the care they need.

In 2016, the physicians of California united in a grassroots campaign to pass the CMAsponsored Proposition 56 (tobacco tax) to provide increased funding for Medi-Cal. It passed in a landslide.

When the governor, just a couple months later, proposed taking that money and putting in the general fund, we fought him tooth and

10 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

nail. During the budget process, CMA mounted public and private campaigns to get the Legislature to honor the will of the voters.

And in the end, they did. The final 20172018 state budget agreement provides over $1 billion to improve Medi-Cal provider payments.

But the fight is not over, and it’s not a battle that any one of us can win in isolation – when we come together and speak with one voice, we can move mountains.

To learn how you can make a difference through your CMA membership, reach out to me personally, or to any of your local elected physician representatives. You can also call the CMA Member Resource Center for assistance at (800) 786-4262.

CALIFORNIA MEDICAL ASSOCIATION FIGHTING TO ENSURE FEDERAL HEALTH REFORM

IMPROVES PATIENT ACCESS TO PHYSICIANS Long before President Donald Trump began campaigning to repeal the Affordable Care Act (ACA), the California Medical Association (CMA) and it’s county medical society partners began fighting for access to health care for all Californians. In fact, access to quality health care has been a core tenet of CMA for many decades.

CMA, which represents over 43,000 physicians across all modes of practice, believes access depends on affordable, quality coverage and reflects the ability of patients to secure appointments with doctors (promptly) for preventative care and when catastrophic circumstances occur.

As Congress embarks on the latest health reform debate, CMA remains committed to working with Congress and the Trump Administration to develop a plan that ensures patients can access doctors to receive high-quality and affordable health care.

CMA is standing by its core health reform priorities, which are to: • Improve access to physicians • Protect state and federal Medicaid funding • Ensure Californians do not lose coverage • Provide affordable coverage, particularly for low- and moderate-income families • Eliminate administrative and regulatory burdens in the Medicaid and Medicare programs • Provide a choice of insurers, HSAs and physicians • Maintain reforms on the insurance industry – coverage for pre-existing conditions, 85 percent medical loss ratio and no annual/lifetime limits on benefits • Stabilize the individual insurance market • Provide access to affordable prescription drugs

For more information, visit www.cmanet.org.

“

Medicaid funding must be protected and increased to care for America’s most vulnerable populations, and more work must be done to deliver access to doctors and affordable, quality care.”

Ruth Haskins, M.D., CMA President Rev. 03/16/2017

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 11

Physicians Are Getting Burned Out

By Lisa Grabl Reprinted with Permission of Physician Family Magazine, Summer 2017 Issue (www.physicianfamilymedia.org) Physician burnout is an often talked-about topic, but what can really be done to solve it? The American Medical Association defines burnout as:

“A long-term stress reaction characterized by depersonalization, including cynical or negative attitudes towards patients, emotional exhaustion, a feeling of decreased personal achievement and a lack of empathy for patients.”

According to the latest Medscape burnout report, 51% of physicians are burned out. When Medscape first asked about burnout back in 2013, only 40% of physicians said they had experienced burnout. The causes of burnout are varied but generally fall into these categories: • Too many bureaucratic tasks • Spending too many hours at work • Feeling like just a cog in a wheel • Increasing computerization of practice (EHRs) • Income not high enough • Too many difficult patients The signs of burnout are varied as well and could include any combination of the following: • Apathy to work and colleagues • Indifference to patients • Loss of joy in the practice of medicine • Feeling overwhelmed and frustrated • Increased mental health concerns Another issue that can lead to burnout is the feedback environment in which physicians traditionally find themselves. Physicians primarily receive feedback in the following three ways: • What they are doing wrong – This focuses on what physicians are not doing well and where they are falling behind.

• Lack of numbers – Negative feedback comes through quantitative data; this focuses on numbers, how many patients were seen, how much was billed and other transactional aspects of practicing medicine.

• Patient complaints – You can have dozens or hundreds of positive interactions with a patient and never hear a word, but as soon as that patient has a bad experience, that is the comment that gets heard. A few bad comments can soon become the focus for a physician who, in reality, is greatly appreciated by 99% of patients.

12 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

Constant negative feedback can lead good physicians to burn out and no longer feel confident in themselves or the field of medicine. Ongoing burnout can lead to depression or other mental illnesses.

HOW YOU CAN HELP

Often a physician’s family members may not be aware their loved one is burning out unless that burnout is rolling over into their home life.

Burnout is not limited to a particular specialty or setting or based on the tenure of the physician. Some of this is due to the culture that has traditionally surrounded physicians and medicine – the idea that physicians are so focused on helping others they never stop to care for themselves.

THERE IS ALSO AN ATTITUDE OF NEVER SHOWING WEAKNESS.

This is where a family member can be of the greatest help. If you notice the physician in your life is acting differently or is less engaged with his or her work, encourage the physician to try and identify what is causing the burnout and start looking for ways to solve it.

Often a simple change of venue can stave off burnout. This can be done through locum tenens assignments, mission trips or volunteering at a local free clinic. All of these give physicians a new outlook, help to remind them why they went into medicine and better prepare them to return to the rigors of their regular job.

If a change of pace is not enough, your loved one may need to consider looking for a new job or seeking help from a therapist or other mental health professional.

Lisa Grabl is president of CompHealth (www. comphealth.com), the nation’s largest provider of locum tenens physicians and founder of the traveling physician industry. Lisa joined CompHealth in 2001 as a sales consultant and has excelled in a variety of management roles. Lisa is passionate about building lasting relationships and helping her team members reach their highest potential.

She holds a Bachelor of Arts degree in liberal arts from Utah State University.

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SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 13

When You Feel Overwhelmed, Do a “Stress Scan”

By Warren Holleman, PhD Reprinted with Permission of Physician Family Magazine, Summer 2017 Issue (www. physicianfamilymedia.org) Stress is a normal part of everyday life, especially if you or your spouse is a physician. I’ll give you a very fresh example. This morning I woke up and my wife wasn’t there! Turns out today is the day her clinic has their monthly meeting—before morning rounds and clinic—so they meet early. And last night she stayed late to cover the evening clinic—so she didn’t get home until nearly 9 p.m. And the day before that was supposed to be her day off in exchange for covering the evening clinic two nights this week. But . . . turns out this was also her week to be on call at the hospital. So she disappeared again, early in the morning, on a day I thought was to be a “day off” and a “family day.”

Does this sound familiar? And now comes the really depressing part. “Familial stress” is only one of at least seven stress factors that physicians and their families must cope with.

We still have all the other “normal” stressors as well: occupational, physical, social, psychological, spiritual and technological.

Don’t get me wrong. “Normal” stress is a good thing. Without it we’d be bored. We’re hardwired to enjoy challenges and new experiences.

But “normal” stress isn’t what I’m talking about here. I’m talking about “dis-stress,” or being overwhelmed by too much stress.

There are at least seven spheres of life where normal stress can overload and become dis-stress. Failing to take care of yourself in these key areas is a surefire way to experience dis-tress. Take a few minutes to scan these seven spheres and their stress factors, and you’ll get a snapshot of where you need to do some preventive maintenance.

Let’s say you do the Stress Scan and find two or three problem areas. The next step is to drill down to see what’s driving the dis-stress.

Then you can develop a strategy to address it.

SPHERE

STRESS FACTORS

Occupational

Workplace demands, priorities, and conflicts. Workplace unfairness. Bad workplace relationships: customers, coworkers, bosses, supervisee.

Physical

Inadequate sleep, nutrition, exercise. Medical problems.

Social

“Functional” relationships: communication, conflict, commitments. Willingness to discuss feelings and values. "Dysfunctional" relationships: abuse, addiction, unfairness.

Familial

Problems in family relationships: marriage, in-laws, children, care for aging parents. Work-life imbalance. Unclear boundaries. Toxic binds.

Psychological Unrealistic expectations: what I think I should do vs. what I can actually do.

Perfectionism. Guilt. Shame. Postponement of happiness.

Spiritual

Feeling that my beliefs and values are disrespected by others; feeling that I have compromised or failed to nurture my faith or my values.

Technological Electronic addiction: phone, email, social media, TV. Cable news. Sports. Over stimulation. Multi-tasking. Unable to unplug Here are a couple of examples.

CASE STUDY #1: PHYSICAL DIS-STRESS

Physical dis-stress is largely a result of your failure to take care of your physical needs.

When we’re fatigued, malnourished or physically weak, even the normal stressors of work and life feel overwhelming. When we’re strong, we become resilient and thus better able to handle stress. Ask yourself the following questions:

Are you getting 7-8 hours of sleep each night?

• If not, take some time to review healthy habits associated with good sleep hygiene: daily exercise; going to bed and getting up at the same time each day; no electronics the last 2 hours before bedtime; no caffeine in the afternoon or evening; reading a novel to help you fall asleep and, if you have young children, going to bed an hour earlier to make up for getting up with them in the middle of the night.

• There are no shortcuts. Don’t take sleeping pills unless you’re one of the rare individuals who suffers from a true sleep disorder. For the other 99% of us, the only healthy solution is to

14 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

change our daytime habits so that when the sun goes down, we can enjoy a good night’s sleep.

Are you eating lots of fresh fruits and vegetables, or mostly junk food, processed food and high-carb “white” food? (White food is bread, pasta, rice and potatoes.)

• Keep a journal of what you eat each day for one week, then calculate the calories.

• Make an appointment with a dietician.

It may cost you some money, but it’s a lot cheaper in the long run than spending your money on weight loss gimmicks and doctor’s bills!

Are you exercising every day, and exercising vigorously at least three times per week?

• Exercise isn’t optional; it’s essential. In fact, it’s the latest trend among many top CEOs. They take 1-2 hours out of their workday to train their bodies with the same care they train their workforce.

• For my inspiration and motivation, I think about my “disabled” friends. I know people who are paralyzed from their waist down, and they still exercise regularly. They say it’s absolutely

essential for their mental health and their ability to manage stress and maintain busy professional lifestyles.

No excuses!

Are you doing the things you are supposed to be doing to manage any chronic health conditions?

• If not, take some time to ask yourself why. Be honest with yourself.

• Get out your calculator and calculate how many bodies you’ve been allocated by the SBAUHD (Supreme Body Allocator of the Universe -Human Division). Write down that number and think about what that means.

Let’s say, on the other hand, that you have a chronic condition and you are doing your best to take care of it, but the condition itself brings on many stressors that are difficult to deal with. That’s a tough situation to be in because you can’t just “do something” and have the problem go away.

• One thing that many find helpful is to join a support group–or to form a group by inviting friends in similar situations.

• We formed such a group where I work, and I’m amazed at how everyone benefits just by sharing information, sharing resources and giving each other the emotional support we need.

People leave the meeting energized and ready to face upcoming challenges.

CASE STUDY #2: SOCIAL DIS-STRESS

Social dis-tress can be caused by having relationships with high levels of disrespect, unfairness, anger, or conflict. If your scan indicates that you’re suffering from social dis-stress, take a few minutes to review the possible stress factors: • Communication: Am I open to discussing important matters and not just superficial topics like sports and weather? Am I assertive in expressing

my needs and wants? Am I appropriate in doing this–being assertive without becoming aggressive–or could I use some skills training in how to communicate difficult things?

• Conflict: Is there too much conflict in my relationships? Do my friends and I express our differences too vociferously or too frequently? Or, is there too little conflict expressed in my relationships?

In other words, do my friends and I avoid conflict to the point that we are not authentic with each other?

• Commitment: Do I know which of my relationships have the highest levels of two-way commitment? These, of course, are the people with whom I can and should be most vulnerable and trusting. Do I make the mistake of sharing deeply with people who are not my trusted friends and thus create situations where the commitment does not match the communication?

• Relationships: Do I have two or three best friends with whom I can share my deepest feelings? My values? My hopes?

Fears? Uncertainties?

These areas–communication, conflict, and commitment–are normal growth areas for all relationships. They are also areas where we can always find room for improvement. Which is what makes good relationships so fun and so fulfilling: they’re always evolving, always improving.

But there are other relationship problems that tip into the pathological or dysfunctional realm, signaling that we need to address these issues urgently or extricate ourselves from the relationship. If you find yourself in this predicament, ask yourself some tough questions, and give honest answers.

• Am I entangled in a toxic relationship involving codependency, enabling, addiction, shame, abuse or violence?

• Am I the junior partner in a relationship where the other does all the taking and expects me to do all the

giving?

• Am I stuck in a relationship that is hopelessly stagnant: where there is no growth, no acknowledgement of problems or no will to solve problems?

If you answered “yes” to any of these questions, you may be trapped in a DYS-functional relationship. My recommendation is very simple: Get out! You aren’t going to fix him or her.

You’re only going to be abused, taken advantage of or enmeshed in someone else’s drama.

Sometimes getting out isn’t as easy as it sounds. You may have to devise an exit strategy.

Trusted friends can help. So can family therapists.

SUMMING UP

Whatever sphere your stress is coming from—and in most cases there is more than one—drill down and make a list of all possible sources of stress. Then develop strategies for coping with the stress.

And don’t be shy about asking for help. You may need to talk with a friend. You may need to take a course or develop a new skill. You may need to break a bad habit or “make” a new one.

You might need to go out and find new friends. Or “train” old friends to play new roles in your relationship.

Finally, don’t underestimate the role that psychologists, clinical social workers, family therapists, clergy, and other skilled professionals can play in helping you address the sources of your dis-stress. You’ll still have to do the hard work, but they can help you devise the most effective strategies.

Warren Holleman is a family therapist and Professor of Behavioral Science at the University of Texas MD Anderson Cancer Center. His wife Marsha is a family physician.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 15

AMA Alliance Efforts to Reduce Physician Burnout

By Julie Newman Reprinted with Permission of Physician Family Magazine, Summer 2017 Issue (www.physicianfamilymedia.org) STRESS. CYNICISM. ANGER. HOPELESSNESS. DESPAIR. SUICIDE. These words are the hallmarks of physician burnout. During my years in AMA Alliance leadership, I noticed an alarming trend. More and more physicians and their families were experiencing symptoms of burnout. Many were actively in crisis. Marriages crumbled, parents discouraged their children from pursuing a medical career, physicians engaged in risky behaviors, suicide became rampant. Physician burnout was classified as an epidemic.

Among other factors, most physicians point to a loss of autonomy and increased regulations as the driving forces behind dissatisfaction. The AMA has developed resources to prevent burnout and increase physician resiliency, but no such guidance existed for the families who love and support the healers.

In response, the AMA Alliance established a task force to develop an assessment quiz and common sense tools to be used by physician families to help cope with this burgeoning emergency in our community. The assembled team of Ilene Bosscher MA, MDiv, LMFT, LPCC, RPT, Racheal Kunesh, Suzanne Manning, Donna Baver Rovito and myself distilled mountains of data to provide resources necessary for healthy physicians and their families.

Here’s what we learned. Physician burnout is at crisis levels in the medical community. Marked by feelings of cynicism, loss of interest in work, and a reduced sense of personal accomplishment, recent studies show that 46%-50% of all physicians classify themselves in burnout. Most clinicians point to increased regulations and technology in combination with decreased opportunities for direct patient care for their overall sense of dissatisfaction. Still, most physicians say they would choose medicine again, especially those in front line practices such as primary care.

We hope you will take our Burnout Quiz to assess if your favorite physician is experiencing symptoms of burnout and take action. To take the online quiz, go to www.surveymonkey.com/r/WHPQWTJ 1 or download as a PDF at www.amaalliance.org/assets/docs/physican%20burnout%20quiz%20final.pdf. 2 Let Survey Monkey tally your score or add it up yourself – four levels of potential burnout appear in our AMA Alliance Guide to Physician Burnout and How to Effect Change.3 Physicians in burnout may become depressed and turn to self-medication or other extremes for relief. If your physician is in crisis, seek confidential assistance from your family’s personal physician, employer or health system’s resources, or your state’s physician health or assistance programs before it is too late.

Most approaches focus on steps the physician can take to overcome burnout. However, the AMA Alliance understands there must be a team effort involving the family and other supporters. According to Emily Gibson, MD, there are practical ways families can help: 16 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

• Encourage the physician to sleep as much as reasonable when not on call. Adult naps are highly underrated.

• Remind the physician to eat and remain hydrated while at work.

Some days may be tougher than others, but physical well-being is closely tied to emotional well-being.

• Help the physician get plenty of exercise. Even a stroll through the neighborhood helps.

• Make sure time off is truly time off. Discourage the physician from answering calls or emails related to work if it is not required. Keep vacation time sacred.

• Embrace unplanned activities. Spontaneity is a welcome break from a highly scheduled career.

• Introduce the physician to interests and hobbies completely unrelated to medicine.

• Nurture the physician as much as you can. When medicine demands so much from the physicians, it is important to remind them there are people who love and support them.

• Additionally, many health and hospital systems have physician wellness programs. See if one exists and if not, ask about starting one. Listen to your physician’s concerns about medical records and try to educate yourself. Engage with your local Alliance and medical society about legislation that may add burdens to the delivery of care. The AMA Alliance can help you to be an effective advocate.

The AMA has developed two modules for physicians to improve resiliency and prevent burnout, recommended by Dr. Michael Tutty as tools for our members’ favorite physicians. Physicians may be able to acquire CME by completing the modules free on the AMA’s website. They are also available as PDFs and Power Points:

AMA’s STEPS Forward Guide to Improving Physician Resiliency https://www.stepsforward.org/modules/improving-physician-resilience AMA’s STEPS Forward Preventing Physician Burnout Module https://www.stepsforward.org/modules/physician-burnout

LINKS:

1. Burnout Survey Online: www.surveymonkey.com/r/WHPQWTJ 2. Burnout Survey PDF: www.amaalliance.org/assets/docs/ physican%20burnout%20quiz%20final.pdf 3. AMA Alliance Guide to Physician Burnout and How to Effect Change: http://www.amaalliance.org/physician-burnout Julie Newman is a past President of the AMA Alliance and served as chair of the Physician Burnout Task Force. When not hanging out with her four furry children, two human children and cardiologist husband, she remains engaged with supporting and promoting strong physician families and health communities at large.

O

ne of the noteworthy benefits of being a member of the California Medical Association is having free access to a robust library of on-demand webinars.

CMA’s webinars give physicians and their staff the opportunity to watch presentations on important topics of interest from industry experts in the comfort of their homes or offices.

CMA’s webinars are unique because all of our live webinars are archived for on-demand viewing, meaning you can access these webinars at any time that is convenient to you.

The webinars are free to CMA members and their staff and provide the timely information needed to help run a successful medical practice.

Below is a sampling of the more than 200 webinars currently in our library. For more information and to view our full on-demand webinar library, visit www.cmanet.org/on-demand.

Assembly Bill 72: What Physicians Need to Know About the New Law on Payment and Billing for Out-Of-Network Services (Members Only) This webinar provides an overview of the new law, when it applies, the interim payment plans/insurers will be required to pay, the process to “opt out” of the AB 72 payment scheme, how to challenge the interim payment, how you can lend your voice to CMA advocacy efforts, and free resources available for CMA members.

Cannabis in Medicine: A Review of Policy and Scientific Evidence In this webinar, we cover the new state requirements under the Adult Use of Marijuana Act and present the most current clinical information pertaining to the potential medical uses of cannabis as well as its medico-legal policy context. The webinar explicitly focuses on whether or not evidence exists, and how strong any evidence is, for the use of cannabis to treat symptoms of a handful of diseases with particu-

lar focus on chronic and neuropathic pain.

ested parties.

Closing a Medical Practice

HIPAA Compliance: Key Risks All Physicians Should Know

This webinar goes over some of the major practical and legal issues that may arise when closing a medical practice, and assists physicians who are retiring or otherwise leaving their practice as well as families or estates of deceased physicians. Issues that are addressed in this webinar include people and agencies to notify when a physician practice closes, medical record retention and other issues and considerations when selling a medical practice.

Medicare Changes: 2017 and Beyond This webinar focuses on changes to the Medicare program in the upcoming year, including the Medicare Access and CHIP Reauthorization Act (MACRA), the 2017 Medicare physician fee schedule, annual updates and other changes. We also provide you with educational resources that help you understand what these changes mean for your practice.

Preventing Burnout: Individual and Organizational Intervention By recognizing and responding to burnout, physicians and their institutions can reduce sources of stress and intervene with tips and tools that support professional well-being. This webinar covers different evidence-based individual and organizational strategies available to implement into daily practice.

The California End of Life Option Act: An Overview This webinar reviews the requirements of the End-of-Life Option Act, including who qualifies to participate, what is required if a physician opts-out and what the documentation and reporting obligations are. It also covers advance care planning, including the completion of important documents like Advance Health Care Directives and POLST forms, as well as strategies on how to incorporate advance care planning discussions and documentation into your practice. This webinar is free to ALL inter-

In this webinar, CMA’s HIPAA advisor, David Ginsberg, gives his annual HIPAA compliance update. This webinar summarizes recent federal enforcement and what this means for every medical practice. We also discuss the top HIPAA privacy and security gaps and risks, along with simple steps to comply.

Aligning Clinical Practice with Diabetes Prevention: Screen, Test and Refer This webinar describes the clinical practice burden and trends in pre-diabetes and type 2 diabetes in California; reviews the evidence that supports systematically screening patients for pre-diabetes and referring to a community based program, like the National Diabetes Prevention Program; and discusses the tools available to help identify patients with pre-diabetes and establish a referral process. This webinar is free to ALL interested parties.

Paying Employees Correctly: Wage and Hour Laws for Health Care Employers Federal and state laws exempt certain employees, including some physicians, from wage and hour requirements, including overtime pay.

This webinar covers the basic wage and hours laws for health care employers in California and helps you ensure your practice is classifying and paying employees appropriately.

How to Manage Your Professional Reputation Online In today’s digital world, monitoring and managing an online presence has become essential. This webinar provides an overview on how to monitor your digital presence, take control of information about you and your practice online, and develop and implement a social media policy.

For a current list of upcoming webinars, visit www.cmanet.org/events.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 17

MEDICAL EDUCATION

Reprinted with Permission of San Francisco Marin Medicine 18 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

C

By Steve Heilig, MPH

hristine Cassel, MD, is a leading figure in geriatric medicine, medical ethics and quality of care and has been President of the National Quality Forum, American Board of Internal Medicine and American College of Physicians. She chaired Institute of Medicine reports on end-of-life care and public health and is author or co-author of 14 books and more than 200 journal articles. She edited four editions of Geriatric Medicine, a leading textbook, and completed a bioethics health policy fellowship program at the University of California, San Francisco (UCSF).

Cassel is the Planning Dean for a new Kaiser Permanente School of Medicine opening in Los Angeles in 2019 and we asked her for a summary of this effort.

What was the impetus for this new medical school?

Kaiser Permanente (KP) has been training residents for over 40 years, in many specialties, with collaborative relationships with medical schools.

It’s a different kind of experience here for residents because of our distinct system. The Kaiser board considered creating a medical school for some time, starting with the vision of a group of Kaiser physicians who worked on the idea for eight years. It’s an organization devoted to delivering affordable quality care to members, and for some, the idea of a medical school seemed a bit of a stretch. But as the country moves towards new models and using data to improve such care, the leadership saw the medical school as another way to create a useful model for our country when so much is changing.

Let’s get this up front—some have surmised Kaiser is doing this mainly because they need more doctors trained in the Kaiser model and the school is to be a kind of “feeder” for KP. Yes, that has been questioned. It does take time for new physicians to work best in our system and I could see how it might seem we are hoping to train our own. But that’s not the case; it’s actually to be a very small school, starting with 48 students per class for the first four years at least, and we have 22,000 Permanente physicians now, so this is a drop in the bucket and it would hardly be efficient to start a whole school for that reason. What we are doing is testing a hypothesis that we can improve care by embedding students in an integrated system of care.

There have been so many high-level efforts to reform and improve medical training, going back a century to Flexner and onward; are you using such reports to guide your new school?

We’re part of the group called Beyond Flexner (beyondflexner.org); their focus is on social missions in health professional education. We do want to be very respectful of the traditional Flexnerian model, which was that students should be taught in a research university with more evidence-based focus than before, with students taught by those at the cutting edge of all areas of science and medicine, and multiple clinical relationships. The message students get is often dependent on where they are rotating, with varied strengths and frustrations, and with education competing with other missions such as research. So we join those who want to give more attention to best teaching, and elevate faculty who are the best teachers. That has been difficult in an NIH-funded research culture. Our students will be embedded in a clinical system where they have all the data available on each patient, where specialists are highly dependent on primary care and the patient also has electronic access to all their data—52 percent of KP interactions with members are done electronically already,

so that is much more efficient for the patients who have to come into the office less. Teamwork is paramount too, with interdisciplinary teams of doctors, nurses, social workers, and pharmacists involved in teaching as well.

So is this a refocus on primary care as so many have recommended?

This school will be focused entirely on primary care physicians. The training and system will be built on respect and the integral importance of primary care. Students who want to focus on molecular biology research should go to another school and we will make that clear. The research these students will do will be based on population data, as we have a very rich data- base there. Of course we will teach basic science, anatomy, physiology, etc, but we are hiring faculty there based mostly on their teaching expertise. Much will be done in small-group settings rather than large lectures. It is being shown that students learn better that way—in fact, it’s harder to re-train faculty in some of these curriculum changes!

Do you see this as also an attempt to address future physician supply problems?

There is debate about exactly how many and what kind of new doctors are going to be needed, of course. I think nobody debates that we need new physicians equipped to practice in the rapidly-changing medicine we now live in. Our students are going to just be starting practice in 2030—how in the world can we know just what that will be like? So we need to equip them with the best understanding of technology, their communities, and the evolving roles of physicians and practice, especially as part of a team.

That’s what this effort is all about.

How about diversity concerns, voiced by so many?

Diversity in terms of social, ethnic and racial diversity but also economic diversity, is something we are committed to addressing. Right now 60 percent of U.S. medical students come from the top 20 percent of income, and 3 percent from the bottom 20 percent. We will have not only scholarships but look at better pipelines for disadvantaged students.

Will the school seek to address high medical school debt?

We are opening in 2019, and the first two classes, for their whole four years, will be tuition-free. After that it will average 50 percent support and I suspect it will be more, as we haven’t begun fundraising for these purposes.

This is kind of a temporary, “consultant” role for you, correct?

Yes. I am not a Permanente physician, although I was on their board for over a decade and have long been an admirer of their system. I’ve been in academic medicine and was a Dean at Oregon Health and Sciences University. We’ll be hiring a new founding Dean and board, and so forth. So credit should go to Kaiser leaders who conceived and will be following through on this very large project. The last time a medical school was developed without an affiliated university was Mayo over 40 years ago, and their concept was similar, in that they wanted it to not be a university, research-oriented culture, but with a clinical focus and culture. Right after Kaiser made it’s announcement in 2015, Geisinger announced it was merging with or acquiring a struggling medical school to train students in their model of care. So it’s kind of interesting that with more integrated systems now, we may see other schools along these lines developing in the future.

For more information, see: https://schoolofmedicine.kaiserpermanente.org/.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 19

Stanford Opens Center to Study, Develop Stem Cell, Gene Therapies Stanford has announced the opening of the Center for Definitive and Curative Medicine (CDCM), which will work to turn discoveries into stem cell and gene therapies to aid the millions of people who have genetic diseases. The center is a joint initiative of the Stanford University School of Medicine, Stanford Health Care and Stanford Children’s Health.

Stem cell and gene therapy hold enormous promise to cure conditions with well-defined genetic causes by engineering cells to treat disease or altering a patient’s personal DNA to “fix” an abnormality.

The center provides the organizational and physical infrastructure to support investigator-initiated clinical translational studies on stem cell and gene therapy from initial discovery through completion of clinical proof-of-concept studies. Stanford Medicine is in a unique position to develop the CDCM because of its outstanding expertise in disease pathophysiology, cell and stem cell biology, and an optimal and collaborative environment between the medical school and the hospitals.

“The Center for Definitive and Curative Medicine is going to be a major force in the precision health revolution,” said Lloyd Minor, MD, dean of the School of Medicine. “Our hope is that stem cell and gene-based therapeutics will enable Stanford Medicine to not just manage illness but cure it decisively and keep people healthy over a lifetime.”

At least 280 million people worldwide are living with a rare genetic disease. For many of these millions, the underlying cause of disease is known and well defined and yet eludes definitive treatment. At times, surgical interventions, public health measures, biological and small-molecule therapies can transform the health of these populations; often, however, the currently available treatment modalities result in mere palliative, rather than curative, medicine.

“We are entering a new era in medicine, one in which we will put healthy genes into stem cells and transplant them into patients. And with the Stanford Center for Definitive and Curative Medicine, we will be able to bring these therapies to patients more quickly than ever before,” said Christopher Dawes, president and CEO of Stanford Children’s Health.

“The work of the center is not being done anywhere else in the country — only at Stanford,” added David Entwistle, president and CEO of Stanford Health Care. “We have a pipeline of clinical translational therapies that the center is now driving forward, enabling us to translate basic science discoveries into state-of-the-art therapies for diseases which up until now have been considered incurable.”

Housed within the Department of Pediatrics, the new center will be directed by renowned clinician and scientist Maria Grazia Roncarolo, MD, the George D. Smith Professor in Stem Cell and Regenerative Medicine, and professor of pediatrics and of medicine.

The center consists of several innovative pieces designed to allow the rapid development of early scientific discoveries into the clinic that in the past have languished. This includes an interdisciplinary team of basic and clinical scientists to shepherd nascent therapies developed at Stanford. The team will be headed by associate directors Matthew Porteus, PhD, associate professor of pediatrics, and Anthony Oro, MD, the Eugene and Gloria Bauer Professor and professor of dermatology.

To help with clinical development, the center boasts a dedicated stem cell clinical trial office with Sandeep Soni, MD, clinical associate profes20 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

sor of pediatrics, as medical director. In addition, the center has dedicated clinical trial hospital beds in the Bass Center for Childhood Cancer and Blood Diseases located on the top floor of the soon-to-open Lucile Packard Children’s Hospital. From work performed by scientists over the past decade, the center already has a backlog of nearly two dozen early stage therapies whose development the center will accelerate.

“The center will provide novel therapies that can prevent irreversible damage in children, and allow them to live normal, healthy lives,” said Mary Leonard, MD, professor and chair of pediatrics and physicianin-chief at Stanford Children’s Health. “The stem cell and gene therapy efforts within the center are aligned with the strategic vision of the Department of Pediatrics and Stanford’s precision health vision, where we go beyond simply providing treatment for children to instead cure them definitively for their entire lives.”

One of the unique features of the center is its close association with the recently opened $35 million Stanford Laboratory for Cell and Gene Medicine, a 23,000-square-foot manufacturing facility located on California Avenue in Palo Alto. One of the first of its kind in the world, the laboratory has the ability to produce newly developed cell and gene therapy therapies according to the Good Manufacturing Practice standards as required for patient treatment.

Headed by Executive Director David DiGiusto, PhD, the lab can produce diverse cellular products for patient use, such as genetically corrected bone marrow cells for sickle cell anemia, genetically engineered skin grafts for children with the genetic disease epidermolysis bullosa or genetically engineered lymphocytes to fight rejection and leukemia.

“We are fortunate that Stanford researchers have created such a strong portfolio of innovative candidate therapeutics to develop,” said DiGusto.

“The capabilities of the laboratory will bridge the gap between research and clinical investigation so that the curative potential of these exciting cell and gene therapies can be realized.”

For more information about the center, or for information about trials associated with the center, go to https://med.stanford.edu/ptrm/faculty.html.

El Camino Hospital Launches Online Tool to Help Patients Estimate Out-of-Pocket Costs Silicon Valley’s El Camino Hospital recently announced the launch of a new price estimator tool on its website for community members to obtain out-of-pocket cost estimates for a variety of medical procedures and services. Estimates for more than 80 procedures and services are based on real-time insurance benefit information at the time of query and are available online 24/7.

“Consumers want information to make good decisions about their healthcare, and we are pleased to launch a new price estimator tool for our community,” said Iftikhar Hussain, chief financial officer of El Camino Hospital. “El Camino Hospital takes a personalized approach to care, and our team has deployed an online tool to provide a customized cost estimate at the convenience of the user, 24 hours a day from their home or on the go. Armed with this information, patients are able to better understand

and predict their out-of-pocket cost of treatment prior to undergoing certain procedures or receiving services.”

Contact information and service hours for scheduling staff, financial counselors and customer service are also available when using the tool. Financial counselors can provide estimates for complex procedures. In addition, insurance carriers accepted at El Camino Hospital are identified and updated regularly, as well as service-related frequently asked questions. Patients may also choose to pay their bill using this secure online tool.

“Transparency in healthcare quality and costs is imperative, and we will continue to work towards making the information available and easy to understand,” said Hussain. “We are very proud of our services, staff, quality of care and pricing structure and want community members to have access to that information to make

informed decisions. We expect to continue adding new procedures and services to the price estimator tool over time.”

The price estimator tool has simple descriptions of the procedures so the patient can select services without knowing the Current Procedural Terminology (CPT) codes. The projected out-of-pocket cost is a good faith estimate based on the real-time information provided at the time of the query and may differ from the patient’s final bill based on changes to care at the time the service is rendered, treatment or services the patient’s doctor determined are necessary and other information provided by the patient’s insurance carrier. Patients who identify themselves as not having insurance will receive an out-of-pocket cost estimate that reflects the hospital’s discounts for uninsured patients.

Verity Health Partners with Philanthropist Donates $10M for Prestigious Orthopedic Group Surgery Center at Lucile Packard Verity Health System has taken a significant step forward by Children’s Hospital Stanford

partnering with SOAR (Sports, Orthopedic And Rehabilitation Medicine Associates) to extend the system’s orthopedic and sports medicine reach in Northern California. SOAR, now part of Verity Medical Foundation as of July 1, has locations in Redwood City, San Francisco, San Jose and Soquel and is recognized around the world as a leader in sports medicine, orthopedic surgery, rehabilitation and rheumatology. As the team physicians for the San Francisco Giants and other high-profile professional and university sports teams, the physicians at SOAR utilize team approach to deliver the highest standard of orthopedic care and personal attention to every patient. “Bringing the prestigious medical team at SOAR into Verity Health’s growing integrated health system is another forward step for the communities we serve,” said Eric Marton, president and CEO of Verity Medical Foundation. “As a part of Verity Medical Foundation, SOAR will not only expand our scope of service and geographic footprint, but also help develop and lead our orthopedic services lines at Verity’s Northern California hospitals: Seton Medical Center in Daly City, Seton Coastside in Moss Beach, O’Connor Hospital in San Jose and St. Louise Regional Hospital in Gilroy.”

SOAR patients can expect enhanced services through the new relationship with Verity, including acceptance of more insurance plans and HMOs, and access to medical specialists in a larger physician network. The SOAR locations will remain the same, and the staff with whom current patients are familiar will continue to provide care.

Bonnie Uytengsu donated $10 million to Palo Alto-based Lucile Packard Children’s Hospital Stanford to further the development of the health system’s surgery center, the Almanac News reports. Uytengsu’s donation will help the hospital build a high-tech surgery center. In recognition of her donation, the surgery suites will bear her name. The project will add six surgical suites, increasing the hospital’s total number of surgical suites to 13, the most of any children’s hospital in Northern California. The center will include a neuro-focused hybrid operating room and imaging equipment.

Improvements Planned for New Stanford Emergency Department Creators of the new Stanford Hospital know that emergency rooms have a bad reputation. That’s why they’re working to employ the best practices in hospital design to ensure the new emergency room is as functional, and as pleasant, as possible. The new department, like the current department, will be called the Marc Andreessen and Laura Arrillaga-Andreessen Emergency Department. The new version will be “private, spacious and quieter,” said Sam Shen, MD, in a recent newsletter article. “We have an intentional, thoughtful layout with regard to activity and flow,” said Alison Kerr, RN, vice president of neuroscience, psychiatry and the emergency department. She likened the new department’s design to that of a well-organized marathon, in which the runners are grouped together according to their speed. Construction of the new hospital should be wrapped up in 2018.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 21

Stanford Launches New Online Center for Health Education to Benefit Learners Worldwide Reprinted with Permission of Physicians News Network (www.physiciansnewsnetwork.com) Stanford University launched a new Center for Health Education on Sept. 1, providing online teaching tools for a variety of learners worldwide — from highly credentialed professionals seeking advanced curricula to community health workers in areas with no access to conventional educational resources.

A collaboration between the School of Medicine and the Office of the Vice Provost for Teaching and Learning, the center will be directed

by Charles Prober, MD, the medical school’s former senior associate dean for medical education and a pioneer in advancing health education through digital training.

“Thanks to Charles’ visionary leadership, Stanford Medicine has earned an international reputation for collaboratively building innovative curricula and blended learning experiences,” said Lloyd Minor, MD, dean of the School of Medicine. “The new Center for Health Education will capitalize on this progress through a strong partnership with the vice provost’s office, helping extend advances in understanding achieved by our world-class faculty to learners far beyond our campus boundaries.”

The center will use the resources and expertise developed by the vice provost’s office over the past five years, including experts in instructional design, program development and learner support. The vice provost’s office will be the center’s home base. Dr. Prober will serve as both the founding director of the center and the senior associate vice provost for health education within the office.

“We are very pleased to serve the School of Medicine and the field of medicine in this way,” said John Mitchell, PhD, vice provost for teaching and learning. “An important part of our mission is to make Stanford’s expertise more broadly available. This new center provides an opportunity to do that through meaningful impact on human health.”

The center’s offerings ultimately may range from free content in resource-poor countries to fee-based certificate and degree programs in developed economies, Mitchell said, and will be funded by private foundations and philanthropy, tuition and, in some cases, research sponsorships.

Dr. Prober noted that the proliferation of smart devices into the farthest reaches of the globe has made it possible to distribute health information broadly, with content tailored to address a wide variety of audiences. A topic like nutrition education, for example, can be tailored to

reach medical students, patients, health professionals in continuing medical education or individual citizens in rural communities in some of the world’s most impoverished countries.

“Anything we create of inherent value for healthcare should be repurposed for healthcare for all, including developing countries,” he said.

The center will build upon existing programs developed by the medical school and the vice provost’s office and also expand partnerships with other organizations, including academic institutions, governmental agencies and nonprofits both in the United States and abroad.

The center will expand Stanford’s Digital Medical Education International Collaborative program, which aims to improve health education by creating high-quality, accessible content for use in developing countries.

Digital MEdIC already has a strong presence in India, where Sakti Srivastava, MD, associate professor of surgery and director of the program, has been building partnerships with public and private medical schools, nonprofits and government agencies to make online and simulation-based resources about health more widely available.

Similarly, Maya Adam, MD, a lecturer in pediatrics, is now expanding the Digital MEdIC program in South Africa by disseminating digital teaching tools on nutrition, pregnancy, breastfeeding and HIV management that can be used by community health workers and local women who might not otherwise have access to this information.

The new center also will promote courses that combine online and interactive learning. For example, students at Stanford’s medical school now learn biochemistry by watching short videos on their own time and then attending interactive class sessions to discuss the material. Whereas attendance in biochemistry lectures once hovered between 20% and 30% (not unusual at medical schools), some 95% of students now attend the interactive sessions. The School of Medicine has been collaborating with other medical schools in developing a similar approach to teaching microbiology and other topics in basic science.

While the center will initially draw content from the School of Medicine, it eventually will include other Stanford faculty whose work touches on health and wellness — for example, experts on climate change, economics, psychology and international law.

“We invite faculty from other Stanford schools with an interest in health to join in the effort and help us make the most effective contribution possible to world health,” Mitchell said.

El Camino Hospital Plans to Open New Clinic in San Jose In an ongoing effort to extend its reach well beyond Mountain View and neighboring cities, El Camino Hospital is aiming to spend $3.6 million on a new primary care clinic in west San Jose. The lease for the property was approved earlier this year behind closed doors as a strategic move to “secure a site in the proximity” of the hospital’s Los Gatos campus. The new clinic,

located at 828 S. Winchester Blvd., will be modeled after Silicon Primary Care Clinic next door to El Camino Hospital’s Mountain View campus. The floor plan includes 18 exam rooms and a procedure room within the 9,350-square-foot “retail building shell” currently on the property.

The site is big enough to support between six and eight physicians, according to a staff report.

22 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

The plans for the new clinic are separate from the hospital’s $23.4 million purchase of 16 acres of vacant land in South San Jose last year, which also flew under the radar and was discussed in closed-session meetings by the hospital’s board of directors.

(CMA Newswire, October 2, 2017 issue)

FDA Says Harm of Untreated Opioid Addiction Outweighs Risks of Concomitant Benzodiazepine Use Medication-assisted treatment (MAT) for opioid addiction is an important tool that has the potential to help millions of Americans with an opioid use disorder. In fact, patients receiving MAT cut their risk of death from all causes in half, according to the Substance Abuse and Mental Health Services Administration. However, health care providers and patients face significant challenges when determining how best to treat opioid use disorder, especially when the MAT drugs contain methadone or buprenorphine – which are also opioids.

The U.S. Food and Drug Administration (FDA) recently issued a statement saying that the opioid addiction medications buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the central nervous system (CNS). However, the agency is requiring changes to MAT drug labels to help decrease the risks of combining these drugs.

The new labeling recommends that health care providers develop a treatment plan that closely monitors any concomitant use of these drugs, and carefully taper the use of benzodiazepines, while considering other treatment options to address mental health conditions that the benzodiazepines might have been initially prescribed to address.

The FDA’s Drug Safety Communication recommends that health care providers take steps such as: • Educating patients about the serious risks of combined use, including overdose and death, that can occur with CNS depressants even when used as prescribed, as well as when used illicitly.

• Developing strategies to manage the use of prescribed or illicit benzodiazepines or other CNS depressants when starting MAT. • Tapering the benzodiazepine or CNS depressant to discontinuation if possible.

• Verifying the diagnosis if a patient is receiving prescribed benzodiazepines or other CNS depressants for anxiety or insomnia, and considering other treatment options for these conditions.

• Recognizing that patients may require MAT medications indefinitely and that their use should continue as long as patients are benefiting and their use contributes to the intended treatment goals.

• Coordinating care to ensure other prescribers are aware of the patient’s buprenorphine or methadone treatment.

• Monitoring for illicit drug use, including urine or blood screening.

Patients taking MAT drugs should continue to take these medicines as prescribed, and should not stop taking other prescribed medicines without first talking to their health care professional.

Physicians are encouraged to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program, available online at www.fda. gov/MedWatch/report. You can also call (800) 332-1088 to request a paper reporting form.

For more information about opioid safety, see the California Medical Association’s safe prescribing resource page at www.cmanet.org/safeprescribing.

(CMA Newswire, September 5, 2017 issue)

CDPH Releases Guide on New Cancer Pathology Reporting Requirements California recently passed legislation that requires electronic reporting of cancer pathology results to the California Cancer Registry (CCR). Pathologists will be required to report cancer diagnoses electronically to CCR beginning January 1, 2019.

The new electronic reporting requirements will allow a broader use of the data—including clinical trials matching, responding to commu-

nity cancer concerns with more timely data and identifying data for research studies requiring rapid identification of cancer cases.

To help health systems, laboratories and pathologists meet new electronic-reporting requirements, the California Department of Public Health (CDPH) has released the California Cancer Registry (CCR) Electronic Pathology Reporting Standards Implementation Guide.

The implementation guide defines the reporting requirements and provides standardized formats for electronic pathology reporting of cancer diagnosis.

CCR is a statewide population-based cancer registry recognized as one of the leading cancer registries in the world and has been the cornerstone of a substantial amount of research on cancer in the California population.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 23

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SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 25

No End in Sight for California’s Skyrocketing STD Rates

By Susan Wolbarst This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Summer 2017 California leads the nation in the total number of bacterial sexually transmitted diseases (STDs), according to the Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH).

According to the Executive Summary of a report discussing the epidemic titled, Sexually Transmitted Diseases in California, “California continues to be ranked first among all states in 2015 based on preliminary CDC data for the total number of cases of chlamydia, gonorrhea, syphilis and congenital syphilis.”

In 2015, according to data from CDPH, California residents experienced the following STDs: • 4,890 cases of primary and secondary syphilis (up 27% from 2014) • 142 babies born with congenital syphilis (up 39% from 2014) • 54,255 cases of gonorrhea (up 20% from 2014), and • 189,937 cases of chlamydia (up 9% from 2014).

“We’ve been seeing these increases year after year,” stated Dr. Heidi Bauer, chief of the STD Control Branch in the California Department of Public Health.

While the 2016 numbers have not yet been finalized, Dr. Bauer said the same trend of steeply increasing rates is continuing, with over 200 of the state’s babies born last year with congenital syphilis.

Persons most likely to catch an STD are “sexually active folks under the age of 29,” Dr. Bauer said, especially those with multiple partners or those whose partners have multiple partners. Those at highest risk are gay or bisexual men. “Folks who have an STD have a high likelihood of getting another,” she said.

For many years, the state saw the vast majority of syphilis cases confined to the communities consisting of men having sex with men (MSM).

Then, about three years ago – for reasons that are not clear – the CDPH began seeing a surge in syphilis cases among young women, especially in 26 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

the Central Valley. This is especially concerning, Dr. Bauer explained, because when women who have syphilis become pregnant, their babies are at risk of being born with congenital syphilis, which can be fatal.

In some states – including California – all pregnant women must be tested for syphilis at their first pre-natal visit. Treating the mother early in pregnancy can result in 98% prevention of congenital syphilis in the fetus, Dr. Bauer explained. But some women don’t seek pre-natal care and show up at the hospital just in time to give birth. By then, it is too late to save their babies from the severe effects of congenital syphilis, which can include premature birth, low birth weight, birth defects, blindness, hearing loss, stillbirth or infant death. These tragedies are “almost all preventable,” Dr. Bauer said.

Some people who have an STD do not know it because they are not experiencing symptoms. Left untreated, syphilis infection can lead to longterm health problems, including brain disease, according to the CDPH website. Regarding gonorrhea, infection can lead to serious reproductive health problems, such as pelvic inflammatory disease (PID) and infertility. Gonorrhea can also cause infections in newborn babies, according to CDPH. Chlamydia, which often exhibits no symptoms, causes the same kinds of damage as gonorrhea.

CDPH cited some disease-specific hotspots for incidence of STDs (number of reported cases taking population size into account): • San Francisco, Kern and Fresno counties ranked first, second and third for chlamydia.

• San Francisco, Lake and Shasta counties had the highest rates of gonorrhea.

• San Francisco, Fresno, Los Angeles and Kern counties ranked highest for early syphilis (includes primary, secondary and early latent stages).

• Kern and Fresno counties ranked highest for congenital syphilis.

The CDPH has not been able to point to any single cause of the rapid STD spread. “We do see evidence that some groups are using condoms less,” Dr. Bauer said, noting that gay and bisexual men may not be using condoms because they are taking HIV preventive medication. “More availability and access to testing” may be a key reason for the rising num-

bers of cases being reported, she said.

What is the most important thing physicians can do to stem the tide of the STD epidemic?

Dr. Bauer suggested that creating a safe, non-judgmental environment is important, as is “normalizing and having conversations with patients about sex.” The most important question a physician can ask a patient in the primary care setting is an open-ended one, she said, such as “Do you have any concerns today about your sexual health?”

Even if a patient did not come in that day with the goal of getting tested, she suggested asking if the patient is interested in an HIV test or an STD test. National guidelines published by the CDC offer specifics about how often to test specific populations for the different STDs and note that some STD testing should be done at more than one site. For example, a sexually active MSM should be tested for gonorrhea at least annually at sites of contact (urethra, rectum, and pharynx). The tests are usually covered by health insurance, Dr. Bauer noted, and, “in terms of medical services, California has fewer uninsured people than ever.”

Dr. Bauer pointed to what she called an “underutilized” Health and Safety Code section 120582, which allows physicians, nurse

practitioners and physician assistants to prescribe and dispense oral antibiotics to treat the sexual partner(s) of patients with an STD without examining the patient’s sexual partner(s).

The original law was applicable only to those infected with chlamydia – it was later amended to include gonorrhea or other sexually transmitted infection. Such expedited treatments for partners may prevent a patient from becoming re-infected.

Dr. Bauer encouraged physicians to work with local health departments, which can be helpful in confidential notification of sexual partners of patients infected with STDs or HIV and in getting patients back in for follow up and doing follow up on expedited partnership treatments.

Note that California law requires that all syphilis infections, including neurosyphilis, ocular syphilis, and congenital syphilis, be reported to the local (local to the patient’s place of residence) health department within 24 hours of diagnosis. In addition, HIV, including acute infection; gonorrhea and disseminated gonococcal infections; and chlamydia, including lymphogranuloma verereum, must be reported within seven calendar days. Reporting requirements for PID were recently eliminated.

DISPENSING ANTIBIOTICS TO PATIENTS’ SEX PARTNERS Health and Safety Code section 120582 allows physicians, nurse practitioners and physician assistants to prescribe or dispense oral antibiotics to treat the sexual partner(s) of patients with a sexually transmitted disease (STD) without examining the patient’s sexual partner(s). The original law was applicable only to those infected with chlamydia; it was later amended to include gonorrhea or other sexually transmitted infection. Such treatments may prevent the patient from becoming reinfected. Incidence of STDs is on an upward trend statewide, according to data from the Centers for Disease Control and Prevention.

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SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 27

Start-Up Develops AI-Fueled Voice Scribe for Healthcare Providers, Hospitals Saykara, a Seattle-based health technology start-up company, recently launched its first mobile app for iOS, an AI-fueled voice scribe that aims to be the Amazon Alexa for providers and hospitals.

The goal is to accurately transcribe audio to text, parse the information to make it structured, and insert it cleanly into an electronic health record, according to CNBC. SayKara was developed by a group of former employees from companies like speech recognition giant Nuance and Amazon.

The app has been used at a number of private practices over the past few months, but with the rollout of the app on iOS, it will begin trials at larger hospitals, as reported

by GeekWire.

“We’re taking the state of the art in

speech recognition and machine learning and we’re applying it,” Saykara CEO Harjunder Sandhu explained. “The key is to couple it with deep knowledge of how physicians work and the information that is relevant to them.”

Unlike Amazon’s Alexa, Saykara is focusing solely on healthcare by simplifying data captured with a new artificial intelligence-based virtual scribe solution that eliminates the hassle and cost of working with EHRs. It also aims to cut months of training for human transcribers, saving time and money.

There are still concerns in the medical field, however. When dealing with patient information, security is a huge factor. Like EHRs, having all that information stored in a cloud-based format is a risk. And while

certain measures are currently being taken across the country to help keep patient information safe, voice-enabled equipment is still relatively new, especially in medicine, and could bring up problems not yet experienced.

One major issue is identifying and understanding different medical terms. A simple misinterpretation between “hyper” and “hypo” can ultimately lead to extreme complications. Speech patterns and certain accents can attribute to this issue and inaccuracy.

“Saykara is built on a combination of speech recognition, natural language processing and machine learning. Most importantly, it is highly customized to a physician’s workflow, by speciality,” Sandhu said in an email to Greekwire.

State Public Health Department Launches Health Information, Education Campaign Regarding Legal Use of Cannabis The California Department of Public Health (CDPH) recently launched a health information and education campaign to address the potential health impacts of cannabis use now that it will be legal in the state.

Sale of cannabis from licensed retail outlets will become legal January 1, 2018, after Senate Bill 94 — Medicinal and Adult Use Cannabis Regulation and Safety Act (MAUCRSA) — made it legal for adults 21 or older to possess, consume and cultivate cannabis in California.

“CDPH engaged in extensive conversations with stakeholders in California and partners in other states with legalized cannabis to target the most vulnerable populations and apply their lessons learned,” said CDPH Director and State Public Health Officer Karen Smith, MD, MPH. “We are committed to providing Californians with science-based information to ensure safe and informed choices.” CDPH has and will continue to incorporate the latest data available into public messages to increase awareness about how cannabis affects bodies, minds and health.

On the website, individuals can find 28 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

information about legal, safe and responsible use, and health information for youth, pregnant and breastfeeding women, parents and mentors, and healthcare providers.

CDPH produced fact sheets with safe storage tips and the important things Californians need to know about purchasing and possessing cannabis for personal use. An educational digital toolkit for local governments and community organizations will be available in the future.

What’s Legal for Adult Use? • Under California law, adults 21 or older can use, carry and grow cannabis (marijuana, weed, pot).

• Buying cannabis (without a current physician’s recommendation or a countyissued medical marijuana identification card) will become legal for adults 21 or older January 1, 2018.

• Use of medicinal cannabis is legal if you have a current physician’s recommendation or a valid county-issued medical marijuana identification card.

• To buy medicinal cannabis, you must be 18 or older and have either a current physician’s recommendation, a valid countyissued medical marijuana identification card, or be a Primary Caregiver as defined in Health and Safety Code Section 11362.7(d).

• You can consume cannabis on private property, but you cannot consume, smoke, eat or vape cannabis in public places. Property owners and landlords may ban the use and possession of cannabis on their properties.

• Even though it is legal under California law, you cannot consume or possess cannabis on federal lands like national parks, even if the park is in California.

• It is illegal to take your cannabis across state lines, even if you are traveling to another state where cannabis is legal.

For additional information, visit the Let’s Talk Cannabis webpage at https:// www.cdph.ca.gov/Programs/DO/letstalkcannabis/Pages/LetsTalkCannabis.aspx.

State to Extend Obamacare Sign-Up Beyond Federal Limit California and several other states will exempt themselves this year from a new Trump administration rule that cuts in half the amount of time consumers have to buy individual health insurance under the Affordable Care Act. In California, lawmakers are contemplating legislation that would circumvent the rule in future years, too.

The Trump administration’s rule gives people shopping for 2018 coverage on the federal exchange 45 days to sign up, from November 1 through December 15.

But in California and some of the other states that run their own exchanges — Colorado, Minnesota, Washington and Massachusetts, as well as the District of Columbia — consumers purchasing insurance for themselves this year will have extra time to make decisions.

In Colorado, for example, the sign-up period is from November 1 to January 12. In Minnesota, it will start November 1 and run through January 14. In Washington state, it is November 1 through January 15.

Consumers shopping for coverage in California’s exchange, Covered California, will still have the full three months they’ve had in recent years, starting on November 1 and ending January 31. Californians shopping for individual market plans outside the exchange will have those same three months to make up their minds.

“We want to make sure our consumers have the time they need to find the best plan that fits their needs,” said James Scullary, a spokesman for Covered California.

The rule that truncated the enrollment period for the federal exchange, published in April by the Centers for Medicare & Medicaid Services (CMS), gives state-based exchanges the ability to extend the amount of time allowed by tacking a “special” enrollment period onto the 45 days set by the federal government.

Because that flexibility is limited to 2018 coverage, California legislators are taking an extra step to keep the three-month enrollment period for 2019 and beyond. Assemblyman Jim Wood (D-Healdsburg) introduced legislation last month that would ensure a three-month enrollment window for consumers seeking coverage in 2019 and subsequent years.

“When the Trump administration issued its new … rules cutting the ACA’s open enrollment period in half, we knew we had to act,” Wood said.

“Californians have enjoyed a three-month enrollment period for years, and this change could catch people off guard and not allow them to sign up in time. That would be a travesty.”

Health policy experts say the federal rule is a political attempt to undermine the viability of the Obamacare insurance exchanges.

“It’s no big secret that the Trump administration isn’t a big fan of the Affordable Care Act or the individual market that it created,” said Dylan Roby, associate professor of Health Services Administration at the University of Maryland. “There’s just this general intent of the administration to reduce enrollment, reduce … subsidies and make it a little bit harder for people to enroll.”

The shortened enrollment window was part of a so-called market stabilization rule rolled out by the Trump administration that also offers insurance companies concessions, including the flexibility to sell some health plans that cover less of the enrollees’ cost of care than currently required by the ACA. California’s insurance commissioner, Dave Jones, expressed concern about the impact of a shortened enrollment period in a letter to the federal government in March, before the rule was finalized.

Jones’ letter cited research that shows younger people tend to sign up for health insurance toward the end of open enrollment, and that putting up barriers to their enrollment could reduce the number of healthy people in the insurance pool.

That would “needlessly destabilize the market” and would “result in increased premiums for those who do enroll in coverage,” the insurance commissioner said.

Shana Alex Charles, an assistant professor of health sciences at California State University-Fullerton, said the pushback by California lawmakers against federal attempts to shorten the enrollment period underscores the state’s commitment to having a marketplace that “actually makes sense.”

“If you want to maximize enrollment, you need to make sure people can get their paperwork together, and have the mind-set and the time for people to complete the application,” she said.

SOURCE: Pauline Bartolone and Carmen Heredia Rodriguez| California Healthline

Amazon Has Stealth Health Tech Team, CNBC Reports A recent report that Amazon has a secret health tech team has the healthcare community buzzing.

“Amazon has started a secret skunkworks lab dedicated to opportunities in healthcare,” CNBC reported, “including new areas such as electronic medical records and telemedicine.

Amazon has dubbed this stealth team 1492, which appears to be a reference to the year Columbus first landed in the Americas.”

According to the article, the new Seattlebased team is currently looking at opportunities that involve pushing and pulling data from

legacy electronic medical record systems and exploring health applications for existing Amazon hardware, including Echo and Dash Wand.

If successful, Amazon could make that information available to consumers and their doctors. It is also hoping to build a platform for telemedicine, which in turn could make it easier for people to have virtual consultations with doctors.

Following reports earlier this year that Amazon had plans to break into the pharmacy sector as well, CNBC reports that Amazon Web Services, its cloud unit, has hired a high number of health experts to beat out Microsoft and

Google for contracts with large hospitals and pharmaceutical vendors. The company has also invested in a health startup called Grail, Illumina’s diagnostics startup. Grail hopes that it can use deep sequencing technology to detect the earliest signs of cancer in the blood while it’s still treatable. The effort requires a huge amount of data processing and storage.

Since news of this broke, an Amazon spokesperson said the company declined to comment on rumor and speculation.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 29

Transparent Standards in Medical Quality Efficiency Reporting Federal and state agencies, health plans and others report publicly on the performance of hospitals and physicians. However, there are no agreed upon standards for what information should be reported, its accuracy, and the underlying data that support it.

This article describes the Medical Value Index (MVI), which is a physician-developed technology for documenting providers’ medical value (quality and costs) by adhering to established clinical standards. The MVI uses six industry-standard measures of hospital and physician quality that clinicians can use to objectively assess the relative quality and cost efficiencies of inpatient care.

Medical Value Index: Verras’ Medical Value Index (MVI) trends hospitals’ quality and cost efficiencies over a three-year period for accuracy. The data are derived from Medicare’s most recent three years of publically available data, or the hospital’s All-Payer data. In addition to severity adjustments, the MVI accounts for differences in hospitals’ Case Mix Indices.

Quality and Cost Efficiency Measures: National Hospital Quality Measures (NHQM) metrics contain quality measures.

HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) adds patient satisfaction data. Reductions in risk-adjusted mortalities and hospital readmission rates are direct quality measures. Reduced morbidity rates improve patient safety while conserving resources. Reductions in outcomes variations (RIV) demonstrate that physicians are reasoning together by deploying consistent practice patterns. Resource Consumption rates document appropriate resource use and financial efficiencies.

Hospital reported charges are useful surrogates for resource consumption that MVI records contemporaneously with inpatient quality metrics. This assures patients and providers that care is not being compromised as physicians improve efficiencies by deploying

fewer resources. Hospitals that use MVI for All-Payer analyses are able to use costs, not charges.

Inpatient Example: The MVI creates a positive score for each measure. Higher scores for each metric’s portion of the total indicates greater three-year improvements in quality and efficiencies.

Example – a low, risk-adjusted mortality rate is desirable and is therefore assigned a higher score. The same is true for morbidity rates. However, the several quality and patient satisfaction scores that make up the National Hospital Quality Measures (NHQM) are positive numbers and therefore no positive conversions are necessary. Each metric has a maximum possible score based on many hospitals and years of experience.

The MVI is based on a total score of 800 points. The NHQM has a potential of only 46 points because experience has shown it is a poor indicator of quality. Resource Consumption has the most points attributed to it because it has both financial and quality attributes.

Displayed are 10 Alabama hospitals, their bed sizes, outcomes scores and Overall MVI score (right column). Maximum potential scores are in red. MVI is transparent and easily understood — the higher the score, the greater the three-year improvements for each outcome and the hospital total.

Summary: Medicare and Medicaid reimbursements as well as private insurers are moving toward global and value-based payments. For hospitals and medical staffs, the Medical Value Index is the most objective and transparent means of measuring and improving each metric of their medical services.

William C. Mohlenbrock, MD, FACS, is an orthopedic surgeon and chief medical officer of Verras Healthcare International, LLC.

SIX INPATIENT METRICS OF QUALITY THAT CONSTITUTE THE MEDICAL VALUE INDEX (MVI): 1.

2.

3.

4.

CMS (QMPS) Combined Metrics: 1. NHQM (National Hospital Quality Measures), 2. HCAHPS (Patient Satisfaction) Hospital Readmission Rate (RADM) – risk-adjusted, 30-day rates as reported to CMS Mortality Rates (MORT) – nine (9) different hospital mortality metrics Morbidity Rates (MORB) — measured for the hospital’s five MS-DRGs (Medicare Severity-Diagnosis Related Group) within each of the five largest clinical services 5. Reductions in Variation (RIV) – top five MS-DRGs for the top five clinical services 6. Resource Consumption (RESC) Combined Metrics – 1. Inflation rates of charges trended over a three-year period, 2. Quality Improvements

30 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

AMA Joins Others in Long-Term Partnership with Human Diagnosis Project to Provide Specialty Care to Underserved Patients Several of the nation’s top medical societies, institutions and boards, including the American Medical Association (AMA), have announced a long-term partnership with the Human Diagnosis Project (“Human Dx”) to help address the gaps that exist in providing specialty care to underserved patients.

Some physicians are expressing doubts about the initiative, according to the news and information website Axios. Ethan Weiss, MD, a cardiologist and associate professor at the University of California San Francisco School of Medicine, told the website he liked the mission of trying to help primary care doctors in areas without access to a lot of specialists, but he thought the crowd-sourcing approach could be vulnerable to “spitting out garbage – I’m not sure how you’d begin to demonstrate that it works or doesn’t work.”

The Human Diagnosis Project is an online system that allows doctors to directly help their patients and each other while simultaneously building a system to help patients and physicians worldwide. The newly formed Alliance will support Human Dx’s mission to create more accurate, affordable and accessible healthcare for millions of underserved Americans.

Nearly 30 million uninsured Americans rely on the nation’s safety net system of roughly 1,300 community health centers and free clinics to provide primary care services regardless of their ability to pay. While many of these individuals are able to receive basic medical care, they lack access to timely and affordable specialist care. For example: When an underserved patient needs to see a cardiologist, oncologist or surgeon, he or she often has to pay out-of-pocket or wait as long as a year for an appointment at a public hospital.

Specifically, over the next five years, the Human Dx Alliance will scale the Human Dx system to support the U.S. medical safety net and help close the specialty care gap for those 30 million patients. In the coming decades, Human Dx will work to expand the Alliance globally as it builds one open health system for all.

“Millions in this country and more than a billion people worldwide lack access to the healthcare they need, so they choose between paying for it themselves and being forced into

poverty, or not getting it and becoming sicker or dying as a result,” said Jayanth Komarneni, founder and chair of Human Dx. “Thousands of doctors from over 70 countries are tired of this and have come together to build a solution. By contributing to Human Dx, doctors will expand access to help people get the care they need, beginning with the underserved: first here in America, and ultimately worldwide.”

The Human Dx system allows doctors to obtain an electronic consult for their patients from specialist doctors and combines their perspectives using technology. A treating doctor simply inputs his or her patient’s background and medical findings into the Human Dx system, which then invites specialists to review the case and input their recommended tests and diagnosis.

The Human Dx system then combines and analyzes the specialist’s input, as well as the patient’s symptoms, physical exams, medical history, medical imaging, and diagnostic and laboratory tests and provides the physician with information to make an informed clinical decision. In the future, Human Dx will also incorporate genomics, epigenomics, proteomics, published medical research, and health outcomes data. The system uses technology to structure, encode and analyze the data so that the system is continually learning and improving.

The Human Dx Alliance includes organizations responsible for educating, training, licensing, and certifying every doctor in the United States. It also involves world-renowned experts and researchers from leading academic institutions.

“We look forward to working with Human Dx as part of this important Alliance to help more uninsured and underinsured patients gain access to the specialty care they need,” said AMA President David O. Barbe, MD. “The AMA is committed to improving the health of the nation and achieving better health outcomes for all Americans. Improving access to specialty care is an important step toward realizing that mission.”

In addition, Human Dx has active research collaborations with Harvard Medical School, the Johns Hopkins University School of Medicine, and University of California, San Francisco Medical Center.

THE ALLIANCE MEMBERS INCLUDE: • The American Medical Association: The AMA will engage its members from throughout the United States to volunteer on Human Dx. • The American Board of Internal Medicine (ABIM) and ABIM Foundation: ABIM, which certifies physicians who practice internal medicine and its subspecialties, will provide technical expertise in validating Human Dx as a scientific measure of physicians’ clinical decision-making abilities.

• The American Board of Medical Specialties (ABMS): ABMS will provide support for physicians to obtain learning and improvement credits through participation in Human Dx to satisfy medical licensure and certification requirements.

• The Association of American Medical Colleges (AAMC): AAMC will help develop a training program for primary care physicians and specialists to improve clinical practice using the Human Dx system. This is based on firsthand experience in supporting eConsult implementation in health systems across the country.

• The Association of Clinicians for the Underserved (ACU): ACU, founded by alumni of the National Health Service Corps and representing the nation’s safety net providers, will help disseminate Human Dx and develop training materials for safety net providers to successfully use Human Dx in their practices.

• The National Association of Community Health Centers (NACHC): NACHC, which represents the nation’s network of over 1,400 Federally Qualified Health Centers (FQHCs), will help implement Human Dx across the safety net system and facilitate a national learning collaborative for clinics across all 50 states.

• The Dartmouth Institute for Health Policy and Clinical Practice: The Dartmouth Institute will be the Alliance’s monitoring, evaluation and learning partner.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 31

The Importance of Keeping Adequate and Accurate Medical Records

By Britt Durham, MD,

Medical Board of California Health Quality Investigation Unit Tustin Field Office This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Summer 2017 The Medical Board of California (Board) has always stressed the importance of adequate and accurate medical records. Complete medical records are necessary to document the quality of care and to facilitate the continuity of care. Business and Professions Code (B&P) section 2266 states that the failure of a physician to maintain adequate and accurate records relating to the provision of service to his or her patients constitutes unprofessional conduct.

Even in the era of electronic records, medical records violations remain one of the most common causes of disciplinary actions imposed by the Board. These violations can range from gross or repeated negligence to incompetence, and may result in citation and fine up to $2,500 with a requirement to take and pass a mandatory records keeping class at the practitioner’s expense, or formal disciplinary action.

In addition to the issues of maintaining accurate records, the physician may be found guilty of inappropriate altering of records, creating false or fraudulent records, or failure to provide records to patients upon request. California Health and Safety Code (H&S) section 123100 establishes a patient’s right to see and receive copies of his or her medical records. Physicians must permit the patient to have access to their records after receipt of a written request under H&S section 123110(a). A patient must be permitted to see his or her records within five working days of the physician receiving the patient’s written request.

Under H&S section 123110(b), physicians must provide copies of a patient’s medical records within 15 days of receiving a written request for the copies. Physicians are allowed to charge a fee (not to exceed 25 cents per page or 50 cents for records that are copied from microfilm) plus a reasonable fee for clerical costs. The willful violation of the patient’s access to his or her health records may constitute unprofessional conduct and grounds for action by the Board.

Almost all investigations by the Board involve the review of relevant medical records. As the central focus, the evaluation of the adequacy and quality of the medical records becomes incorporated into the routine investigation process. Failure to have and keep medical records to be produced upon subpoena for an investigation by the Board is a record keeping violation. The adequacy and accuracy of the records are evaluated by expert reviewers based on the standard of care. Deficiencies and violations in record keeping may lead to the finding of additional violations during the course of an investigation.

Medical records may be general reports such as progress notes, SOAP notes, history and physical exams, telemedicine evaluations, telephone conversations records, informed consent, DNR documentation, physician orders and supervision attestation documentation. Some records are 32 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

specialty-specific such as anesthesia reports, operation notes, informed consent and surgical procedure notes. These records are evaluated for accuracy and adequacy by the corresponding specialty-specific reviewer.

Many medical record violations are discovered after undercover investigations in which the medical encounter is recorded on video and, when compared to the associated medical records, indicate inaccurate or fraudulent documentation. These are common occurrences, especially with medical marijuana, overprescribing, and workers’ compensation cases. Physicians have been disciplined for dishonesty for generating fake medical records.

Although there is no general law requiring a physician to maintain medical records for a specific time period, there are situations or government health plans that have agency-specific requirements. In workers’ compensation cases, qualified medical evaluators must maintain medicallegal reports for five years. H&S section 123145 indicates that providers who are licensed under section 1205 as a medical clinic shall preserve the records for seven years. The statute of limitations in most Board cases is seven years.

The Health Insurance Portability and Accountability Act (HIPAA) offers protection for personal health information and establishes a series of privacy standards for health care providers. Physicians should be aware of their responsibility in maintaining adequate HIPAA-compliant medical records. Providers that do electronic billing and or electronic record transmission should be HIPAA compliant as described under H&S section 130300.

The use of electronic records has improved the maintenance, storage, and legibility of medical records. However, the volume of complaints regarding inaccurate medical records has increased. Some of the documentation is often entered into the record as a default normal. With one click, a provider can enter a standard normal physical exam. Many times this default normal exam will enter an overly comprehensive normal exam into the record. A patient may present for an isolated complaint such as hip pain but the record shows a default exam that includes normal examinations of the eye, neck, head, lungs and heart, which were not examined.

Likewise, a provider may enter a normal default review of systems that may actually contradict the complaints in the history of present illness. In addition, the electronic record may generate inaccurate diagnostic billing codes that result in billing discrepancies and unintended recorded clinical impressions. Patients do have the right to ask that addendums be placed in their record if they believe their medical record is inaccurate or incomplete.

Accordingly, if you have room for improvement in your medical record-keeping skills, consider taking a continuing education course on this topic. Information on providers who offer classes on medical record keeping is on the Board’s website at http://www.mbc.ca.gov/Enforcement/ Approved_Courses/courses_ provider-info.pdf.

Complete medical records are required to document the quality of care and to provide continuity and efficiency of patient care.

NEW RESOURCES

New Opioid Guideline Mobile App from CDC This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Summer 2017 The Centers for Disease Control and Prevention (CDC) introduced a free Opioid Guideline Mobile App that allows users ready access to the agency’s recommendations on pain management and opioid treatment.

According to the CDC, “The purpose of the app is to provide health care professionals and patients with quick reference materials on the prescription opioid overdose crisis and help them make informed clinical decisions.”

A Morphine Milligram Equivalent (MME) calculator for drugs such as hydrocodone, transdermal fentanyl, and other opioids is included. The app also includes a glossary and an interactive motivational interview feature designed “to help providers practice effective communications skills and prescribe with confidence.” The app can be downloaded free from the Apple App Store, the iTunes store, and the Google Play store by searching for CDC Opioid Guideline. The Medical Board of California also has helpful prescribing guidelines available on its website at http://www.mbc.ca.gov/licensees/prescribing/ pain_guidelines.pdf.

New Resources for California Physicians Treating Alzheimer’s Disease The California Department of Public Health released its 2017 Alzheimer’s Clinical Care Guidelines, which were developed by an interdisciplinary workgroup representing academia, research, specialty medicine, primary care and social work. The workgroup made key recommendations in four areas: assessment, care planning, education and support, and legal considerations. All recommendations were based on recent scientific literature, evidence-based research and best practices in Alzheimer’s disease management.

Alzheimer’s disease is the most common form of dementia and disproportionally impacts many Californians. Dementia is a general term for memory loss and other impairments serious enough to interfere with daily life. Alzheimer’s accounts for 60 to 80 percent of dementia cases and currently impacts an estimated 610,000 Californians, a number projected to grow to 840,000 by 2025. Alzheimer’s is the 5th leading cause of death in California and the only condition in the top 10 without a known cause, cure or prevention.

More women than men have Alzheimer’s disease and other dementias such as vascular dementia and dementia with Lewy bodies, among others. Almost two-thirds of Americans with Alzheimer’s are women, as are the majority of family caregivers.

Older African Americans and Hispanics are more likely than older whites to have Alzheimer’s disease and other dementias, with African Americans at twice the prevalence rate and Hispanics one and one-half times the rate.

This 2017 update reflects new evidence, as well as improved practice and changes in law. This is the 4th edition of the California Alzheimer’s Clinical Care Guidelines, first published in 1968 and revised in 2002 and 2008. The 2017 update specified in statute (SB 613, Chapter 577, 2015) addresses changes in scientific evidence, clinical practice, and state and federal law.

For additional information contact Susan DeMarois, State Policy Director, Alzheimer’s Association at (916) 447-9231 or sdemarois@alz.org or visit www.caalz.org.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 33

NORCAL Mutual Risk Management Insight— 3 Steps to Responding to Negative Online Comments Because online reviews can affect your practice—both positively and negatively—the issue certainly warrants a plan of action. Developing one can help prepare you for when you become the target of negative online comments and help you avoid an emotional response in favor of a more measured one.

These steps can also help improve your online ratings, mitigate the effects of negative online comments and guide your response to negative ratings before you ever face a crisis.

Remember: Always maintain compliance with HIPAA and other privacy laws. Do not reference patient information, the medical record or other protected information in public forums.

01

Be Proactive: Develop a digital and social media plan for your practice. To proactively build your online reputation, consider monitoring online comments and requesting reviews from patients. Also, creating your own practice website and social media presence can help you control your message. Also consider the information and suggestions in this article to develop guidelines for responding to online reviews. Other helpful tools include office surveys and patient complaint processes to help you understand and address the needs and concerns of your patients.

02

Don’t Panic: Objectively assess the situation that led to the comments. Avoid an emotional, off-the-cuff response. Review the medical record for potential issues, but never reference the medical record in your response. If there are significant issues, contact your professional liability insurance carrier and inform a representative about the situation. If the issue directly affects patient care and you therefore have interactions with the patient, document all communication and follow-up in the medical record.

03

Maintain Professionalism: Keep your tone professional and put the patient’s needs first.

If you decide to respond, remember your response becomes part of your online reputation.

Follow group practice guidelines if you’re part of a group practice. Always maintain compliance with privacy laws and don’t directly or personally attack the individual posting the comment.

Attempt to move the discussion to a private forum with a response like, “I’m sorry you had this experience. I’d like to discuss it with you. Please contact my office.”

T HE IMPACT O F ONL INE RATINGS ON PARENTS 3

30 67% 87%

%

Mothers more likely than fathers to visit ratings sites used online ratings to research physicians chose or avoided physicians based on online ratings say the online ratings accurately reflected their subsequent experiences

34 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

22% FATHERS

36% MOTHERS

Considering Legal Action?

Think Twice.

When physicians have attempted to use the legal system to stop online harassment, the courts have generally been less than accommodating to them. The following case demonstrates the courts’ attitude toward physicians’ attempts to protect their reputations.

Case Study: This case involved a neurologist who filed a lawsuit against the son of a former patient claiming defamation. The judge dismissed the case and stated, “The court does not find defamatory meaning but rather a sometimes emotional discussion of the issues.”

The case was widely publicized through newspaper, internet and television media outlets, and it resulted in a negative impact on the physician’s practice.

If you’re considering suing a reviewer, there are many potential issues you need to be aware of to avoid pitfalls and counter-suits.

Consult with your attorney as soon as possible before taking any steps in that direction.

“

She did not listen to my concerns and did not answer my questions. While I was sitting in her office, she took two phone calls and on one, scheduled a presentation for her practice by a drug rep.

”

I am getting my records and getting another doctor.

Responding to the Challenge of Online Ratings With the growth of social media and online marketing outlets, physicians are experiencing a not-so-new phenomenon—bad publicity—but in a new medium. New websites allow people to rate, review, or leave comments about their doctors, operating in much the same way as online services that help people find the best hotels or avoid plumbers who overcharge. A September 2016 study published in JAMA evaluated 28 physician ratings sites that allowed users to leave ratings and comments about physicians. Among physicians with at least one rating on any site, physicians had an average of seven reviews, while 34% had no reviews on any site.1 With so few reviews for any given physician, a negative review may loom larger in a consumer’s mind and weighs more on the physician’s rating. And while the ratings are generally positive, some patients are using these sites to make serious and repetitive attacks on providers’ reputations and competency.

As a result, physicians may feel personally under attack, and some have claimed that the comments negatively affect them emotionally and financially. When these attacks occur, physicians may naturally want to go into a defensive mode in order to preserve their reputations, but they must still always maintain compliance with HIPAA and other privacy laws. Furthermore, if physicians respond immediately and impulsively, they may do more harm than good.

While this new reality may seem daunting, with a deliberate, reasoned approach, physicians can not only respond to negative online comments appropriately, but also enhance patient satisfaction by identifying and addressing any underlying issues that may have led to them.

Numbered references available at negativecomments.norcalmutual.com SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 35

MEMBERSHIP

Welcome 298 New Members Santa Clara County Medical Association Name Rose Alapat Huma Ali Ashley Aratani Alexander Arzeno Janhavi Athavale Gordon Bae Ioana Baiu Steven Baker Abiram Bala Janos Barrera Keegan Barry-Holson Arthur Bartolozzi Kae Bendixen Isabel Beshar Amrita Bhagat Rishi Bhatnagar Michael Black John Bonano Liam Bosch Jonathan Bradley Julie Brichard Mara Broadhurst Kelly Bruce Andre Burnier Akaila Cabell Sean Campbell Jennifer Caris Jeremy Chan Helen Chang Gregory Charville Faraaz Chekeni Michael Chen Simon Chen Ted Chen Yi-Ren Chen Angela Chiang Deepak Chona Kwong-Hon Chow Benjamin Colvard Elizabeth Connelly Kevin Cyr Susannah Daniel Rajiv Das Malcolm Debaun H. Ruppie Dehal Richard Delfs

City Specialty Santa Clara OM San Jose IM Palo Alto ORS Stanford ORS San Jose US Palo Alto D Sunnyvale US Stanford PTH Stanford ORS Mountain View PS Stanford PTH Los Altos ORS Santa Clara OBG Palo Alto US Milpitas PD San Jose US Santa Clara US Stanford ORS Stanford ORS Palo Alto AN San Jose US Stanford PTH Sunnyvale OBG Los Altos EM Palo Alto ORS Stanford ORS San Jose EM Stanford ORS Millbrae PD Stanford PTH Palo Alto PD Stanford ORS Stanford PTH Santa Clara US Palo Alto NS San Jose US Stanford ORS Stanford NS Stanford VS Stanford US Menlo Park US Palo Alto FP Saratoga PM Redwood City ORS Santa Clara IM Santa Clara IM

Sahitya Denduluri Kelly Devereaux Conner Dixon Esther Dunn McKenzie Eakin Samantha Easley Bryn Eisfelder Lawrence Enweze Aimee Estrellado Michael Fahmy Orly Farber Frances Farrimond Sebastian Fernandez-Pol Megan Fitzpatrick Nathaniel Fogel Todd Fong Erna Forgo Deshka Foster Mathilde Fredrickson Lindsey Frischmann Thomas Gaffey Vilasini Ganesh Eric Gars Elizabeth George Jacob Gire Saurabh Gombar Lawrence Goodnough Ashleigh Guilbeau Richard-Tien Ha Tiffany Hackett Belal Hakim Kimberly Hall Sonja Halterman Xiao Han Nick Hatamiya Kathryn Hawrylyshyn Jared Herr Kevin Higashigawa Vindhya Hindnavis Allen Ho Jenny Hoffmann Mark Hollemon Margaret Huang Ryan Huber Eloka Ikebuda Nathan Itoga Aditya Iyer

Palo Alto ORS Stanford PTH Sunnyvale EM San Jose EM Menlo Park US Santa Clara PTH Santa Clara EM Stanford ORS Milpitas PD Palo Alto AN Palo Alto US Belmont OBG Stanford PTH Stanford PTH Stanford ORS San Jose IM Stanford PTH Palo Alto US San Jose FP Mountain View N Palo Alto AN Los Gatos FP Stanford PTH Stanford VS Stanford ORS Stanford PTH Stanford ORS San Jose FP Santa Clara CDS Danville EM San Jose US Stanford ORS San Jose FP Santa Clara OM San Jose FP Palo Alto AN Palo Alto CDS San Jose ORS Santa Clara IM Palo Alto NS Stanford US San Jose HOS San Jose EM Santa Clara NM San Jose US Stanford VS Palo Alto NS

US - Unspecified 36 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

Ryan Jackson Eric Jackson-Scott Nisha Jadhaw Shiv Jain Rohit Jayakar Adam Johannsen Jessica Johnson Tyler Johnston Michelle Jones Ariane Jong Darius Joshi Rohan Joshi Brian Karamian Maya Kasowski Andrew Kelada Shanthala Keshavacharya Daniel Kim Byron Knowles Caroline Koan Yusuke Kobayashi Lakshmi Kona Kevin Kumar Gina Kwon David Lange Cindy Lau Hubert Lau Jonathan Lavezo Lauren Lawrence Hoa Le Dana Leonard David Levy Songqian Li Chieh-yu Lin Shareene Lindquist Emilia Ling Raymond Liou Shirley Liu Devin Lonergan Anna Lucero Kyaw Lwin Sean Mackey Ryon Maland Sasikala Manavalan Kiranvir Mangat Ernest Maningding Michael Marques Bobby Mathew

Palo Alto PTH San Jose US San Jose FP Mountain View FP Mountain View US Stanford ORS San Jose EM Redwood City ORS San Jose PD San Jose US Santa Clara IM Stanford PTH Stanford ORS Palo Alto PTH Santa Clara US Palo Alto AN Gilroy FP San Jose US San Jose US San Jose FP Campbell IM Stanford PTH Santa Clara US Santa Clara CD San Jose FP Stanford PTH Stanford NP Stanford PTH Santa Clara ON Stanford US Stanford PTH San Jose IM Stanford MGG San Jose US Palo Alto US Stanford US Palo Alto AN Palo Alto OTO Santa Clara HOS Palo Alto AN Palo Alto APM Santa Clara US Milpitas P San Jose PD San Jose US Palo Alto AN San Jose AN

Eric Matsumoto Milton Mccoll Graeme Mcfarland Zachary Medress Justin Meyerowitz Collin Michels Kai Miller Blake Montgomery Edward Moon Kelly Mooney Adrienne Moraff Cameron Mozayan Chen Mu Aditya Mukund Babitha Nagarajan Vidya Nagaraju Gayathri Nanja Kalpana Narapasetty Neha Narula Aaron Nayfack Michael Ngumi Josephine Nguyen Joshua Nguyen Jason Ni Julia Nordgren Ryan O’malley Jessica Ocampo Anabel Ortiz Gabrielle Paci Kavitha Pancholy Eric Pang Jonathon Parker David Parris Nicholas Parziale Pranjal Patel Arjun Pendharkar Jeffrey Peng Nhat Pham Andy Pham Brendan Pierce Wachirapon Piluek Carrie Pinchbeck Laura Polding Angela Pollard Jennifer Quon Ehsan Rahimy Arifeen Rahman Shivani Reddy

San Jose US San Jose FP Stanford VS Stanford US Portola Valley US Mountain View EM Stanford NS Palo Alto ORS Palo Alto ORS Lafayette PTH Stanford NS San Jose EM Santa Clara US Stanford US San Jose IM San Jose HOS San Jose HOS Santa Clara HOS San Jose FP Los Altos PD San Jose US Sunnyvale OBG San Jose IM San Jose US Portola Valley PD Santa Clara IM Santa Clara OBG San Jose US Stanford ORS Santa Clara FP Stanford ORS Stanford NS Palo Alto AN Santa Clara N San Jose US Stanford NS San Jose US San Jose FP San Jose US Palo Alto OTO Palo Alto OPH Santa Clara EM Palo Alto US Los Gatos OBG Stanford NS Palo Alto OPH Stanford US Santa Clara IM

Neil Rens Allison Roe Pablo Romano Elsie Ross Daniele Rottkamp Beth Ellen Ruben Elisabeth Russell Victor Sadauskas Amir Saffarian Jeffrey Sakamoto Farah Salahuddin Atif Saleem Mark Saleh Eric Sarkissian Ansuman Satpathy Dasha Savage Heidi Schmidt Blake Schultz Gregory Scott Sujatha Sri Seetharaman Michael Sgroi Lauren Shapiro Emily Shearer Siyu Shi Sheetal Shukla Oscar Silva Brandi Sinkfield Heidi So Omar Soha Nelly Song Renu Soni Sunita Sood Padmashri Srinivasa Sharlene Su Eric Sussman Steven Swinford Aileen Sy Megan Tabaka Kristen Tamura Anh Tan Serena Tan Sheila Thampi Patrick Thompson Ashley Titan Lucia Tome Sandra Torres Elaine Tran Kenneth Tran

Stanford US Palo Alto ORS Stanford US Stanford VS Palo Alto END Palo Alto D Union City US East Palo Alto EM Morgan Hill U Mountain View EM San Jose RHU San Jose PTH Palo Alto N Stanford ORS Stanford PTH Stanford US Palo Alto IM Palo Alto ORS Stanford PTH Santa Clara PD Stanford VS Stanford ORS Menlo Park US Palo Alto US Santa Clara PD Stanford HMP San Jose AN Santa Clara PD San Jose FP San Jose FP Campbell IM San Jose GE Cupertino FP Redwood City PM Stanford NS Stanford ORS Santa Clara OPH San Jose FP San Jose NEP San Jose FP Stanford PTH Santa Clara PHO San Francisco US East Palo Alto US San Jose FP San Jose FP San Jose US Stanford PTH

Van Tran Jeremy Truntzer Tram Truong Yana Vaks Areli Valencia Vinod Valluri Maile Van Hentenryck Gurunadh Vemulakonda Valerie Vigil Norma Villalon Roger Villanueva Stephen Vogel Heather Volkamer Samuel Wald Anthony Wang Julianna Weiel Daniel Weisel Daetwan Williams Jason Williams Dylan Wolman Jonathan Wong Lydia Wong Mona Wood Edward Wu Mengoiao Xi Allison Xie Linda Xu Marisa Yanez Soo Ryum Yang Jonathan Yap Derek Yecies Kevin Yee Onur Yenigun Jane Yieh Byung “Jason” Yoon Wing-yan Yuen Sybil Zachariah Arash Zeighami Allison Zemek Bing Zhang Qing Meng Zhang Hongyu Zhou Gefei Zhu Lawrence Zieske Chason Ziino Mark Zukunft

Palo Alto AN Palo Alto ORS Santa Clara IM Santa Clara PD Stanford US Santa Clara US Stanford US Palo Alto OPH Aptos EM San Jose FP Santa Clara FP San Jose FP Santa Clara EM Stanford AN San Jose FP Stanford PTH San Jose FP Palo Alto AN San Jose GE San Francisco DR San Jose US San Jose FP Stanford PTH Redwood City ORS San Jose EM San Jose FP Stanford NS San Jose FP Stanford PTH San Jose US Palo Alto NS San Francisco IM Cupertino EM Los Gatos HOS Mountain View RNR Santa Clara FP San Francisco EM San Jose AN Stanford PTH Palo Alto PTH Santa Clara US Santa Clara US San Mateo D San Jose FP Stanford ORS San Jose EM

Monterey County Medical Society Name Jose Ajoc Christopher Burke Christopher Carpenter Jae-Sung Cho Joshua Deutsch

City Specialty Salinas FP Gilroy EM Oakland PD Salinas VS Salinas US

Maria Espinoza Quinn Fujii Forrest Hamlin Anne Irvine Jordan Katz Natalie LaCorte

Salinas Monterey Salinas Salinas Salinas Salinas

US US US US US US

Diane Sanchez Marina OBG Tracey Taylor Salinas US Poorna Thirugnanasambandam

Salinas FP Shane Walker Salinas US Nicole Woodel Salinas US

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 37

CASE LAW UPDATE

Just Because HIPAA Does Not Provide a Private Right of Action, Doesn’t Mean that Other Avenues Exist By: Rachel V. Rose, JD, MBA Rachel V. Rose, Attorney at Law, PLCC This article was previously published by BC Advantage Magazine and CEU Center in August 2017. www.billing-coding.com Simply stated, the Health Information Portability and Accountability Act (HIPAA) does not provide a private cause of action[1]. And, prior to the 2009 passage of the Health Information Technology for Economic and Clinical Health Act (HITECH Act)[2] and the more robust chain of liability (e.g. covered entities, business associates and subcontractors) under the Breach Notification Rule, several courts had held this notion to be true.

[3] Over the past decade, a shift has occurred where state and federal courts are holding that healthcare providers who breach HIPAA and other cybersecurity provisions may be pursued for a variety of common law claims including: negligence, emotional distress, breach of confidentiality, invasion of privacy, contract violations, and punitive damages.[4] The premise for bringing a cause of action for privacy violations stems from the fundamental source of American jurisprudence - the United States Constitution.

In re Columbia Valley Regional Medical Center, 41 S.W.3d 797, 802 (2001) established that, “there is a constitutional right of privacy in this case. Apart from any statutory or evidentiary privileges that apply, the medical records of an individual have been held to be within the zone of privacy protected by the United States Constitution.”

See In re Xeller, 6 S.W.3d 618, 625 (Tex. App. - Houston [14th.] 1999, orig. proceeding) (citing Alpha Life Ins. Co. v. Gayle, 796 S.W.2d 834, 836 (Tex. App. - Houston [14th Dist.] 1990 no writ).

utilized in establishing the applicable standard of care.

• Acosta v. Byrum, 638 S.E.2d 246 (N.C. Ct. App. 2006) - A patient was treated by a physician who gave his access code to a third party, who in turn, viewed his records. The North Carolina Court of Appeals held that a privacy violation based on HIPAA violations was not a malpractice claim, so no expert certification was necessary; and HIPAA may be utilized in establishing the applicable standard of care.

• John Smith v. Arvind R. Datla, et al., Case No. A-1339-16T3 (Superior Court of New Jersey Appellate Division (Jul 12, 2017) - The judge kept alive a suit accusing a physician for disclosing a patient’s HIV status without the patient’s consent to an unauthorized third party.

These cases underscore the importance of compliance with HIPAA and the HITECH Act. Actions brought by the Federal Trade Commission, class action law suits and Securities and Exchange Commission requirements were not discussed. The take-away is that HIPAA, the HITECH Act, and other cybersecurity violations can and do form the basis of a wide variety of causes of action. Therefore, underscoring the need to be proactive instead of reactive.

Rachel V. Rose, JD, MBA, is a Houston, TX-based attorney advising on federal and state compliance and areas of liability associated with a variety of healthcare, legal and regulatory issues including: HIPAA, the HITECH Act, the False Claims Act, Medicare issues, women’s health as well as corporate and security regulations.

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Jonas Salk The Polio Protagonist

By Michael Shea, MD Leon P. Fox Medical History Committee In the early twentieth century, polio was one of the most feared diseases in the United States. It infected mainly children under the age of five, with one out of two-hundred suffering permanent paralysis. In 1952, there were 58,000 cases in the U.S. with 3,145 dying and 21,269 left with mild to disabling paralysis.

Parents reactions bordered on hysteria. Children were kept out of swimming pools, park settings, even schools in an attempt to protect them from exposure to polio.

Poliomyelitis is a viral infection that enters the body through the oropharynx and infects the gastrointestinal tract. There are three antigenically distinct types of polio.virus (I, II, and III), with no cross-immunity between them.

Most infections are asymptomatic, but of those who become ill, the following are the clinical courses: 1. Minor illness – fever, headache, vomiting, and sore throat.

2. Non paralytic – the above symptoms plus meningeal irritation and muscle spasm.

3. Paralytic ȧȧ Spinal – with weakening/paralysis of muscles supplied by the spinal nerves. ȧȧ Bulbar – with weakness of muscles supplied by the cranial nerves and involvement of the respiratory and vasomotor centers. Hence the appearance of the “iron lung” to assist in ventilation for patients with the inability to adequately expand the diaphragm. Bulbar polio carries the highest mortality rate 40 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

(up to 50%).

Outcomes are that mild weakness of small muscles is more likely to regress than severe weakness of large muscles. Weakness may develop and progress slowly years after recovery from acute poliomyelitis.

Many famous Americans developed weakness and paralysis from polio. Perhaps the most famous was Franklin Roosevelt (soon to be Governor of New York), who became infected at age 39. He spent most of his presidency in a brace or a wheelchair. Some others were: Itzhak Perlman, Donald Sutherland, Mia Farrow, Alan Alda, Dinah Shore, and Francis Ford Coppola.

Treatment of polio was primarily symptomatic. Bed rest, polio bed with change of positions, firm mattress, foot board, sponge rubber pads, and light splints. Fecal impaction and urinary retention needed to be managed also.

Respiratory paralysis or weakness required intensive care and the use of the iron lung.

Prevention by immunization was the ultimate answer to polio. Much of the credit for the immunization discovery goes to Dr. Jonas Salk.

Jonas Salk was born in New York City on October 28, 1914 of Jewish immigrant parents from Poland. He had two younger brothers, Herman and Lee. At age 13 Jonas enrolled in Townsend High School, a public school for intellectually gifted children. He graduated in three years and at age 15, entered the City College of New York, where he earned a BS degree.

He studied medicine at New York University and earned his MD in 1939. Known as a perfectionist, he took a year off to study biochemistry and then bacteriology. He was addicted to the Laboratory and studied the influenza virus in his last year of medicine. Mt. Sinai Hospital was the place of his internship. He was one of twelve accepted out of 250 applicants.

After his internship, he received a fellowship with Dr. Thomas Francis, Jr. at the University of Michigan and together they developed a flu vaccine that was used by the army. In 1947, Dr. Salk received his own lab and began work that would eventually lead to a polio vaccine.

This work was aided by a grant from the National Foundation for Infantile Paralysis established

by FDR. The vaccine was derived from killed polio virus and was known as IPV. He first vaccinated his own family (wife and three sons).

This was followed by animal studies and ended with vaccinating 43 children at Polk State School in 1952. These had successful outcomes, but larger trials were needed. Fundraising for these trials were accomplished by thousands of volunteers and 100 Jonas Salk, MD million people in the United States donating through the March of Dimes. In the Francis Field Trial, using the Salk vaccine, 1.8 million children were vaccinated. This included a placebo and control arm in the study. It was successful and in 1955 a nationwide vaccination program began. Polio cases fell from 35,000 in 1953 to 5,600 in 1957. By 1961 only 161 cases of polio were reported in the United States.

An oral vaccine using an attenuated strain of virus was developed by Albert Sabin in the 1950’s. It had the advantage of ease of administration, eliminating the need for needle and syringes. Between 1962 and 1965 about 100 million Americans received the Sabin Vaccine.

Today, vaccination in this country, is via the enhanced Salk vaccine. It is given to infants at two, four, and six months of age, with a booster at five years.

Between the two vaccines, polio has been

eliminated from most countries (Nigeria, Pakistan, and Afghanistan excepted).

Dr. Salk preferred anonymity. However, by age 40, he had received a presidential citation, honorary degrees, six foreign decorations, and thousands of letters from grateful parents.

Following the Salk Vaccine, he was able to open the Salk Institute for Biological Studies. It opened in 1963 in La Jolla California. It was here that Salk and other scientists explored molecular and cellular biology, studying such diseases as cancer, multiple sclerosis and HIV. Jonas Salk died from heart failure on June 23, 1995. He was 80 years of age. He was buried at El Camino Memorial Park in San Diego.

Dr. Salk earned his place in medical history. He will always be remembered as the one who discovered the vaccine that eliminated polio.

Leon P. Fox Medical History Committee The Leon P. Fox Medical History Committee meets bi-monthly, the first Monday at noon (lunch provided). The purpose of the committee is to identify, collect, and preserve archival material, memorabilia, and artifacts representing the medical history of Santa Clara County. A guest speaker gives a historical presentation at each of the meetings, which is then transcribed for SCCMA’s Medical History archives.

If you are interested in joining this committee, please contact Pam Jensen at SCCMA at (408) 998-8850 or pjensen@sccma.org.

SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 41

Classifieds OFFICE SPACE FOR RENT/LEASE MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste.

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2,500–4,000 sq. ft. Call Rick at 408/2280454.

MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Timeshare also available. Call Betty at 408/8482525.

BEAUTIFUL MENLO PARK OFFICE TO SHARE New office, upscale and modern – to share with existing pain management practice.

Ideal for psychologist or psychiatrist. Contact Dr. Maia Chakerian at 408/832-3930.

MEDICAL OFFICE SPACE TO SHARE • CAMPBELL Convenient location. 5+ exam rooms M-F. In-office digital x-ray. Two large private offices, shared waiting room and front office.

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MEDICAL OFFICE SPACE TO SUBLET • MTN VIEW Mountain View Medical Office space to sublet. 1,100 sq. ft. Available three days a week. In large medical complex, behind El

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Camino Hospital. Basement storage, utilities included. Large treatment rooms, small lab space, bathroom, private office, etc. Call Dr. Klein. Cell 650/269-1030.

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.

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.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or e-mail riflovin@allianceoccmed.com for additional information.

INTERNAL MEDICINE PHYSICIAN NEEDED We are looking for an internal medicine physician for our multi-specialty group.

Please email your CV to kaajhealthcare@ gmail.com.

42 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

WANTED FAMILY PHYSICIAN Family medicine physician needed to share a growing outpatient practice. Start at 16 hours/week and share patient load. Practice caters to 75% PPO, rest Medicare and HMO. Contact ntnbhat@yahoo.com / 408/839-6564.

PRIMARY CARE PHYSICIAN Busy primary care office is looking for board certified Internal or Family Medicine Physician. Contact inna@dryaskin.com or call 650/318-3384.

PEDIATRICIAN NEEDED IN LOS GATOS Four member Pediatric Group looking for a new physician to replace retiring partner. Office is independently owned and operated. Congenial working environment.

Partnership track available, or remain as an associate indefinitely. Contact sbezecny@ comcast.net.

FOR SALE PRIVATE PRACTICE / OFFICE / MEDICAL BUILDING FOR SALE FP/GP. Primary Care Practice for sale including inventory, equipment and medical building. 132 Alta Street, Gonzales, CA 93926-3005. If interested, please call Dr. Gines at 831/262-9238.

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.

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SUMMARY OF THE BOARD OF TRUSTEES MEETING

JULY 28, 2017 Sacramento Convention Center (1400 J Street, Sacramento, 95814) The following is a (non-exhaustive) summary for informational purposes only. Official actions are recorded in the minutes, which will be approved at the next meeting of the Board.

COUNCIL AND SUBCOMMITTEE REPORTS

The report of the Council on Medical Services was extracted to discuss Resolution 209-17. The Board adopted the following as amended: RESOLVED: That CMA advocate for health plans and insurers to be required to take steps and have responsibility for ensuring that physicians receive prompt and full payment of patient copays, coinsurance, and deductible.

The report of the Council on Health Professions and Quality of care was extracted to discuss Resolution 602-17. The Board adopted the following as amended: RESOLVED: That the CMA advocate for the improvement of health and human rights conditions and investment in California’s ICE detention facilities health workforce; and be it further RESOLVED: That the CMA advocate that any California city and/or county facility contracted with ICE to detain immigrants for any period of time be subject to correctional facility standards such as the Institute for Medical Quality’s Standards for Corrections and Detention and consideration of the National Commission on Correctional Healthcare Standards.

The Board also approved several other Council reports on consent, with recommendations addressing; forwarding a resolution to the House to issue a charter to the newly merged San Francisco Marin Medical Society, support of sustained and robust federal funding for biomedical and applied public health research, supporting efforts to address tobacco cessation among incarcerated individuals, among others.

FIREARMS VIOLENCE AND PREVENTION COMMITTEE REPORT

The U.S. continues to struggle with an epidemic of firearm violence. Not only are physicians in a unique position to assess risk, provide education and change behaviors related to gun violence, they may also address this issue more broadly as a consumer safety and public health issue. While CMA has extensive policy on gun violence and firearm safety, it had been developed in an incremental and piecemeal fashion, and CMA did not have a comprehensive statement on this issue. The report of the Firearms Violence and Prevention Committee crafted such a statement addressing firearms violence, and recommended sunsetting older individual policies.

PRESIDENT’S REPORT SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 43

Dr. Ruth Haskins, CMA President gave a recap of events she has attended on behalf of CMA. Also of note, CMA plans to meet with all of the declared candidates for the upcoming 2018 Governor’s Race to identify candidate knowledge of health care, and how we can provide further education.

PROP 56 UPDATE

Janus Norman, VP of Government Relations, summarized the extended budget battle to have Prop 56 funds allocated sufficiently to providers. The passage of Prop 56 created a sizable amount of available funding to be dispersed to improve payment rates for Medi-Cal. In January, Governor Brown decided to allocate the money for the General Fund relief instead. A combined effort from CMA, CDA, Planned Parenthood and local societies helped bring this lengthy battle – and ultimate victory for CMA – to the forefront of the media. CMA highly encourages local component societies to invite Janus to deliver his presentation to leadership/members. CMA invested $1M to support Prop 56, and we anticipate over $750M in new funds will be available to Medi-Cal providers each year.

MEMBERSHIP AND MARKETING

CMA’s active membership counts are roughly the same as they were this time last year. Last year CMA experienced record growth of 6.20 percent, the largest single year increase since 1962. While it is not likely to break last year’s record, CMA continues to work on a number of membership prospects, to continue growing membership.

COMMUNICATIONS

CMA continues progress on our new website to improve overall functionality, design and content.

A web development firm will start rebuilding the site in mid-August, with an anticipated roll-out next year.

FEDERAL GOVERNMENT RELATIONS

U.S. Senate Action on Health Care Reform. It was a dramatic week in the U.S. Senate and it came to an even more dramatic end early morning on Friday when the GOP’s final attempt to move a “skinny repeal” bill failed 49-51 with the help of Senator John McCain (R-AZ). After repeated attempts to move a “repeal and replace bill”, the “skinny bill” was merely a last-ditch attempt to keep negotiations going with the House in hopes of finding a solution that both moderates and conservatives could support. After the vote, the Republican leaders signaled that it’s time to move on and potentially work with the Democrats to make improvements to the ACA. The Democratic leaders have recently reached out again to the House and Senate GOP leaders to forge bipartisan discussions. There may need to be a short “cooling-off” period in Congress, but the insurers are extremely anxious for some change before they make final decisions about the 2018 contracts.

CMA and AMA are hoping to be bridge organizations to try to bring both sides together to develop short-term and long-term improvements to the health care system.

CMS Released MACRA Rule for 2018 and significantly reduced reporting burdens - but more work to be done.

• Allows virtual groups to report on behalf of small practices • Allows 2018 to be another transition year - basically without penalties • New exceptions and reduced requirements for small & rural practices • Physician Expenditure category does not count in 2018 • Reduced reporting requirements in the EHR category CMS Released the Medicare Physician Payment Rule for 2018 44 | THE BULLETIN | SEPTEMBER / OCTOBER 2017

• • •

Notable, CMS soliciting physician ideas - reducing regulatory burdens in Medicare & Medicaid. CMA will respond based on CMA member survey, existing policy, and new policy form the health care reform TAC. CMS delayed implementation of the appropriate use criteria for imaging services.

2nd year of the CMA-sponsored California GPCI update.

STATE GOVERNMENT RELATIONS

CMA continues to work on the maintenance of certification issue. In September, ABMS will meet with the Executive Committee to discuss the need for changes.

LEGAL, HEALTH POLICY AND CES

CMA has been lobbying implementation of A.B. 72 while preparing our members for the new law.

CMA created a member-only Resource Center in mid-May, which includes an FAQ, sample consent form, template letter to appeal to the plan for additional money, on demand webinars and more. CMA provided comments to the DMHC and DOI advocating for a fair and reasonable average contracted rate methodology and independent dispute resolution process. CMA continues to press legislators who authored and supported the bill to ensure the regulatory implementation of AB 72 does not result in unintended consequences. Finally, CMA staff has and will continue to conduct listening sessions with our members to understand the full impact of AB 72 on their practices, which will then guide our advocacy and education strategy.

CMA has thirteen active litigation matters as either plaintiff, as an amicus curiae or "friend of the court" involving Medi-Cal reimbursement rates, medical damages, managed care, elder abuse, medical staff rights and peer review, privacy, silent PPOs, confidentiality of patient information in prescription drug monitoring programs, child abuse reporting and workers' compensation. As a result of CMA's advocacy, for the first time in at least a decade, there are no appellate cases challenging the constitutionality of MICRA.

Santa Clara and Monterey County Medical Associations

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SEPTEMBER / OCTOBER 2017 | THE BULLETIN | 45

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