California Family Physician (Fall 2012)

California

FAMILY PHYSICIAN Vol . 6 3 No.4 Fal l 2 012

The FM Revolution Occupies CAFP’s Strategic Planning Discussions

16

Why Care About 30-Day Readmission Rates?

18

Supreme Court Decision: 22 Here is What the Dissection Really Says Lead Poisoning Can Be Prevented…And Here is How

What Health Care Reform Means for California and Family Physicians

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We Celebrate Excellence – James Strebig, MD CAP member, internal medicine physician, and former President of the Orange County Medical Association.

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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.

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Executive Vice President Susan Hogeland, cae Foundation President Jimmy H. Hara, MD AAFP Delegates Jack Chou, MD Carla Kakutani, MD AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD CMA Delegation Ashby Wolfe, MD, MPP, MPH Nathan Hitzeman, MD Michelle Quiogue, MD Suman Reddy, MD Kevin Rossi, MD Patricia Samuleson, MD

California FAMILY PHYSICIAN Quarterly publication of the California Academy of Family Physicians

• Julia Blank, MD • Nathan Hitzeman, MD

Michelle Quiogue, MD, Editor Communications Committee: Michelle Quiogue, MD, Chair • Jeffrey Luther, MD • Jay Mongiardo, MD

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

Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe.

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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4 California Family Physician Fall 2012

o v e r v i e w o f h e a lt h c a r e r e f o r m

16 The FM Revolution Occupies CAFP’s Strategic Planning Discussions

Mark Dressner, MD

18 Why Care About 30-Day Readmission Rates?

Nathan Hitzeman, MD

21 CMS and CAFP Preceptorship Program a Success!

20 Four Total Lies About ACA...From Death Panels To Obamacare

Carla Kakutani, MD, FFAFP

22 Supreme Court Decision: Here is What the Dissection Really Says

Leah Newkirk

26 Lead Poisoning Can Be Prevented … And Here is How

6 Editorial

Our Obligation is Simple: SLP

7 President’s Message

ACA Upheld ... Now Our Work Really Begins

8 Resident News

What Can Your Academy Do for You? What Can You Do for Your Academy?

9 Foundation News

How Do We Get to the Coveted 50 Percent Primary Care Physicians?

Jean Woo, MD, MPH, MBA

Michelle Quiogue, MD Steven Green, MD Irene Lee-Klass, MD and Raul Ayala, MD

Jimmy H. Hara, MD

10 In The News 12 PCMH Corner

The Mojo of the Medical Home: Beyond NCQA Recognition

14 Political Pulse

CAFP Working Hard as the 2011-12 Legislative Session Comes to a Close

30 Executive Vice Presidents Forum

Look Closely and You’ll Find Good Stuff for FPs and Their Patients in the ACA

David Ehrenberger, MD Ashby Wolfe, MD, MPP, MPH

Susan Hogeland, CAE

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

editorial

Michelle Quiogue, MD

Our Obligation is Simple: SLP Our path as family physicians remains clear despite the ongoing debate surrounding the Supreme Court ruling on the constitutionality of the Patient Protection and Affordable Care Act this summer. There is little motivation during this election year for either bipartisan compromise or progress. The only certainty is that the political fights will continue. Yet, the crisis of the exponential rise in the cost of providing fractured, episodic care continues to threaten private and public financial stability. Therefore, family physicians need to stay on track and continue to model patient-centered, comprehensive and coordinated health care. What can each of us do next? Share. Lead. Participate.

SHARE the evidence that supports the cost effectiveness of delivering high quality care in a patient-centered medical home (PCMH). Across the state, communities and practices continue the work of transformation toward a PCMH model. If you belong to one of these pioneer practices, send us your stories. What have been your successes and challenges? If your team has yet to start its journey down the road to transformation, visit the CAFP website to find an abundance of tools and resources. Then, share your experiences through social media and the CAFP website, or by emailing us. Also, you can contact your government representatives who need to hear real stories from practicing primary care physicians.

“To embed family medicine values throughout the span of medical education could inspire future generations to choose primary care more often than other specialties.”

LEAD local conversations about emerging health policy issues.

Locally, we have the opportunity to regain some level of control and physician autonomy. If family physicians secure leadership positions in local Accountable Care Organizations (ACOs), we can define the quality and performance standards that determine who will be eligible to receive a portion of the ACO savings. The CAFP website includes educational materials on how the PCMH/ACO models work together, updates on ACO development in CA, links to external resources and the Family Physician’s ACO Blueprint for Success document. Media outlets have reached out consistently to the CAFP for public comment. The voice of family medicine is highly valued and widely considered essential to meaningful transformation of the health delivery system. Without a strong presence from family physicians, can ACOs really deliver all of the promised quality improvements?

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PARTICIPATE in the modernization of your own practice. A national survey released in June 2012 revealed that 67 percent of all primary care physicians had a “basic EHR,” (electronic health record) which under the federal government’s definition means it includes patient history and demographics, a problem or diagnosis list, physician notes, medications, allergies, electronic prescribing and the ability to view laboratory and imaging results electronically. That is up from 15 percent of primary care physicians who had a basic EHR in 2008.

Also in June 2012, the Department of Health and Human Services announced that 4,277 eligible providers in California have received $413,459,380 in modernization incentives. Technological change is no longer something on the horizon but a part of the daily work of family physicians.

Underlying this mountain of work is the projected shortfall of primary care physicians. Physicians currently in practice have a vested interest in maintaining a strong pipeline of primary care physicians who are prepared to practice in this complex environment. From medical school admissions committees to summer preceptor programs to residency programs, now is the time to stake our ground. To embed family medicine values throughout the span of medical education could inspire future generations to choose primary care more often than other specialties. Some of us can still remember the reasons we chose our specialty. Future family physicians deserve mentors who remember the joy of Match Day, mentors who are willing to share, to lead and to participate.

Written on the wall of the U.S. Department of Health and Human Services building in Washington, DC is this quotation: “The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.”

Former Vice President Hubert Humphrey could have been speaking about our specialty and our mission when he uttered those words.

Perhaps, then, the moral test of a health care system is how it treats its family physicians—and our charge, as ever, is to make it live up to the test.

president’s message

Steven Green, MD

ACA Upheld ...

Now Our Work Really Begins In June, the Supreme Court upheld key provisions of the Affordable Care Act (ACA). Your Academy believes this is a victory for Californians. Millions of people in California who previously had no health insurance soon will. Already parents may include their children up to age 26 on their health insurance policies. Removal of pre-existing condition exclusions beginning in 2014 will be a huge step forward as well. Many who can’t afford insurance now will be able to through the health exchanges in 2014. With these changes come great challenges for our profession and specialty. How can we help ensure access for all the newly insured, as well as those who currently are covered?

Practice transformation to Patient Centered Medical Homes (PCMH) is a key element of how affordable access to care can happen. The elements of PCMH will vary depending on size of practice and practice environment. Team-based care in which physicians lead a team including registered nurses, nurse practitioners and physician assistants, medical assistants, chronic care managers, social workers, pharmacists and pharmacy techs all working to the full extent of their licenses is a key part of PCMH. The idea is members of the team work together, avoiding having physicians and other team members performing tasks which do not require their level of knowledge and training. If we have our staff or fellow team members seeing the more straightforward cases, we may be able to spend the time needed by our patients with more complex medical and psychosocial issues that don’t lend themselves well to 15or 20-minute visits. Larger integrated practices and organizations like Kaiser Permanente may already be doing elements of this type of team practice. We can learn much from them.

Working in teams will be more of a challenge for smaller practices.

Some pooling of their resources may be an answer for them. Sharing members of the team among smaller practices, or a stronger affiliation among these practices may be a solution. Rural practice presents a challenge, given the distances between practices and resources.

Options such as telehealth or other new ways of linking remote practices may need to be considered.

Electronic Health Records (EHR) will become necessary for all of us.

While the conversion to electronic records can be painful, the days of paper written notes are going away. Errors from hand-written prescriptions will not be tolerated in the future, regardless of how health reform progresses. EHRs allow better use of registries that let us reach out to our patients. With registries, we can contact our patients with diabetes who have stopped coming in for regular care. Likewise, we can alert patients to their needs for preventive care such as colon or breast cancer screening, rather than wait for them to show up for a special physical visit at which we address prevention.

Patients are demanding their care be convenient. Most of us have concerns that retail clinics in supermarkets and drugstores fragment care and damage the doctor-patient relationship. The problem is our patients sometimes choose these options. They want to go by a store after work and pick up milk, eggs, and see someone about their sore throats. Ignoring this trend is not an option. That doesn’t mean we have to have office hours at Wal-Mart, but we must work on ways to be more available to our patients. Use of smart phones or texting may become routine for patient communication.

How do we pay for these larger teams and electronic health records?

Ultimately better, more efficient care has been shown to prevent emergency room visits and hospitalizations. Demonstration projects in the Medicaid population in North Carolina proved just this. Group Health in Seattle showed similar savings. Unfortunately, having teams and EHRs alone do not guarantee better outcomes and cost savings.

This is a new area for many of us, and we can anticipate a learning curve for doing it right.

We must ensure an adequate primary care workforce if we are going to have an efficient health care delivery system. Countries with robust primary care bases typically show better health outcomes for less cost.

Rising medical student debt has caused more students to choose higher paying specialties to pay off their several hundred thousand dollar debts. Loan repayment programs for students choosing primary care are one option. Your academy promoted legislation to increase funding for primary care residency programs in underserved areas, although the bill was held up in the Senate Appropriations Committee. Residency programs often take care of the patients in these areas, and residents often choose to practice near where they do their residency, so such legislation may help. We will try again next year.

The accountable care act has been upheld, but our work is ahead of us.

The ACA did not address the issue of undocumented residents, who will not be among the newly insured, so the emergency room and hospital will still be the only place some of these people can be seen. The health exchanges and the ACA itself are hot topics in our upcoming November elections, adding to our uncertainty. Practice transformation to PCMH and ensuring an adequate primary care workforce seem the best choice for us at this point, regardless of politics and the election.

Congratulations to CAFP President

Steve Green, who on August 24 swam the English Channel from Dover to Calais in 19 hours, 25 minutes!

California Family Physician Fall 2012 7

Irene Lee-Klass, MD and Raul Ayala, MD

resident NEWS

What Can Your Academy Do for You? What Can You Do for Your Academy?

As incoming co-chairs for the Residency Council, we would like to welcome you to what promises to be a year of transformation for family medicine. The voices of residents will be well represented as we adapt health care policy into actual practice. CAFP offers effectives means not only to talk with others, but also to make positive changes for a career in family practice, from the privacy of a patient room to the platform of a legislative hearing. Through CAFP, you can tap into a wealth of educational and networking resources that can help transform your vision of family medicine into reality.

With our busy resident schedules, and so many CAFP opportunities, knowing where to begin may seem overwhelming. To help you out, we put together a brief summary of what CAFP has to offer. We recommend choosing one thing that piques your interest and letting your involvement develop and grow.

First, consider joining the Student and Residency Council.

We are family medicine residents and medical students in California who bring to CAFP the concerns important to us. We organize the annual Family Medicine Summit, affect academy policy at state and national levels and promote family medicine through multiple resident- and student-initiated projects across the state.

Next, attend an upcoming CAFP event, including any of the following.

The Family Medicine Summit occurs every fall. The 2012 Summit was September 15, so unfortunately you’ve missed it, but 2013 Summit planning begins soon. This one-day conference is specifically for medical students and residents and offers thought-provoking keynote speakers and fun workshops. It features a Residency Fair at which medical students can mingle with residents to learn about the variety of strong residency programs in our state.

The Congress of Delegates (perhaps soon to be called the All Member Advocacy Meeting) is March 2 - 4, 2013 at The Citizen Hotel in Sacramento. This is an annual meeting at which CAFP medical students and residents can develop leadership skills by helping to develop CAFP policy, participating as delegates, and joining in the legislative process during the annual Lobby Day alongside experienced family physicians.

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CAFP’s 2013 Annual Scientific Assembly (ASA) will be held May 3-5, 2013 at The Marriott Marquis in San Francisco. The Assembly features exciting speakers and workshops to build on clinical knowledge and skills relevant to family medicine.

Friendly rivalry among residency programs is played out at the game show style Jeopardy game-like competition, Battle of the Residents.

The National Conference of Family Medicine Residents and Medical Students is August 1-3, 2013 in Kansas City, Missouri at the Downtown Convention Center. The National Conference is a three-day gathering of students and residents from across the country, with speakers and workshops. It is the FM Summit on a national scale, including a Residency Fair with more than 300 programs in attendance, including those from California.

Beyond these conferences there are ongoing projects and activities. For instance, Future Faces of Family Medicine is a pilot project started in Sacramento to work with minority high school students and inspire interest in entering primary care. The program is currently being expanded to other high schools in California. The Family Medicine Revolution movement is a social networking project for realizing the value of family medicine in our communities (see www. familymedicinerevolution.org).

In addition to these events, another of our goals is to launch the California Central Valley Family Medicine Alliance, a network to address the physician shortage in our beautiful Central Valley. This rich agricultural region with a population of 6.5 million continues to have a shortage of primary care doctors. The current residency programs in the region produce excellent physicians, but not enough stay in the region after graduation. A number of great resources and spirited people have already committed a lot of effort to this cause, and we invite and encourage everyone to come together to achieve our goal.

We look forward to a great year. Whether you can spare a little time, or a lot, you can make a difference. Choose just one of these opportunities and see what CAFP has in store for you.

Irene and Raul are third-year residents and co-chairs of the Resident Council. Please check out familydocs.org for any interest in the above. If you would like to get in touch with either Irene or Raul, send the message through Cody Mitcheltree, cmitcheltree@familydocs.org.

FOUNDATION news Jimmy H. Hara, MD, CAFP Foundation President

How Do We Get to the Coveted 50 Percent Primary Care Physicians?

In 2013, the CAFP Foundation’s Summer Preceptorship Program celebrates its 20th birthday. During summer break each year, 40-50 medical students spend four weeks in a family physician’s office learning about life as a family doctor. They have the opportunity to observe the breadth of family medicine, from the physician exam to performing procedures. Some students even spend their four weeks living with the family physician’s family. Since the Preceptorship Program began, more than 32 percent of participants have selected family medicine compared to just 11-15 percent of medical students overall. The success of this program has the CAFP-Foundation wondering what it would take to increase the percentage of primary care physicians to the recommended 50 percent of all physicians, and how can the Foundation help achieve that goal?

A few years ago, policy analysts at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care studied exactly this question and in their report “What Influences Medical Student and Resident Choices?” made the following recommendations—including a few the CAFP-Foundation is already tackling:

half as likely to practice in rural areas.”)

9. New medical schools should be public with preference for rural locations.

Although no one said tackling these changes would be easy, the CAFP-F Preceptorship Program embodies many of these suggestions.

There is no doubt the program has the potential to positively influence students’ perception of family medicine. In addition to the Preceptorship Program, sponsorship of events such as the Family Medicine Summit and the Future Faces of Family Medicine Mentoring Program can help us achieve the 50:50 goal. Please consider helping CAFP-Foundation with a contribution to support our future family physician workforce in California.

Specialty Selection by Preceptee participants prior to 2008

1. Create more opportunities for students and young physicians to trade debt for service.

2. Reduce or resolve disparities in physician income.

3. Admit a greater proportion of students to medical school who are more likely to choose primary care, rural practice and care of the underserved.

4. Study the degree to which educational debt prevents middle class and poor students from applying to medical school and potential policies to reduce such barriers.

5. Shift substantially more training of medical students and residents to community, rural and underserved settings.

6. Support primary care departments and residency programs and their roles in teaching and mentoring trainees.

7. Reauthorize and revitalize funding through Title VII, Section 747 of the Public Health Service Act. (Title VII is a small, little known federal program that supports primary care residency training, but has been severely reduced by budget cuts during the past decade.)

8. Study how to make rural areas more likely practice options, especially for women physicians. (The report found that “female physicians are twice as likely as men to choose primary care but

Maryjane Vennat from UC-Irvine with her preceptors, Drs. Elaine King and Marlene Yacoob.

California Family Physician Fall 2012 9

IN THE NEWS Two New Staffers Welcomed to CAFP Ranks

Please join us in welcoming two new staff members: Allison Bauer and Rachel Guillermo.

We welcomed Allison and Rachel to the staff on August 20. Allison is our new website and communications coordinator and takes the position formerly held by Chris Navalta, who left the Academy in May. Rachel, our new receptionist/membership administrator, fills the seat left vacant by Cecile Awayan, who left the CAFP in July.

Allison spent the past year serving as a national Volunteer in Service to America (AmeriCorps*VISTA) member for an Oaklandbased non-profit. She graduated from the University of Wisconsin – La Crosse where she majored in public relations and organizational communication and minored in art.

Rachel was born and raised in Honolulu. She recently graduated from Central Washington University with a BA in CommunicationsPrint Journalism. Please be sure to welcome Allison and Rachel.

Proposed Revised CAFP Bylaws Now Available for Member Review Resolution A-03-12, Transition CAFP Congress of Delegates to All Member Advocacy Meeting was adopted unanimously by the 2012 Congress of Delegates. It called for changing the name of the Congress of Delegates (Congress) to the All Member Advocacy Meeting (AMAM) and opening the AMAM to all members of the Academy in addition to duly elected delegates and alternates from county chapters.

Five years ago, the Congress was separated from the CAFP Annual Scientific Assembly, and moved to Sacramento with the goal of focusing on advocacy training and legislative meetings in addition to the policy making business of the Academy. Now, the Congress has voted to open up the meeting to all members to increase the opportunities for activating, giving voice to and empowering members as advocates for themselves and their patients and to present 10 California Family Physician Fall 2012

CAFP Hits the Airwaves with Health Care Reform Commentary June 28: San Diego NBC Ch. 7 Steven Green, MD Experts Break Down Health Care Provisions CAFP president discusses Supreme Court ‘s ACA ruling on live television news Program http://www.nbcsandiego.com/ news/local/Heathcare‐cheaper‐ to‐opt‐out‐paypenalty.html 6.28.12 Bakersfield Californian Michelle Quiogue, MD Local Health Officials See Wins, Losses in Ruling CAFP member explains benefits to patients of Supreme Court ACA ruling. http://www.bakersfieldcalifornian.com/he alth/x1330930664/Congressman‐McCarthy others‐ react‐to‐health‐care‐ruling 6.28.12 Fresno Bee Adriana Padilla, MD Valley Reacts to Obama Health Care Ruling CAFP member discusses benefits to patients of Supreme Court ACA ruling http://www.fresnobee. com/2012/06/28/2 892338/valley‐ officials‐and‐business.html

ci_2096 5529/marin‐health‐care‐leaders‐ celebratesupreme‐ court‐ruling 6.28.12 Modesto Bee Del Morris, MD; Peter Broderick, MD Opinions on Health Care Ruling Vary in Modesto. CAFP members discuss benefits to patients of Supreme Court ACA ruling http://www.modbee. com/2012/06/28/2262577/opinions‐on‐ health‐care‐ruling.html

6.28.12 Marin Independent Journal Sharon Lin, DO and son, Austin) Marin Health Care Leaders Celebrate Supreme Court Ruling CAFP member and son are featured while distributing flyers to patients about benefits of Supreme CourtACA ruling http://www.marinij.com/sausalito/

ideas and problems to the CAFP leadership.

As requested by the Congress, revised proposed CAFP Bylaws have been prepared with the assistance of CAFP legal counsel and with the approval of the Board of Directors for presentation to the members and to the 2013 Congress of Delegates. To review the revised proposed Bylaws and an explanation for the proposed changes, please go to the CAFP website at [insert url].

Comments and questions may be directed to cafp@familydocs.org or on the comment section on the website.

CAFP President Steve Green is a Swimming Machine

When he’s not leading CAFP, President Steve Green is swimming the English Channel, as he did on August 23 in 19 hours and 25 minutes, entering the water at Shakespeare Beach in Dover and exiting in Calais, France. Congratulations, Steve!

Click here to see Steve in action http:// www.youtube.com/watch?v=SpC4qd4R37M &feature=youtube

IN THE NEWS CAFP’s Heartfelt Gratitude to Tom Riley …

Tom Riley, CAFP’s legislative advocate for more than 22 years, ended his contractual relationship with the Academy at the end of September.

Mr. Riley first came to work as CAFP’s communications director 26 years ago, and later became its legislative advocate as an independent contractor.

Tom takes over as the Executive Director of the Molina Foundation the first of October.

“Tom has been an incredible asset to the Academy over these many years,” said CAFP President Steve Green, MD. “He will be greatly missed; we want him and everyone to know how much we have appreciated his efforts and commitment on behalf of family medicine and the Academy.”

“I have learned so much about the legislative process from Tom. He has been a valuable mentor as I have moved through the academy,” added CAFP President-elect Mark Dressner, MD. CAFP’s current and past legislative committee chairs joined President Green in praise of Mr. Riley –Ashby Wolfe, MD, MPH, MPP and Taejoon Ahn, MD, MPH, among others, praised Mr.

Riley’s management of the Academy’s sponsored bills and of the hundreds of other bills affecting health care, family physicians and their patients considered by state legislators annually, in addition to the mass of regulations issued by state agencies.

“I’ve known Tom for a decade. He mentored me in politics, policy and philosophy as a partner on the Legislative Affairs Committee and as one of my faculty professors during the California Health Care Foundation/University of California San Francisco Center for the Health Professions leadership fellows program.

He demonstrated class and intelligence both socially and academically in his ability to work with others. He’s been a tireless advocate for family physicians and their patients, always fighting the good fight. He will be sorely missed,” said Dr. Ahn. With a special session of the state legislature called by Governor Jerry Brown in December to consider health care reform implementation legislation, CAFP will begin work immediately to identify an individual or lobbying firm to assume Mr. Riley’s advocacy role.

CAFP’s leaders, members and staff extend their heartfelt gratitude to Tom Riley and his staff at CalCapitol Group for his dedicated work on behalf of family medicine and wish him success in all his future endeavors.

California Family Physician Fall 2012 11

David Ehrenberger, MD

PCMH Corner

The Mojo of the Medical Home: Beyond NCQA Recognition Often lost in the technical complexities of the Patient Centered Medical Home is its richness and power as it fulfills the promise of family medicine. This article is the first in a series sharing the medical home experience from the perspective of family medicine practice teams that began the journey four years ago. We begin by exploring the concept of data competency, the first of four pillars of advanced primary care that also include meta-teamwork, the learning organization and population health literacy.

After caring for patients, making good use of clinical data – “clinical data competency” – should be a top priority for family physicians. Knowing what measures matter, figuring out how to input and analyze data and sharing performance and outcomes data is what makes the medical home a discipline.

Data competency empowers family physicians to do something extraordinary and evolve through continuous improvement.

I have two confessions to make. Data competence cannot happen in the absence of an electronic health record (EHR) and even then, an EHR is not enough. You also need additional information systems that can mine and report on performance and outcomes.

Step 1: The true worth of clinical data competency is determining what to measure. This is the easy part and begins with the national quality agenda that lays out a map: diabetes, chronic obstructive pulmonary disease, hypertension, immunizations, cancer screenings, access and care coordination. These are some of the “high impact” areas for primary care where patients can receive better value for their health care dollar.

The National Quality Forum (NQF) and other standard bearers of evidenced-based medicine specified the relevant measures – including HbgA1c, smoking status and counseling, and time to the third next available appointment – within the past year.

Some measures focus on process (e.g., the use of a depression screening tool for your patients with diabetes) and others on outcomes, (e.g., the percent of people with ischemic vascular disease with blood pressure <140/90).

Step 2: Now the fun starts: measures are different from metrics. A measure is a statement of the dimension of care (i.e., the process or outcome) to be evaluated. A metric is a specific definition of a measure, with a numerator and a denominator, exclusion and inclusion criteria, and often a time parameter.

12 California Family Physician Fall 2012

An example of a process measure is “breast cancer screening performance.” The corresponding metric is: Numerator = all women between ages of 50 and 69 who have had a mammogram in the past 730 days Denominator = all women between ages of 50 and 69 who don’t meet exclusion criteria Exclusion Criteria: double mastectomy Because of the technical nature of metrics, they are hard work and tricky to create. For instance, is the metric for up-to-date A1c the same for United Healthcare as it is for the National Quality Forum or for your local accountable care organization or independent practice association? Metrics are essential for translating measures into technical terms that drive the work of performance improvement. The moral here is that your performance as a medical home is only as good—and relevant—as the metrics you create and use.

Since we are in the digital era with the mantra “gold in, gold out,” getting meaningful process and outcomes metrics are highly dependent on reliable data capture: are all data points that feed the metrics being captured by your practice (e.g., are there corresponding, discrete data fields – so called “structured data” -- located in the EHR, has your care team been trained to do -- and be accountable for – correct data entry, does your EHR have validated, reliable interfaces with outside lab vendors?). Arguably, the most important step in data capture has to do with patient attribution: which patients consider you their family physician? How and where is this caught in the record? What process is in place to ensure that patients that have “moved or gone elsewhere” have their attribution changed? Without reliable attribution, performance reports lose their reliability, accountability wanes and there is less gold and more garbage.

Step 3: When the measures and metrics are defined and the important data are reliably captured in the clinical workflow process, then comes the reckoning. It is time for a reality check regarding the state of the art in health information technology: EHRs are good transactional tools, documenting and retrieving patient-specific, therapeutic information for the purposes of the encounter, but they generally are lousy analytic engines.

What this means is that getting good, primary source data into an EHR database is far easier than getting aggregate, analyzed and meaningful data out.

PCMH Corner

Get in gear.

But help is on the way! Health care clinical analytics will be the buzzwords for the next several years. Clinical analytics are facile, reliable, valid, real-time reporting on clinical performance and outcomes. Clinical analytics are common in the non-health care business world and require mapping of EHR data to separate servers with analytic databases and the specialized software for number crunching. The challenges and benefits of data mining are becoming just as important to the small primary care practice as they are to larger health care organizations. It is, after all, this kind of meaningful clinical data that powers the improvement work of a medical home.

The good news about data competency is that doctors love data but they love it only when they own it. Remember that getting buy-in from all staff and involving them in metric definitions and the validation process can foster trust that makes the data valid and meaningful. This, I believe, is the key to ownership.

Examples to try with your practice team: 1) In order to improve efficient data capture, change the medical assistant rooming workflow to include “smoking status” as a vital

sign and training them to do brief supportive counseling for every smoker every time. This will result in dramatic improvements with process measures and in the critical outcome measure of smoking cessation.

2) In order to improve data validation and provider engagement, develop performance reports. Our performance reports for pneumococcal vaccination rates in patients over 65 were approximately 60 percent. The numbers stayed that way for a year because physicians believed the data was incorrect. The physician who was least likely to change was invited to drill down each of his 110 outliers, he discovered the following: although 10 percent of his patients were in fact up-todate with their vaccinations, 90 percent were not immunized. We used his insights to improve on the performance reports and he is now our biggest data champion.

Dr. David Ehrenberger is Chief Medical Officer of Avista Adventist Hospital and Integrated Physician Network, an Accountable Care Organization north of Denver. He practices medicine part-time in a Level III NCQA recognized medical home. He may be reached at davidehrenberger@centura.org

CAFP is a partner in CS2Day, a smoking cessation collaboration. To access hundreds of tools and resources to help your patients on their cessation path, go to: www.ceasesmoking2day.com.

You’re a creative, innovative professional who’s already mastered some of your field’s most challenging terrain. Now you’re ready to shift into a whole new gear. So make tracks for Mercy Medical Group, a service of Dignity Health Medical Foundation. We are a multi-specialty group with 300+ healthcare providers providing services throughout Sacramento, California.

OUTPATIENT FAMILY MEDICINE OPPORTUNITIES AVAILABLE! Sacramento, California

We are currently looking to add both part-time and full-time providers to our busy primary care department.

Highlights include: • Development of a patient-centric, physician-led medical home model with advanced clinical practitioners and nurses • Ability to perform procedures • Excellent telephone call schedule (1:10); 24-hour advice nurse; and Hospitalists available 24/7 • Leading-edge technology, including EMR • Working in a collegial and supportive environment • Shareholder-track opportunity Compensation package includes: • Generous benefits package, including health insurance and matched savings retirement plan • Loan repayment option available Sacramento is one of the fastest growing cities in the nation and one of the most affordable places to live in California. The area offers a wide variety of activities to enjoy, including fine restaurants, shopping, biking, boating, river rafting, skiing, and many types of cultural events. Lake Tahoe, the Pacific coastline, San Francisco, the vineyards of Napa and Sonoma Valleys, and historic Gold Rush towns of the Sierra foothills are all within easy driving distance.

For more information, please contact and send your CV to: providers@dignityhealth.org ph: 888.599.7787 www.dignityhealth.org www.mymercymedgroup.org

California Family Physician Fall 2012 13

Ashby Wolfe, MD, MPP, MPH

political pulse

CAFP Fights Health Care Cuts Through November Ballot Proposition Positions Next month, citizens will be asked to vote on more than 10 propositions, numerous candidates for state and federal offices and the President of the United States. This past July, the CAFP Legislative Affairs Committee and Board of Directors reviewed the propositions and narrowed their focus to those that would most affect the practice of family medicine. The Committee recommended, and the Board approved, two positions: Yes on Proposition 30 and No on Proposition 31.

Yes on Proposition 30 The economic recession has led to a precipitous decline in California state revenue. Despite tens of billions of dollars in state funding cuts and program eliminations, California has been unable to reduce its debt burden. Proposition 30 is an attempt to change the state’s economic course by balancing cuts with an increase in state revenue.

Family physicians have seen firsthand the effect cuts to health and human services have had on their practices and their patients. Medi-Cal payment reductions have driven physicians out of the program and forced nearly half of those remaining to close their practices to new Medi-Cal patients.

Family physicians have also seen an increase in patients seeking oral care in their offices because Medi-Cal dental coverage has been eliminated. The state has made cuts to child care assistance, In-Home Supportive Services, developmental services, hospitals and nursing home services, and Adult Day Health Care. The number of visits a patient could have with his or her physician has been capped. This attrition and elimi-

...the CAFP Legislative Affairs Committee and Board of Directors reviewed the propositions and narrowed their focus to those that would most affect the practice of family medicine. The Committee recommended, and the Board approved, two positions: Yes on Proposition 30 and No on Proposition 31.

14 California Family Physician Fall 2012

nation of coverage and services have hit the most vulnerable patients the hardest and must be addressed.

A “Yes” vote on Proposition 30 would increase the personal income taxes on high-income taxpayers (individuals making $250,000 or more; couples making more than $500,000) for seven years and sales taxes by 0.25 cent for four years. It is estimated that approximately $6 billion would be generated through 2019. The new tax revenues would fund current state programs that have been hit hard by cuts over the past four years. The proposition would also guarantee funding for public safety services realigned from state to local governments and prevent implementation of “trigger” cuts to education. Organizations such as the California Medical Association, California Budget Project, California State Association of Counties, League of Women Voters, California Primary Care Association and others support this measure as a way to avoid further strain on the state’s General Fund and thereby prevent further cuts to health care programs. CAFP agrees and urges your support of Proposition 30.

No on Proposition 31 The CAFP Board faced a difficult decision on Proposition 31. It is a government reform proposition with the goal of streamlining and improving budgetary processes. Certain aspects of the measure could yield positive results, such as establishing a two-year state budget cycle, requiring performance reviews of all state programs and requiring the Legislature to show how bills that increase state spending would be paid for with spending reductions, revenue increases or a combination of both. Other provisions, however, could affect programs important to family physicians and their patients in a severely negative way, including the provision that would allow the Governor to cut health and human service programs unilaterally. Programs such as Medi-Cal, the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program, the Family Planning, Access, Care and Treatment Program (FPACT) and others could be decimated in favor of other state programs, such as prisons and education, without a vote of the Legislature. Because this measure would give the Governor significant new powers to unilaterally cut spending, including for health programs, a future Governor hostile to health care programs or primary care could exercise this power to the detriment of family physicians and their patients. Given these concerns, CAFP is opposed and urges a “No” vote on Proposition 31.

Dr. Wolfe is Chair, CAFP Legislative Affairs Committee

political pulse

CAFP Working Hard as the 2011-12 Legislative Session Comes to a Close The 2011-2012 Legislative Session has been a whirlwind of health care legislative activity. Close votes, last minute amendments and the quickly approaching election in November have added to the drama.

CAFP is happy to report that, as of this writing, several priority bills are on the Governor’s Desk awaiting his signature. It will be an intense couple of weeks before Governor Jerry Brown’s deadline to sign or veto the bills arrives on September 30, but rest assured CAFP has been pulling out all the stops to ensure family medicine’s voice is heard. For those of you who took the time to write, email or call the Governor to advocate for family medicine’s priority legislation, we cannot thank you enough for your efforts.

Of all the bills awaiting action from the Governor, the highest priority is CAFP’s sponsored bill, SB 393, authored by the Chair of the Senate Health Committee Ed Hernández (D – West Covina). The bill would create a statewide definition for the Patient Centered Medical Home (PCMH) based on the nationally recognized Joint Principles of the PCMH. CAFP and the eight other co-sponsors of the bill worked with the Department of Health Care Services (DHCS) over the past several weeks to develop amendments to address DHCS’s opposition, but as of this writing it is not yet known whether these amendments will be sufficient to garner Governor Brown’s signature.

The bill has been on a four year journey and has seen many different iterations, but this is the first time it has reached the Governor’s Desk. It would define the PCMH as “a health care delivery model that meets the following criteria:” 1) Facilitates a relationship between a patient and his or her personal physician or other licensed primary care provider in a physiciandirected practice team to provide comprehensive and culturally competent primary and preventive care.

2) Utilizes a team approach to care.

3) Delivers high-quality, comprehensive care including whole person orientation, and coordinates the patient’s health care needs across the health care system.

4) Uses evidence-based medicine, patient input and clinical decision support tools to guide decision-making.

5) Enhances patient access to, and communication with, his or her medical home team.

6) Engages in continuous quality improvement with the involvement of patients and their families.

While this definition is not all encompassing, it provides a minimum set of standards to ensure that when a patient is looking for a PCMH, a provider just can’t put a sticker on their door and say they are one. This would be a huge win for patients and for California. Other states that have passed PCMH definition legislation has seen an increase in PCMH transformation – something California has fallen behind in nationally.

CAFP and its members are also urging the Governor to sign other health

care legislation including: • AB 441, authored by Assemblymember Bill Monning (D – Santa Cruz), would require the California Transportation Commission to include a summary of policies, practices, or projects that metropolitan planning organizations have employed to promote health and health equity.

The goal is to integrate health criteria into city planning so that local governments can develop plans that increase access to healthier food, safer parks, and transit option strategies that meet the needs of all users.

• AB 589, authored by Assemblymember Henry Perea (D – Fresno) and sponsored by the CMA, would create the Steven M. Thompson Medical School Scholarship Program (not to be confused with the Steven M. Thompson Loan Repayment Program) and provide up to $105,000 in scholarship funds if, prior to graduating from an accredited U.S. medical or osteopathic school, a student agrees in writing to practice in an underserved area for at least three years in a medical practice. The doctor could also qualify by agreeing to practice in a clinic that serves county indigent patients.

CAFP also saw success in legislation we were able to PREVENT from getting to the Governor’s Desk. SB 1528 and AB 1062 sought to create small but significant exceptions to the Medical Injury Compensation Reform Act (MICRA), which has helped maintain patient access to physicians through reasonable malpractice insurance rates for more than 30 years. MICRA limits the amount attorneys can charge clients, as well as non-economic damage claims, in medical malpractice cases. CAFP, as part of the Californians Allied for Patient Access (CAPP) coalition, ensured that these bills did not pass out of the legislature despite last minute procedural strategies taken by the trial attorney associations.

Regardless of what happens between the time of this writing and the deadline for action for the Governor, the Academy already has one big win under its belt. The Governor has signed CAFP-Supported AB 1533, authored by Assemblymember Holly Mitchell (D – Los Angeles). This bill, sponsored by the University of California and the Medical Board of California, would authorize a five-year UCLA IMG pilot program allowing participants to engage in supervised patient care activities for 16 to 24 weeks as part of an approved and supervised clinical clerkship/rotation at UCLA health care facilities or with other approved UCLA affiliates (e.g., participating California family medicine programs). The goal of this bill is to train more doctors for primary care in underserved communities and to prepare international medical graduates (IMGs) for residency in family medicine. It is a small but important step in improving the diversity and number of primary care physicians.

Thank you, again, to all the CAFP Key Contacts and members whose advocacy has been so crucial in helping CAFP achieve its legislative goals!

Dr. Wolfe is Chair, CAFP Legislative Affairs Committee California Family Physician Fall 2012 15

STRATEGIC PLANNING REPORT

The FM Revolution Occupies CAFP’s Strategic Planning Discussions

By Mark Dressner, MD CAFP President-Elect

Imagine being a leader in a room of leaders. The excitement from the energy, the ideas, and just plain fun was palpable. The leaders of your academy came together the last weekend in July for our every-threeyear, strategic planning meeting.

Many of the old guard were present and accounted for, but many of our emerging leaders participated as well. Our excellent staff guided and assisted us in setting our direction – they’re the people who do the lion’s share of the work to move us along while we are busy caring for our patients.

This year we decided up front that there are many things we assume we will do and we already do well, including membership, education and communication (in all of its various forms). By leaving such activities for staff to develop plans for Board review, we were able to use the retreat to focus on three main areas: workforce, practice transformation and advocacy. Our job was to develop specific goals for the next three years and then imagine where we wanted to be in five and 10 years as well. In preparation for the meeting, attendees received three sets of materials for review, including trend reports, environmental scans and the Action Update on the 2009-2012 strategic plan. We were one very informed group! We also brought our expertise from different parts of the state to bear on the planning process, representing rural, urban, private practice, academia, Kaiser Permanente, Sutter and more. Donna Valponi, AAFP Vice President for Communications and Membership, helped facilitate our meeting.

As we worked on our goals, our theme was FAMILY MEDICINE REVOLUTION. (see http://www.familymedicinerevolution. org/). The weekend had a revolutionary theme in dress and décor. The spirit of the theme was to position our specialty as leaders in health care and the specialty of choice, and it also allowed for much humor. It was, in fact, a peaceful revolution.

A physician shortage in primary care already appears evident.

Poor distribution of physicians and underutilization of non-

16 California Family Physician Fall 2012

physician primary care professionals in team-based care are at least partially at fault for what seems like a shortage of primary care physicians. It is certain that by 2014, when the Affordable Care Act (ACA) comes into effect, the problem will be worse. Up to six million people may be newly insured in California. How do we ensure access to a personal family physician for each of them?

Workforce: The workforce squad identified several factors that would help. More medical students must go into family medicine. They must be encouraged to enter family medicine even before they get to medical school. They must be of excellent quality so they are accepted to medical school as step one. These students need to be exposed to the breadth of family medicine so they choose FM residencies. Once they are practicing family physicians, they must be supported and happy. From the start, these students need to see happy family physicians who inspire them to want to be family physicians. Once in the specialty, they must find satisfaction throughout their long practice careers.

Several plans of action were developed to accomplish these goals: Plan 1: 1) Get more family physicians on admission committees to influence the selection of students most likely to go into family medicine; 2) Ensure at least one FP is on every admissions committee; and 3) Increase that number over the next 10 years.

Plan 2: 1) Identify what gets in the way of happiness and professional satisfaction for FPs; and 2) Work-to address these challenges.

Plan 3: 1) Provide tools for FPs to be competent and confident in re-designed practices; and 2) Ensure FPs are active in the leadership of emerging Accountable Care Organizations (ACOs).

Plan 4: 1) Actively support all our residency programs and come to their aid as needed; and 2) Seek 100 percent CAFP membership for residents and faculty in training programs.

Advocacy: As a primary function of our academy, CAFP lobbies to ensure laws family physicians support are passed and those we do not support are not passed. No one else is looking out specifically for the interests of family physicians and their patients in Sacramento. Our academy is our voice in Sacramento.

The squad working on the advocacy plan identified plans to accomplish our goals around three areas: money, membership, and message.

Plan: 1) Money talks. Support candidates who agree with our goals; 2) Strategize about how to maximize our contributions to the FP political action committee (FPPAC); 3) Maximize political involvement of our dues paying membership. Get members more active in advocacy – contacting local and state politicians on a regular basis.

(A 10-year goal is that every legislator knows at least one FM Revolution, continued on page 18

Clockwise, from above: Veronica Jordan, rural director, explains her team’s strategies; San Diego Drs. Steve Green, Dave Bazzo and Lee Ralph prepare for work; AAFP’s Dona Valponi gets a good laugh out of General Green’s beard; and the CAFP FM Revolutionary forces complete the peaceful actions.

o v e r v i e w o f h e a lt h c a r e r e f o r m

Why Care About 30-Day Readmission Rates?

By Nathan Hitzeman, MD

Health as a family doctor who works in the clinic and hospital, I much prefer seeing my patients return to the clinic than to the hospital. Readmission rates have been a black cloud following physicians for years. A perfect storm of chronic disease, inadequate health coverage and coordination and pressures to decrease length of stay have driven readmission rates to the brink.

National 30-day readmission rates for Medicare patients with heart attack, heart failure and pneumonia are 19.7 percent, 24.7 percent, and 18.5 percent, respectively. In California, the 30-day readmission rate for all Medicare patients is around 20 percent. (Utah has the lowest rate at 14.2 percent and Maryland the highest at 22 percent.)

Search your institution’s readmission rates online at http:// www.hospitalcompare.hhs.gov/.

Under the Accountable Care Act, the government is saying enough is enough. Heart attacks, heart failure and pneumonia are leading causes for readmission; starting October of this year, Medicare will penalize the discharging hospital if the patient is readmitted within 30 days to the same or any other hospital. For the first year of the program, payment reductions will be capped at a maximum of one percent of net inpatient Medicare payments. The payment reduction rates will subsequently increase by one percent each year before being capped at three percent for fiscal year 2015 and beyond.

18 California Family Physician Fall 2012

If this were an infomercial to decrease readmissions, here is where the free steak knife set comes in. You, as the family physician, will be paid for helping with transitions of care and keeping your patients from being readmitted. In 2013, doctors providing primary care services for Medicare patients may bill with a new G code for “post-discharge transitional care services.”

Who better than family physicians to help patients pick up the pieces of their post traumatic discharge syndrome (PTDS) lives where a bag of meds, a discharge summary and follow-up on outstanding tests awaits your attention? As the dust settles, it will be up to you to update medical records, make sure that care is coordinated and help your patient understand all that has happened. And, this may increase payments to family physicians by seven percent. Not a bad deal.

On a parting note, despite a gravitational pull toward the clinic setting, family physicians can still thrive in in-patient care. Some family docs, especially those in residency training programs like me, still enjoy doing both. According to a 2003 survey, three percent of hospitalists are family physicians. I’d like to see that number go up. The time is right to cultivate good transitions of care at the medical student, resident and attending level. The National Transitions of Care Coalition has a website with various tools to help in this endeavor at http:// www.ntocc.org/WhoWeServe/HealthCareProfessionals.aspx .

30 25 -

Congestive heart failure Acute myocaridal infarction

20 -

Pneumonia

15 10 -

National Trends in 30-Day Readmission Rates, 2002-2009.

2007

2008

-

2006

-

2005

-

2004

-

2003

-

2002

-

0-

-

5-

Risk Adjusted 30-Day Readmission Rate (%)

Is this yet another draconian act of Medicare, to be added to other cost containment strategies such as diagnosis-related groups (DRGs), or diagnosis-based bundled payments (DBPs and hospital acquired conditions (HACs), such as central line infections? Or is this a laudable attempt to improve patient outcomes that matter? I would argue for the latter. Hospitals have long had a lovehate relationship with readmissions.

On one hand, readmissions are causes of patient dissatisfaction; on the other hand, they lead to

additional payments under the fee-for-service model. More service, more fees!

2009

FM Revolution, from page 17

family physician by first name – for example, when my state legislator called my house recently, he wanted to know if he was speaking to Mark or Matt – my partner who is also a family physician!); 4) Take positions on health-related bills to reflect our membership’s needs, with maximal input from our members; 5) Teach that advocacy outside the exam room is an essential part of our profession; 6) Mentor others and emphasize this in residency programs so we graduate physicians who actively engage in advocacy.

Practice Transformation: The three main topics addressed were Patient Centered Medical Home (PCMH), Health Information Technology (HIT) implementation, and Accountable Care Organizations (ACOs). This is perhaps our most challenging area. How do we support family physicians in this time of rapid transformation in care delivery? These changes are hitting us at breakneck speed and we have little time or money to deal with them, though deal with them we must.

Plan 1: 1) To so many FPs the concept of PCMH is still somewhat nebulous – facilitate knowledge transfer of best practices with stories from patients, clinics, and finances; 2) Share the successes of what a PCMH looks like and how it is implemented (this could include collaborations for coaching and resources).

Plan 2: 1) Continue to supply support for adopting electronic health records (EHRs), including selection, financing, and implementation.

Plan 3: 1) Advise FPs on participating in ACOs; and 2) Advocate for payment reform.

From all this discussion of goals in these three categories, we winnowed down the activities the most important, while at the same time ensuring that we have the staff, time, and money to accomplish our goals. We accomplished our mission.

Much laughter, support and camaraderie accompanied our deliberations, of course. We celebrated Saturday night by creating family medicine revolutionthemed songs sung karaoke style to different popular songs highlighted by choreography and flashy dance moves by some of those from whom you’d least expect it. (I still can’t decide if I should put Dr. Jimmy Hara’s name here, but oh, well, here it is!)

We left our meeting with a clear vision of what we wanted to accomplish over the next three years. We also had a gleam in our eye about the future. Now it is the job of our amazing staff, led

by Susan Hogeland, CAE, to develop action plans on how we accomplish our goals. So much of what we are already doing is heads us in the right direction, but it’s important to meet on a regular basis to review that direction. Who would have guessed six years ago, with California doing well financially and actively planning how to efficiently deliver health care to the state, that all would come to a crashing halt as the financial crisis hit? Who would have guessed that three years ago we would have been looking at a national plan to bring most of our population into the health care fold?

These are exciting times and our academy is positioned well to meet the challenge and support our members and our patients. Please email me with any comments, questions, or points of view at cesto@aol.com.

Family Medicine Opportunities across Los Angeles!

Providence Health & Services operates dozens of hospitals and hundreds of primary and specialty care clinics across the West, including Los Angeles County. We also partner with private groups to recruit the best providers. We offer diverse communities, settings and practice models, including some with loan repayment and visa sponsorships.

LEARN MORE AT www.providence.org/physicianopportunities or contact Rosa Park, rosa.park@providence.org (503) 215-1331

University of California • Irvine Faculty Position

in Orange County, CA The University of California, Irvine Department of Family Medicine, has openings for board-certified/eligible family physicians to join the UC Irvine faculty in the Health Sciences Clinical Series at the Assistant, Associate, or Professor level. We are seeking qualified individuals with a strong commitment to teaching of Medical Students and Residents.

DUTIES: Ambulatory practice which includes direct patient care, residency teaching, medical student teaching and inpatient service coverage. Obstetrical and procedure skills desirable.

REQUIREMENTS: American Board of Family Medicine certified or eligible, excellent clinical skills, interest in clinical teaching, eligible for UC Irvine Medical Center medical staff privileges, and proven leadership skills. Bilingual in either Vietnamese or Spanish desirable. Academic rank and salary are commensurate with experience. Applications will be considered until the positions are filled.

TO APPLY: Please log onto UC Irvine’s RECRUIT located at https://recruit.ap.uci.edu/apply/ or email tarslani@uci.edu Contact Details Taleen Arslanian • tarslani@uci.edu (714) 456-7081 UC, Irvine is an equal opportunity employer committed to excellence through diversity.

California Family Physician Fall 2012 19

o v e r v i e w o f h e a lt h c a r e r e f o r m

Four Total Lies About ACA...

From Death Panels To Obamacare

By Carla Kakutani, MD, FAAFP

Hundreds of reporters, supporters and protestors gathered to hear the Supreme Court ACA decision live while many thousands more followed along on TV, smartphones and laptops across the country. Millions of electrons and much ink had been used up in the weeks leading to this day, handicapping the outcome.

Conventional wisdom put the ACA as the underdog, even though at the beginning of the law’s journey to the Court, almost all legal scholars felt it was constitutional.

MYTH #2 The ACA will cause Medicare premiums to increase more than 100 percent in 2014.

Medicare beneficiaries are charged premiums to make up 25 percent of the estimated cost of running the program.

CMS calculates the premiums annually and can also roughly predict future premiums. The 2012 monthly premium was $99.50; future estimates run in the $ 110-120 per month range. There is nothing in the ACA that changes Medicare’s process for setting premiums.

MYTH #3 Obamacare is Sharia law, because it exempts Muslims from the individual mandate.

It was the politics and health policy junkie’s version of the Super Bowl, with the same sense of drama and excitement, as people waited for the opinion to be announced. For a few minutes several media outlets had the decision reported inaccurately, leading to momentary delight or despair for people on both sides of the political divide. But then the story flipped: the ACA was upheld, the individual mandate ruled constitutional as a tax and Chief Justice Roberts, whom many SCOTUS watchers thought would be a reliable vote to strike down the ACA, turned out to be the deciding vote to uphold it.

Believe it or not, this is #4 on the Snopes.com Top 25 rumors. There is language in the ACA to exempt established religious groups like Christian Scientists and Anabaptist sects that do not use or believe in mainstream health care and insurance, but nothing specifically exempting Muslims.

The exact regulations governing those exemptions have yet to be written. Remind patients that for those people not covered by Medi-Cal or an employer’s or parent’s policy, they will be eligible for subsidies to cover part of their premium for coverage purchased on the Exchange so that it won’t cost more than 9 percent of income.

So after all that fuss, why are there still so many myths surrounding the law? Part of the reason is that much of America hasn’t been paying attention. In a survey taken over the first four days following the Supreme Court decision, the Kaiser Family Foundation found that only 59 percent of those questioned were even aware the law had been upheld!

MYTH #4 Obamacare is funded by cuts to Medicare.

Myths born of both confusion and political expediency continue to thrive and spread. Be aware of these so you can educate patients, family and friends!

Yes and no. The “cuts to Medicare” are actually cuts to Medicare Advantage Plans, which were getting a reimbursement above the cost of standard Medicare to care for their plan members. Basically those plans are no longer getting to keep a nice “middle man” cut of the pie, but instead are being challenged to compete with standard Medicare on the same playing field. Opponents of the ACA have not bothered to spell out this distinction and want seniors to think the cuts came from their actual benefits.

The goal of the ACA is to slow the growth of Medicare spending by aligning incentives for quality and cost effective care, and cutting waste.

MYTH #1 Death Panels!

Yes, this myth is still going strong. Often people will get emails warning that seniors over a certain age will be denied treatments or have to go before some kind of “ethics board.” In 2011 a viral email stating that neurosurgeons would not be allowed to do surgery on anyone over age 70 prompted the American Association of Neurologic Surgeons to put out a written statement stating that there was nothing in the ACA that limited anyone’s access to appropriate procedures or care.

20 California Family Physician Fall 2012

The Supreme Court ruling allows the ACA implementation to move forward, but there still is much change coming.

Fear of change breeds rumors and myths, so expect patients to ask you about these and many others as we move toward 2014. It’s our job to stay informed, and CAFP is at the ready to assist.

CMS and CAFP Preceptorship Program a Success!

Centers for Medicare & Medicaid Services and CAFP kicked off a preceptor program for regional employees on August 29. The program was designed to increase CMS staff understanding of the challenges facing family physicians and inform the work CMS does that affects primary care physicians. The morning session began with Kevin Grumbach, MD, Chair, UCSF Department of Family and Community Medicine, discussing current challenges and opportunities in primary care followed by associate regional administrators discussing the impact of CMS’s various programs on primary care. In the afternoon, 12 CMS staff members, accompanied

by CAFP staff, visited family physicians in the San Francisco Bay Area. The entire day was considered a resounding success

by CMS Region IX Chief Medical Officer Betsy Thompson, MD, who proposed the idea. Dr. Thompson is providing assistance to CAFP in seeking to duplicate the preceptor program for state Medi-Cal staff. “CAFP, specifically Jane Cho, was great to work with and found fantastic practice sites for the clinic visits,” said Dr. Thompson. CAFP thanks Drs. Grumback, Mike Zimmerman, Bill Kapla and Larry Shore for opening their offices for the preceptorship visits!

Taman Hoang (medical student); Betsey Thompson, MD, CMS; Kevin Grumbach, MD; David Sayen, CMS SF Regional Administrator; Jon Langmead, CMS Regional Officer; and Jane Cho, CFP staff, participated in the August 29 program.

CAFP member Mike Zimmerman, MD (fourth from the left), hosted a group of CMS team members during the August 29 program.

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California Family Physician Fall 2012 21

o v e r v i e w o f h e a lt h c a r e r e f o r m

Supreme Court Decision: Here is What the Dissection Really Says

By Leah Newkirk

On Thursday, June 28, the US Supreme Court issued its decision on the Patient Protection and Affordable Care Act (ACA), a decision that CAFP and many other health care stakeholders celebrated, as the Court preserved the vast majority of the law. The broad strokes of the Court’s decision are probably familiar by now, but read on for a dissection of the decision and a description of its effect on California family physicians and their patients.

In a five-four decision and a line-up that surprised many, Chief Justice John Roberts authored the majority opinion, supported by Justices Breyer, Ginsburg, Kagan and Sotomayor.

The majority concluded that the individual mandate and Medicaid expansion were permissible, although they set limits on the repercussions for states that did not implement the expansion. The dissent, written by Justice Anthony Kennedy and joined by Justices Scalia, Thomas and Alito, argued that the entire reform law should have been struck down. The dissent argued that the law exceeds federal power in mandating the purchase of health insurance and in denying non-consenting states all Medicaid funding.

Four basic questions were before the Court: Can the Supreme Court Decide on the Constitutionality of the ACA Now? The Supreme Court considered whether the 1867 Tax AntiInjunction Act, which bars people from suing over a tax until after the tax is paid, barred this lawsuit. The ACA requires that people purchase health insurance or pay a penalty (the individual mandate), beginning in 2014. Because no penalties will be paid until 2015, the Supreme Court had the opportunity to punt until that time. Chief Justice Roberts and the majority did not take this opportunity; they concluded that the label used by Congress (i.e., “penalty”) is significant for the purposes of the Tax Anti-Injunction Act. Because it was not labeled a tax, the Tax Anti-Injunction Act did not apply.

This part of the decision was not a surprise. What was a surprise is some of the judicial wizardry that followed.

22 California Family Physician Fall 2012

Is the Individual Mandate Constitutional?

The second legal question before the Court was whether Congress has the authority under the Commerce Clause of the Constitution to require Americans to purchase a product – health insurance. The majority held that the individual mandate was not a valid exercise of Congress’s power under the Commerce Clause, but that the decision did not end there. The majority described the Court’s obligation to show deference to Congress and find any reasonable construction of a statute that could save it from unconstitutionality. The majority then concluded that for purposes of this review, the individual mandate could be construed as a tax and upheld it as within Congress’s power to tax.

For those who find this “yes, it’s a penalty, no, it’s a tax” construction confusing or even disingenuous, you are not alone. The dissenting justices fumed that the argument “carries verbal wizardry too far, deep into the forbidden land of the sophists.” The majority comforted itself with precedent, or earlier Supreme Court decisions that applied a different test to determine whether a law constitutes a tax for constitutional purposes than it did to determine whether the same law constitutes a tax for statutory jurisdiction purposes (i.e., the Tax Anti-Injunction Act).

Supreme Court Decision, continued on page 24

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o v e r v i e w o f h e a lt h c a r e r e f o r m Supreme Court Decision, from page 22

If the Individual Mandate is Unconstitutional, Can the Rest of the ACA Go Forward?

After determining that the individual mandate is constitutional, the Court did not need to delve very far into the “severability” of the ACA’s various provisions. It preserved the individual mandate and therefore preserved the law, with one exception.

the blind, the elderly, and needy families with dependent children…Under the [ACA], Medicaid is transformed into a program to meet the health care needs of the entire non-elderly population with income below 133 percent of the poverty level. It is no longer a program to care for the neediest among us, but rather an element of a comprehensive national plan to provide universal health insurance coverage.”

Is the Medicaid Expansion Constitutional?

Family Physicians and the ACA Going Forward

The ACA expands Medicaid eligibility to adults earning 133 percent of the federal poverty level. For states to continue receiving any federal money for Medicaid, the ACA required them to comply with this expansion. The final question before the Court was whether this requirement – withholding all funding for Medicaid – is unconstitutional.

The California Academy of Family Physicians (CAFP) supported the ACA and is pleased with the Supreme Court’s decision. CAFP leaders believe California family physicians will benefit from the ACA provisions that advance new health care delivery models, such as the patient centered medical home, and address the primary care physician shortage.

CAFP supported the individual mandate as an integral part of the ACA. Economic realities dictate that ensuring affordable coverage for all Americans depends on the participation of all Americans.

The ruling generates uncertainty surrounding the Medicaid expansion in many states, but not California.

California’s legislative and regulatory leaders have vowed to move ahead with the expansion and implementation of the law.

The majority decision permits the Medicaid expansion, extending coverage to adults with incomes up to 133 percent of the federal poverty level beginning in 2014, to go forward, but struck down the provision of the ACA that required the federal government to withhold all Medicaid funding from a state that failed to comply with the expansion. Chief Justice Roberts wrote “[a]s a practical matter, that means states may now choose to reject the expansion... but that does not mean all or even any will.”

To get to this decision, after decades of allowing Congressional changes to the Medicaid program, the majority focused on the qualitative difference in the Medicaid program, under the ACA, writing that the expansion “accomplishes a shift in kind, not merely degree.

The original program was designed to cover medical services for four particular categories of the needy: the disabled, 24 California Family Physician Fall 2012

Overall, the Supreme Court decision lifts much of the uncertainty surrounding the ACA for family physicians and their patients. Health care reform is likely here to stay. Some political uncertainty remains, with a looming presidential election and a Republican party that has vowed to repeal the law, but the legislative hurdles to repeal are many and only become more difficult to overcome over time.

The ruling generates uncertainty surrounding the Medicaid expansion in many states, but not California. California’s legislative and regulatory leaders have vowed to move ahead with the expansion and implementation of the law.

Family physicians are likely to see increases in the number of patients wanting their services – and resulting challenges related to access and burgeoning patient panels – as the ACA extends coverage to millions of previously uninsured Californians.

Family physicians should also pay close attention to the ACA provisions related to payment innovation — shared savings programs, bundled payments and pay-for-performance initiatives, for example — and health care purchasers’ increased focus on reining in health spending and improving quality. These have only increased the impetus for family physicians to transform the delivery of care to the patient centered medical home model.

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Lead Poisoning Can Be Prevented … And Here is How

By Jean Woo, MD, MPH, MBA Medical Consultant Childhood Lead Poisoning Program

Management guidelines for lead-exposed children Because lead is widespread and enduring in the environment, childhood lead poisoning remains the most common, preventable environmental disease among California children. Anticipatory guidance by health care providers to prevent lead exposure is mandatory for all young children. Most lead-burdened children are asymptomatic, so routine blood testing of those at risk is key to early diagnosis and removal from the lead source.

Since 1991, the Centers for Disease Control and Prevention (CDC) had used 10 mcg/dL as a “level of concern,” but studies have shown harmful effects of lead below 10 mcg/ dL, and have not shown any safe lead level. In May 2012, CDC set a “reference value” of 5 mcg/dL for management of children between 6 months and 6 years, based on the 97.5th percentile of the blood lead level (BLL) distribution in U.S. children aged 1–5 years. However, even a BLL less than 5 mcg/dL can have adverse effects.

No known safe level of lead in the body California has mandated a standard of care for the medical management of lead-exposed children that requires anticipatory guidance and BLLs at specified times.

California’s current Management Guidelines, based on a child’s BLL and issued by the Childhood Lead Poisoning Prevention Branch (CLPPB) and the Child Health and Disability Prevention Program, are available at www.cdph. ca.gov/programs/CLPPB/Documents/HAGS_201107.pdf .

Effect of lead poisoning Lead crosses the placental barrier, and prenatal exposure is associated with intra-uterine growth restriction, maternal hypertension, and an increased frequency of spontaneous abortion.

In children, the main absorption of lead is gastrointestinal.

Lead’s primary effect is neurodevelopmental, and can result in learning disabilities, cognitive deficiencies, and decreased IQ. Lead is associated with anemia, hypertension, cardiovascular and renal disease, delayed puberty, and reduced fertility. 5 Lead exposure has also been linked to Attention Deficit Hyperactivity Disorder, 5

26 California Family Physician Fall 2012

increased school drop-out rates, and aggressive behavior.

Sources of lead exposure The most common childhood lead hazards are lead-based paint and lead in dust and soil resulting from leaded gasoline, air emissions, and paint deterioration. Young children play in dust or soil that may be contaminated with lead and then put their hands or playthings in the mouth.

Lead poisoning has been reported due to water or pipes in some areas, lead brought home by a worker whose job involves lead, and use of such hobby items as bullets and fishing sinkers. Immigrants or foreign adoptees may have been exposed in their country of origin. 9 Other sources, while less common, add to the cumulative body burden. Lead-containing consumer products continue to be identified, 10 including alternative remedies (e.g., greta, azarcon, some Ayurvedic medications), imported eyeliner (kohl, surma), and imported foods (spices, dried plums, candy, fried grasshopperschapulines). Ingesting dirt or clay during pregnancy, even chewing on clay pots, is practiced in some cultures.

WHAT YOU CAN DO • Provide anticipatory guidance to parents and caregivers of all children between 6 months and 6 years of age. 6 • Order blood testing as recommended by the California Management Guidelines for Health Care Providers. 7 • Recognize that a highly elevated BLL in a person of any age is an urgent or emergency situation requiring immediate action. While lead poisoning is typically asymptomatic, acute lead exposure must be considered when a patient presents with seizures, encephalopathy, or a history of pica or small-object ingestion. A venous BLL and an abdominal x-ray, in the case of a swallowed non-food object, are necessary to confirm the diagnosis.

• Remember that venous blood draws are required for all but general screening because capillary specimens are easily contaminated.

• Pay close attention to developmental delays and behavioral issues in lead-exposed children. Encourage

early childhood enrichment activities.

• Stress good nutrition because iron, calcium, and vitamin C may lessen or prevent absorption of lead by the body.

• Refer recent immigrants or household members of lead-exposed children (especially pregnant or nursing women) for BLLs. • Work with the local or state childhood lead poisoning program to identify and remove lead hazards, and to provide ongoing case management.

• Be both attentive to possible sources of exposure and sensitive to culture. Not all cultural practices or imported products are harmful, and not all items produced in the U.S. are lead-free.

Contact the State of California, CLPPB, for further information at http://www.cdph.ca.gov/programs/CLPPB/ Pages/default.aspx or (510) 620-5600.

National Childhood Lead Poisoning Prevention Week is October 21-27, 2012. Contact your local childhood lead poisoning prevention program at http://www.cdph. ca.gov/programs/CLPPB/Pages/CLPPPIndex.aspx for lead poisoning prevention information, activities and events.

1. MMWR May 27, 2005 / 54(20); 513-516.

2. Canfield et al. NEJM 2003; 348(16):1517-26.

3. Koller et al. EHP, Jun 2004.

4. Bellinger, Current Opinions in Pediatrics, 2008, 20:172177.

5. http://www.cdc.gov/nceh/lead/ACCLPP/CDC_ Response_Lead_Exposure_Recs.pdf.

6. California Code of Regulations, Sec. 3700-37100, Screening for Childhood Lead Poisoning, http:// cdphinternet/programs/CLPPB/Pages/ScreenRegs-CLPPB. aspx.

7. www.cdph.ca.gov/programs/CLPPB/Documents/ HAGS_201107.pdf.

8. Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women, www. cdc.gov/nceh/lead/publications/LeadandPregnancy2010. pdf.

9. Guidelines on lead poisoning in immigrants and refugees, http://www.cdc.gov/immigrantrefugeehealth/ guidelines/lead-guidelines.html 10. See http://www.cdc.gov/nceh/lead/Recalls/default. htm for recent alerts.

California Family Physician Fall 2012 27

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Executive Vice President’s Forum

Look Closely and You’ll Find Good Stuff for FPs and Their Patients in the ACA

Examining some of the practical applications of the Patient Protection and Affordable Care Act, one finds some pretty good stuff for family physicians and their patients. Provisions extending coverage of children to age 26 under their parents’ insurance plans and elimination of pre-existing conditions as a reason to deny coverage have been addressed in previous issues of California Family Physician.

On July 31, the Centers for Medicare and Medicaid Services announced that effective that day, certain preventive services would be offered without cost sharing in all new health plans (with the exception of group health plans and issuers that have maintained grandfathered status and certain nonprofit religious organizations, such as churches and schools, which are excused from covering these services). The services were selected based on recommendations from the Institute of Medicine, which relied on independent physicians, nurses, scientists and other experts as well as evidence-based research to develop its recommendations.

The services are: • Well-woman visits

Previously some of these services were not covered at all and others required co-pays and deductibles. The new rules in the health care law requiring coverage of these services take effect at the next renewal date – on or after Aug. 1, 2012 – for most health insurance plans and are expected to apply to approximately 47 million women.

“On July 31, the Centers for Medicare and Medicaid Services announced that effective that day, certain preventive services would be offered without cost sharing in all new health plans...”

• Gestational diabetes screening • Domestic and interpersonal violence screening and counseling • FDA-approved contraceptive methods and contraceptive education and counseling • Breastfeeding support, supplies and counseling • HPV DNA testing, for women 30 or older • Sexually transmitted infections counseling for sexually-active women • HIV screening and counseling for sexually-active women

30 California Family Physician Fall 2012

The costs to patients of the above services have not been insignificant. For example, a woman on oral contraceptives can expect to pay more than $3,300 over five years for her prescriptions and some other forms of contraception have not been covered at all. Family physicians will be paid for the above services consistent with their insurance contracts, although co-pays will be waived.

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