California Family Physician (Summer 2012)

California

FAMILY PHYSICIAN Vol . 6 3 No.3 Sum mer 2 012

What does the health benefit exchange mean for family physicians?

14

Exchange presents golden opportunity to promote PCMH

16

How will the exchange affect california?

18

think you can explain the essential health benefits?

20

2012 Award Winners

.........

23-24

Bo Greaves, MD (left) is the 2012 Family Physician of the Year and J. Dennis Mull, MD is the recipient of the 2012 Barbara Harris Award for Educational Excellence.

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Susan Hogeland, CAE

Cody Mitcheltree

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President-Elect Mark Dressner, MD

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Vice-Speaker Jay Lee, MD, MPH

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Callie Langton, PhD

Shelly Rodrigues, CAE, FACEHP

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Michelle Quiogue, MD, Editor Communications Committee: Michelle Quiogue, MD, Chair

AAFP Delegates Jack Chou, MD Carla Kakutani, MD

• Julia Blank, MD • Nathan Hitzeman, MD

AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD

The California Family Physician (CFP) is published quarterly by the California Academy of Family Physicians (CAFP).

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CMA Delegation Steve Green, MD Nathan Hitzeman, MD Carla Kakutani, MD Kevin Rossi, MD Patricia Samuelson, MD Ashby Wolfe, MD, MPH

Correction: In the spring 2011 issue of California Family Physician (Vol. 63, No. 2), Page 26 featured an article on “How Physicians and Nurses Can Collaborate in Team-Based Care” by Heather M. Young, PhD. The article was actually written by both Heather M. Young, PhD, RN and Casey R. Shillam, PhD, RN-BC. Dr. Shillam’s photo was also added to the article, but not Dr. Young’s. CAFP apologizes to Drs. Shillam and Young for this error.

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T h e C a l i f o r n i a H e a lt h B e n e f i t E x c h a n g e 14 Political Pulse

What Does the Health Benefit Exchange Mean for Family Physicians?

Tom Riley

16 The Exchange Presents a Golden Opportunity to Promote PCMH

Leah Newkirk

18 What Does the Exchange Mean For California?

David Panush

20 Think You Can Explain the Essential Health Benefits?

Leah Newkirk

23 2012 Family Physician of the Year: Bo Greaves, MD 24 2012 Award for Educational Excellence in Honor of Barbara Harris: Dennis Mull, MD, MPH 26 2012 CAFP Residents of the Year: Alisha Dyer, DO, Charlene Hauser, MD, MPH and Randi Sokol, MD, MPH

6 Editorial

Family Medicine Revolution Helps Save Residency Program

7 President’s Message

Enthusiasm for Family Medicine’s Future Remains Strong

8 Student News

Five Reasons to Attend the AAFP National Conference?

9 Resident News

FFFM Continues to Empower High School Students

Michelle Quiogue, MD Steve Green, MD Yemi Ajirotutu Randi Sokol, MD, MPH

10 News In Brief 12 In The Spotlight

With the Summer Olympics on the Horizon, Cindy J. Chang, MD is Ready for the World

Chris Navalta

30 Executive Vice Presidents Forum

HBEX Is Here to Stay – PPACA or No PPACA

Susan Hogeland, CAE

For the upcoming CME calendar go to www.familydocs.org California Family Physician Summer 2012 5

editorial

Michelle Quiogue, MD

Family Medicine Revolution Helps Save Residency Program The Family Medicine Revolution is catching fire.

Once separated by geography, our voices are coalescing into a coherent rally cry much like small wild fires finding and feeding off one another. Our fight, for broader recognition and fair valuation of primary care services, has already entered the mainstream conversation. In April, CAFP Vice Speaker Jay Lee, MD’s Twitter hash tag #FMRevolution caught the attention of Forbes Magazine’s health care contributor, who went on to quote AAFP past president Ted Epperly, MD.1 The #FMRevolution, now amplified across borders real and imagined, began simply as the idea of two residents who wanted to sell family medicine revolution t-shirts at a CAFP meeting. Family medicine not only attracts media attention, but also the attention of increasing numbers of medical students who look forward to careers in our specialty.

See what medical students and residents are saying these days about their passion for family medicine, and why they’re choosing our specialty, on the AAFP FMIG website (www.fmignet.aafp. org. 2) This is just one example of how something small grew into an unstoppable force.

I witnessed this force firsthand. When the Kern Medical Center (KMC) family medicine residency program was threatened with closure just days before Match Day, my community spoke up to support family medicine. I learned about the breaking news when fellow CAFP member Tiffany Pierce MD posted her disappointment about the decision on Facebook. Within days, our CAFP leaders, Immediate Past President Carol Havens, MD and Associate Director of Health Care Workforce Policy Callie Langton, PhD, in cooperation with CAFP media consultant Catherine Direen, responded forcefully and strategically. The news roused the attention of my local CAFP chapter members, who met in substantial numbers for the first time in years to plan our objectives and talking points for the meeting of the Kern County Board of Supervisors, whose members held the fate of the residency program in their hands. Because of the media attention, attendance at this meeting overflowed into the hallway. Even though Supervisors limited each person’s comments to just two minutes, the community’s testimony lasted for more than two hours. Obviously, family physicians were not the only ones to argue against the hospital administration’s decision.

The most moving testimony came from patients and from KMC residents such as CAFP member Maryam Yazdanshenas, MD.

6 California Family Physician Summer 2012

The testimony that meant the most to me, however, came from people such as a community nephrologist who spoke of the importance of primary care in reducing preventable causes of dialysis, a KMC urologist who talked about the hospital’s dependence on family medicine residents to take calls in multiple departments, an internal medicine resident who countered the CEO’s stated plan to use internet mecdicine residents to replace the family medicine residents by stating he was not trained to do the same work as family medicine residents, and an economic development leader who warned of the financial impact to the local economy should KMC close its family medicine residency program. At the end of the testimony, the Kern County Board of Supervisors unanimously voted to direct the hospital to fill its six PGY1 spots. Since it was too late to enter the Match, the program was forced to wait until The Match’s completion. When the Match ended that Friday afternoon, thousands of calls flooded KMC and the program director, CAFP member David Moore MD, filled all six positions.

This experience taught me two lessons. First, family physicians are no longer alone in this fight. Second, all family physicians and all of our communities benefit from the dedicated and professional work of our Academy. Each issue of California Family Physician highlights the work of our Academy’s staff of professionals who work fulltime to protect our interests and to advance our cause so that we can keep our day jobs. I know that my community is indebted to the rapid and forceful response of the CAFP leadership to the threatened closure of Kern County’s only local source of primary care physicians. In this issue, I hope you will see more examples of how forward-reaching and vital the Academy’s work is for the survival and growth of our specialty.

Together, we can broadcast the value of comprehensive primary care and embed our values in future health policy. Now is a good time to be a family physician. Thank you for your continued membership – your individual investment in the Family Medicine Revolution.

1. http://www.forbes.com/sites/davechase/2012/04/28/primary-care-spring-unleashed-by-ibm/ 2. http://fmignet.aafp.org/online/fmig/index/resources/ fammedvideo.html.

president’s message

Steve Green, MD

Enthusiasm for Family Medicine’s Future Remains Strong

CAFP’s Annual Scientific Assembly (ASA) in Indian

changing over from paper charts. It was important that these concerns were heard and addressed. I got some hard questions from a few attendees. Some wanted to know why the Academy was supporting the move to EHRs when it could be costly and difficult for some practices. Realistically, some of the major elements of PCMH will require use of an EHR. Using registries to contact patients who are due for their mammograms or colon cancer screening or are late for their diabetes check will be nearly impossible without an EHR. CAFP has an online resource center dedicated to this topic Within minutes of sitting back while listening to (www.familydocs.org/pcmh.php) to help our members Dr. Stream’s keynote address, I noticed something understand PCMH transformation and EHRs. The energy new. CAFP members were coming up to me to share of the docs at the ASA their thoughts on what convinced me we will be was going on in family able to do what is needed medicine and what CAFP to successfully transform was doing. I was struck “CAFP members were coming our practices. by their enthusiasm and energy. It was clear to me up to me to share their It was also inspiring to that family medicine and thoughts on what was going see the level of resident its role in the future of participation at the health care was genuinely on in family medicine and meeting. They were important to them. engaged throughout the what CAFP was doing. I was ASA, especially during the The Patient Centered “Battle of the Residents.”

Medical Home (PCMH) struck by their enthusiasm and Congratulations to the was a real priority. From energy. It was clear to me that residents of Long Beach residents to docs who Memorial, who were had been in practice for family medicine and its role in again victorious. The decades, they knew a “Diabetes: The Musical” transformation in how the future of health care was performance by the Santa we delivered care was Rosa residents reassured coming and there was genuinely important to them.” me the pipeline of future excitement about it. They family physicians is secure. also seemed realistic Overall, it was great seeing that the transformation so many members who to PCMH would not be were enthusiastic about strengthening family medicine easy. Any change is hard, but changing fundamental things about how our practices work is both exciting and for the future. a bit scary. For those not already using an electronic By the way, when I got home, I found my President’s Pin health record (EHR), the change will be monumental. safely tucked into my briefcase … where I had put it so I Not everyone at the ASA agreed that EHRs were a good thing. There were concerns about implementation wouldn’t lose it. I’m looking forward to an exciting year! costs as well as how productivity will be affected by Wells this past April was a great experience. It started with AAFP President Glen Stream, MD introducing Carol Havens, MD, CAFP’s Outgoing President. After Dr. Havens addressed the ASA crowd, she ceremonially put my President’s Pin on my coat lapel. Actually, it was her pin, since I’d managed to misplace mine prior to the meeting. Dr. Stream then swore me in, making things official.

California Family Physician Summer 2012 7

STUDENT NEWS

Yemi Ajirotutu

Five Reasons to Attend the AAFP National Conference As one of the newly appointed Family Medicine Interest Group (FMIG) Coordinators for the David Geffen School of Medicine in the spring of 2011, I was anticipating an eventful year of promoting and learning more about family medicine through workshop planning, networking, and service in the community. In addition, I was excited for the National Conference of Family Medicine Residents and Medical Students in Kansas City, MO at the end of July. CAFP provides scholarships to firsttime conference attendees, and I was selected as one of the recipients. I was looking forward to networking with other FMIG leadership, attending the CAFP reception, receiving the Program of Excellence Award for our FMIG, visiting the highly regarded residency fair and traveling to Kansas City for the first time, among many other things.

The weekend came and went, and I had an absolutely wonderful experience at the conference – one that only strengthened my interest in family medicine. The various aspects of the conference I enjoyed most include: No. 5: Kansas City The downtown area of Kansas City was a pleasant surprise! From the delicious barbeque to the spirited nightlife of the Power and Light district in the heart of downtown, Kansas City is a great host city and offers many attractions outside of the conference.

No. 4: Networking with Students at the FMIG Breakfast The conversation and collaboration between FMIG students over an early breakfast was great. The event was a helpful way to share ideas for the academic year.

other medical students, residents, residency program and fellowship program directors and various physicians from across the state. This informal event was an excellent opportunity to establish helpful contacts for FMIG events during the year.

No. 1: The Residency Program Exhibit Fair The exhibit hall featured rows and rows of residency programs from around the country. Many booths featured enthusiastic residents and highlighted characteristics that made their programs unique. This was another excellent opportunity to establish helpful contacts with residency programs for future FMIG events.

The National Conference of Family Medicine Residents and Medical Students was an amazing event. I urge all those who have never experienced the conference to attend. Especially if you have a leadership role in an FMIG or have even the slightest interest in family medicine. You will not regret attending the conference. With so much to offer, the conference is an excellent resource to explore family medicine, gain useful tools to run a successful FMIG for the year, and engage with dynamic leaders in the field of family medicine.

If you are interested in attending this year’s conference (July 26-28), contact CAFP Student and Resident Affairs Coordinator Cody Mitcheltree at cmitcheltree@familydocs.org.

Yemi Ajiroutu is a fourth-year student at the David Geffen School of Medicine at UCLA.

No. 3: Spending Time with the People Who You Traveled With to the Conference Whether it’s your fellow classmates or board members for your school’s FMIG, the conference was a wonderful opportunity to spend time with peers while exploring the conference and the city. The weekend was an excellent preview of experiences that came during the year as we continued to work with one another learning about how to champion family medicine.

No. 2: The CAFP Reception This was an excellent opportunity to hear from CAFP. In a very intimate setting, we had the opportunity to meet The residency fair at the AAFP National Conference is a great opportunity for students to meet with residency programs from across the country.

8 California Family Physician Summer 2012

resident news

Randi Sokol, MD, MPH

FFFM Continues to Empower High School Students Mentoring is truly a selfless act. We give our time, hopefully, to inspire the next generation. At the same time, we reap the rewards of watching others grow and thrive over time.

The Future Faces of Family Medicine Program (FFFM), which completed its second year, hopes to inspire high school students to pursue careers in family medicine. It is a pipeline program aimed at closing our current primary care workforce gap, but it is also a mentorship program.

This year, 50 Sacramento High School students applied for 20 spots in the program. Residents from both UC Davis and Sutter Sacramento led seven in-class sessions with the students on topics such as “What is Primary Care,” “The Basic Physical Exam,” suturing and OB delivery workshops. The OB delivery workshop was particularly wellreceived.

“The experience was wonderful,” Sac High School junior Zemeka Ware-Smith said. “I learned that natural birth is a very emotional yet beautiful process. It was nothing like I’d ever imagined it would be, not like the ‘Teen Mom’ show (on MTV) or anything.”

Twenty students from Sacramento High School completed the Future Faces of Family Medicine program in April.

Sessions also included getting certified in CPR, touring the UC Davis Virtual Care Center, shadowing family medicine Residents in an underserved health clinic and listening to a panel of family medicine residents share their own journeys. The students also had workshops on professionalism and career development.

development skills to get started. At the conclusion of the four-month program, students were partnered with local family physicians who mentor the students over the next year, offering them a true taste of family medicine in practice.

Patricia Samuelson, MD, a graduate of Sacramento High, explained why she decided to get involved in the program. “I decided to mentor because I love family medicine and I know that many students would love it too,” she said. “Unfortunately, at major tertiary centers, family medicine is often pushed aside or not taught at all. By the time students have a chance to see a fully functioning family practice, they have made up their minds to do something else, as likely or not based on what they saw on TV.” At graduation this past April, mentors met with students to exchange contact information so they can set up follow-up visits. Students initially appeared intimidated as they introduced themselves to a large circle among respected community doctors, several stuttering along the way. But after an hour of games and discussion, a foundation for lasting relationships had been laid.

As students leave the program, we hope they will follow up with their mentors in clinic. We hope they will be inspired to pursue meaningful careers – even if they are not in family medicine; we hope they will follow their hopes and dreams and feel inspired and encouraged by those who care.

CAFP Foundation plans to track these students over time to see how their careers unfold. FFFM will also expand to three other sites next year, while the current site will support recurring classes.

As the founders of FFFM, Charlene Hauser, MD, MPH, Alisha Dyer, DO and I are in awe of how this program has grown and of the positive feedback we’ve received from all those involved: the students, residents and mentors. For the program to continue to flourish, however, family physicians must continue to play a role.

Even if you are not involved in FFFM, I encourage you to be a mentor – to a high school student, an undergrad or a medical student. Think about the people who helped you be where you are today. Be THAT person. Though it is an additional time commitment, there is no doubt that you will reap the benefits immensely!

Sacramento High School career counselor David Marks said students normally don’t consider careers in medicine. Because our students come from low-income, urban households, their ideas for future careers are often limited to those that they have become the most familiar with in their daily lives: social workers, therapists, criminologists, celebrities, or nurses,” he said.

If you are interested in learning how to bring a program like FFFM to your residency or community, contact CAFP Associate Director of Health Care Workforce Policy Callie Langton, PhD at clangton@familydocs.org. CAFP Foundation has a pre-made tool kit that will help you with implementation and can help support you along the way.

FFFM hopes to show students that a career as a physician is indeed a possibility if they work hard, and it teaches them the necessary career

Randi Sokol, MD, MPH is a fourth-year resident at UC Davis Health System in Sacramento.

California Family Physician Summer 2012 9

news in brief CAFP Member Elected 2013 Minority Co-Convener

CAFP congratulates newly-elected 2013 Minority Co-Convener MarieElizabeth Ramas, MD. Dr. Ramas is medical director of Mercy Community Health Center, a rural health center in Mt. Shasta. During the AAFP National Conference of Special Constituencies (NCSC) on May 3-5 in Kansas City, Dr. Ramas was elected to serve as Minority Co-Convener for the 2013 NCSC and was also elected as an alternate delegate to the 2012 AAFP Congress of Delegates in Philadelphia. She spoke passionately of her own patient experience as a child and how it fueled her commitment for effecting change. Dr. Ramas’ perspective as a mother, wife and physician resounded well with the chapter representatives, her message was “this is our home and the time to make a difference is now.” Congratulations, Dr. Ramas, for a job well done!

CAFP Board Welcomes New Directors

The changing of the guard – new directors for old (or, rather, seasoned) – took place at the conclusion of the Board of Directors meeting on April 20. True to tradition, it happened prior to the start of the Annual Scientific Assembly in Indian Wells. Outgoing president Carol Havens, MD passed the gavel to incoming president Steve Green, MD at the Celebration Dinner and everyone welcomed president-elect Mark Dressner, MD was welcomed.

CAFP also welcomed its new directors and alternate directors: District V, Tae-Woong Im and Jean-Claude Hage; District VI, Joan Rubenstein; District VII, Jeannine Rodems and Sumana Reddy; New Physician, Lisa Ward; Rural Physician, Veronica Jordan.

10 California Family Physician Summer 2012

New student and resident directors have not yet been announced.

The Academy would like to send a special thanks to outgoing directors: District V, Lauren Simon; District VI, Adriana Padilla; District VII, Sumana Reddy, who was also honored for her service as chair of the Medical Practice Affairs Committee; New Physician, Jay Won Lee; resident director, Alisha Dyer; co-student directors Edwin Kwon and Erica Brode.

Longtime Educator Sue Melvin, DO Named Chief Medical Officer at Long Beach Memorial

CAFP member Susan Melvin, DO, FAAFP, a prominent figure in family medicine, medical leadership and physician education and training, was named the Chief Medical Officer at Long Beach Memorial last week.

In 2008, the CAFP Foundation awarded Dr. Melvin the Barbara Harris Award for Educational Excellence. Dr. Melvin will partner with physician leadership at Long Beach Memorial to advance the medical staff and advocate for patients.

She will serve as the bridge between the 1,200-member medical staff and management — fulfilling the vision of communication, education, collaboration and overall quality of care provided by the hospital. Congratulations, Dr. Melvin!

Physicians are concerned about their ability to comply with the ICD-10 code sets even with the new date. To prepare your practice for ICD-10 implementation, visit CAFP’s online Coding and Billing Strategies page or contact CAFP Manager of Medical Practice Affairs Jane Cho at 415-345-8667.

CAFP Well Represented at AAFP Family Medicine Congressional Conference

Seven CAFP members and Executive Vice President Susan Hogeland, CAE traveled to Washington, DC May 15-16 to attend an all-day issues briefing by the AAFP and another day of meetings on Capitol Hill with key California congressional members and senators. Team CAFP, who committed their precious volunteer time to advocate for Medicare payment reform, support of primary care graduate medical education, and sustained funding of key programs in primary care, including Title VII Health Professions programs and the National Health Service Corps, included: emcee Carla Kakutani, MD; AAFP Commission on Governmental Advocacy Chair; Robert Bourne, MD; Kevin Rossi, MD; CAFP Legislative Affairs Committee chair Ashby Wolfe, MD and John Young, MD. Resident Christina Chavez-Johnson, MD received an AAFP scholarship from the Association of Family Medicine Residency Directors to attend. The Academy extends its thanks and appreciation to all.

HHS Proposes One-Year Delay of ICD-10 Compliance Date – October 1, 2014

The Department of Health and Human Services (HHS) published a proposed rule that pushes the compliance date for ICD-10 to October 1, 2014, a year beyond the current compliance date.

To view a brief history of the ICD-10 compliance and implementation issue, see the Centers for Medicare and Medicaid Services’ statement about the final rule on its website www.hhs.gov.

(from left to right): John Young, MD; Christina ChavezJohnson, MD; and Robert Bourne, MD.

Emerging Science. Expanding Knowledge. Enhancing Patient Care.™

Upcoming 2012 Fall Programs Credits may vary per program. Please refer to PrimaryCareEd.com/cafp.htm for specific location information.

Who Should Attend: All primary care clinicians (physicians, physician assistants, and nurse practitioners) who are active in patient care.

Atlanta, GA October 5 -6

Las Vegas, NV October 5 -6

Chicago, IL November 16-17

Dearborn, MI November 2-3

Anaheim, CA Nov 30 - Dec 1

Register online at: www.PrimaryCareEd.com/cafp.htm REGISTRATION FEE – $35 per attendee

Seating is Limited! Reserve Your Seat Today !

Primary Care Network program attendees are eligible for discounted room rates. Rooms are limited so make your reservations early!

Visit website for more information and to make a reservation.California Family Physician Summer 2012

11

In the spotlight

With the Summer Olympics on the Horizon, Cindy J. Chang, MD is Ready for the World While all of the athletes representing the Red, White and Blue prepare to take on the world at the 2012 Summer Olympics in London later this month, CAFP member Cindy J. Chang, MD is preparing her medical team to provide medical care for those athletes.

Dr. Chang, an Academy member since 1993, will serve as Team USA’s Chief Medical Officer and will oversee a team of more than 80 physicians, chiropractors, athletic trainers, physical therapists and massage therapists. The majority will be based at the Olympic Village and prepared to provide care for some of the best athletes in the world.

“I’m very proud of my family medicine training,” said Dr. Chang, who trained at UCLA and currently works at the UC Berkeley campus health center. “In family medicine, you get broad-based training in everything. So now when I see an athlete, and I’m dealing with a musculoskeletal issue, I am also feel very comfortable in dealing with a cardiac issue or a gynecological issue. If it’s a younger athlete, I would be dealing with more of a pediatric issue. And certainly the emotional issue is there as well. The psychiatric training that we get is very helpful because of the psychological challenges athletes face when they get injured.”

After residency, Dr. Chang pursued a fellowship in sports medicine at Ohio State University. After her fellowship, she began volunteering with the US Olympic Committee (USOC) in 1996 as a team physician at the US Olympic Training Center in Colorado Springs.

She was a member of the US staff at the 1998 Nagano and 2002 Salt Lake City Paralympic Winter Games and eventually served as Chief Medical Officer at the 2007 Rio Parapan American Games and 2008 Beijing Paralympic Games. She was the head team physician at UC Berkeley from 1995 to 2008.

Dr. Chang says thanks to a family medicine background, she is able to provide the best care to not only the patients in

12 California Family Physician Spring 2012

her community, but the best athletes in the world as well.

“I definitely think a good emphasis in family medicine training helps in developing that good doctor-patient relationship,” she said. “That’s a large part of what we do in terms of working with families and relating to people of all ages. You have to have a good understanding about the challenges every one of your patients will face when you work with them as a family physician. So I believe that aspect of training in family medicine helped me in my role with the US Olympic Team.”

Dr. Chang is also active in the state and local community. She has been

In the spotlight

part of the California Interscholastic Federation’s health and safety committee since 1997 With the committee, she addresses sports-related issues that affect high school athletes. She also helps educate other primary care physicians on the right approach for clearing concussed athletes to resume playing.

She explains, “(As a physician), if you’re expected to clear someone back to activity, it’s important that you are knowledgeable about the literature about concussions.”

Despite the busy schedule, Dr. Chang maintains a healthy work-life balance. She’s a wife and mother of two and enjoys most of her weekends and evenings with her family.

Although she will be tied up throughout the Olympics, she is excited about returning home to serve her community. She also believes the future of family medicine is a bright one and says more medical students should be exposed to the specialty to really appreciate its impact on patients.

“Medical students should try and pursue opportunities where they can observe family physicians who are in practice in a multitude of different settings,” she said. “Family physicians can meet the needs of more than 90 percent of the medical population with our diverse training and knowledge of a wide range of illnesses and injuries,” she added. “When I was a medical student and wanted to go into family medicine, someone told me that I was going to be a jackof-all-trades, but a master-of-none. And a family physician is the ideal personal physician. When someone goes to see several specialists for their health care issues, with no one to put it all together, it can often result in fragmented care.

Individual diseases are being treated, instead of the whole person.”

The Opening Ceremony of the London 2012 Olympic Games is on July 27, 2012.

Photos and Story by Chris Navalta. Photos: Cindy J. Chang, M and patient, K.C. Farrell.

Note: Chris Navalta, CAFP’s Manager of Communications left the Academy in May to join the staff at Graham and Associates. We wish him good luck in his endeavors.

California Family Physician Summer 2012 13

Tom Riley

political pulse

What Does the Health Benefit Exchange Mean for Family Physicians?

While the Patient Protection and Affordable Care Act (PPACA) guarantees that no person can be denied health care due to a preexisting condition, the state’s Health Benefit Exchange program (HBEX), created by the PPACA, will help ensure that Californians don’t miss out on coverage because it is too complicated or unaffordable.

To most patients, the HBEX will be a website that provides a grid of easy-to-read and comparable information on health plans and benefit options. It will include a calculator for applicants to compare costs across plan options and a web-based eligibility tool to help link individuals to available health coverage options. It has the potential to increase competition among health plans, thereby lowering premiums and standardizing health insurance coverage. This means starting January 2014, nearly five million of California’s seven million uninsured who now receive episodic health care or no care at all will have insurance coverage for primary and preventive care services.

Will this make your job as a family physician more or less rational and fulfilling? The answer is both: More because care will shift from triage to prevention; less because like Massachusetts, where demand for primary care services skyrocketed in the wake of its 2006 health care reform law, primary care physicians in California are likely to be overwhelmed by new demand. We have neither an adequate health care workforce nor the primary care infrastructure to meet the increased demands of this breathtaking expansion.

Without increasing the primary care physician workforce and reengineering the way care is delivered, there are simply not enough of you to meet the increased demand. That’s why CAFP’s legislative advocacy work in Sacramento has focused on anticipating the primary care workforce needs and delivery system reforms needed by enrollees in the HBEX and all patients in California.

CAFP’s sponsored SB 393 (Hernandez), for example, would help California’s existing primary care workforce to go farther and in a more patient-centric fashion by creating the Patient-Centered Medical Home Act. The

14 California Family Physician Summer 2012

bill defines the medical home as a health care delivery model in which a patient establishes an ongoing relationship with a physician or other provider who would work in a physician-directed team to provide comprehensive, accessible and continuous, evidence-based primary and preventative care, and to coordinate the patient’s needs across the health care system in order to improve quality and health outcomes in a cost-effective manner.

As a founding member of the Health Exchange Advocacy and Responsibility Team (HEART) coalition, CAFP has also advocated for team-based care within the HBEX. As with the PCMH, CAFP supports the concept of a physician-directed team in which each member works at the top of his or her professional license to ensure that California’s limited primary care workforce can be effective and efficient at meeting the HBEX’s demands.

While much of the current debate is over what essential benefits will be offered in the HBEX, the HEART Coalition has focused on how those essential benefits will be delivered most effectively.

CAFP and the California Medical Association are also cosponsoring SB 1416 (Rubio), a bill to create a Graduate Medical Education (GME) Trust Fund to support grants to medical residency training programs for the creation of new primary care residency positions. According to a 2009 report commissioned by the California HealthCare Foundation, there were 69,460 practicing DO and MD physicians in California and 24,124 (or 35 percent) of these reported practicing in primary care. This translates to a ratio of 63 primary care physicians per 100,000 population, a ratio that is dangerously close to falling below the Council on Graduate Medical Education’s recommended range of 60 to 80 primary care physicians per 100,000. The Office of Statewide Health Planning and Development estimates that only 16 of California’s 58 counties have an adequate supply of primary care physicians. SB 1416 is an effort to increase California’s residency positions particularly in areas of the state where they are most needed.

Funding new residency positions and placing the patient at the center of the health care delivery team will not, in

themselves, make primary care fulfilling. For this, primary care physicians and the PCMHs they lead must be reasonably compensated. While some analysts believe primary care incentives built into the PPACA will naturally create demand for primary care once HBEX enrollment begins, CAFP advocacy efforts in Sacramento don’t rely on this. Instead, we’ve focused our 2012-13 state budget efforts on seeing that key components of California’s fragile primary care infrastructure are not dismantled at the very time we are ramping up for 2014. This includes: • Opposing rate cuts to the Healthy Families Program • Opposing limits to the number of visits that a Medi-Cal patient may have with his or her physician annually (and then “backing out” the actuarial value of these from capitated contracts) • Opposing a proposal by Governor Brown to change the Prospective Payment System formula for California’s federally qualified and rural clinics • Opposing cuts to Medi-Cal payment and services • Opposing a proposal by Governor Brown to transfer nearly one million children in the Healthy Families Program into the MediCal program

With your support, CAFP’s advocacy efforts will help ensure the answer to those questions are positive for patients and family physicians. Go to CAFP’s website (www. familydocs.org/advocacy/get-involved.php) to find out how you can help.

Tom Riley is CAFP’s Director of Government Relations.

Even with the Supreme Court’s PPACA decision behind us, there is much we do not know about the future of the HBEX: How adequately will plans within the HBEX pay for primary care services? Will the explosion in California’s small group and individual health insurance markets, sparked by the HBEX, create more consumer flexibility, and what will this mean for family physicians? Will more consumer options mean more patient risk sharing (i.e., co-payments or coinsurance) and, if so, will this turn the physician’s office into the bill collector or rule enforcer? Will the state make good on its promise to create a seamless, one-stop approach to the HBEX, Medi-Cal (regardless of the extent to which it is combined with the Exchange) and array of other state and federal programs?

California Family Physician Summer 2012 15

T h e C a l i f o r n i a H e a lt h B e n e f i t E x c h a n g e

The Exchange Presents a Golden Opportunity to Promote PCMH

By Leah Newkirk

The California Health Benefits Exchange presents an opportunity to drive large-scale improvement in health care. If well-designed, the Exchange will ensure that Californians eligible for federally-authorized tax credits and subsidies get those benefits, increasing the number of insured Californians. The Exchange will make it easier for individuals and small businesses to select insurance by making comprehensive information about health plans available, including information regarding price, quality and service of health coverage. The Exchange will also enhance competition among health plans and give the state a means to incentivize innovation in health plan products. The Patient Centered Medical Home (PCMH) is just the type of innovation the state should promote on the Exchange.

Getting PCMH on the Exchange may not be easy to operationalize. Insurance products historically have been based on payment for discreet benefits or capitated payment for managed care. The pillars of PCMH – a whole person orientation, coordination of care across the health care system, care that is facilitated by health information technology and clinical decision-support tools, and enhanced access to care available through systems such as open scheduling and expanded hours – are not historically considered health benefits and should be distinguished from managed care. Health plans are changing their approach, however, and creating PCMH insurance products. Early this year, WellPoint and Aetna announced the launch of medical home programs and corresponding financial incentives for primary care physicians who function as medical homes.

The California Exchange Board needs to persuade these insurers to move their PCMH products onto the Exchange and other insurers to join them.

There is movement in this direction. The Exchange Board’s Guidelines for Selection and Oversight of Quali-

16 California Family Physician Summer 2012

fied Health Plans and the Development of the Small Employer Health Options Program propose to take into account “… how Exchange policies can expand primary care access over the medium to long term, including through innovations in care delivery….” The Board wants the Exchange to be “a catalyst for delivery system reform” by “fostering improvements in care delivery; measuring provider payment and contracting; promoting evidence-based care that meets the needs of the patient; supporting effective use of health information technology; and making care affordable.”

The Office of Personnel Management (OPM), the branch of the federal government that manages federal employees, has also recently linked PCMH to the state exchanges. The OPM is charged by the Patient Protection and Affordable Care Act with contracting with health insurers to offer at least two multi-state qualified health plans through each exchange in each State. With more than eight million beneficiaries and contracts with 91 insurance carriers, the OPM is an influential contractor. Annually, the OPM issues a request for benefit and rate proposals from carriers for its beneficiaries. This year, that request called for proposals to increase OPM beneficiaries’ access to primary care providers who have adopted the principles of the medical home and required all plans to submit data on the percentage of in-network primary care practitioners who are recognized as medical homes at the start of the plan year.

Inevitably, the California Health Insurance Exchange Board will consider the example of the OPM. By joining the OPM, WellPoint and Aetna in embracing the PCMH model and encouraging plans to make an investment in coordinated, team-based care that is proven to save costs and improve quality, the Exchange Board could transform the delivery of care in California. CAFP, a founding member of the Healthcare Exchange Advocacy and Responsibility Team (HEART) and a participant in Health Benefit Exchange Eligibility and Enrollment Stakeholders groups, will make sure they do.

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California Family Physician Summer 2012 17

T h e C a l i f o r n i a H e a lt h B e n e f i t E x c h a n g e

What Does the Exchange Mean For California? insurance into programs that will offer affordable health coverage. This is an enormous challenge in a state as large and diverse as California. Family physicians and other health providers will be keystones in both the outreach and enrollment process as well as the successful delivery of health care services for the new individuals who have coverage.

As the “keystones” that you mention, how can family physicians (and other health care providers) help in letting patients know about this coverage availability?

The Exchange is working in collaboration with the Department of Health Care Services and the Major Risk Medical Insurance Board on plans for our outreach and navigator programs. It is our hope that family physicians will participate in these efforts to provide information to their patients about all of their options.

As mentioned in Political Pulse, the California Health Benefit Exchange (HBEX) program, created by the Patient Protection and Affordable Care Act, will help ensure that insured Californians don’t miss out on coverage because it is too complicated or unaffordable. To further explain what the exchange means for California and its family physicians, California Family Physician caught up with Exchange Director of Government Relations David Panush and asked him what the Exchange means for those affected.

What does the Health Benefits Exchange Program mean to California Providers?

The passage of the Affordable Care Act will result in the most significant reforms to the health care system since the passage of Medicaid and Medicare more than 40 years ago. We’ve already seen the benefits of significant reforms that have included the enactment of a new method to provide insurance coverage for individuals with pre-existing conditions, the extension of coverage to dependents who are under 26 years of age and new consumer protections that limit how much insurance companies pay for their own administrative costs.

Beginning October 2013, we will begin the task of enrolling nearly three million individuals who currently don’t have

18 California Family Physician Summer 2012

We also want to enlist the support of trusted individuals such as family physicians in fostering a new culture of coverage. We will be working with family physicians and other providers to ensure that they have the tools and information they need to help enroll eligible Californians.

Can you talk about the “No Wrong Door” philosophy?

How does adopting the philosophy enhance having this opportunity for patients?

One of the requirements of the Affordable Care Act is that states create a seamless web-based eligibility and enrollment portal that would inform patients of all their options, including what programs they might be eligible for, what level of federal assistance they are entitled to, etc. We are building a system that hopes to provide a first-class consumer experience for Californians to provide this information and service in a seamless, simple and expedient manner. We would expect that the “No Wrong Door” philosophy would mean Californians could use this web portal from their own homes, a community-based organization, physician office or any location that best fits their needs. The “No Wrong Door” philosophy is central to our effort to enroll as many Californians as we can – quickly and easily.

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T h e C a l i f o r n i a H e a lt h B e n e f i t E x c h a n g e

Think You Can Explain the Essential Health Benefits?

By Leah Newkirk

As a family physician, perhaps you think you could describe what are Essential Health Benefits (EHBs) or health care services that your patients cannot live without. ‘Not so!’ say the attorneys, legislators and insurers who have coopted the term and are dragging it through the twists and turns of the federal and state regulatory process. While EHBs left the realm of health care providers to become a legal term of art, they remain central to the expansion and improvement of care under the Patient Protection and Affordable Care Act (PPACA) and an important concept for family physicians to understand.

The PPACA requires that health plans offered in the individual and small group markets, both inside and outside of the Insurance Exchanges (Exchanges), offer a package of items and services known as EHBs. Non-grandfathered plans in these markets must cover EHBs beginning in 2014. As statutes often do, PPACA provides only an austere definition of EHBs, leaving it to the Department of Health and Human Services (HHS) to elaborate through regulations. The PPACA does require that essential health benefits include items and services in the following 10 categories:

9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care On December 16, 2011, the Center for Consumer Information and Insurance Oversight issued the Essential Health Benefits: HHS Informational Bulletin outlining the approach HHS intends to pursue to define EHBs. The Bulletin was based on reports from the Department of Labor, the Institute of Medicine, and research conducted by HHS and describes the intent to define EHBs using a benchmark approach.

States would select a benchmark health plan that reflects the scope of services offered by a “typical employer plan” in the state; they would choose from one of the following: • One of the three largest small group plans in the state by enrollment; • One of the three largest state employee health plans by enrollment; • One of the three largest federal employee health plan options by enrollment; and • The largest HMO plan offered in the state’s commercial market by enrollment.

1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services

If states choose not to select a benchmark, the Bulletin proposed that the default benchmark would be the small group plan with the largest enrollment in the state. The benefits and services included in the benchmark plan selected by the state would be the EHB. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.

Essential Health Benefits, continued on page 22 20 California Family Physician Summer 2012

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T h e C a l i f o r n i a H e a lt h B e n e f i t E x c h a n g e Essential Health Benefits, from page 20

To maintain some control over federal costs, PPACA requires states to defray the cost of benefits required by state law in excess of the EHBs for individuals enrolled in any plan offered through an Exchange. Given California’s fiscal condition, this is likely to mean no state mandates above the EHBs/benchmark plan. As a transition in 2014 and 2015, however, some of the benchmark options will include health plans in the state’s small group market and state employee health benefit plans. These benchmarks are generally regulated by the state and would be subject to state mandates.

The Bulletin is not the final word on EHBs. Stakeholders, including CAFP, submitted comments to HHS advocating for changes in the approach. Among other things, CAFP urged coverage of comprehensive preventive and wellness services, as well as other primary care services offered in the Patient Centered Medical Home. You can view CAFP’s comments on our website. HHS will consider these comments and likely issue a proposed regulation governing EHBs. There will be another opportunity for stakeholders to comment before HHS issues a final regulation.

Meanwhile, the California Health Benefit Exchange Board and legislature are busy building the California Health Benefit Exchange and developing the California-specific definition of EHBs. The Exchange Board retained the actuarial and consulting firm Milliman to analyze and compare the health services covered by the 10 California benchmark plans. Milliman identified benefits excluded from some potential benchmark plans and not from

22 California Family Physician Summer 2012

others, specifically in the areas of assisted reproductive technology, hearing aids, acupuncture and chiropractic services. Milliman also identified services with variability in coverage among the potential benchmark plans. These include coverage of physical therapy, occupational therapy, speech therapy, acupuncture, chiropractic services and skilled nursing facilities.

In the legislature, AB 1453 and SB 951, authored by Assemblyman Bill Monning and Senator Ed Hernandez, respectively, formalize the concept of EHBs in California law. Both bills select the Kaiser Small Group HMO as the benchmark plan for EHBs. Both bills require individual and small group plans or health insurance policies issued, amended, or renewed on or after January 1, 2014, to cover EHBs. Both bills apply to plans or policies regardless of whether they are offered inside or outside the Exchange, but do not apply to grandfathered plans or plans that offer excepted benefits. Both bills prohibit insurers from indicating or implying that a plan or policy covers EHBs unless they do.

While it may be clear to family physicians what health benefits are essential, the legal construct of EHBs is still cloudy. CAFP will continue to watch this evolving concept carefully, advocating for the inclusion of comprehensive primary care services and the Patient Centered Medical Home model of care. We urge California family physicians to join us.

Leah Newkirk is CAFP’s Director of Health Policy.

Fa m i ly P h y s i c i a n o f t h e y e a r

2012 Family Physician of the Year: Bo Greaves, MD director. That’s how loyal Bo is to his patients … and that’s how much he was needed at the Health Center.

Bo is a natural born leader and advocate. While attending Johns Hopkins University, where he majored in English literature and minored in pre-med, he threw himself into demonstrating against the Viet Nam war and for civil rights. And while in residency at Santa Rosa, he worked his way up to become chief resident and started a residents’ union that still exists today.

After graduation, he opted to stay in the community and started one of the largest private practice groups in Santa Rosa. Bo’s passion for having the best care provided for patients came to a head in 2007, when he co-chaired a work group on primary care for Sonoma Health Action, a panel set up by the Sonoma County Board of Supervisors to devise ways to improve health care in the community. Bo advocated for the Patient Centered Medical Home (PCMH) and ultimately launched the PCMH Learning Collaborative, which went live in March 2010. The goal is to ensure that every person in Sonoma County has a personal medical home by 2020.

The California Academy of Family Physicians presents this prestigious award to an individual who exhibits the finest qualities of family physicians and who goes above and beyond in service to patients and community.

Lyman “Bo” Greaves, MD exemplifies everything a family physician should be. A true champion of family medicine, Dr. Greaves has cared for families from birth to end of life – and he’s been doing it since graduating from the Santa Rosa Family Medicine Residency Program in 1990.

Better known simply as “Bo,” he became the medical director at the Santa Rosa Community Health Centers in 2011, but initially hesitated taking the position because he didn’t know if his patients would be able to follow him to the new Center. The Centers found a way to solve the dilemma and paved the way for Bo to become

Bo is also considered one of CAFP’s true leaders. Along with being a past president at CAFP, he was also the CEO of Primary Care Associates and Chief Medical Officer for several IPAs and Medical Groups.

When he’s not seeing patients, Bo is a proud husband, father and grandfather. He and his wife Daisy enjoy big hikes through Annadel State Park. His daughter Maria Greaves, MD, one of four children, was in the sixth grade when Bo started medical school. She became a family physician after witnessing her father’s enthusiasm and passion for medicine and is now trying to implement some of the same PCMH concepts at her practice in Santa Cruz.

Dr. Bo Greaves is truly a role model of the quintessential family physician, both a jack and a master of all trades.

We are thrilled to honor him as CAFP’s 2012 Family Physician of the Year.

California Family Physician Summer 2012 23

e d uc at o r o f t h e y e a r

2012 Award for Educational Excellence in Honor of Barbara Harris: Dennis Mull, MD, MPH physician . . . especially a family physician.” His legacy at USC includes revitalizing a nutrition curriculum, enticing students to complete their longitudinal clerkships in areas of unmet need in Los Angeles, and encouraging students to not only learn a patient’s health history, but also their language and culture to serve them best.

In his educational career, Dr. Mull also has taught at UC Irvine and the Aga Khan University in Karachi, Pakistan. His vision of providing quality medical care in developing countries (including Mexico, Vietnam and Saudi Arabia,) coupled with his commitment to teaching, led him to help establish the Sota Village Health clinic in Shirati, Tanzania, in East Africa. A partner of the Sota Village Health Clinic and President of the Shirati Health Education and Development Foundation, US Branch, Dr. Mull continues to visit his clinic in Tanzania every year.

The California Academy of Family Physicians Foundation is proud to name J. Dennis Mull, MD MPH as the 2012 Barbara Harris Award for Educational Excellence.

For many involved in medical education in California, the name J. Dennis Mull needs no introduction.

Throughout his career, he has been a professor, a mentor, and residency director to students from California to such far-flung places as Pakistan, Mexico, and Texas.

For the past 15 years, Dr. Mull has been a professor of clinical family medicine and Vice Chair for Faculty Affairs in the Department of Family Medicine, Keck School of Medicine, University of Southern California. In this role, he has been responsible for enticing many students into joining the family medicine fold, where he is often quoted as saying “it is a joy and a privilege to be a

24 California Family Physician Summer 2012

Dr. Mull’s contributions to family medicine have had an enormous impact on fostering future family physicians, particularly through his successful efforts to bring teams of health professionals and medical students to Tanzania for medical rotations. He has published extensively and worked as a reviewer for six professional journals.

He is the founder of the Summer Institute of Medical Spanish in Ensenada, Mexico and continues to provide medical treatment at the South Central Family Health Center in Los Angeles, a Federally Qualified Community Health Center serving indigent Spanish-speaking clients. In 2002, Dr. Mull was appointed by Governor Gray Davis to the California Healthcare Workforce Policy Commission and served on the Board of Directors of the International Health Medical Education Consortium and the Nhan Hoa Community Health Care Center in Garden Grove, California.

Although he is known most for his skills as an educator, colleagues frequently describe Dr. Mull as the ultimate family physician—often caring more about his impoverished patients than his own career. He continues to inspire and mentor through his words and actions and we are proud to call him a Lifetime Member of CAFP. Congratulations to 2011 Barbara Harris Award winner Dennis Mull, MD.

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Residents of the year

2012 CAFP Residents of the Year: Alisha Dyer, DO, Charlene Hauser, MD, MPH; and Randi Sokol, MD, MPH The California Family Medicine Resident of the Year award is given to a resident who represents the finest characteristics of family medicine. This year, CAFP Foundation is honored to give the 2012 award to three outstanding residents: Alisha Dyer, DO, Charlene Hauser, MD, MPH, and Randi Sokol, MD, MPH. In addition to their relentless advocacy for family medicine and commitment to CAFP, Drs. Dyer, Hauser, and Sokol, in collaboration with CAFP Foundation, worked together to create the inspiring “Future Faces of Family Medicine” (FFFM) program. FFFM exposes classes of 20 high school students to careers in Family Medicine and primary care. Now just two years later, FFFM has won a national award, had two successful years in Sacramento, and is set to be launched throughout California.

Through a four-month program, residents from Sutter and UCDavis, led by Drs. Dyer, Hauser, and Sokol, worked together to design a curriculum that exposes high school students to lively discussions, hands-on workshops, and patient care, while building their leadership skills. A total of six 75-minute weekday sessions and two half-day weekend sessions are conducted. Sessions include health topics, CPR training, visits to the cadaver lab and simulation center at UC-Davis, and a panel of Family Medicine residents, who share their struggles and victories on the road toward medical careers. Students shadow pre-med students, medical students and residents at a local volunteer clinic serving a medically underserved population.

Dr. Dyer had experience with the Medical Pathways Program during high school—ultimately shaping her desire to pursue a career in primary care. Then, after a wavering pathway that

Alisha Dyer, DO 26 California Family Physician Summer 2012

included joining the Army National Guard, her passions for primary care were rekindled when she had the opportunity to work one-on-one with Winters, CA, family physician Carla Kakutani, MD, for four weeks through CAFP’s Summer Family Medicine Preceptorship Program. Now a third-year family medicine resident at Sutter, and President of CAFP’s Residency Council, Dr. Dyer strives to inspire a new class of family physicians.

Dr. Charlene Hauser, now a Chief Resident at UC-Davis Family Medicine Residency Program, also had a bumpy path to her career in primary care. After completing her Intern year of surgery residency, Dr. Hauser realized that if she wanted to help patients, she needed work on preventing their poor lifestyles. Thus, Dr. Hauser converted to family medicine, where public health and prevention are the treatments of choice. Dr. Hauser’s early exposure to public health, earning an MPH while in medical school, fueled her desire to provide high school students with early exposure to preventive medicine.

Dr. Sokol, who is now a third-year family medicine resident at UC-Davis, hopes this model of collaboration across Family Medicine projects will serve to inspire other primary care residency programs to similarly unite and lead programs that amplify the future primary care workforce. She is interested in further pursuing public health and advocacy work throughout her career as a family physician.

Congratulations to 2012 California Family Medicine Residents of the Year Randi, Alisha, and Charlene!

Charlene Hauser, MD, MPH

Randi Sokol, MD, MPH

California Family Physician Summer 2012 27

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Susan Hogeland, cae

Executive Vice President’s Forum

HBEX Is Here to Stay – PPACA or No PPACA California took the lead among states in responding to the passage of the Patient Protection and Affordable Care Act (PPACA) by immediately enacting legislation to establish the California Health Benefit Exchange program (HBEX) (www.healthexchange.ca.gov/Pages/ Default.aspx), now under the direction of Peter Lee. Your Academy has reported in Academy in Action newsletters and other issues of California Family Physician about the work we have undertaken to influence the HBEX, including participation on the Stakeholders’ Group on Eligibility and Enrollment, identifying family physicians to represent CAFP at HBEX regional meetings on eligibility and enrollment and essential health benefits, commenting on proposed federal regulations and advocating for inclusion of health plans that include team care and other features of the Patient Centered Medical Home in HBEX plan options.

CAFP past president Carla Kakutani, MD addressed media and health care stakeholders at a press conference in late March as part of the Health Exchange Advocacy and Responsibility Team (HEART) coalition.

HEART, of which CAFP is a founding member, launched its public efforts to influence benefit design the week of March 26 in a series of events, including legislative and Health Benefit Exchange staff briefings and the release of the results of a survey by the Field Research Corporation at the press conference.

Those Field Poll results indicate public support (particularly among young, insured Californians) for team-based care options, such as the Patient Centered Medical Home, within the HBEX offerings. The goals of the HEART coalition are to optimize patient outcomes and access to care, reduce growth in health care costs and drive continuous quality improvement through a properly designed “smart” HBEX that promotes robust market competition among health plans, enables consumers to make informed decisions and assures that consumers have access to teambased, coordinated care.

Continuing uncertainty exists about whether PPACA will be upheld in part or in its entirety by the Supreme Court, of course, and about what either decision might mean for implementation in states, such as California, that have embraced health care reform. California State Health and Human Services Secretary Diana Dooley has suggested the state might wish to enact its own version of universal health care coverage, including the mandate, if the Supreme Court strikes down PPACA (Sacramento Bee 3.30.12), depending on conditions. But that would raise the issue of how Medicaid (Medi-Cal in California) would be expanded if that element of reform legislation is deemed unconstitutional, according to the Wednesday, April 4 issue of California Healthline, which noted that “by the end of January, nearly 50 counties (in California) had set up such programs, covering about 370,000 residents.” Those individuals could lose coverage if the Medicaid provision is struck down.

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CAFP and AAFP supported the health care reform law because it dramatically expanded access to care for millions of Americans and placed a high value on primary care and the Patient Centered Medical Home, among other reasons. The New York Times reported on April 4 that a study issued by the IMS Institute for Healthcare Informatics found patients cut back on prescriptions by 1.1 percent in 2011, compared to 2010, and visits to physicians fell by 4.7 percent, while emergency room visits increased by 7.4 percent, the result of loss of health insurance linked to long-term unemployment. According to the report, the drop in prescriptions was even higher for those older than 65 – 3.1 percent, with declines highest in prescriptions to treat high blood pressure and osteoporosis even though, thanks to Medicare Part D prescription drug coverage and subsidies that took effect in 2010 as part of PPACA, out-ofpocket expenses fell by nearly $2 billion for enrollees.

Conversely, use of prescription drugs for young adults ages 19-25 rose by two percent, a change the report also attributed to the impact of PPACA, which permitted adult children younger than age 26 to be covered by their parents’ health care plan. To date, 2.5 million young Americans have taken advantage of this feature of the health care reform legislation.

I have a hard time understanding the visceral opposition of some to ALL of PPACA, a complicated piece of legislation involving hundreds of provisions. Some critics are unfairly ascribing negative trends to the law. A conservative columnist in the San Francisco Chronicle recently expressed her outrage about a nine percent increase in the cost of insurance premiums, a rise attributable to PPACA, she claims. I’m not sure where she gets her health care insurance coverage, but here at CAFP, I am happy when we get only a nine percent increase – we’ve had increases as high as 18 percent, and our premium expense has more than doubled in the past five years alone, despite choosing plans with higher deductibles and co-pays. If anything, basing reform on the current commercial health insurance system may be its biggest flaw – many of our members complain loudly about shareholder profits coming before patient care, so here’s another benefit of PPACA that’s paying off now: an April 26 Kaiser Family Foundation press release reported on a new analysis indicating an estimated $1.3 billion in health insurance premium rebates will be distributed to businesses and consumers by this August as the result of health insurers spending more on administrative expenses and profits than allowed by the Affordable Care Act (ACA). Would that have happened without reform?

Whatever the Supreme Court decides, PPACA will have a lasting impact on health care. The HBEX, for example, established by California law, will exist regardless of the Supreme Court’s decision. As long as there is a HBEX, CAFP will advocate that it select health plan options with essential benefits that cover all appropriate care, especially primary care services, and offer the features of the Patient Centered Medical Home, especially team care.

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At NORCAL Mutual, our numbers testify to great claims support for you. Of the claims we closed in 2011, 88% were closed without settlements or jury awards, compared to an industry average of 71%.* We won 86% of our trials, compared to 80% industry-wide.** You’re prepared for each stage of litigation and kept fully informed — and we don’t settle without your consent. We help you manage events so they don’t become claims, and, to back up our promise to stand by you, we remain financially stable, as evidenced by 29 consecutive years of “A” ratings by A.M. Best.

Our numbers add up to great claims support for your practice. * Physicians Insurers Association of America Risk Management Review: 2011 Edition. **Jena et al. Research Letter, Online First: Outcomes of Medical Malpractice Litigation Against U.S. Physicians. Archives of Internal Medicine. May 14, 2012.

Call 1-800-652-1051 or visit norCalmutual.Com Proud to support the California Academy of Family Physicians Our passion protects your practice

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