ACCMA Bulletin January/February 2023

BULLETIN ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION

Serving East Bay physicians since 1860

HIGHLIGHTS FROM THIS ISSUE:

• Congress fails to stop Medicare payment cuts • 2022 Legislative Recap

• Compliance with new health laws

January/February 2023

• Physician Leadership Program kicks off • MediCal Managed Care transition • Medicare updates for 2023

• Addressing health equity in the East Bay

we are still in this together and We Are Here for You Serving our Community Since 1996

Vaccines + Well-Child Visits + Health Screenings for ALL = More Celebrations, Smiles, and Health and Well-Being Across the Lifespan.

www.alamedaalliance.org

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ACCMA EXECUTIVE COMMITTEE Edmon Soliman, MD, President Albert Brooks, MD, President Elect Irene Lo, MD, Secretary-Treasurer Robert Edelman, Immediate Past President COUNCILORS Lisa Asta, MD Eric Cain, MD Eric Chen, MD Rollington Ferguson, MD Harshkumar Gohil, MD James Hanson, MD Terry Hill, MD Shakir Hyder, MD Alexander Kao, MD Irina Kolomey, MD Steve Lee, MD Terence Lin, MD Kristin Lum, MD Nimisha Mishra-Shukla, MD Aileen Murphy, DO Kiran Narsinh, MD Ross Pirkle, MD Stephen Post, MD Jeffrey Poage, MD Thomas Powers, MD Richard Rabens, MD Steven Rosenthal, MD Suresh Sachdeva, MD Jonathan Savell, MD Sonia Sutherland, MD Clifford Wong, MD Sijie Zheng, MD

BULLETIN ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION

Serving East Bay physicians since 1860

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News & Comments

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Committees & Upcoming Events

November/December 2022 | Vol. LXXIX, No. 1

YOUR ADVOCACY 7

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PRESIDENT’S PAGE ACCMA to Congress: You Failed

By Edmon Soliman, MD, FACP, ACCMA President

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Rising Physician Leaders

The Past and Future of East Bay Place-Based Health Equity

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2022 Legislative Wrap-Up

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Your New Local Legislators

The Bay Area Physician Wellness Collaborative

IN YOUR PRACTICE 11

Dual Eligibles Move to Medi-Cal Managed Care

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New Health Laws & Action Items

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Telehealth and Prescribing Controlled Substances By the Medical Insurance Exchange of California (MIEC) 23 Council Reports

CMA & AMA REPRESENTATIVES Patricia L. Austin, MD, AMA Delegate Mark Kogan, MD, CMA Trustee, AMA Alternate-Delegate Suparna Dutta, MD, CMA Trustee Katrina Peters, MD, CMA Trustee

23 New Members

ACCMA STAFF Joseph Greaves, Executive Director Griffin Rogers, Director, Napa Solano Medical Society David Lopez, Director of Advocacy and Governance Meghan Arthurs, Director of Community Health Jennifer Mullins, Assoc. Director of Education & Events Alejandra Hinojosa, Marketing & Communications Manager Christine Maki, Administrative Assistant

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ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION 6230 Claremont Avenue, Oakland, CA 94618 Tel: 510/654-5383 Fax: 510/654-8959 www.accma.org

REDUCE – REUSE – RECYCLE Printed in the U.S.A. with soy inks on paper stock certified by the Forest Stewardship Council.

ACCMA BULLETIN | JANUARY/FEBRUARY 2023

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NEWS & COMMENTS

MEDI-CAL MANAGED CARE TRANSITION

ALL CA PHYSICIANS NOW ELIGIBLE FOR PSLF

CALHEALTHCARES LOAN REPAYMENT APP OPEN

SIGN THE DATA SHARING AGREEMENT

All patients in Alameda and Contra Costa counties who are dually covered by both Medicare and Medi-Cal (known as “dual eligible” or “Medi-Medi” patients) and were covered by Medi-Cal fee-for-service (FFS) in 2022 have been enrolled in a Medi-Cal managed care plan as of January 1, 2023. This change has no impact on Medicare coverage or reimbursement rates; this change only applies to the Medi-Cal component of coverage for dual eligible patients. The claims submission process and reimbursement are expected to remain unchanged. Visit accma.org/News to learn more.

The application cycle of the CalHealthCares Loan Repayment Program opened on January 18. Eligible physicians can apply for an award of up to $300,000 in exchange for a five-year service obligation. Visit CalHealthCares.org to apply.

E-PRESCRIBING EXEMPTION FOR LOW VOLUME PRESCRIBERS

Under AB 852, physicians are exempt from the e-prescribing mandate if they meet one of the following criteria: issue 100 prescriptions or less in a year; are practicing in an area affected by natural disaster, officially declared disaster or emergency zone; or are granted a waiver based on other extraordinary circumstances. You must register with the California Board of Pharmacy to claim this exemption at this link: bit.ly/3IK7R1y.

MIPS HARDSHIP EXEMPTION DEADLINE EXTENDED

Physicians who feel they have been impacted by the COVID19 pandemic in 2022 may file a 2022 MIPS Extreme and Uncontrollable Circumstances (EUC) hardship exemption with CMS to avoid a 2023 MIPS penalty. The deadline has been extended to March 3.

EVUSHELD AND BEBTELOVIMAB NOT AUTHORIZED FOR USE

As of late last year, all California (and Texas) physicians can participate in the Public Service Loan Forgiveness (PSLF) program, despite state prohibitions on physician employment.

Prior to this new rule, only physicians “directly employed” by a hospital/clinic were eligible, leaving many California physicians unable to apply for loan forgiveness through PSLF. The final rule ensures that physicians in all 50 states have equal access to loan forgiveness. Applications will open in July 2023 under the new rules, which are retroactive for the last 10 years of work in public and private non-profit hospitals and clinics.

CalHHS has opened its new online portal to allow practices to sign California’s Data Sharing Agreement (as part of the state’s new Data Exchange Framework). Under state law, physician practices and medical groups are required to sign a template Data Sharing Agreement by January 31, 2023. Signing the agreement is the first step in complying with the new framework. Find our brief overview of the framework at ACCMA.org/ News.

REMINDER TO LOWER BARRIER FOR ACCESS TO COVID-19 TREATMENT

There is an ample supply of COVID-19 therapeutics and evidence suggests that patients who may benefit from being treated for COVID-19 infection are not being treated. CDPH reminds physicians to ensure all individuals with suspected COVID receive testing for SARS-CoV-2 and influenza based on risk factors, enable pathways for symptomatic individuals who test positive for SARS-CoV-2 and/or influenza to connect to a prescriber within 24 hours of seeking care, and ensure all patients are aware that a new law enacted 9/25/22 requires all health plans in California to cover out-of-network care for patients seeking COVID-19 therapeutics evaluation with no cost sharing to patients. Providers should have a low threshold to prescribe COVID-19 therapeutics given the broad range of individuals who are at higher risk for severe COVID-19 and can benefit from COVID-19 treatment.

Recently, the FDA revised the EUA for Evusheld (tixagevimab co-packaged with cilgavimab) and Evusheld is not currently authorized for use in the U.S. until further notice by the Agency.

Data show Evusheld is unlikely to be active against certain SARS-CoV-2 variants. This action to limit the use of Evusheld prevents exposing patients to possible side effects of Evusheld such as allergic reactions, which can be potentially serious, at a time when fewer than 10% of circulating variants in the U.S. causing infection are susceptible to the product. Similarly, The FDA announced that Bebtelovimab is no longer authorized for use because it is not expected to neutralize Omicron subvariants. Physicians should use other products that are expected to retain activity against the subvariants, including Paxlovid, Veklury, and Lagevrio, of which there are ample supply.

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ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION BULLETIN

RENEW YOUR DUES

Your membership dues allow us to continue to fight for you and the betterment of the practice of medicine. Please remember to renew your dues for 2023 before March 1st to avoid a lapse in membership.

You may renew and pay online at www.cmadocs.org/ renew, or by mailing a check to California Medical Association, Attn: Medical Society Services, PO Box 515448, Los Angeles, CA, 90051-6748. Please call the ACCMA office with questions or if you need a copy of your 2023 Membership Dues invoice.

COMMITTEES & EVENTS

ACCMA COMMITTEES: RECENT ACTIVITIES

The ACCMA Community Health Committee met on November 8 and discussed the status of the Alameda County Behavioral Health Care Services Department’s Fiscal Year (FY) 2022-23 Mental Health Services Act (MHSA) and the Contra Costa Behavioral Health Services FY 2022-23 MHSA. Melissa Stafford Jones, Director of Children and Youth Behavioral Initiative, presented on the state’s Children and Youth Behavioral Health Initiative.

The ACCMA Medical Services, Technology, and Quality of Care Committee met on December 1 and continued their discussion about the California Health Information Data Exchange. David Ford, CMA’s Vice President of Health Information Technology, presented on health information, electronic medical records, and the CA Data Exchange Framework.

The ACCMA Health Equity Committee met on December 6 and discussed the grant application that they submitted. The grant is being offered by the Office of Health Equity within the CA Department of Public Health and the Center at Sierra Health Foundation. Alameda County Health Care Services and Contra Costa Health Services led a presentation on each county’s health equity data and actions taken by the county to tackle health equity. See page 17 for more info on the work of the Health Equity Committee.

The ACCMA Executive Committee met on December 12 and discussed ACCMA committees and committee appointments. They renamed the Membership and Communications Committee to the Membership and Engagement Committee, plus made the Health Equity Task Force a standing committee. The Executive Committee discussed the current council vacancies, annual meeting review, and resident membership recruitment.

They also made a recommendation to change the ACCMA COVID Policy, which was recommended to the ACCMA Council.

UPCOMING MEETINGS & EVENTS

HEALTH EQUITY COMMITTEE MEETING Wednesday, February 22 | 6:30 pm

EAST BAY SAFE PRESCRIBING COALITION STEERING COMMITTEE MEETING Tuesday, February 28 | 6:00 pm

MED. SERVICES, TECHNOLOGY, & QUALITY OF CARE COMMITTEE MEETING Thursday, March 2 | 6:00 pm

BAY AREA PHYSICIAN WELLNESS COLLABORATIVE Tuesday, March 7 | 6:00 pm

ACCMA DISTRICT IX DELEGATION MEETING Thursday, March 9 | 6:30 pm

LEADERSHIP IN ACTION: ADVOCACY TRAINING Saturday, March 18 | All day event

COMMUNITY HEALTH COMMITTEE MEETING Thursday, March 23 | 6:30 pm

BAY AREA READING AND DISCUSSION GROUP Wednesday, April 5 | 6:00 pm

CMA LEGISLATIVE DAY

Wednesday, April 19 | All day in Sacramento

SAVE THE DATE

ACCMA 155TH ANNUAL MEETING Friday, November 3rd , 2023

Visit pathlms.com/medical-society for all the latest educational CME opportunities from ACCMA

ACCMA BULLETIN | JANUARY/FEBRUARY 2023

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HEALTHY CHECKOUT

Health Professionals for Clean Air and Climate Action Are you a health professional concerned about air pollution and climate change?

Climate change is already harming our health, from worsened ozone pollution due to warmer temperatures, to more frequent and intense wildfires producing dangerous particle pollution.

Medical and health voices are critical to raising awareness of the overwhelming health burden caused by air pollution and climate change.

To take part in the American Lung Association’s growing Health Professionals for Clean Air and Climate Action community and sign up for our monthly newsletter, visit Lung.org/climatechangeshealth

CRITICAL UPDATES TO MAINTAIN COMPLIANCE

CME AVAILABLE

What's new with HIPAA this year? In this one-hour webinar, you will review some of the most critical privacy and security standards in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Rules and receive important updates on who is covered, what information is protected, how you can stay secure in the Information Age, and how to avoid costly mistakes.

PRESENTER: David Ginsberg is co-founder and president of PrivaPlan Associates, Inc. He has more than 30 years of experience in the health care industry with expertise in medical practice management and regulatory compliance. He is the official HIPAA advisor to ACCMA and the California Medical Association (CMA).

Available on demand at bit.ly/3TIZ02c Accreditation Statement: The ACCMA is accredited by the California Medical Association (CMA) to provide continuing medical education Credit Designation Statement: ACCMA designates this live activity for a maximum of 1 hour of AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

PRESIDENT'S PAGE

ACCMA to Congress: You Failed

By Edmon Soliman, MD, FACP

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he ACCMA is extremely disappointed that Congress failed to prevent all of the Medicare payment cuts that were scheduled to take effect in 2023. In partnership with AMA, CMA, and scores of medical and specialty societies across the nation, ACCMA called on Congress and advocated extensively to reverse the 8.5% cuts scheduled for 2023. Unfortunately, Congress decided instead to take half measures, erasing 6% of those cuts in the year-end Omnibus legislation and leaving a 2.5% cut to take effect.

Congress failed to recognize that cuts of any amount will threaten the financial viability of physician practices and endanger access to care for Medicare beneficiaries, mostly seniors and disabled persons. Since 2001, inflation has increased by 40%, yet physician Medicare payments have only increased by 7%. Today’s Medicare payments on average lag 40% behind the cost of providing care. While hospital and nursing home payments are indexed to inflation (and as a result have increased by 60% since 2001), the broken physician payment system has burdened physicians with an uphill fight just to stop statutory and budget neutrality payment cuts year after year.

Physicians have a raw deal, and Congress needs to step up and fix it.

CMA recently surveyed physicians about the financial health of their practices and how Medicare payment rates are impacting access to care in their communities. According to the survey results, 76% of physicians report that Medicare fee-for-service payments do NOT cover their costs to provide care. Furthermore, 61% of physicians report average revenue losses between 11-50% and 13% even report average revenue losses over 50%.

In response to these cuts, our members have expressed their immense disappointment regarding how these cuts will impact patients: • “If the federal government wants to decrease the number of practicing physicians, this is the way to do it. I fear for patients... as their doctors leave practice earlier than they had planned, due to the never-ending increases in paperwork, pointless regulations, denials, authorizations, and on and on and the never-ending decreases in reimbursement.”

• “With rising costs and declining Medicare reimbursement

rates, my physician colleagues and I, who serve our community, are forced to choose between rebalancing our patient group to reduce Medicare enrollees or ultimately risking the viability of our practices.”

• “I worry more about our Medicare seniors/retirees and their ability to secure good healthcare.”

• “Staff wages are increasing even more in order to retain good employees able to help us deliver care in this increasingly complex environment. This 2.5% pay cut will force us to reevaluate our relationship with Medicare and potentially to close our clinic to new Medicare patients.”

• “We have severe staffing shortages throughout all of our medical departments. Medicare physician payment cuts during a time of economic challenges and severe inflation is going to further threaten our fragile and overstretched health systems.”

The fight is not over, however. We are resolved to continue applying as much pressure as possible until Congress enacts a permanent fix to Medicare’s broken physician payment system.

The AMA put forward a framework that, among other things, calls on Congress to: • Institute an annual automatic payment update tied to inflation or the Medicare Economic Index.

• Revise the budget neutrality requirements in the Medicare Physician Fee Schedule (PFS) to allow for appropriate changes in spending without penalizing physicians, including exempting new services from budget neutrality.

• Recognize physician contributions in providing high value care that reduce costs in other Parts of Medicare, such as reducing hospitalizations in Medicare Part A. • Reduce administrative burdens.

Making these changes will not be easy given today’s political environment, but it is achievable with your support. Your membership supports a wide range of activities that go into advancing your priorities through advocacy: developing workable policy solutions, arranging meetings with our elected representatives, writing multiple letters to their offices, communicating with their staff to elevate our issues, and engaging our membership in calls to continued on page 11 ACCMA BULLETIN | JANUARY/FEBRUARY 2023

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NEWS & COMMENTS (continued from page 21)

2022 Legislative Wrap-Up

By Janice Rocco, CMA Chief of Staff

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n 2021, with emergency use authorization for COVID-19 vaccines, the hope was that the pandemic would end and life could go back to normal. Instead, it wasn’t until 2022 that the state legislature began moving back to something resembling business as usual.

The state declaration of the COVID-19 State of Emergency remains in effect. The State Capitol is again open to the public, but even that has changed in ways that provide less access to legislators and their staff than was the case prior to the pandemic. The Capitol building is undergoing construction and legislators have moved their offices outside the Capitol.

Committee hearings are being conducted in person again, though often with a hybrid phone-in option. Separate from the legislature, public meetings held by state departments and commissions have begun shifting back to a hybrid approach, so that we can be back in person again. These changes mean that we have adjusted and found new ways that we, as advocates, communicate with legislators and their staff.

In California, we had five legislative seats become vacant during the year, which meant five special elections to fill them. By the time each of these races had concluded, a total of five new Democrats had been sworn into office. With these additions, Democrats continue to have a supermajority in both the Assembly and the Senate.

The closing of the 2021–2022 legislative session also brought with it the end of an era for a well-respected member of the legislature. Senator Richard Pan, M.D., spent 12 years serving California in the legislature by focusing on improving the state’s health care system, fighting for patients and the practice of medicine. Though Dr. Pan has many legislative accomplishments, we are particularly grateful for his leadership during the COVID-19 pandemic, where his expertise was critical to our state on a daily basis.

2022 ANNUAL MEETING

HEALTH CARE REFORM

As the legislative year began, AB 1400, the single payer health care coverage bill, was before the State Assembly for a vote. That bill died in the Assembly at the end of January, which then shifted the discussion to other health care reform measures. The Governor’s Office of Health Care Affordability proposal from 2021 was back for discussion and debate, with the California Medical Association (CMA) fighting to prevent this broad measure from becoming an administrative burden for physician practices.

Ultimately, we were successful in getting physician practices with fewer than 25 physicians exempted from both the data submission requirements and the cost targets that the state will develop. Similarly, we fought to prevent independent practice associations (IPAs) from being included as a way to impose cost targets and data submission requirements on smaller physician groups, ultimately seeing them removed from the bill. We were also able to get the Newsom Administration to commit to include $200 million in the state budget for grants to assist physician practices with implementation of some of the provisions in Office of Health Care Affordability legislation, such as a shift to alternative payment models.

STATE BUDGET

Another victory in the health care reform space was achieved via the 2022–23 state budget. Continuing California’s commitment to achieving universal health care access, the $308-billion budget includes a phasedin system to provide full scope Medi-Cal coverage to all income-eligible Californians regardless of age or documentation status by January 1, 2024. This makes California the first state in the nation to expand its Medicaid program to provide full benefits to all eligible individuals—a critical step in our shared goal of ensuring that every Californian has access to quality health care.

Many other CMA priorities and supported issues were addressed in the 2022–23 budget, including: a permanent extension of key Medi-Cal telehealth flexibilities implemented during the pandemic; full funding for the Prop. 56 Medi-Cal supplemental payments and graduate medical education funding programs; major investments in health care workforce development; $1.3 billion for health care worker retention pay; $700 million in equity and practice transformation payments; and $200 million for reproductive health and reproductive justice issues.

(For more details on the state budget, see cmadocs.org/ budget-22-23.)

MICRA

When the year began, the expectation was that CMA’s focus in 2022 would be working to defeat the socalled “Fairness for Injured Patients Act” (FIPA) ballot initiative that had qualified for the November 2022 ballot. The ballot initiative, if it had passed, would have eviscerated the protections of California’s Medical Injury Compensation Reform Act (MICRA). After Californians Allied for Patient Protection (CAPP), led by CMA CEO Dustin Corcoran, negotiated a legislative deal with FIPA proponents, Assemblymember Eloise Gómez Reyes put that legislative deal into AB 35, the MICRA Modernization Act. Just 16 days later, Governor Newsom signed the bill into law and FIPA proponents removed their initiative from the ballot. This historic agreement prevented a costly ballot fight and ushered in a new and sustained era of stability around malpractice liability.

MEDICAL BOARD

CMA aggressively fought AB 2060 (Quirk), which would have created a public member majority on the Medical Board of California. We were able to kill this bill in its first house.

At the same time, CMA sponsored legislation— AB 1636

by Assemblymember Akilah Weber, M.D. —to preserve the integrity of the medical profession by ensuring physicians convicted of sexual assault with a patient lose their license with no ability for it to be reinstated. This bill removes the medical board’s discretion to give or reinstate the license of a physician or surgeon who lost their license due to sexual misconduct with a patient. This bill would also deny a physician’s and surgeon’s license to an applicant who has been or is required to register as a sex offender.

HEALTH IT

CMA had three significant victories addressing health information technology issues. The passage of AB 852 (Wood) eliminates administrative burdens associated with complying with California’s electronic prescribing mandate. AB 32 (Aguiar-Curry) permanently ensures parity in reimbursement for telehealth services provided through Medi-Cal managed care plans, so that this reimbursement reform lasts beyond the public health emergency. Finally, SB 1419 (Becker) helps physicians comply with the new federal information blocking rule and protects patients’ sensitive medical information.

REPRODUCTIVE RIGHTS

In June, the U.S. Supreme Court decision in Dobbs v.

Jackson Women’s Health caused shockwaves on a national scale, as access to reproductive health care services was stripped away from millions of Americans overnight.

2022 ANNUAL MEETING CMA and other organizations had begun planning for this reality in late 2021 by forming the Future of Abortion Council to develop legislative and budget proposals to ensure that access to abortion care would not be denied in California once the court overturned Roe v. Wade.

This year, 15 reproductive health care bills were signed into law by Governor Newsom, including bills meant to strengthen protections for physicians and other health care providers from civil or criminal actions that could arise in other states if providers treat patients from outside California. Additionally, $200 million was included in the 2022–23 state budget to expand access to reproductive health care, including abortion.

ADMINISTRATIVE BURDENS

CMA sponsored SB 250 (Pan) to reduce administrative burdens from health plans’ prior authorization requirements and ensure that patients get the care they need, when they need it. This bill was strongly opposed by the health plans and although it passed the Senate, it fell short in the Assembly Appropriations Committee.

SCOPE OF PRACTICE

Another big fight this year was CMA’s work with the California Academy of Eye Physicians and Surgeons to oppose AB 2236 (Low), which would have allowed optometrists to perform certain surgical procedures without the same training as ophthalmologists. This bill was hard-fought in the legislature and was the last bill to pass the Assembly before midnight on the final night of the legislation session, when it eventually received the 41st vote it needed for passage. Even though this bill narrowly made it out of the legislature, Governor Newsom heard from hundreds of physicians and vetoed it to protect patients, issuing a strong statement about the inadequacy of its training requirements.

LOOKING BACK AT A BUSY SESSION

By the time the Governor’s bill final signing period for the 2021–22 legislative session ended, Governor Newsom had signed 997 bills into law and vetoed 169 bills.

For more details on the major bills that CMA was involved with in 2022, visit cmadocs.org/legwrap2022.

Subscribe to CMA’s free biweekly Newswire and stay informed on CMA’s legislative efforts and other issues critical to the practice of medicine at cmadocs.org/ subscribe.

The California Medical Association (CMA), working to empower physicians to lead and transform the health care system, recently welcomed Stuart Thompson, J.D., as its new Senior Vice President. In that role, he will lead the association’s government relations and political operations efforts.

“Stuart’s impressive record of success inside the halls of government and across California’s political landscape will be a great asset as we navigate rapid changes in our health care delivery system and look for opportunities to improve the health of all Californians by helping people get timely, high-quality care,” said CMA CEO Dustin Corcoran.

“We have a big year ahead of us and Stuart’s deep understanding of health care policy, and the legislative and regulatory agencies in California, will position CMA as an even greater force in the health care advocacy space.”

Thompson has over 15 years of legislative, government and legal experience in California, most recently serving as the Chief Deputy Legislative Secretary in Governor Gavin Newsom’s administration. Having already served as Associate Director of Government Relations at CMA for five years prior to joining the Newsom administration, Thompson’s wealth of experience advocating on behalf of physicians and the patients they serve makes him uniquely suited for the role.

“This is a pivotal time for health care in our state and I am thrilled to join CMA’s lobbying team to advance meaningful, measurable improvements in California’s health care delivery system,” said Thompson. “By bridging the gap between policymakers and medical professionals, we can achieve a health care system that delivers for all Californians.”

MEDI-CAL MANAGED CARE

Dual Eligible Patients Moving from Medi-Cal FFS to Medi-Cal Managed Care

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tarting January 1, 2023, all patients in Alameda and Contra Costa counties who are dually covered by both Medicare and Medi-Cal (known as “dual eligible” or “Medi-Medi” patients) were enrolled in a Medi-Cal managed care plan. This means that any dual eligible patients who were covered by Medi-Cal fee-forservice (FFS) in 2022 are now enrolled into a Medi-Cal managed care plan effective January 1. In the East Bay, these plans include Alameda Alliance for Health (Alameda County only), Contra Costa Health Plan (Contra Costa County only), and Anthem Blue Cross (both Alameda and Contra Costa).

This change is part of the state’s CalAIM implementation, which calls for all dual eligible patients to be enrolled in a MediCal managed care plan to receive their benefits. Patients may request a waiver to remain in Medi-Cal FFS, but the state is discouraging patients from doing so unless there is a clear need.

It is important to note that this change has no impact on Medicare coverage or reimbursement rates; it only applies to the Medi-Cal component of coverage for dual eligible patients. For patients enrolled in Medicare FFS, physicians should continue to submit claims to Noridian and Noridian will then send it along to the patient’s secondary insurer for any additional payment that may apply. The only difference for patients who were previously enrolled in Medi-Cal FFS is that the remittance for Medi-Cal secondary coverage will now come from the patient’s Medi-Cal managed care plan instead of the state intermediary.

For patients covered by a Medicare Advantage (MA)

plan, physicians should continue to submit the claim to the patient’s MA plan and should submit the secondary claim to the patient’s Medi-Cal managed care plan. The claims submission process may be streamlined, however, in cases where the carrier is the same for both the Medicare and Medi-Cal components (e.g. a patient has Anthem Blue Cross for both their MA and Medi-Cal managed care coverages). Please consult with your contracted MA plans for guidance on processing secondary claims.

Also important to note: You are not required to be a contracted provider with the Medi-Cal managed care plans to submit claims for reimbursement for secondary coverage. You can submit secondary claims without becoming part of the Medi-Cal managed care plan’s network of providers.

To help you better understand this transition, the ACCMA recently recorded a presentation with officials from the California Department of Health Care Services, which oversees the MediCal program, to review what is changing, why, and how it will impact physician practices. To access this brief video and other helpful links, go to ACCMA.org > Issues > Hot Topics.

If you have issues or questions related to processing secondary claims, please contact the local Medi-Cal managed care plans directly: • Alameda Alliance: 510-747-4510 or providerservices@ alamedaalliance.com • Contra Costa Health Plan: 877-800-7423, option 5 • Anthem Blue Cross: 800-407-4627

PRESIDENT'S PAGE (continued from page 7)

action. Advocacy doesn’t just happen. It takes work, and membership dues make it possible.

Thank you for your continued membership. We ask you to please renew for 2023 if you have not done so yet. If you know of

colleagues who have yet to join, please urge them to support our efforts. More members generate a stronger voice, leading to more favorable policy outcomes.

Looking for support? Visit ACCMA.org/Wellness to explore all the wellness resources available to you as a member.

ACCMA BULLETIN | JANUARY/FEBRUARY 2023

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2023 ACCMA COUNCIL

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Aisha AishaWahab Wahab Senate SenateDistrict District10 10

Liz LizOrtega-Toro Ortega-Toro Assembly AssemblyDistrict District20 20

District: District:Fairview, Fairview, Fremont, Fremont,Hayward, Hayward, Newark, Newark,Union UnionCity, City,Santa Santa Clary ClaryCounty County

District: District:Ashland, Ashland,Castro Castro Valley, Valley,Cherryland, Cherryland,Dublin, Dublin, Fairview, Fairview,Hayward, Hayward, Pleasanton, Pleasanton,San SanLeandro, Leandro, San SanLorenzo, Lorenzo,Union UnionCity City

Phone: Phone:(510) (510)794-3900 794-3900 Phone: Phone:(510) (510)583-8818 583-8818

Lena LenaTam Tam Alameda AlamedaCo. Co.Board Boardof of Supervisors Supervisors

Ken KenCarlson Carlson Contra ContraCosta CostaCo. Co.Board Boardof of Supervisors Supervisors

District: District:Alameda, Alameda,San San Leandro, Leandro,aaportion portionof of Oakland, Oakland,San SanLorenzo, Lorenzo, Ashland Ashland

District: District:Pleasant PleasantHill, Hill, Concord, Concord,Clayton, Clayton,and andaa portion portionof ofWalnut WalnutCreek Creek Phone: Phone:(925) (925)521-7100 521-7100

Phone: Phone:(510) (510)278-0367 278-0367

In In2022, 2022,California Californiaredrew redrewtheir theirlegislative legislativedistricts districtswhich whichled ledto tosome some changes changesininlegislators legislatorsininAlameda Alamedaand andContra ContraCosta CostaCounties.

Counties.

JoshHarder Harder Josh CongressionalDistrict District99 Congressional FirstElected: Elected:2018 2018 First

SusanTalamantes TalamantesEggman Eggman Susan StateSenate SenateDistrict District55 State FirstElected: Elected:2020 2020 First

District:Discovery DiscoveryBay, Bay, District: Byron,San SanJoaquin Joaquin Byron, County County

District:All Allof ofSan SanJoaquin Joaquin District: County&&inin2024, 2024,SD SD55will will County addLivermore, Livermore,Pleasanton, Pleasanton, add Dublin.

Dublin.

Phone:(209) (209)579-5458 579-5458 Phone: Phone:(209) (209)472-9535 472-9535 Phone:

NEW HEALTH LAWS

Action Items for the New Year

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here are several new health laws and policies that took effect January 1 that require your compliance. Please find a full list of new health laws by visiting bit.ly/3XkLHaD. Call the ACCMA at (510) 654-5383 if you have any questions regarding these new laws and how they affect your practice.

MEDICAL BOARD LICENSING NOTICE As of January 1, all physicians licensed by the Medical Board of California must provide an updated “notice to consumers” that informs patients that physicians are licensed and regulated by the medical board and provides details about how patients can check the status of a license or file a complaint.

Under the new regulation, the notice must be provided in a language understood by the patient or patient representative and include a QR code that leads to the board’s Notice to Consumer webpage.

Physicians can comply with this requirement by doing one of the following: • Post a notice in an area visible to patients on the premises where the physician provides medical services; • Provide the patient with a notice and retain in that patient’s medical record an acknowledgement of receipt and understanding, signed and dated by the patient or the patient representative; • Include the notice in a statement on letterhead, discharge instructions or other document given to a patient or the patient representative.

E-PRESCRIBING EXEMPTION REQUEST Low volume prescribers and health care practitioners that meet certain criteria can now request an exemption from California’s e-prescribing mandate, under a new law (AB 852) strongly supported by CMA. Under the new law, physicians are exempt from the e-prescribing mandate if they issue 100 prescriptions or less in a year; are practicing in an area affected by natural disaster, officially declared disaster or emergency zone; or are granted a waiver based on other extraordinary circumstances.

To claim the exemption, physicians must register with the California Board of Pharmacy using the E-Prescribing Exemption Request Form. The form will allow pharmacists to confirm that a physician is exempt from the requirement.

SIGN THE DATA SHARING AGREEMENT As part of the Data Exchange Framework, all physician practices are required by law to sign the Single Data Sharing Agreement by January 31. All that is required this year is to sign the agreement and begin familiarizing yourself with the framework which will go into effect in 2024 or 2026 depending on your practice type.

Find a presentation to help you understand how to prepare for this transition, the link to sign the agreement, and other helpful resources at ACCMA.org > Issues > Hot Topics.

APPLY FOR MIPS HARDSHIP EXCEPTION CMS has extended the extreme and uncontrollable circumstances application deadline for the 2022 performance year. Physicians and physician groups affected by the COVID-19 pandemic now have until March 3, to apply for a 2022 Medicare hardship exception. While COVID-19 flexibilities are still in place due to the public health emergency, the exceptions will not be automatically applied as they have been the past two years.

IMMUNIZATION REGISTRY REQUIREMENT As of January 1, physicians who administer vaccines are required to enter the immunizations they administer into a California immunization registry – CAIR. They will also be required to include race and ethnicity information for each patient in the immunization registry to support assessment of health disparities in immunization coverage. Contact the CAIR Help Desk at CAIRHelpdesk@cdph.ca.gov or 800-578-7889 with any questions or if you want to find out whether your practice is already participating in CAIR. NOTIFY PATIENTS OF OPEN PAYMENTS DATABASE A new California law requires physicians to provide patients with a written or electronic notice about the availability of the federal Open Payments database. It also requires physicians to post in their offices and on their websites a notice informing visitors about the Open Payments database, which can be used to search payments made by drug and medical device companies to physicians, physician assistants, advanced practice nurses and teaching hospitals. To assist physicians with this new requirement, the California Medical Association (CMA) has published sample forms and notices available at cmadocs.org/open-payments.

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MEDICARE CHANGES

MEDICARE CHANGES

2023 AND BEYOND Review the policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective for Calendar Year 2023 and beyond. This on demand webinar will provide you with the resources to help you maneuver regulatory and procedural challenges that impact your practice.

FEATURING GUEST SPEAKER: CHERYL BRADLEY Cheryl Bradley, Associate Director of the CMA Center for Economic Services, has over 25 years experience in the Medicare Program and has held a variety of responsibilities including Education and Training Specialist, Medical Review Analyst, and has worked with providers in virtually all specialties across all the CA Medicare contractors. Cheryl provides problem solving assistance to CMA member physicians on a number of healthcare issues. She is skillful at using humor to help providers navigate this difficult program.

JOIN US AS WE DISCUSS: • Telehealth Services • Updates to Other Evaluation and Management (E/M) Visits • Behavioral Health Services • CY 2023 Quality Payment Program • Noridian Compliance • Other Medicare Part B issues

Available on demand at: bit.ly/3WYaBww Please contact Jennifer Mullins, ACCMA Associate Director of Education and Events at jmullins@accma.org or 510-654-5383 with any questions.

Accreditation Statement: The ACCMA is accredited by the California Medical Association (CMA) to provide continuing medical education Credit Designation Statement: ACCMA designates this live activity for a maximum of 1 hour(s) of AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

PHYSICIAN LEADERS

Physician Leadership Program Welcomes New Rising Physician Leaders

T

his January, the ACCMA kicked off the sixth iteration of the Bay Area Physician Leadership Program. Forty-one physicians join us from across the Bay Area, from 21 different medical groups/organizations and representing a diverse range of specialties. The course is offered in a hybrid format for this cohort, providing flexibility to participants and allowing us to extend the program widely to physicians throughout the Bay Area. Working with a diverse group of participants provides a rich array of perspectives

as we discuss the common challenges to work in healthcare.

The Physician Leadership Program faculty includes experienced physician leaders who provide participants with a deep understanding of leadership and guide discussions in topics that make effective leaders like trust, decision-making, power and influence, systems thinking, coaching, and values and ethics.

We invite you to join us for the seventh cohort of the Bay Area Physician Leadership program in the winter of 2024.

MEMBERS OF THE 2023 BAY AREA PHYSICIAN LEADERSHIP PROGRAM

Chika Akera, MD – La Clinica De La Raza Mercedes Bell, MD – TPMG Lee Botkin, MD – Santa Clara Valley Medical Center Georgina Calderon, MD – Adventist Health Ukiah Valley Rhonda Caldwell-Williams, MD – TPMG Beth Collins, MD – TPMG Rebecca Carrillo, MD – Berkeley Mental Health Program Sharon Chang, MD – TPMG Kathleen Doo, MD – TPMG Nima Eftekhary, MD – TPMG Laura Foster, MD – TPMG

Michael Gagnon, MD – Valley Eye Care Ctr Melinda Glines, MD – TPMG Shelly Gupta, MD – Epic Care Amit Gupta, MD – UCSF Children’s Hospital Oakland Rebekah Harding, MD – Marin Community Clinics Jagmohan Jandu, MD – Palo Alto Foundation Med Grp Flyn Kaida-Yip, MD – San Joaquin General Hospital Parveen Kaur, MD – Tiburcio Vasquez Health Center, Inc Christina Kinnevey, MD – Touro University

Man-Kit Leung, MD – Asian American Medical Group Peter Lo, MD – San Joaquin General Hospital Robert Lurvey, MD – Sutter East Bay Medical Group Ian Mclachlan, MD, MPH – TPMG Jennifer Miller, MD – East Bay Pediatrics Medical Group Anuruddh Misra, MD – Premise Health Heyman Oo, MD – Marin Community Clinics Krushangi Patel, MD – Epic Care Amgad Salib, MD – TPMG Debra Schenk, MD – TPMG

Conrad Schoenwald, DO – TPMG Sagar Shah, MD – TPMG Padmaja Sharma, MD – Fremont OB/Gyn Nitasha Sharma, MD – San Joaquin General Hospital Kulwinder Singh, MD – Psychiatric Care for Seniors Sohni Singh, MD – San Joaquin General Hospital Jorge Siopack, MD – La Clinica De La Raza Isabel Tejeda, MD – TPMG Veena Vanchinathan, MD –TPMG Adam Warren, MD, MPH – Adam Warren MD Inc. Johnny Yep, DO – Palo Alto Foundation Med Grp

ACCMA BULLETIN | JANUARY/FEBRUARY 2023

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PHYSICIAN LEADERS

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HEALTH EQUITY

The Past and Future of East Bay PlaceBased Health Equity

By Terry Hill, MD, FACP

I

f it’s true, as Dr. Tony Iton said in his 2018 address to the ACCMA, that one’s zip code matters more to health and longevity than one’s genetic code, then what could healthcare delivery systems and the local physician community do to help? The ACCMA’s Health Equity Committee has begun to discuss just this question, and we invite broad participation in the conversation. At our December meeting we posed the question to our local health officers, Drs. Ori Tzvieli and Nick Moss, who led the massive efforts of their counties (Contra Costa and Alameda, respectively) to prioritize equity in their pandemic outreach efforts. Here I’ll focus on (1) why change is hard, and (2) how change is possible.

THE DURABILITY OF HEALTH INEQUITY For the hard part, the 1930s “redlining” maps are a good place to start. The federally-sponsored Home Owners’ Loan Corporation developed these color-coded maps to promote home ownership in white neighborhoods while discouraging loans in “Negro” neighborhoods. This legacy, together with our mortgage interest tax deduction and other intergenerational wealth transfer policies, has solidified our wealth disparities. The Black/white homeownership gap is wider today than in the 1960s and is part of what is now known as structural racism. Oakland’s “red” zip codes in 1937 are today’s zip codes of poverty.

In a remarkable demonstration of how inequitable health outcomes persist geographically, Nancy Krieger found that New York’s 1930s redlining maps predict today’s risk of preterm birth – even though the racial/ethnic mix has shifted with new immigration.* The place-based health determinants include housing quality, air quality, transportation, jobs, schools, social services, food stores, health facilities, parks, sidewalks, and the tree canopy.

In the East Bay we have four zip codes in the bottom quartile of California’s Healthy Places Index: 94801 in West Contra Costa and 94601, 94621 and 94603 in East Oakland. Low-income jobs predominate in this East Oakland area; employment is relatively low (third quartile) but income is yet lower (fourth quartile).

Housing quality is in the lowest decile. Through April 2021, the deadliest period of the pandemic, these zip codes were among the county’s top zip codes for COVID-19 mortality (excluding longterm care facilities) with 101 deaths for this period, of which 61% were Hispanic/Latino and 27% were Black/African American;

67% were older adults (age 65+).

Three separate hospital systems serve East Oakland. Alameda County Medical Center is closest, and in 2021 it had 1,439 admissions from zip code 94601. But Alta Bates Summit and Kaiser Oakland, also nearby, together had 1,562 (793 and 769, respectively, data from California’s Department of Health Care Access and Information and California Healthcare Compare). As tax-exempt, non-profit hospitals, Summit and Kaiser are required to do community needs assessments and distribute community benefit funds. They collaborated on their most recent assessments, and together they make community investments totaling hundreds of millions of dollars annually. In addition, Alameda County’s Measure A funding yields millions more. And yet these disparities persist.

In our December discussion, Dr. Tzvieli pointed out that disease-based interventions often disappoint. In a recent Health Affairs paper, Dr. Iton said that programs “that seek to change individuals’ behaviors – such as smoking, eating high-fat diets, or physical inactivity – have largely failed.” So with all this bad news, how can I possibly argue that change is possible?

There is an increasing body of evidence that with enough multi-stakeholder, multi-sector commitment, communityfocused initiatives can indeed change the upstream social determinants of health and achieve measurable positive outcomes.

Emerging from decades of community-based initiatives is the Accountable Community for Health (ACH) model. With funding from philanthropy and federal and state governments, including California, we now have hundreds of ACHs, and researchers have teased out the factors required for success. Rather than describing the ACH model, however, I would like to highlight a home-grown initiative that preceded it but included its elements: the Richmond Health Equity Partnership.

HEALTH EQUITY IN ALL POLICIES Richmond’s focus on health equity emerged in 2006 from outside the healthcare community when environmental justice activists pushed the city to include a health dimension in its General Plan.

With new-found support from health consultants and city officials, health implications began to be visible in multiple domains continued on page 18 ACCMA BULLETIN | JANUARY/FEBRUARY 2023

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HEALTH EQUITY (continued from page 17)

of the plan, not only in air quality and housing. The use of placebased strategies helped citizens and officials understand the interconnectedness of policy domains. For example, residents in two neighborhoods conducted walk-audits to create maps of need and opportunity that could be matched with available land use and health data. These led to local improvements in streets, sidewalks, and parks and further increased residents’ sense of power. Young people led efforts to reclaim unsafe, violence-prone places, and the city leveraged their efforts to secure funding for parks development, which led to more youth jobs.

In 2010, with funding from The California Endowment, the Richmond Health Equity Partnership was created within the city manager’s office, and a Health in All Policies Strategy was formalized – inclusive of schools, policing, and economic development – all to be monitored by an annual health equity report card. Structural racism and toxic stress became foundational ideas among stakeholders in and outside of city government. This momentum helped Richmond compete for and win its new UC Berkeley and Lawrence Livermore Lab campus.

I have condensed a complex story, of course. Challenges included organizational inertia, political opposition, and inadequate data. Richmond continues to struggle with poverty and its consequences. Chevron refinery incidents still occur, albeit not on the scale of the disastrous 2012 explosion. But some health indicators have improved, community resilience has dramatically increased, and the concept of “health equity in all policies” is now widely disseminated.

ACCOUNTABLE COMMUNITY FOR HEALTH IN ALAMEDA COUNTY? A new initiative for health equity in East Oakland or Alameda County, which lacks Richmond’s environmental justice strength, would require much more leadership from the healthcare community itself. It would need to conform more closely to the ACH model elements, including shared vision and goals, a stable backbone entity and governance model, commitments and trusting relationships across sectors (education, business, government).

Dr. Iton and others have also argued that the engagement of community residents and community-based organizations is not enough; rather, strategies to increase community power are critical. Sustaining an ACH is challenging, and structural inequities run deep. Community power is essential to meet challenges and achieve accountability in ACHs. But community power is also an end in itself from a health perspective. At a metabolic level, perceived power is an antidote to the cumulative toxic stress of poverty, racism, violence, and environmental hazards. At a community

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level, identification of strengths and previously unseen sources of resilience can create a positive spiral that improves population health. High school students in Richmond have contributed to research on air pollution. As part of the California Endowment’s Building Healthy Communities program, Dr. Iton has already been supporting youth power-building programs in East Oakland for more than a decade.

For communities without Richmond’s unique background, just getting started on an ACH can be hard, and it’s clear that a long-game mindset is essential. But it’s also clear that our health equity ambitions are hobbled by the fragmentation of initiatives currently funded by hospitals, government, and philanthropy.

Without a shared governance structure, vision, goals, and measurement, these initiatives are likely to be disappointing, and our disparities with endure. The ACCMA’s Health Equity Task Force has at least begun a conversation about how to proceed.

And there are new reasons to believe that change is possible.

Foremost among these are the relationships, values, and sense of collective efficacy that emerged in response to COVID-19. As the pandemic began, a vast number of diverse stakeholders exercised collaboration muscles that we didn’t even know we had. Many of those same stakeholders have now expressed their commitment to equity. Finally, the availability and quality of data on small-area variation in health status are dramatically improving, both from public sources and within our delivery systems, enhancing our ability to realize accountability.

Flogging physicians and healthcare delivery systems won’t achieve health equity, but delivery systems do have considerable social, political, and financial power. And physician leaders are distributed throughout the hospitals and clinics of our delivery system – with access to C-suites and credibility with the public and other stakeholders. Our public health officers would welcome more support. What is the appropriate role of health systems in the quest for equity? What is the appropriate role of us as physician leaders? Of the ACCMA? We encourage you to join the conversation.

NOTE *References available upon request.

Corburn J, Curl S, Arredondo G. A health-in-all-policies approach addresses many of Richmond, California’s place-based hazards, stressors. Health Aff (Millwood). 2014 Nov;33(11):1905-13.

Corburn J, Curl S, Arredondo G, Malagon J. Making health equity planning work: A relational approach in Richmond, California. Journal of Planning Education and Research. 2015 Sep;35(3):265-81.

Farhang L, Morales X. Building Community Power to Achieve Health and Racial Equity: Principles to Guide Transformative Partnerships with Local Communities.

NAM Perspect. 2022 Jun 13;2022:10.31478/202206d.

Iton A, Ross RK, Tamber PS. Building Community Power To Dismantle Policy-

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PHYSICIAN WELLNESS

The Bay Area Physician Wellness Collaborative

S

ince the Bay Area Physician Wellness Collaborative (BAPWC) kicked off in June 2022, the group of wellness leaders from across the Bay Area have convened twice. Led by Program Director, Dr. Paul DeChant, the collaborative enjoyed robust discussions with guest speakers paving the way in physician wellbeing efforts.

THE ROLE OF A WELLNESS LEADER The September 2022 session of the BAPWC featured guest speaker Dr. Gaurava Agarwal, the Chief Wellness Executive for Northwestern Medicine. He is a psychiatrist with expertise in organizational and occupational psychiatry.

Dr. Agarwal addressed how to deal with cynical colleagues as an organization begins to approach wellness challenges. It is of utmost importance to engage colleagues at the individual or team level to determine their motivations, take the time to address the causes of “unwellness”, and work with leaders to create protected time dedicated to wellness efforts. By having leadership emphasize the importance of wellness and allowing time to be set aside, it aids in helping cynical colleagues overcome any perception challenges.

To that extent, ensuring support from senior leadership is critical when implementing wellness activities. Dr. Agarwal suggested finding a few senior leaders willing to be wellness champions and ensuring the benefits of the wellness work senior leaders are doing is then broadcast across the organization. Leaders should address smaller, nagging problems that may be viewed as quick wins. These might include things like ergonomics, call schedule burdens, or wastefulness in clinical and administrative workflows.

Dr. Agarwal closed with a few key reminders to members of the collaborative. Each person or team at your organization has different wellness needs and different definitions of wellness.

Finding out what those motivations are is critical in the organization’s success. Empowering local stakeholders and departments to make changes will result in happier employees. Having wellness changes only come from the wellness committee can send the wrong message. Instead, helping teams to try to make meaningful changes using evidence informed approaches has been shown to have lasting effects.

CREATING A CENTER FOR PHYSICIAN WELLBEING The November 2022 convening featured guest speaker Jen Barna, MD. She is a trained radiologist and entrepreneur in the physician wellbeing space. Dr. Barna addressed was how to create a Center or Committee for Physician Wellbeing (Cf PW) at your organization.

A Center for Physician Wellbeing is a place in your organization that provides wellbeing resources for physicians. Oversight of the Center depends on your organization, but there are some key characteristics of a successful Center. A Center for Physician Wellbeing should have organizational oversight by C-level leaders. Ideally, a Chief Wellness Officer runs the Center and reports directly to the CEO (although, most organizations are not organized this way). Further, the Board of Directors should be actively involved in the Center operations. Organization charts for a Center can vary based on the size and mix of issues in an organization. Dr. Barna emphasized ChristianaCare in Maryland/ Delaware is viewed as an optimal approach for how to organize a Center for Physician Wellbeing.

The Center can run professional development programs, regular facilitated team discussions, or advocacy programs to reduce stigma and increase psychological safety in the workplace.

Additionally, the Center can be a place to support physicians in times of stress or crisis through things like peer support programs, on-going support groups focused on unique circumstances, litigation support or Diversity, Equity, and Inclusion (DEI) resources.

Finally, Dr. Barna discussed the importance of tracking programs run through the Center to ensure the effectiveness of them.

She states that the key element of growth and resilient Cf PW programs included: tracking metrics, ongoing physician support, access to digital and web-based content, programs being anonymous and secure, evidence-based courses and coaching, and access to self-paced learning opportunities.

The Bay Area Physician Wellness Collaborative meets bimonthly, with our next convening on March 7th at 6 pm. If you are interested in learning more about the Collaborative, please contact ACCMA’s Director of Community Health, Meghan Arthurs, at marthurs@accma.org.

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HEALTH EQUITY (continued from page 18)

Based Structural Inequity In Population Health. Health Aff (Millwood). 2022 Dec;41(12):1763-1771.

Krieger N, Van Wye G, Huynh M, Waterman PD, Maduro G, Li W, Gwynn RC, Barbot O, Bassett MT. Structural Racism, Historical Redlining, and Risk of Preterm Birth in New York City, 2013-2017. Am J Public Health. 2020 Jul;110(7):1046-1053.

Mittmann H, Heinrich J, Levi J. Accountable Communities for Health: What We Are Learning from Recent Evaluations. NAM Perspectives. 2022 Oct 31.

PHYSICIANS

Nolan JES, Coker ES, Ward BR, Williamson YA, Harley KG. “Freedom to Breathe”: Youth Participatory Action Research (YPAR) to Investigate Air Pollution Inequities in Richmond, CA. Int J Environ Res Public Health. 2021 Jan 11;18(2):554.

Pastor M, Speer P, Gupta J, Han H, Ito J. Community Power and Health Equity: Closing the Gap between Scholarship and Practice. NAM Perspect. 2022 Jun 13;2022:10.31478/202206c.

NURSE PRACTITIONERS PHYSICIAN ASSISTANTS LOCUM TENENS PERMANENT PLACEMENT

Phillips S, Reid C, Cuff D, Wong K. The Future of Housing and Community Development: A California 100 Report on Policies and Future Scenarios.

Rigby E, Hatch ME. Incorporating Economic Policy Into A ‘Health-In-All-Policies’ Agenda. Health Aff (Millwood). 2016 Nov 1;35(11):2044-2052.

Wright BJ, Masters B, Heinrich J, Levi J, Linkins KW. Advancing Value and Equity in the Health System: The Case for Accountable Communities for Health.

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TELEHEALTH PRESCRIBING

Telehealth and Prescribing Controlled Substances By the Medical Insurance Exchange of California (MIEC)

I

n response to the COVID-19 outbreak and escalating pandemic, in January 2020 the U.S. Department of Health and Human Services (HHS) declared a federal public health emergency (PHE) that is still in effect today. The PHE declaration resulted in numerous waivers of federal laws and regulations impacting the practice of medicine, including telehealth, HIPAA, scope of practice, and Stark laws. The PHE also provides healthcare providers with COVID-related liability protections under the PREP Act. Simultaneously, many individual state medical boards instituted waivers around licensure requirements for out-of-state physicians when providing telehealth services during COVID; these waivers were generally tied to state public health emergency declarations.

Since 2020, HHS has reviewed and extended the federal PHE every three months. HHS also indicated that it would provide 60 days of formal notice before terminating the PHE; given the lack of such an announcement, expectations are that it will likely be extended again in October. Additionally, advocacy groups including the Federation of American Hospitals and the National Association of Chain Drug Stores have formally requested that HHS extend the PHE for at least another 6 months to allow facilities and providers more time to adjust to the expiration of federal waivers.

For physicians, one of the most prominent changes related to the PHE is the ability to utilize telehealth to evaluate and treat patients remotely, including through the prescription of controlled substances.

RYAN HAIGHT ACT While many states allow physicians to establish a physician-patient relationship through telehealth for the purposes of prescribing medications, federal law imposes additional requirements for controlled substances. Before prescribing controlled substances to new patients, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 typically requires prescribers to evaluate each patient through an in-person visit before prescribing and at least every 24 months thereafter, even if a patient has already been taking the controlled substance in question.

During the PHE, the in-person evaluation requirement imposed by the Ryan Haight Act was formally waived to allow physicians to use videoconferencing to perform the required

examinations initially and every 24 months when prescribing controlled substances.

This waiver has allowed medical practices to enroll new patients and treat them entirely via telehealth, including prescribing controlled substances. The overall effect has led to a 63-fold increase in telehealth visits since the pandemic, with 52.7 million Medicare telehealth encounters in 2020 alone. Many of these patients have been prescribed a controlled substance by a physician whom they have never met in person.

However, it is important to note that, once the PHE is over, the DEA will likely once again require in-person visits before prescribing controlled substances to new patients, and once every 24 months.

Of note, the Ryan Haight Act has some exceptions that do allow for telehealth prescribing.

Looking further into the requirements, the first two exceptions read as follows: 1. Treatment in a hospital or clinic. The practice of telemedicine is being conducted while the patient is being treated by, and physically located in, a hospital or clinic registered under section 303(f) of the Act (21 U.S.C. 823(f)) by a practitioner acting in the usual course of professional practice, who is acting in accordance with applicable State law, and who is registered under section 303(f) of the Act (21 U.S.C. 823(f)) in the State in which the patient is located, unless the practitioner: i. Is exempted from such registration in all States under section 302(d) of the Act (21 U.S.C. 822(d); or ii. Is an employee or contractor of the Department of Veterans Affairs who is acting in the scope of such employment or contract, and registered under section 303(f) of the Act (21 U.S.C. 823(f)) in any State or is utilizing the registration of a hospital or clinic operated by the Department of Veterans Affairs registered under section 303(f); 2. Treatment in the physical presence of a practitioner. The practice of telemedicine is being conducted while the patient is being treated by, and in the physical presence of, a practitioner acting in the usual course of professional practice, who is acting in accordance with applicable State law, and who is registered continued on page 22 ACCMA BULLETIN | JANUARY/FEBRUARY 2023

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TELEHEALTH PRESCRIBING (continued from page 21)

under section 303(f) of the Act (21 U.S.C. 823(f)) in the State in which the patient is located, unless the practitioner: i. Is exempted from such registration in all States under section 302(d) of the Act (21 U.S.C. 822(d)); or ii. Is an employee or contractor of the Department of Veterans Affairs who is acting in the scope of such employment or contract, and registered under section 303(f) of the Act (21 U.S.C. 823(f)) in any State or is using the registration of a hospital or clinic operated by the Department of Veterans Affairs registered under section 303(f); The references to 21 USC 823(f) refers to a law allowing the special registration for prescribing controlled substances over the internet, but it appears that this allows for a future process that has not yet been implemented by the DEA. Physicians looking to apply one of the exceptions under the Ryan Haight Act should be aware of the overall requirement of the Act, which is that controlled substances may only be prescribed for a “legitimate medical purpose issued within the usual course of professional practice.” This is intended to create a separate requirement to meet certain standards in prescribing a controlled substance. In other words, it means that simply performing a faceto-face evaluation (whether in person or by telehealth) doesn’t necessarily demonstrate compliance with the law if the medication was otherwise not appropriately indicated. This is another reason to approach compliance by trying to stay well within the requirements of the law, rather than attempting to apply exceptions.

An October 2020 statement from the DEA puts this concept into further perspective: “While the lack of an in-person medical evaluation has always been viewed as highly probative evidence that a prescription has been issued outside of the usual course of professional practice and for other than a legitimate medical purpose, the Act makes it unambiguous that it is a per se violation of the CSA (Controlled Substances Act) for a practitioner to issue a prescription for a controlled substance by means of the internet without having conducted at least one in-person medical evaluation, except in certain specified circumstances.

However, as Congress expressly stated under the Act, the mere fact that the prescribing practitioner conducted one in-person medical evaluation does not demonstrate that the prescription was issued for a legitimate medical purpose within the usual course of professional practice.

Even where the prescribing practitioner has complied with the requirement of at least one in-person medical evaluation, a prescription for a controlled substance must still satisfy the longstanding requirement of federal law that it must be issued for

22

a legitimate medical purpose by a practitioner acting in the usual course of professional practice.”

STANDARD OF CARE Importantly, physicians must not only practice within the bounds of federal and state law, but they must also treat patients in accordance with the applicable standard of care. During the pandemic, restricting unnecessary in-person visits was essential to controlling the spread of COVID, and standards of care adjusted to include telehealth visits as a specific COVID mitigation strategy, even in situations in which in-person care was previously required.

As the pandemic recedes and community public health measures increasingly control the spread of COVID, standards of care are adjusting back to require in-person care when appropriate.

Physicians are decreasingly able to rely on COVID mitigation as the sole reason to treat patients remotely. This effect is likely to be more significant in the setting of controlled substances, including benzodiazepines and opioids in particular. Thus, physicians should consider again requiring in-person visits for controlled substance patients, even if those who are on stable treatment regimens.

Physicians with telemedicine-only practices should consider how they can implement this into their practice, or how they will transition controlled substance management to another provider.

RECOMMENDATIONS Until or unless further information comes to light or there is a change in the law, MIEC recommends that all physicians who prescribe controlled substances implement in-person visits with the prescribing physician before the first controlled substance prescription, and every 24 months while the prescription is maintained. While federal law still allows for telehealth-only visits, physicians should start preparing for the anticipated changes in the law sometime in the next year and plan with patients accordingly. Patients who are unwilling or unable to be seen physically in the office should be given adequate time to transition their care to another physician. Advance planning and careful transition of care will save physicians from potentially having to choose between inappropriate prescribing and patient abandonment.

For patients who are on a controlled substance and have never been seen in person, physicians should make sure to schedule their 24-month follow-up and consider bringing them in sooner, if practical. Additionally, physicians should be aware of any state requirements to check the prescription monitoring database (PDMP) and changing standards of care around the management of specific controlled substance medications and be sure to follow them.

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COUNCIL REPORTS

NOVEMBER 3, 2022

The Council meeting was called to order by Doctor Robert Edelman, President (now Immediate Past President).

The Council received a presentation from Elizabeth McNeil, Vice President of Federal Government Relations at the CMA, regarding HR 8800, “Supporting Medicare Providers Act of 2022” (Bera, MD, D-CA/Bucshon, MD, R-IN), a bill to stop the 4.42% Medicare physician payment cuts caused by budget neutrality adjustments in the 2023 Medicare physician fee schedule. Ms. McNeil thanked the ACCMA for its grassroots support to advance the bill and requested that the ACCMA and its members continue to pressure Congress to approve the legislation before the end of the year. Ms. McNeil also reported on HR 3173 (Bera, MD, D-CA), a bill to streamline the Medicare Advantage health plan prior authorization process to allow patients to receive more timely access to care, which passed out of the House of Representatives.

Doctor Edelman introduced two members of the ACCMA staff: Meghan Arthurs was recently hired as Director of Community Health, and Alejandra Hinojosa was recently promoted to full time position as Communications and Marketing Manager. Doctor Edelman also announced that David Lopez was promoted to Director of Advocacy and Governance.

Doctor Soliman presented a plaque from the ACCMA Council to Doctor Edelman, commending his service as ACCMA President over the prior year. Doctor Edelman thanked the Council and offered some personal reflections about his experience as ACCMA President. The Council also expressed appreciation to Doctor Kwan for his service on the Council.

The Council was requested to make nominations for several vacancies on the ACCMA Council from District 1 (West Contra Costa), District 3 (Southwest Contra Costa), District 4 (East Contra Costa), District 8 (City of Alameda), District 9 (San Ramon/Danville), and District 10 (Oakland).

The Council considered a recommendation from the Membership and Communications Committee to cease tracking Medicare and Medi-Cal participation status among members. The Council approved the recommendation to remove the Medicare and Medi-Cal search criteria from the website search tool.

Doctor Dutta reported on the CMA Board of Trustees (BOT) meeting held prior to the House of Delegates (HOD) meeting. The main focuses included winding down of MICRA activities and an update on health information technology issues, which were also presented at HOD. The Council debriefed the HOD meeting. Members expressed concern about the management of the schedule and the need to ensure adequate time to debate the business of the House, utilizing less time for didactic lectures, ceremonial matters, and informational presentations.

The Council received information about recent legislative advocacy efforts, including: a summary of key health care bills that Governor Newsom signed into law; a copy of a letter ACCMA sent to local members of Congress advocating for the passage of HR 8800; and, a copy of a letter ACCMA sent to Governor Newsom urging a veto of AB 2236, a bill authorizing optometrists to perform several surgical procedures on a

patient’s eyes that require the use of a scalpel or an injection and “anterior segment lasers” without adequate training and education, which was subsequently vetoed. Members of the Council were also asked to save the date for 2023 Legislative Day, which will be held on Wednesday, April 19th.

The Council received information about the implementation of the ACCMA Success Plan. Mr. Greaves noted that ACCMA had recently conducted focus groups with physician members in group practice settings and was working with a communications consultant to revitalize ACCMA’s digital marketing and communications.

The Council received a report on ACCMA membership recruitment and retention efforts. As of September 30th, ACCMA membership was 113.9% higher than 2021.

Doctor Saba noted that Respiratory Syncytial Virus (RSV) Infection is spreading rapidly and much earlier in the season than previous years, which is overwhelming hospital emergency departments and taxing pediatricians in the community.

Physicians should continue to encourage COVID and flu vaccinations among all eligible patients to help ease the strain on the healthcare system and ensure adequate capacity to manage the influx of RSV patients.

There being no further business the meeting was adjourned.

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