Fall-Winter 2018 by Merced-Mariposa County Medical Society

Fall/Winter 2018

C M A O U T L I N E S B O L D H E A LT H C A R E AG E N DA TO I M PR OVE PA T I E N T A F FO R DA B I L I TY, ACC E S S A N D Q UA L I TY

2018

HOUSE OF

DELEGATES

CONTENTS

The Bulletin MMCMS Leadership Officers

Eduardo T. Villarama, M.D. President

2018 HOUSE OF DELEGATES

Tahir Yaqub, M.D. President-Elect Timothy S. Johnston, M.D. Secretary-Treasurer Thavalinh Mark Sphabmixay, M.D. Immediate Past-President

Governors

19 MEDICAL STAFF PREVAILS IN LEGAL BATTLE OVER MEDICAL STAFF SELF-GOVERNANCE

E. Kip Hensley, M.D. Alfred B. Johnson, M.D. Oscar V. Ramos, M.D. Atul T. Roy, M.D. Ajinder Singh, M.D. Mark W. Via, M.D.

CMA Delegates Donald P. Carter, M.D. Pamela Roussos, D.O.

21 CMA LEGISLATIVE WRAP-UP

CMA Alternate Delegates Timothy S. Johnston, M.D. Oscar V. Ramos, M.D.

Staff Chrisy Muchow Executive Director

Contact Information

2848 Park Avenue, Suite C Merced, CA 95348 (209) 723-2976 Fax: (209) 723-8371 chrisy@mmcms.org www.mmcms.org

OPIOID ADVOCACY

MORE ARTICLES, EVENTS & RESOURCES: 5

PRESIDENT’S MESSAGE… Eduardo T. Villarama, MD MMCMS President

OUR HOLIDAY PARTY IN PICTURES, ETC.

EVENT: MEDICARE CHANGES: 2019 AND BEYOND

CMA’S ADVOCACY SECURES $1 BILLION+

The Bulletin is published quarterly by the Merced-Mariposa County Medical Society, 2848 Park Avenue, Suite C Merced, CA 95348. Phone (209) 723-2976; Fax (209) 723-8371; Email chrisy@mmcms.org; Website www.mmcms.org. The Bulletin does not assume responsibility for author’s statements or opinions; opinions expressed are not necessarily those of The Bulletin or the Merced-Mariposa County Medical Society. Acceptance of advertising in The Bulletin of the MercedMariposa County Medical Society in no way constitutes approval or endorsement by MMCMS of products or services advertised, and MMCMS reserves the right to reject any advertisement.

For Advertising Opportunities Contact Chrisy Muchow at (209) 723-2976 or chrisy@mmcms.org.

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PRESIDENT’S MESSAGE…Eduardo T. Villarama, MD Greetings! I want to take this opportunity to express my sincerest gratitude to all the Officers and Board of Governors of the Merced-Mariposa County Medical Society, you are what makes our Medical Society functional, strong and relevant. I also want to thank each and every member of our Medical Society for your ongoing support and belief in the value and significance of our Medical Society, thank you very much! The healthcare industry is ever changing and ever evolving, we need to stay alert with changes in laws and processes that affect our profession and the delivery of healthcare services to our patients. Your Medical Society keeps track and actively participates in the discussions that concern policies affecting our community and the House of Medicine. Our recent victory against AB 3087 that called for rationing of healthcare services and against Proposition 8, Limits on Dialysis Clinics’ Revenue and Required Refunds Initiative, is a great testament to the significance of a Medical Society working with our professional partners in the community in affecting these types of measures to protect our profession and our patients. We need to remain on guard at all times and recruit more members to join our cause and fight for better regulation of healthcare services, so I challenge you all to become more active members of our Medical Society and consider serving as Officers or Board members to bring more ideas and energy to the group. I also challenge you to talk to your colleagues and friends that are currently non-members to join and help strengthen our Society. Please refer to our website (www.mmcms.org) and connect or refer them to our Executive Director or any of our Officers or Board members so we may provide further information as needed. I would like to give a special shout out to Dr. Kip Hensley, who is currently finishing his term as a Board Member for 19 consecutive years, the longest term any board member has served and currently on his 29th year as a member of MMCMS. Thank you very much Dr. Hensley! I also would like to recognize Dr. Eric Disbrow for celebrating his 45th year as a member of MMCMS. Thank you very much Dr. Disbrow! The following are the events that we have engaged and participated in over the last few months and the upcoming events for the next couple of months: AUGUST—The 2018-2019 MMCMS Membership Directory was mailed out. All member physicians should have received at least one copy.

AUGUST 6—We had our bimonthly Board of Governors meeting. Highlights of this meeting were the vote to oppose Proposition 8, the Limits on Dialysis Clinics’ Revenue and Required Refunds Initiative and the vote to update our Logo. We regularly discuss membership, finances, upcoming events, approve new applicants and discuss topics that are brought to the Board’s attention. AUGUST 21—Dr. Johnston, Dr. Carter, Dr. Roussos and Chrisy participated in the 4th Quarter online GoToMeeting with District VI (our CMA district) that is necessary under CMA’s Governance structure. They reviewed 6 resolutions submitted by physicians throughout California. Following are the titles of the resolutions reviewed:  A MORE APPROPRIATE APPROACH TO A PARKINSON'S DISEASE DATABASE  LIVE STREAMING OF CMA BOT MEETINGS  SOLO AND SMALL GROUP PRACTICE FORUM REPRESENTATION  UPDATE TO CMA BYLAWS RE: DELEGATE AND ALTERNATE REPRESENTATION AS ELECTED  REFORM OF THE MEDICAL BOARD OF CALIFORNIA  CLOSING THE GENDER PAY GAP IN MEDICINE SEPTEMBER 20—We had our MMCMS General Membership meeting. The featured speaker was CMA President-Elect, David Aizuss, MD. There were 34 attendees and it was very well received. SEPTEMBER 24—We had our bimonthly Board of Governors meeting. The highlight of this meeting was the discussion of the Major Issues reports for the CMA’s House of Delegates. We regularly discuss membership, finances, upcoming events, approve new applicants and discuss topics that are brought to the Board’s attention. SEPTEMBER 25—Dr. Ramos, Dr. Carter, Dr. Roussos and Chrisy participated in the Pre-HOD online GoToMeeting with District VI (our CMA district). They reviewed 4 reports that were reviewed in more detail at the CMA’s House of Delegates. Following are the titles of the reports reviewed:  ADDRESSING UTILIZATION THROUGH IMPROVED CARE DELIVERY  ENHANCING COMPETITIVENESS OF HEALTHCARE MARKET  REDUCING ADMINISTRATIVE BURDENS ON PHYSICIAN PRACTICES  ADDRESSING INCREASING PHARMACEUTICAL COSTS OCTOBER 12—Chrisy attended the California Medical Executives meeting in Sacramento. The purpose of this meeting is for the Executive Directors/CEO’s of the medical societies and CMA to collaborate. (Continued on page 7)

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OCTOBER 13-14 – Dr. Carter, Dr. Roussos and Chrisy participated in the 147th CMA House of Delegates. The House reviewed Major Issues concerning different aspects of Addressing the Cost of Healthcare.

 TRACKING OUTCOMES & SUPPORTING BEST PRACTICES OF

OCTOBER 31 – We had our KNOW YOUR RIGHTS: How to Protect Your Practice From Payor Abuse event. There were 15 people (2 physicians, 13 staff) in attendance and it was very well received.

DECEMBER 12—We had our annual Holiday Party where we honored Dr. Kip Hensley for 19 consecutive years of service to our Board of Governors and I was honored for my year of service as president. Thank you so much! It was also the first year of our new member recognition program and many of our members were honored for their years of membership in MMCMS (for details see page 14). In addition, our 2019 President, Dr. Tahir Yaqub made a few remarks and the 2019 Officers and Board members were announced. Thank you Dr. Yaqub for your willingness to serve as our President for 2019!

NOVEMBER 12—We had our bimonthly Board of Governors meeting. Highlights of this meeting were the vote to approve our new membership recognition program and the vote to approve our 2019 budget. We regularly discuss membership, finances, upcoming events, approve new applicants and discuss topics that are brought to the Board’s attention. NOVEMBER 27—Dr. Carter and Chrisy participated in the 1st Quarter online GoToMeeting with District VI (our CMA district) that is necessary under CMA’s Governance structure. They reviewed 24 resolutions submitted by physicians throughout California. Following are the titles of the resolutions reviewed:  SUPPORTING AUTONOMY FOR PATIENTS WITH DIFFERENCES OF SEX DEVELOPMENT  REPEAL ANTI-CAMPING ORDINANCES TO PROTECT THE HEALTH OF HOMELESS INDIVIDUALS  DECREASING BURDEN OF CURES US BY PROVIDER PARTNERS  REQUIREMENT FOR GENDER AFFIRMING SERVICES WITHIN HEALTH INSURANCE PLANS  YOGA THERAPY TO SUPPORT THE HEALTH AND WELL-BEING OF PATIENTS  SCREENING, INTERVENTION AND TREATMENT FOR ADVERSE CHILDHOOD EXPERIENCES (ACES)  REDUCING HASSLE FACTOR IN QUALITY IMPROVEMENT PROGRAMS  MEDICATION ASSISTED TREATMENT (MAT) AND TELEMEDICINE  CHANGE IMMUNIZATIONS FROM MEDICARE PART D TO PART B COVERAGE  ROOT CAUSE ANALYSIS OF MEDICAL DISASTERS  MEDICARE PART B DRUG PRICE NEGOTIATIONS  PREVENT FURTHER REDUCTION IN PEDIATRIC BEDS IN CALIFORNIA  LIVE STREAMING OF CMA BOT MEETINGS  UPDATE TO CMA BYLAWS RE: DELEGATE AND ALTERNATE REPRESENTATION AS ELECTED  ESTABLISHMENT OF MEMBER INTEREST GROUPS/CHAT ROOMS  REFERENCE COMMITTEES FOR THE HOUSE OF DELEGATES  SUPPORT FOR DISSEMINATION OF NEGATIVE RESULTS  DIVESTMENT FROM THE GUN AND AMMUNITION INDUSTRIES  GUN VIOLENCE: COMPENSATION FOR HEALTHCARE EXPENDITURES  HOLDING THE PHARMACEUTICAL INDUSTRY ACCOUNTABLE FOR OPIOID-RELATED COSTS  PHYSICIANS AND JURY DUTY  FLEXIBLE MATERNITY AND PATERNITY LEAVE FOR RESIDENTS

HEALTH PIPELINE PROGRAMS  GRADUATE MEDICAL EDUCATION AND THE CORPORATE

PRACTICE OF MEDICINE

Your 2019 MMCMS Officers and Board of Governors: Tahir Yaqub, MD, President Timothy Johnston, MD, President-Elect Oscar Ramos, MD, Secretary-Treasurer Eduardo T. Villarama, MD, Immediate Past-President Thomas Barrett, MD, Board Member Gabriel Garcia Diaz, MD, Board Member Alfred B. Johnson, MD, Board Member Atul T. Roy, MD, Board Member Ajinder Singh, MD, Board Member Glen Villanueva, MD, Board Member Donald P. Carter, MD, CMA Delegate Pamela Roussos, DO, CMA Delegate Leena Chaudhury, MD CMA Alternate Delegate Timothy S. Johnston, MD, CMA Alternate Delegate Our 2nd Quarter online GoToMeeting with District VI (our CMA district) is on March 5. Any member physician is welcome to submit a resolution for review by the CMA House of Delegates. The next deadline for resolution submission is January 21. Our MEDICARE UPDATE 2019 event will be on January 24. We approved 14 new physicians for membership. Nadir E Adam, MD of Dignity Health Medical Group, Rohit Arora, DO of Livingston Community Health, Ibrahim W Azer, MD of Dignity Health Medical Group, Christopher P. Costa, MD of Golden Valley Health Centers, Carlos M Diaz, MD of Olivewood Pediatrics, R. Michelle Porras, MD of Olivewood Pediatrics and the following residents from the Mercy Medical Center Family Medicine Residency Program: Thomas A Barrett, MD, Gregory R Ceus, MD, Amineh S El-Ghali, DO, Travis A Lyon, DO, Rajbinder K Mann, MD, Thu P Truong, MD, Massud R Weiss, MD and Wiktoria Z Zaleska, MD. I wish you the best of the Holiday Season and a great start for the New Year! It has been both a privilege and an honor to serve as your County Medical Society President for 2018. Respectfully, Eduardo T. Villarama, MD MMCMS President 2018

2018

HOUSE OF

DELEGATES

C M A O U T L I N E S B O L D H E A LT H C A R E AG E N DA TO I M PR OVE PA T I E N T A F FO R DA B I L I TY, ACC E S S A N D Q UA L I TY > >

2018 HOUSE OF DELEGATES Dear Physician Colleagues, In October, the California Medical Association (CMA) convened its 147th annual House of Delegates (HOD) meeting in Sacramento. Over 500 California physicians convened to debate on the most critical issues affecting members, the Association and the practice of medicine. The major focus of HOD was the creation of an initial framework for a bold agenda to increase health care affordability, improve health care delivery, create efficiencies throughout the health care system, and improve health outcomes, which includes addressing social determinants of health and expanding telehealth services. Virtually all of us have directly witnessed the impacts on our patients, but the following statistics bear repeating because they reinforce the critical nature of CMA’s charge:

because it’s hurting our patients’ ability to access needed care, treatment and medications. No family should have to forego medical care to pay household bills or take on debt, yet that is exactly the situation more Californians are facing. If health care isn’t affordable, then it isn’t accessible, and the California health care system must do better for our patients.” With physicians at the center of health care delivery, CMA has long advocated on behalf of our patients to ensure they are receiving affordable, timely and quality care, and we doubled down on that commitment at HOD. After hearing expert testimony, CMA debated and identified four critical issues that California must address to make health care affordable while improving quality and access:  Reform

health care delivery and utilization by making payment and delivery more efficient, as well as expand telehealth.

 Prescription drugs prices have increased 25 percent

since 2012 (Health Care Cost Institute).  Health

insurance deductibles have more than doubled since 2008, and half of all workers now have a deductible of at least $1,000 for an individual, up from 22 percent in 2009 (Kaiser Family Foundation).

 Employer-sponsored

 Expand

patient choice and affordability by increasing competition throughout health care with market-based solutions.

 Maximize physicians’ time spent with patients by

reducing administrative burdens and eliminating duplicative tasks that add unnecessary costs without improving health outcomes. CMA also remains committed to ensuring that all modes of medical practices are financially vibrant.

insurance premiums have risen from $6,000 in 1999 to more than $18,000 in 2016, and out-of-pocket costs have increased by more than 53 percent between 2006 and 2016 (Economic Policy Institute).

 Ensure patients have access to necessary treatment

 The average American spent $10,345 on health care

and medications by addressing pharmaceutical costs.

in 2016, yet roughly 41 percent of Americans say they can’t pay a $400 emergency expense without borrowing or selling something (Centers for Medicare and Medicaid Services, Federal Reserve).  Thirty-three

percent of Americans with health insurance said they or a family member had problems affording care in the last year (Kaiser Family Foundation survey).

 Twenty-seven percent of our time is spent with

patients, while nearly half is spent on electronic health records or other desk work. Spending three hours a day on administrative tasks equals a loss of 2,200 patient visits per physician per year. (Annals of Internal Medicine)

In the coming months, CMA will develop targeted, pragmatic and workable solutions, as well as continue to work with our members, health care stakeholders and policymakers to ensure patients can access quality care in an affordable and timely manner. As a physician-led organization, CMA’s collective strength is derived from the dedication and passion of its membership. We thank the HOD delegates, and we thank you for your continued commitment to patients and the profession. On the following pages you will find more highlights from this year’s House of Delegates. Sincerely,

CMA President David H. Aizuss, M.D., put it best: “Health care costs continue to grow, with patients paying more and getting less–except for more runarounds, fine print and larger medical bills. This is our current reality and the battle we must fight,

Lee T. Snook, Jr., M.D., CMA Speaker of the House Tanya W. Spirtos, M.D., CMA Vice-Speaker of the House

2018 HOUSE OF DELEGATES LOS ANGELES OPHTHALMOLOGIST INSTALLED AS 151ST PRESIDENT OF CMA CMA installed Los Angeles ophthalmologist David H. Aizuss, M.D., as its 151st president during the organization’s annual House of Delegates meeting in Sacramento. In his address to the delegates, Dr. Aizuss said that physician satisfaction and practice sustainability would be among his top priorities in the upcoming year. “The presence of third parties in clinical decision-making is corrosive to our relationship with patients,” said Dr. Aizuss. “We must protect both our patients and professional prerogatives, independence and authority.” Dr. Aizuss also noted that heavy administrative demands and emerging payment systems have forced physicians to spend increasing amounts of time on computer work at the expense of patient care, leading to physician dissatisfaction and burnout. “CMA recognizes the urgent need for additional programming to mitigate physician burnout...Good care includes caring for us, the physicians,” said Dr. Aizuss. Dr. Aizuss officially took over from Immediate Past President Theodore M. Mazer, M.D., at the end of HOD, and will serve a term of one year. “Our CMA brand has strength, effectiveness, power and influence,” said Dr. Aizuss. “My goal as your president is to be an effective spokesman and to communicate your concerns, desires, needs and hopes for a professionally satisfying medical practice and effective patient care.” Dr. Aizuss has been a CMA and Los Angeles County Medical Association (LACMA) member for 37 years. He has been a member of the CMA Board of Trustees since 2010—serving as vice-chair and chair of the board before being named president-elect at last year’s HOD. Dr. Aizuss has also represented the physicians of California as a delegate to the American Medical Association (AMA), and is currently serving on the AMA Council on Legislation. Dr. Aizuss is a former president of LACMA and the California Academy of Eye Physicians and Surgeons. Through the David H. Aizuss, M.D., Medical Corporation, and the Ophthalmology Associates of the Valley Medical Surgical Group, a partnership of medical corporations, Dr. Aizuss focuses exclusively on direct patient care. He is a medical staff member at Tarzana Hospital and West Hills Hospital in Los Angeles County, and serves as an assistant clinical professor of ophthalmology at the David Geffen School of Medicine at UCLA. He received his medical degree from Northwestern University Medical School and completed his residency and fellowship in ophthalmology at the Jules Stein Eye Institute in Los Angeles.

THE FULL 2018-2019 CMA EXECUTIVE COMMITTEE INCLUDES: PRESIDENT: David H. Aizuss, M.D., Los Angeles PRESIDENT-ELECT: Peter N. Bretan, Jr., M.D., Watsonville CHAIR OF THE BOARD: Robert E. Wailes, M.D., Oceanside/Encinitas VICE-CHAIR OF THE BOARD: Shannon L. Udovic-Constant, M.D., San Francisco SPEAKER OF THE HOUSE: Lee T. Snook, Jr., M.D., Sacramento VICE-SPEAKER OF THE HOUSE: Tanya W. Spirtos, M.D., Redwood City IMMEDIATE PAST PRESIDENT: Theodore M. Mazer, M.D., San Diego

2018 HOUSE OF DELEGATES

UROLOGIST AND TRANSPLANT SURGEON NAMED CMA PRESIDENT-ELECT Urologist and kidney transplant surgeon Peter N. Bretan, Jr., M.D., was elected by the CMA House of Delegates as the association’s new president-elect. He assumed office at the close of this year’s meeting and will serve as on the CMA Executive Committee as president-elect for one year. Dr. Bretan will be installed as president at the close of the 2019 House of Delegates. He will be the first Filipino-American physician to serve as CMA president. Dr. Bretan practices in Marin, Sonoma and Santa Cruz counties. He has served as a CMA trustee and delegate, and is a three-time county medical society president. He is the current president of the California Urological Association and serves as an adjunct clinical professor at Touro University, where he has taught classes in health care policy for the past 15 years. Dr. Bretan is also the founder and CEO of Life Plant International, a charitable organization that promotes disaster preparedness, organ donation and early disease screening worldwide. He has provided care around the world on medical missions. "My greatest motivation is in service to give back to society for my good fortune. I grew up a s a child farm laborer, and I know what it is to be without adequate health care,” said Dr. Bretan. Dr. Bretan earned his B.S. in physiology from UC Berkeley and his medical degree from the UC San Francisco, where he completed residencies in general surgery and urology, as well as a fellowship in radiology. He also completed a fellowship at The Cleveland Clinic Foundation in transplantation and renovascular surgery.

MODESTO FAMILY PHYSICIAN RECEIVES CMA’S PRESTIGIOUS “COUNTRY DOCTOR” AWARD Modesto family physician Silvia Diego, M.D., was honored at the 2018 CMA House of Delegates with the association’s most prestigious award, the Frederick K.M. Plessner Memorial Award. The award honors a California physician who best exemplifies the ethics and practice of a rural country practitioner. The daughter of farmworker parents, Dr. Diego grew up in the small town of San Joaquin in western Fresno County. She was the first in her family to graduate from college, and went on to get her medical degree from Stanford University School of Medicine—one of the top medical schools in the nation. After graduating from medical school in 1994, Dr. Diego completed her residency in family medicine at the Stanislaus Medical Center in Modesto, and has remained in Stanislaus County ever since, with a mission of providing care to the poor and uninsured. “I am really very passionate about taking care of my patients—about helping them get the very best health care that they can,” said Dr. Diego. “What is really important, is to care for your patients with compassion and respect.” Dr. Diego practiced for 18 years at the nonprofit Golden Valley Health Centers, where for eight years she served as chief medical officer. In that role she oversaw care for 20 primary care clinics and more than 100,000 patients. Dr. Diego selflessly stood up for her patients when a new management policy sought to increase patient numbers at clinics in response to the wave of Medi-Cal enrollments through the Affordable Care Act. Dr. Diego stood her ground, insisting that doing so meant they would have to compromise the quality of the care they were known in (Continued on page 13)

2018 HOUSE OF DELEGATES (Continued from page 12)

the community for providing. Ultimately, Dr. Diego and Golden Valley Health Centers parted ways after irreconcilable differences over these new policies, which she believed would undermine care for low-income and indigent patients. Now in private practice at Family First Medical Care, Dr. Diego has maintained her commitment to providing patients with the very best care—with a focus on those most in need. Even though it’s a financial challenge for the practice, 50 percent of her patients are on either Medi-Cal or government-assistance programs. Dr. Diego has been a member of CMA and the Stanislaus Medical Society (SMS) for more than two decades. She is a past president of SMS and is currently a member of the CMA House of Delegates. This year, she was the first female physician named as Stanislaus Physician of the Year.

FRESNO EMERGENCY PHYSICIAN RECEIVES CMA’S COMPASSIONATE SERVICE AWARD Fresno emergency physician Kenny Banh, M.D., was selected as the 2018 recipient of the CMA Compassionate Service Award, which honors a CMA member physician who best illustrates the association’s commitment to community and charity care. Dr. Bahn was honored for his role in creating the first medical student-run mobile health clinic in the Central Valley, with the ultimate goals of training the next generation of San Joaquin Valley physicians, increasing the diversity of the medical profession, and providing a significant and positive impact to the valley for those who do not have the normal access to care. California’s Central Valley has one of the highest underserved populations in the state, with one of the lowest ratio of physicians to population. Dr. Bahn’s hope for the mobile clinic was to reach some of those patients who are overlooked or do not have a way to access care on their own—all while giving medical students (and soon undergraduates) hands-on experience to learn first-hand about the challenges and rewards of patient care and community medicine. Today, his mobile clinic concept has come to reality, providing 100 percent free services to its patients. The clinics focus on several areas, including pediatric school outreach in rural areas, LGBT communities, undocumented and homeless communities. The first clinic Dr. Bahn developed was for gender health, working with the LGBT community to provide a safe, supportive environment at every stage of the coming out or transition process. Another clinic provides health care and screenings services to the homeless population in the Central Valley, offering them what is often their only access to health care.

“The reason I felt Dr. Banh deserved this award is because he did all off this on his own!” said Nicole Butler, executive director of the Fresno Madera Medical Society. During his own downtime he worked on applying for grants, reaching out for donations and coordinating with the communities involved on how to make the clinics happen. “The overall concept is modeled after the UC Davis student-run clinics, but if it wasn’t for Dr. Banh’s passion to care for his community, this program would have never been developed here.” Dr. Bahn is board-certified in Emergency Medicine. He earned his medical degree at Drexel University College of Medicine and completed his residency in emergency medicine at UCSF Fresno. He has stayed in the area where he was trained and has been practicing and giving back ever since.

Our Holiday Party in Pictures,

Thank you, Dr. Villarama for Serving as Our 2018 President

Honoring Our Outgoing President, Not Pictured:

Eric C. Disbrow, MD

Mohan P. Reddy, MD

Pictured left to right:

Carlos C. Say, MD, Man-Siak Mak, MD and Gary C. Graham, MD

Pictured left to right:

Maureen Reid and James G. Reid, MD

Not Pictured:

Pictured left to right:

Salvador Sandoval, Jr., MD, MPH, Julian Y. Yip, MD and Thomas B. Bryan, MD

Frank W. Berry, MD Steven K. Hansen, MD Maciej G. Ossowski, MD Annapurna M. Reddy, MD Steven L. Taggart, MD

Honoring Board Members and... Not Pictured:

Chenn-Yow Fuh, MD Randy Grossman, MD Madhu K. Kris, MD Hanimireddy Lakireddy, MD Robert (David) Simenson, MD

Pictured left to right:

Kin C. Chan, MD, Ravi Kumar, MD, Mark T. Hellner, MD and Samuel B. Tacke, MD

Not Pictured:

M. Daisy Ilano, MD Atul T. Roy, MD Mark W. Via, MD Mark A. Wagner, DO

E. Kip Hensley, MD

Thank you, Dr. Hensley for 19 Years of Service to the Board of Governors

Pictured left to right:

Ramakrishna R. Thondapu, MD, Donald P. Carter, MD, Nirmal S. Aujla, MD, Timothy S. Johnston, MD and Mani Nallasivan, MD

Appreciation for Years of Membership Not Pictured:

Michael C. Dumars, MD

Dirk H. Mous, MD

Not Pictured:

Abhilasha Sharma, MD Pictured left to right:

Monique T. Godbold Sanchez, MD and George Alkhouri, MD

Not Pictured:

Jeannette Lopez Ayala, MD Shivarama Bhat, MD Grant Carmichael, MD Richard P. Holm, MD J. Edward Hughell, MD

Timothy A. Livermore, MD, MPH Phillip Mansur, MD Donald Mason, MD John F. Mevi, MD Donald Miller, MD

Charles A. Novotny, MD James M. Raveret, MD Arani S. Reddy, MD Peter R. Rugani, MD Thomas M. Weed, MD

Congratulations to all who have supported MMCMS for such a long time. Your membership and support is so greatly appreciated!

Thank you!

MEDICARE CHANGES: 2019 AND BEYOND T h u r s d a y, J a n u a r y 2 4 , 2 0 1 9 Location: Bella Luna Bistro & Bar 350 W. Main Street, Merced, CA

Registration and Lunch: 11:30am Presentation: 12:00pm-2:00pm CHERYL BRADLEY, Associate Director, CMA’s Center for Economic Services In her capacity as Associate Director of CMA’s Center for Economic Services, Cheryl provides one-onone support to CMA member physicians on Medicare issues. Cheryl has more than 20 years’ experience in the Medicare Program, having worked as an Education and Training Specialist, Medical Review Analyst, and as a Customer Service Representative across all of the CA Medicare contractors including Noridian Healthcare Solutions. Over the years, Cheryl has provided problem solving assistance to physicians, specialty organizations, billing staff, and other healthcare professionals throughout CA, Hawaii and Nevada.

This workshop will address current and updated Medicare payment policies, compliance, and quality reporting for services furnished under the 2019 Medicare Physician Fee Schedule in the upcoming year. This includes but is not limited to: • Medicare Hot Topics • Avoiding common mistakes

• The Quality Payment Program (MACRA) Year 3 • Compliance with the current MAC

We will also review and assess the impact of key CMS initiatives on your practice.

WHO SHOULD ATTEND: Physicians, Administrators, Office Managers & Billing Staff

Registration Required | COST (includes lunch):

Please complete a separate registration for each individual attending:

MMCMS Member: $40.00

Staff of MMCMS Member: $40.00

All Others: $80.00

Attendee’s Name:__________________________________________________________________________________________________ Phone Number:_________________________________

E-mail Address:________________________________________________

Practice Name:____________________________________________________________________________________________________ VISA/MC Card Number:________________________________________________________

Exp Date_________________________

Billing Address:____________________________________________________________________________________________________ Name on Card:_____________________________________

Signature:___________________________________________________

Return Registration By: January 16, 2019 PHONE: 209-723-2976 | FAX: 209-723-8371

MAIL: 2848 Park Avenue, Suite C | Merced, CA 95348 E-MAIL: chrisy@mmcms.org | ONLINE: www.mmcms.org

By Tina Tedesco Tulare, California is a small town in the Central Valley best known as the milk producing capital of America. More than half of its 60,000 residents are enrolled in Medi-Cal and served by a small, 108-bed health care district hospital – Tulare Regional Medical Center (TRMC) – with a separate medical staff of about 175 physicians. Two years ago, this small agricultural community became ground zero in a high-profile battle testing the legal scope of a hospital medical staff’s independence and right to be self-governing. Fundamentally, the question was raised who should be in charge of patient care and safety in a hospital – lay administrators or physician leaders? In 2016, hospital administrators at TRMC executed a coup to take unilateral control over patient care at the hospital by terminating the entire medical staff and its duly elected officers. The hospital then adopted new medical staff bylaws in secret and without input from physicians at the hospital. The hospital installed handselected individuals to serve as leaders of the new medical staff, dictated standards of medical care, seized control of the disciplinary process without legal or factual justifications, and prohibited members of the terminated medical staff from voting on medical staff matters or holding leadership positions in the replacement staff. The California Medical Association (CMA) supported the medical staff in its lawsuit against the hospital. CMA and the medical staff sought to enforce California law requiring all hospitals to recognize and honor the self-governance rights of their medical staffs. Had TRMC’s actions been left unchallenged, it would have created a dangerous precedent that could have had a negative effect on patient care across the country. This July, a favorable settlement of the lawsuit was reached that dissolved the replacement medical staff and fully reinstated the original medical staff, its officers and bylaws. The hospital also consented to a stipulated judgment agreed upon by the parties and issued by the Tulare superior court that, among other things, expressly recognizes that the 2016 actions of the hospital board violated the medical staff’s rights to

self-governance under California law. “The Tulare case was not just about one hospital medical staff that was being wrongly treated by its governance structure,” said Theodore M. Mazer, M.D., CMA past-president, “it’s about every medical staff. It’s about autonomy of physicians to make medical decisions and the clear division of power between a governing body, which is administrative, and the medical staff and making sure that that separation of powers and duties and responsibilities stayed in place was important for Tulare and every medical staff in California and frankly, in the nation.” “Medical staff is there to oversee the quality of care provided to patients in the hospital,” said Damodara Rajasekhar, M.D., CMA Board Trustee, Organized Medical Staff Section. “That role is not designated to the CEO of the hospital or the board members.” “What the hospital was doing was a blatant violation of very clear law in California that requires hospitals to honor a medical staff’s independence and selfgovernance,” said Long Do, J.D., CMA Director of Litigation. CMA worked with the medical staff’s attorneys and filed two amicus briefs to support the medical staff and take on the hospital, which had loaded up its defense from three different law firms. “This was a case involving 125 doctors. There’s no possible way they could have afforded to prosecute the case themselves,” said John Harwell, J.D., the medical staff’s attorney. “It’s only by the collective action of organized medicine through the California Medical Association that this was possible.” “This case moved quickly in large part because we were there to help the medical staff and then to seek outside resources and help in getting this resolved,” said Dr. Mazer. In collaboration with CMA, the Litigation Center of the American Medical Association (AMA) and State (Continued on page 20)

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Medical Societies provided significant legal and financial support in the California medical staff’s lawsuit. “The narrative, when the case started, was that this was a group of trouble making doctors who were making it impossible for the hospital to run as an efficient hospital,” said Michael Amir, J.D., lead trial attorney. “We had to dispel that notion.” TRMC filed for bankruptcy before closing arguments in the medical staff’s trial could take place, closing its doors and significantly challenging the availability of care to the community. “It was very devastating for the community to have the hospital close,” said Anil Patel, M.D., immediate past chief of staff of Tulare Regional Medical Center. “But they knew that they had to wipe out all the previous administration, the board.” Patients seeking care at other hospitals reportedly had to wait 10 to 15 hours for care. The lawsuit, however, enabled the medical staff to get its story out to the community. In turn, the community changed hospital leadership, which ultimately resulted in the favorable settlement. As part of the settlement, TRMC has also agreed to:  Not recognize the replacement staff, its leaders or bylaws.  Reinstate the original medical staff, its duly-elected officers, with all the

privileges, rights and status that existed before the Jan. 26, 2016 termination.  Reinstate the pre-existing medical staff bylaws, rules and policies.  Pay $300,000 for the TRMC medical staff’s attorneys’ fees and costs.  Waive all rights to appeal or challenge the settlement’s validity. Perhaps most importantly, the settlement allows for the hospital to begin the process of reopening its doors and once again serving its community. “The importance of this case is it’s an example of what will happen to a hospital and the hospital’s leadership when it tries to trample the rights of the medical staff,” said Amir. “Doctors can take comfort that when their rights get trampled and their autonomy and self-governance is questioned, they have a remedy.” This case sends a message well beyond Tulare; it will likely have ramifications statewide, if not nationwide. The support of CMA and AMA enabled the medical staff to stand up to a large and well-funded hospital. In fact, AMA’s contributions to the litigation in this case represent the single largest legal contribution in the history of the AMA. “I learned a lot about what CMA means. It’s not only an organization, it is a partner,” said Abraham Betre, D.O., chief of staff of Tulare Regional Medical Center. “The litigation fund that is housed in the CMA Center for Legal Affairs is the bloodline of our work. Without the support from medical staffs and individual physicians, CMA would not be able to advocate for doctors,” said Do. It cannot be understated how grave the consequences could have been on patient care and safety if the hospital’s illegal actions were left to stand. Medical staff self-governance would become meaningless if a hospital can pick for itself a replacement medical staff and eschew the large body of laws and regulations that require a truly independent medical staff that is self-governing and democratic.

The Importance of Medical Staff SelfGovernance Medical staff self-governance is a vital part of a carefully crafted system designed to ensure the delivery of quality patient care. This system recognizes that the hospital’s medical staff is the only body with the medical expertise to conduct quality assurance activities integral to the health and welfare of the public. Under state law and Medicare regulations, hospitals are required to have an independent, self-governing medical staff charged with the professional work of the hospital. The medical staff works with the hospitals to ensure quality of care and insulate medical decision makers from undue influences driven by profit motives or other reasons unrelated to patient care. To preserve this autonomy, medical staffs have a variety of rights provided for under California law, including the ability to retain legal counsel, elect leadership, conduct peer review and manage a separate bank account dedicated to medical staff funds. Medical staff associations also have the option to sue a hospital, should they feel their right to selfgovernance has been violated. “Many physician members of a hospital’s medical staff often are not fully aware of the California laws that establish medical staff selfgovernance,” said Long Do, J.D., CMA Director of Litigation. “CMA offers informational materials and makes speakers available to educate medical staffs of the importance of self-governance.” CMA provides hospital physicians with a variety of resources to help medical staffs maintain and assert self-governance. If you are interested in consulting with representatives from CMA’s Center for Legal Affairs or who would like to schedule a CMA speaker on this topic, contact the CMA Member Service Center, (800) 786-4262 or medstaffhelp@cmadocs.org.

By Janus L. Norman, CMA Senior Vice-President, Centers for Government Relations and Political Operations It has been said that “diligence makes the difference between all-time greats and one-hit wonders.” For over 160 years, the physician leadership of the California Medical Association (CMA) has practiced unmatched devotion to its members and the entirety of the physician community. CMA’s physician leaders care for their individual patients at all hours of the day or night and are stewards of the profession in their limited time off. This investment of sacrificed family and personal time has powered the state’s largest medical association forward. Innovations in the association’s governance structure have increased CMA’s ability to maintain its vaulted position within the Golden State’s political “Game of Thrones.” Success in the legislative process is sometimes difficult to measure. Insiders often refer to published lists of powerful special interest groups or individuals, articles listing interest groups that have spent the most money on lobbying and/or campaign activities, or the number of mentions an association receives in news articles. If those are the measurements of success, CMA is at the top of the class: staff are consistently included in the Capitol Weekly Top 100; CMA is routinely recognized by news outlets as one of the most effective lobbying organizations in the state; and rarely does an article regarding health care legislation not include a quote from the CMA president.

“The 2018-2019 State Budget included over $1 billion in new funding to support supplemental payments for physicians participating in the Medi-Cal program.”

Prominence is significant; it aids in the creation of political capitol. But distinction itself is not the goal. Physician leaders want to ensure CMA improves the health care delivery system by obtaining state budgetary appropriations to increase patient access and protect against ill-conceived legislation that would directly threaten their ability to financially maintain a practice and provide the best care.

RETURN ON INVESTMENT In 2016, CMA, the California Dental Association, the Service Employees International Union (SEIU) and their coalition partners beat the odds. Together, we convinced voters to increase the state’s tobacco tax by $2 in order to invest a majority of the revenue into increasing access to care. CMA contributed $1 million to the statewide Proposition 56 campaign. Now that the tax is being collected and distributed, the physician community sees the impact. The 2018-2019 State Budget included:  Over

$1 billion in new funding to support supplemental payments for physicians participating in the Medi-Cal program.

 An expansion of the number of CPT codes that are

eligible for those supplemental payments.  $190 million for medical student loan repayment.  $40 million in new funds for graduate medical

education, which will be administered by Physicians for a Healthy California (formerly known as the CMA Foundation). In the 2017-2018 legislative session, two detrimental proposals were introduced that would have upended the state’s health care delivery system. SB 562 (Lara, Los Angeles) would have required California to implement an extremely flawed single-payer proposal. AB 3087 (Kalra, San Jose) would have empowered a politically-appointed committee to price fix physician services. In both instances, the health care community looked to CMA for leadership and expertise. On a weekly basis, opposition coalitions met at CMA headquarters to execute a substantial grassroots program, earned media strategy, Capitol lobbying strategy and a digital media campaign. The defeat of SB 562 and AB 3087 once again showcased CMA as an unapologetic leader in health care policy. As a result of (Continued on page 22)

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defeating both bills, the Legislature now looks to our House of Delegates for a solution to improve access and increase the affordability of health care in California. During the first quarter of the year, the CMA Board of Trustees adopted CMA’s sponsored bill package. The bills focused on:  Improving state oversight and regulation of predato-

ry behavior by health plans (AB 2674 by Assemblymember Aguiar-Curry and AB 2427 by Assemblymember Wood).  Improving access to medication assisted treatments

for individuals fighting opioid addiction (AB 2384 by Assemblymember Arambula).  Improving the medical board disciplinary process (AB

505 by Assemblymember Caballero).  Increasing

transparency and oversight in the pharmaceutical supply chain (AB 315 by Assemblymember Wood).

 Protecting

medical independence for physicians working in county sheriff’s departments (SB 1303 by Senator Pan).

“all sponsored legislation made it through both houses of the Legislature and were sent to the Governor for consideration.”

I am pleased to report that all sponsored legislation made it through both houses of the Legislature and were sent to the Governor for consideration. While the fate of each bill will vary, it is important to note this year the Legislature agreed with each of the policy principles of our sponsored legislation. For a full description and status of each measure visit cmadocs.org/leg-wrap-2018. The call for leadership is once again before us. Guided by our grand history, we must continue to exercise our diligence, provide solutions and construct the development of the next iteration of California’s health care delivery. Let’s do it again! In Unity,

Janus L. Norman CMA Senior Vice President Centers for Government Relations and Political Operations

OPIOID ADVOCACY

By Theodore M. Mazer, MD

From the beginning of the opioid epidemic, the California Medical Association (CMA) has been one of the most engaged and determined stakeholders working to strike a balance between patient access to necessary medicine and preventing and addressing abuse.

payors, legislators, pharmacies and medical boards seek ways to be proactive in addressing the opioid epidemic – sometimes ignoring the actual realities of medical practice and creating barriers to good care. And as you’re aware, California physicians have been engaged in the debate since the beginning, on behalf of our patients and profession.

“Over the last few years, the changing landscape surrounding prescribing opioids has been dizzying as payors, legislators, pharmacies and medical boards seek ways to be proactive in addressing the opioid epidemic – sometimes ignoring the actual realities of medical practice and creating barriers to good care.”

CMA has been a leader in advocating for increased funding, access and availability of preventive services, opioid-use disorder treatment programs and non-opioid therapies, including mental health services and medication-assisted treatment (MAT). We have successfully worked to stop legislation that interferes with the practice of medicine and creates barriers to care, such as government-mandated dosage and duration limits. Over the last few years, the changing landscape surrounding prescribing opioids has been dizzying as

CMA released a white paper, “Opioid Analgesics in California: Relieving Pain, Preventing Misuse, Finding Balance” in 2013. Developed through CMA’s Council on Science and Public Health, it has been the cornerstone of our work to educate physician colleagues, guide the medical board and policymakers, and help health care stakeholders navigate the evolving science related to opioids. At its core is the premise that care must be evidence-based and reflect the individual needs of the patient – ultimately, allowing physicians to make proper care decisions. CMA’s emphasis on these principles has remained (Continued on page 24)

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constant, including advocacy on opioid-related activities in 2018, which include: Controlled Substance Utilization Review and Evaluation System (CURES): CMA has been working with the state for years to ensure adequate educational and technical support for physicians who will have to check CURES as part of their prescribing workflow, starting on October 2, 2018. CMA has advocated for sustained user outreach and educational efforts by the state that provide clarity of this new law, as well as prioritize the clinician perspective on an ongoing basis following implementation. We will continue to engage as the new requirement to consult CURES is implemented and work with stakeholders to ensure CURES has adequate support.

The federal opioid bill continues to push treatment in the right direction by providing grants to improve access to MAT and codifying the ability for physicians to prescribe MAT for up to 275 patients, which is critical since the current caps are far too limiting and leave many patients on waiting lists for years. Individual Patient Care: At the federal level, CMA successfully fought back against legislation that would have required one-size-fits-all medicine by mandating prescription drug dosage and duration limits. California legislators also sought to statutorily limit dosages and durations of opioid pain relievers through AB 2741 (Burke) and AB 1998 (Rodriguez), using arbitrary and minimal amounts. Both bills were defeated earlier this year.

Federal Funding and the Congressional Opioid Crisis Response: Earlier this year, Congress approved $10 Ensuring Fair Enforcement: The Medical Board of billion in new funding for states to address opioidCalifornia is examining deaths associated with the use of related education, prevention, treatment and law prescription opioids and is reviewing whether the care enforcement issues. The House and Senate reached an and treatment provided by physicians to those individuals met the standard of care. As part of a “routine” review, the board sent letters to physicians who were “At the federal level, CMA successfully fought back against identified as prescribing legislation that would have required one-size-fits-all medicine by opioids in a manner that, mandating prescription drug dosage and duration limits.” after physician review, merited further investigation, and requested that those physicians submit additional information including a summary of the care agreement on the “Substance Use Disorder Prevention provided, the patient’s medical records, and any that Promotes Opioid Recovery and Treatment for additional materials that would be pertinent to the Patients and Communities Act,” and they will send it to board’s investigation. President Donald Trump soon. It is a comprehensive package of more than 300 bills that, among other CMA has raised concerns about the board’s process and things, provides grants to states to address prevention will continue to work with the board to address and treatment, as well as stop the flow of illicit drugs, physician concerns, monitor the board's process to such as fentanyl. It also expands the number of Institute determine whether disciplinary actions are based on the for Mental Diseases inpatient Medi-Cal beds available for appropriate standard of care, and if the process used to opioid substance abuse disorder treatment and enhancidentify physicians subject to these inquiries needs es Medi-Cal patient access to non-opioid options. additional transparency or modification. Physicians who Medicare coverage for treatment has been expanded, are under review may contact CMA (800-786-4262, with new Medicare payment and delivery demonstration CMAdocs.org) for information about the disciplinary projects approved for comprehensive management of opioid-use disorder. process and their legal rights. Access to Medication-Assisted Treatment and Overdose Reversal Medications: To help reduce the rates of overdose and stigma associated with opioid-use disorder, CMA sponsored AB 2384 (Arambula), which would have removed barriers to coverage of MAT services and naloxone to ensure that people who face addiction have better access to treatment. Governor Jerry Brown vetoed AB 2384, claiming a need for utilization controls and barriers to patient access of life-saving treatments. In response, CMA issued a statement expressing disappointment and concern, while reiterating our intention to work with the next governor to make this issue a priority in 2019.

Unfortunately, the bill package also includes a mandate for physicians to e-prescribe controlled substances for Medicare patients after January 1, 2021. However, it includes many exceptions, and it directs the Centers for Medicare and Medicaid Services to implement additional exceptions. In a major win, the Drug Enforcement Administration (DEA) has been mandated to update its antiquated and burdensome process for e-prescribing. While more than 90 percent of physicians e-prescribe, only 21 percent e-prescribe controlled substances, largely due to the DEA’s burdensome requirements. The state mandate takes effect in 2022. (Continued on page 25)

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Physician Education on Safe Prescribing and Treatment: Governor Brown recently signed AB 2487 (McCarty), which originally mandated all California physicians to take an eight-hour course required to qualify for a federal waiver to the Drug and Addiction Treatment Act of 2000 in order to allow physicians to prescribe MAT drugs, like buprenorphine, outside of an opioid treatment center.

This approach has produced promising results. From 2013-2017, California experienced over a 24 percent decrease in opioid prescriptions, and is only one of five states with a multi-year decrease in prescription opioid overdoses. California is now tied for the lowest per capita opioid prescription rate in the country, while opioid prescribing has decreased for the fifth year in a row.

More work remains, as the drugs responsible for these overdose deaths are changing and have been spurred by illicit fentanyl. CMA will continue to work with policymakers, elected officials and health care “From 2013-2017, California experienced over a 24 percent stakeholders to ensure your decrease in opioid prescriptions, and is only one of five states voice – and your patients’ voices – are heard. with a multi-year decrease in prescription opioid overdoses.”

After CMA-led negotiations with the author, the bill was amended to allow physicians who seek to prescribe MAT to fulfill their annual continuing education requirement by completing the DATA-Waivered Physician course along with four additional credit hours on treating substance use disorders. Successful advocacy prevented additional and mandatory continuing education. The road has been long and hard-fought, and California’s comprehensive approach has focused on safe prescribing, naloxone distribution, public education campaigns, local opioid safety coalitions and increasing access to treatment, including MAT.

I want to thank our physician members for their dedication to finding a balance between prescribing controlled substances safely and effectively to relieve pain, while simultaneously reducing the risk of prescription medication misuse, addiction and overdose.

Theodore M. Mazer, M.D., is a board-certified otolaryngologist who has been working in a small, solo practice in San Diego for more than 25 years. He is the immediate past-president of the California Medical Association.