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Fall 2012

The Bulletin

Inside this Issue: FEATURES:

New Health Laws...(page 5) HOD 2012...(page 9) One Must Imagine Sisyphus Happy…(page 11)

ICD-10-CM Training…(See pages 14&15) Meet our Newest Member…(See page 18) Join Us for our Holiday Party…(See page 20) Join the Conversation!…(See page 21)


Our Mission The mission of MMCMS is to promote the science and art of medicine, the care and well-being of patients, the protection of the public health, and the betterment of the medical profession; to cooperate with organizations of like purposes; and to unite with similar societies in the State of California as component societies of the California Medical Association.

MMCMS Leadership Officers Nirmal Aujla, M.D. President Samuel B. Tacke, M.D. President-Elect Donald P Carter, M.D. Secretary-Treasurer David Simenson, M.D. Immediate Past-President

Governors E. Kip Hensley, M.D. Timothy A. Livermore, M.D. Atul T. Roy, M.D. Thavalinh Mark Sphabmixay, M.D. Mark W. Via, M.D. Eduardo T. Villarama, M.D.

CMA Delegates James H. Jones, M.D. Pamela Roussos, D.O.

CMA Alternate Delegates Stephen F. Corcoran, M.D. Eduardo T. Villarama, M.D.

Staff

CONTENTS New Health Laws 2013 ......................................................................................5 The 2013 Antibiotic Resistance Education (AWARE) Project Publishes it’s 2013 Provider Toolkit ..................................... 7 Now is the time for a new Dental Plan! .........................................................7 HOD 2012 CMA delegates set policy at annual meeting ..................................................9

One Must Imagine Sisyphus Happy The California Medical Association’s 2012 Legislative Wrap-Up .............. 11

What to Know Before You Store Patient Credit Card Numbers .......... 13 Mandated Disease Reporting Requirements A Roadmap ........................................................................................................ 17

Meeting Schedule .............................................................................................. 18 News from the California Medical Association ........................................ 19 Top News Healthy Families to Medi-Cal transition to begin Jan. 1 ............................... 19 Anthem Blue Cross Physicians who wish to opt out of new Blue Cross network must act soon................................................................. 21 EHR CMA publishes handy guide to EHR meaningful use, stage 2.................... 22

Chrisy Muchow Executive Director

Medicare CMA joins amicus brief challenging Medicare RAC’s ability to reopen paid claims ............................................................... 22

Contact Information

2013 Medicare fee schedules posted ................................................................ 23

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

For Advertising Opportunities Contact Chrisy Muchow at (209) 723-2976 or chrisym@pacbell.net. 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; E-mail chrisym@pacbell.net; 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 Merced-Mariposa 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.


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Fall 2012

Page 5

NEW HEALTH LAWS 2013

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he California Legislature had an active year passing many new laws affecting health care. Below are highlights of the new laws likely to impact physicians next year and beyond. For more details, see "Significant New California Laws of Interest to Physicians for 2013," in the California Medical Association's online resource library at www.cmanet.org/resource-library.

Allied Health Professionals AB 761 (Hernandez, R.) – Optometrists Allows optometrists to independently perform waived clinical laboratory tests necessary for the diagnosis of conditions and diseases of the eye. Specifically, this bill adds licensed optometrists to the list of persons who are authorized under current law to perform a clinical laboratory test or examination classified as waived under the federal Clinical Laboratory Improvement Amendments (CLIA) of 1988. In addition, defines a “laboratory director” as a duly licensed optometrist serving as the director of a laboratory, which only performs clinical laboratory

testing as authorized. Clarifies that an optometrist who is certified to use therapeutic pharmaceutical agents (TPAs) may also perform tear fluid analysis. Allows optometrists who are certified to use TPAs to perform a clinical laboratory test or examination classified as waived under CLIA and as designated under current law, as specified, necessary for the diagnosis of conditions and diseases of the eye or adnexa, or if otherwise specifically authorized by the Optometry Practice Act. (Business & Professions Code §§1206.5, 1209 and 3041) AB 2348 (Mitchell) – Nurses: Drug Dispensing Allows registered nurses (RNs) to dispense and administer hormonal contraceptives under a standardized procedure, as specified, and allows RNs to dispense drugs and devices upon an order by a certified nurse-midwife (CNM), a nurse practitioner (See LAWS, Page 6)


Fall 2012

LAWS (Continued from page 5)

(NP) or a physician assistant (PA) issued pursuant to standardized procedures while functioning within specified clinic settings. Expands the types of clinics in which an RN may dispense drugs or devices upon an order by a physician and surgeon, a CNM, an NP, or a PA to include intermittent clinics and student health centers operated by public higher education institutions. (Business & Professions Code §§2725.1 and 2725.2) SB 628 (Yee) – Acupuncture Regulation Makes it unprofessional conduct for an acupuncturist to use the title of doctor or use a certain abbreviation in connection with the practice of acupuncture unless he or she holds a degree that is approved by the Acupuncture Board for use of the title, and to use the title doctor or that certain abbreviation in connection with a practice unless he or she holds a license authorizing that use or a specified degree, or without indicating the type of license that entitles him or her to use that title. (CMA Position: Oppose Unless Amended) (Business & Professions Code §4936) SB 1446 (Negrete McLeod) – Naturopathic Doctors Authorizes a naturopathic doctor to furnish specified substances and to administer epinephrine and natural and synthetic hormones. Authorizes a naturopathic doctor to independently prescribe and administer specified substances by intramuscular, intravenous or other specified routes only when such substances are chemically identical to those for sale without a prescription. Requires the naturopathic doctor to comply with specified requirements and complete specified coursework. (Business & Professions Code §§3640, 3640.7 and 3640.8)

Clinical Laboratories AB 2253 (Pan) – Clinical Laboratory Test Results: Electronic Conveyance Revises provisions relating to the disclosure of test results. Authorizes the disclosure by Internet posting or other electronic means of clinical laboratory test results related to HIV antibodies, the presence of hepatitis antigens and the abuse of drugs and specified test results that reveal a malignancy if requested by the patient and if a health care professional has already discussed the results with the patient. Provides that the telephone is not a form of electronic communication. (Health & Safety Code §123148)

Confidential Information SB 1407 (Leno) – Medical Information: Disclosure Prohibits a psychotherapist, who knows a minor has been removed from the physical custody of his or her parent or guardian in a dependency proceeding, from releasing or disclosing the information in the records of a minor patient to the patient's parent or guardian based solely on a signed authorization, and from allowing the parent or guardian to inspect or obtain those records, except as authorized by the juvenile court. Relates to the psychotherapist's immunity from liability for not providing records. (Health & Safety Code §123116; Civil Code §56.106; and Welfare & Institutions Code §5328.03)

Page 6

Corporate Bar AB 1548 (Carter) – Practice of Medicine: Cosmetic Surgery: Employment of Physicians Amends the Medical Practice Act, which established the Medical Board within the Department of Consumer Affairs. Provides that a business organization that provides outpatient elective cosmetic medical procedures or treatments that is owned and operated in violation of the prohibition against employment of licensed physicians and surgeons and podiatrists and that contracts with or employs these licensees is guilty of a fraudulent claim for payment of a health care benefit. Accordingly, increases the penalty for a violation from $1,200 to $50,000 or twice the fraudulent amount. Also increases period of incarceration from 80 days to 2-5 years. (Business & Professions Code §2417.5)

Health Care Coverage AB 137 (Portantino) – Health Care Coverage: Mammographies Requires every individual or group health insurance policy to provide coverage for mammography, for screening or diagnostic purposes, upon referral by a participating nurse practitioner, participating certified nurse-midwife, participating physician assistant or participating physician, as specified, based on medical need regardless of age. Because this bill would specify additional requirements for health care service plans, the willful violation of which would be considered a crime. (CMA Position: Support) (Health & Safety Code §1367.65; Insurance Code §10123.81) AB 792 (Bonilla) – Health Benefit Exchange Requires a court, upon the filing of a petition for dissolution of marriage, nullity of marriage or legal separation to provide a specified notice informing the petitioner and respondent they may be eligible for coverage through the California Health Benefit Exchange or Medi-Cal. Requires health care service plans and insurers to provide the same notice to individuals who have ceased to be enrolled in individual or group coverage. Requires the same notification to an adoption petitioner. (CMA Position: Support) (Family Code §§2024.7, 8613.7; Health & Safety Code §1366.50; Insurance Code §10786) AB 1453 (Monning)/SB 951 (Ed Hernandez) – Health Care Coverage: Essential Health Benefits Requires an individual or small-group health care service plan contract issued, amended or renewed to include the health benefits covered by particular benchmark plans. Establishes the Kaiser Small Group HMO 30 plan as the Essential Health Benefit (EHB) benchmark plan for individual and small group health plan products licensed by the Department of Managed Health Care (DMHC). Prohibits treatment limits imposed on benefits from exceeding the corresponding limits imposed by benchmark plans. Prohibits a plan from making substitutions of the benefits required to be covered. Authorizes emergency regulations implementing these provisions. (Health & Safety Code §1367.005; Insurance Code §10112.27) SB 255 (Pavley) – Health Care Coverage: Breast Cancer Amends existing law, the Knox-Keene Health Care Service Plan Act of 1975, and the regulation of health insurers regarding mandatory coverage for the diagnosis and treatment for breast (See LAWS, Page 23)


Fall 2012

Page 7

The 2013 Antibiotic Resistance Education (AWARE) Project Publishes it’s 2013 Provider Toolkit!

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he California Medical Association Foundation’s Alliance Working for Antibiotic Resistance Education (AWARE) project has taken the lead to bring together physicians, pharmacists, health plans, and key healthcare stakeholders to develop the 2013 AWARE Provider Toolkit for the upcoming cold and flu season. AWARE supports physician efforts to promote appropriate antibiotic use and decrease the incidence of antibiotic resistance. We appreciate the challenges physicians face to increase patient knowledge and influence behavior. This toolkit contains resources that support your work to educate your patients with information. The toolkit includes:  2013 Acute Respiratory Tract Infection Guideline Summary

(Adult and Pediatric)  Prescription Pad – Available in English and Spanish, this hand-

out offers home remedies that can help alleviate symptoms of colds.  Handout – Careful Antibiotic Use: Pharyngitis in Children (English only).  Patient Education Materials (offered in English and Spanish):  Bronchitis and Other Cough Illnesses – These adult and pediatric handouts contain useful home care options and prevention tips.  Feel Better Soon…Without Antibiotics! – These adult and pediatric brochures identify common symptoms and remedies that can provide symptomatic relief.

 Preserve

a Treasure Brochure - This brochure contains frequently asked questions to help patients understand the importance of prudent antibiotic use. (English only).  A Veces, el Remedio es Peor que la Enfermedad – This brochure explains that antibiotics only cure bacterial infections and not viral infections, such as cold and flu. (Spanish only). Visit www.AWARE.md for additional clinical resources and patient education materials, including COPD materials provided by Boehringer Ingleheim Pharmceuticals and AWARE’s GOLD guideline flyer pertaining to COPD. After reviewing the 2013 AWARE Provider Toolkit, please take a moment to complete our evaluation survey. Participation is voluntary and anonymous. The results from this survey will help us strengthen our clinical and patient education tools to support physician efforts to educate patients about appropriate antibiotic use. http://www.zoomerang.com/Survey/WEB22GHRJXVCQ4 AWARE is committed to providing you with clinical resources and additional patient education materials. If you have ideas on how AWARE can best serve you and your patients, please contact the CMA Foundation at (916) 779-6620 or by e-mail at aware@thecmafoundation.org.

Now is the time for a new Dental Plan!

I

t’s Open Enrollment time for the Merced-Mariposa County Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period ending on January 1, 2013.

This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money:

Call a Client Advisor at 800-842-3761 for more information. Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.

 Annual Benefits of $2,000 per person for dental care, using

network providers ($1,500 if you use non-network providers).  During Open Enrollment only, members may join as an individual or as a group with your employees.  Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families).  Pay no deductible on oral exams, x-rays and routine cleanings.

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Fall 2012

Page 9

HOD 2012

CMA delegates set policy at annual meeting

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ore than 700 California physicians convened in Sacramento October 13-15 for the 2012 House of Delegates (HOD), the annual meeting of the California Medical Association (CMA). Each year, physicians from all 53 California counties, representing all modes of practice, meet to discuss issues related to health care policy, medicine and patient care and to elect CMA officers. Over 120 resolutions were introduced and debated in reference committees on Saturday, October 13, 2012. Over the next two days, the complete house met again to debate and vote on reference committee recommendations. A total of 97 resolutions were adopted. The debates were passionate, polite and sometimes humorous. For example, during a debate on the health hazards of sitting, one speaker suggested that the House stand for the rest of the debate. In another instance, during a contentious debate on whether to support nurse practitioners’ ability to sign POLST forms, the debate was interrupted so that former CALPAC chair, Richard E. Thorp, M.D., could have his mustache shaved off by his wife – part of a fund-raising challenge. (He did have his

mustache shaved off after the $150,000 fundraising goal was shattered). On Sunday the House elected new officers, including Sacramento pediatrician, Paul R. Phinney, M.D., as the 2012-2013 CMA President, and the now clean-shaven Dr. Thorp as PresidentElect. The rest of the CMA Executive Committee were affirmed by the HOD including the immediate Past-President, James T. Hay, M.D., Speaker, Luther F. Cobb, M.D., Vice-Speaker, Theodore M. Mazer, M.D., Board Chair, Steven E. Larson, M.D., and board Vice -Chair, David H. Aizuss, M.D. The following are summaries of some of the resolutions that were adopted as policy. Revised blood donor deferral criteria (Resolution 108-12) The delegates expressed support for the use of rational, scientifically-based deferral periods for blood donations, applied based on level of risk rather than on sexual orientation. (See HOD 2012, Page 10)


Fall 2012

Page 10

HOD 2012 (Continued from page 9)

Awareness and prevention of bullying (Resolution 113-12) The delegates called on CMA to support awareness and prevention of bullying in all its forms and to support the development of family, school and community programs and referral services for victims and perpetrators of bullying. Support for amending the affordable care act (Resolution 201-12) The delegates directed CMA to support amending the Affordable Care Act to address issues of concern to the practice of medicine. Duel eligible monitoring and reporting (Resolution 208-12) This resolution directs CMA to collect data from its membership regarding difficulties with the planned transition of dual eligibles to managed care plans and to report the findings to the California Department of Health Care Services, the California Department of Managed Health Care and the federal Centers for Medicare & Medicaid Services. Electronic prescribing and EHR payment reductions (Resolution 214-12) The delegates voted to oppose financial penalties by any payor for physicians who do not adopt health information technology, such as electronic medical records and electronic prescribing. RAC audits of E&M codes (Resolution 222-12) The delegates spoke out strongly against aggressive down coding efforts being taken up by Medicare's Recovery Audit Contractor (RAC) firm, and have adopted policy that officially puts the association on record as opposing the practice. Pharmacist’s substitution of physician prescriptions (Resolution 507-12) The delegates asked that CMA consider legislation to make it illegal for pharmacists to receive financial incentives to substitute a physician’s prescription. Increasing utilization of POLST orders (Resolution 512-12) The delegates approved a resolution that calls on CMA to support awareness and use of Physicians Orders for Life-Sustaining Treatment (POLST) forms by physicians in all appropriate instances where medical services are provided to patients at the end of life. HIPAA and medical record accessibility (Resolution 606-12) The delegates asked CMA support a study on the extent to which HIPAA laws impede the timely transfer of medical information necessary for the appropriate coordination of care. Helping physicians improve their health (Resolution 610-12) The delegates voted to encourage all physicians and physicians-in-training to properly manage their own physical and mental health and to serve as exemplars of healthy behaviors. The complete and final actions of the 2012 House of Delegates are available to members at www.cmanet.org/hod under "Documents." (See HOD 2012, Page 25)

Delegates strongly oppose Medicare RAC audits Members of the California Medical Association's (CMA) House of Delegates spoke out strongly against aggressive down coding efforts being taken up by Medicare's Recovery Audit Contractor (RAC) firm, and have adopted policy that officially puts the association on record as opposing the practice. The resolution, 222-12, stems from an ongoing problem of an out-of-state auditing firm, Connolly Healthcare, selectively down coding claims on behalf of Medicare, forcing physicians to undertake costly and time-consuming appeals. The audits and subsequent down codes, which several speakers equated to financial "bounty hunting" on behalf of the Centers for Medicare & Medicaid Services (CMS), were almost always reversed upon physician appeal, which suggested that they were of little merit to begin with, speakers said. "I can't tell you how outraged we doctors should be that this is going on," James Hinsdale, M.D., a past CMA president, said during the resolution's floor debate. In addition to asking that CMA work to stop the audit practice, the resolution also requests that, if efforts to halt the practice are unsuccessful, CMA urge CMS to reimburse physicians who file successful appeals for the time and resources expended in the appeal efforts. Successful passage of the resolution brought CMA in line with the American Medical Association’s (AMA) position on the matter. AMA has been actively lobbying CMS to halt the recovery audits.


Fall 2012

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ONE MUST IMAGINE SISYPHUS HAPPY The California Medical Association’s 2012 Legislative Wrap-Up By Jodi Hicks CMA Vice President of Government Relations

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n years past, the California Medical Association (CMA) has defended physicians in battles waged by hospitals, health plans and mid-level practitioners, but this year we initiated a few fights of our own. CMA did what physicians do best: We fought to protect patients. CMA fought to keep patients out of the middle of billing disputes, to educate parents about immunizations, to require mandatory flu vaccinations for health care workers, to remove sugared beverages from schools, to create a physician health program, to expand residency programs and a last minute effort to save the Healthy Families Program. Sponsoring legislation is the equivalent of pushing rocks up a hill…or rather big righteous boulders. The CMA Government Relations team struggled to push those rocks up the legislative hill while fighting off the enemies trying to get in the way, and at the same time stopping the many other rocks being thrown down at physicians. Sounds dramatic, but by all accounts, it was a crazy, precarious, contentious, hazardous and dramatic pathway to the finish line. We finished with some big wins and although we lost a few along the way, CMA fought for physicians and their patients until the very end. Out of the gate in January, CMA came out swinging. We introduced AB 1742 (Pan), which would have enabled patients to assign their benefits directly to the provider furnishing medical services. Sounds simple enough, but the bill soon came under attack from the health plans and culminated in what was described on one blog as the "juiciest" health committee hearings of the year. After much back and forth, the bill came up one vote short before reaching a legislative deadline to move the bill. That same week, CMA battled the unions, championing a bill through both a health and labor committee that would mandate flu vaccines for health care providers in hospitals. Against all odds and much opposition, SB 1318 (Wolk) moved through the Senate in a decisive win for public health. Though CMA was able to maneuver this contentious bill all the way through the Legislature, it was subsequently vetoed by the Governor. CMA also joined a large coalition of health care providers in a

valiant attempt to create a physician health program in California. The coalition worked tirelessly to address the opposition’s concerns surrounding funding, oversight and standards, and the bill made it all the way through both committee hearings and was on its way to the floor when it stalled. Despite the coalition’s diligence, the overwhelming demands of the opposition damaged the bill beyond repair before the last legislative deadline. Despite an end to this bill, we are confident that the conversation can continue and this will be an issue CMA will look to advance next year. And then came Rob Schneider. CMA, along with the American Academy of Pediatricians, the Health Officers Association of California and the California Immunization Coalition, sponsored AB 2109 (Pan) in an attempt to decrease the number of parents exempting their children from being vaccinated before entering public schools. Hundreds of anti-vaccine activists flooded the committee hearings to oppose the measure and eventually were (See Wrap-Up, Page 26)


Fall 2012

Page 13

What to Know Before You Store Patient Credit Card Numbers By Fran Cain, Information Technology Department, NORCAL Mutual Insurance Company

E

veryone uses credit cards. Patients love to rack up points for travel and cash-back rewards. But before you store a credit card number in your practice database, be aware of the consequences if your patient records ever become compromised. Credit card companies can impose huge fines if your office system is not securing patient credit card information adequately and it becomes compromised — to the tune of up to $100,000 per incident. After reviewing this article and weighing the risks, ask yourself, “Does my practice really need to store credit card information on file?”

I have a small practice. How does this apply to me? All credit card companies belong to the Payment Card Industry (PCI). PCI has established a Security Standards Council to set and manage standards known as the Data Security Standard, or PCI DSS. If your practice accepts or processes payment cards, you must comply with the PCI DSS.

Patients prefer that I keep their credit card numbers on file. What if I want to store credit card numbers? There are many rules to follow to be in compliance. You will be required to build and maintain a strong network; protect cardholder data; maintain a vulnerability management program; implement strong access control measures; regularly monitor and test networks; and maintain an information security policy. Here are some tips from the Payment Card Industry website:       

Encrypt all credit card numbers if stored in any system or database, including but not limited to logs and backups. Ensure the network has adequate firewall and up-to-date antivirus software. Use strong encryption for transmission of cardholder date over the Internet. Regularly apply all systems and software security patches. Quarterly, run external vulnerability scans or penetration tests on the network. Limit access to cardholder information to staff with a legitimate business need. Enforce strong passwords.





Avoid printing any card data on paper, but if any exists, it must be carefully secured and destroyed when no longer needed. Maintain data security policies that provide clear guidance to staff about handling of sensitive data (e.g., never e-mail Primary Account Numbers or PANs) and how to respond in case they discover data is compromised.

You must assess your business systems and processes annually to ensure you are in compliance. The PCI website can help you to assess your environment. You may be able to use a SelfAssessment Questionnaire, which must be completed annually, depending on the bank card. For example Master Card allows you to self-assess if you process less than 50,000 transactions annually, while JCB International allows you up to 1 million transactions. Check with each credit card company or look on its website to determine your merchant level and the requirements for your business. If you are allowed to self-assess, it is not necessary to submit a report to the credit card companies or PCI, but compliance is still required at all times. There are several different self-assessment questionnaires, and it may be confusing to decide which one to use. Use the chart on the website to choose the questionnaire that most closely fits with your credit card collection practices. If you are not allowed to self-assess, you will need to use a Qualified Security Assessor (QSA) to conduct annual assessments.

What happens if I store credit card numbers and a practice computer is lost or stolen, or some other breach of my system occurs? You must be able to demonstrate that you have been in compliance with PCI DSS. If your practice computers, network and/or database are compromised in any way, you must notify the credit card companies. If you cannot demonstrate that the data was completely protected and that you have been in compliance with PCI DSS, you will be subject to significant fines and lawsuits. If the credit card company does not terminate the (See Credit Cards, Page 27)


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Fall 2012

Page 17

Mandated Disease Reporting Requirements a Roadmap By Linda Louise Hill, MD, MPH

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racticing physicians are mandated to report a number of conditions to their local Department of Health Services (DHS); the list of reportable conditions in California has been recently updated and can be found at www.cdph.ca.gov/ HealthInfo/Pages/ReportableDiseases.aspx. Compliance is less than ideal, despite potential sanctions against physicians for not reporting. Of importance to note is that some of the conditions must be reported within the hour of diagnosis, others within a day, and the rest within a week. Guidance is provided by the icons (phone, fax, etc.) that precede the diagnosis on the list. The California Department of Public Health provides forms by county for reporting communicable and non-communicable diseases, and a separate form for tuberculosis use: http://www. cdph.ca.gov/HealthInfo/Documents/LHD_CD_Contact_Info.pdf. Do not assume that your laboratory will report for you; it remains the responsibility of the physician to report these diseases to the county. The DHS would rather have duplicates, than lapses in reporting. The noninfectious diseases that must be reported to DHS include lapses of consciousness, cancers, and pesticide-related illnesses. Lead poisoning is reported by laboratories, but DHS would welcome physician reporting as well. Compliance with reporting of non-communicable disease has been even more problematic. This is at least partially due to the impaired understanding of the mandate and (unfounded) concerns about the protections afforded to reporting physicians. The California Department of Motor Vehicles’ (DMV) reporting requirement, “every patient 14 years of age or older, when a physician and surgeon has diagnosed a disorder characterized by lapses of consciousness in a patient,” (www.dmv.ca.gov/pubs/ vctop/appndxa/hlthsaf/hs103900.htm) Title 17, section 2806, describes lapses of consciousness (LOC) as those conditions that involve:  Marked reduction of alertness or responsiveness to external

stimuli  Inability to perform one or more activities of daily living, or  Impaired sensory motor functions used to operate a motor vehicle. Examples of these conditions include:  Loss of consciousness (e.g., syncope, hypoglycemia)

 Seizures  Dementia, including Alzheimer’s disease and other dementias

(e.g., post-CVA, brain neoplasm)  Conditions such as sleep apnea and narcolepsy, where they

interfere with driving Physicians are protected from liability with good-faith reporting for these and other conditions they feel interfere with safe driving. In fact, physicians have had judgments against them for failure to report when drivers with these conditions had subsequent motor vehicle crashes. Physicians do not need to report former drivers who are unlikely to drive again (admitted to long-term care facility, severely impaired, coma, etc.), or when there is documentation in the chart that the patient has been reported previously and you believe they no longer operate a motor vehicle. As stated above, non-communicable disease, including lapses of consciousness, can also be reported on the CMR form. The reported cases of lapses of consciousness are forwarded by the DHS to the DMV; however, simultaneous direct reporting to the DMV will result in timelier follow-up by the DMV. To report directly to the DMV, it is best to use the DMV’s Request for Driver Reexamination (DS699), which can be found at www.dmv.ca.gov/forms/ds/ds699.pdf, but faxing the CMR form, or even using office letterhead, is acceptable. Lapses in consciousness should be reported only when associated with an event in a patient who has an underlying condition likely to impair driving. Therefore, while a loss of consciousness due to diabetes-associated hypoglycemia is reportable, the loss of consciousness from an injury-induced mild concussion is not. Narcolepsy associated with somnolence during driving is reportable, but recumbent-only associated sleep apnea is not. Even mild dementia is reportable, but confusion postoperative is not. The development of a reporting system and written protocols will improve compliance in your institution. The physician making the diagnosis is responsible for the reporting, whether in the emergency department or office. However, do not assume that another physician has reported, unless there is written documentation in the chart. Again, the DHS and DMV would rather have duplicate reporting than none at all. For example, if your (See Roadmap, Page 27)


Fall 2012

Page 18

Meet our Newest Member... Sukhdip K. Kang, M.D. Internal Medicine Golden Valley Health Centers 847 W. Childs Avenue Merced, California Welcome, Dr. Kang and thank you for your support of organized medicine!

Meeting Schedule December 12, 2012

6:30 p.m.

Holiday Reception De Angelo’s Restaurant

January 21, 2013

6:00 p.m.

Medical Society Board of Governors Medical Society Office

February 28, 2013

6:30 p.m.

General Membership Meeting De Angelo’s Restaurant

March 18, 2013

6:00 p.m.

Medical Society Board of Governors Medical Society Office


Fall 2012

Page 19

News from the California Medical Association Top News Healthy Families to Medi-Cal transition to begin Jan. 1 The Department of Health Care Services (DHCS) will soon begin transitioning over 860,000 low income children from the Healthy Families program to Medi-Cal. Healthy Families enrollees recently received notices of the impending transition, which is scheduled to be rolled out in four phases, with the first phase beginning January 1, 2013. The transition, proposed by Governor Brown and passed by the Legislature this summer as part of a larger plan to close the budget deficit, is expected to save about $64 million next year. The California Medical Association has opposed the plan since it was first proposed, and believes the move will likely have a negative impact on those who rely on the Healthy Families program for health care coverage. CMA is, however, actively participating in the Healthy Families transition process and stakeholder meetings in an effort to minimize any potential confusion caused by such a large scale transition. The first set of notices to enrollees, mailed by DHCS on November 1, 2012, contained basic information about the transition and promised that additional information would be contained in future notices.

The Healthy Families transition is scheduled for a four phase roll out. The first two phases will affect children who are covered by health plans that participate in both the Healthy Families and Medi-Cal managed care programs in their counties of residence. These children will continue to be covered by their current plans. Children in all four phases will receive additional notices at least 60 days in advance of the effective date that will include more details about the transition, covered benefits under Medi-Cal and their health plan options, as well as information on who to contact for assistance. Phase 1 – Approximately 409,000 children will be transitioned in the first phase. This phase is divided into two parts. Part A will begin on or after January 1, 2013, and affects Alameda, Orange, Riverside, San Bernardino, San Diego, San Francisco, San Mateo and Santa Clara counties. Part B will impact Contra Costa, Fresno, Kern, Kings, Los Angeles, Madera, Monterey, Napa, Sacramento, San Diego (Health Net), San Luis Obispo, Santa Barbara, Santa Cruz, Solano, Sonoma, Tulare and Yolo counties and will begin on or after March 1, 2013. Phase 2 – Approximately 259,000 children will be transitioned in phase 2, which is scheduled to begin on or after April 1, 2013. Phase 3 – This phase will impact approximately 151,000 children who are covered by health plans that do not participate in Medi-Cal managed care or subcontract with a Medi-Cal managed care plan. These children will be enrolled in a Medi-Cal managed care health plan in their county of residence. Enrollment will include consideration of the child’s primary care providers. The Phase 3 transition is scheduled to begin on or after August 1, 2013. Phase 4 – This phase will impact 42,000 children residing in counties that currently do not participate in the Medi-Cal managed care program. These children will be moved into the Medi-Cal fee-for-service system. If the state is successful in expanding Medi-Cal managed care statewide, these children will at that time move into managed care plans. Phase 4 is scheduled to begin on or after September 1, 2013. CMA will provide additional information as it becomes available. You may also find additional details on the Healthy Families to Medi-Cal transition online at: www.dhcs.ca.gov/services/Pages/ HealthyFamiliesTransition.aspx. DHCS has also created a list of frequently asked questions, available at www.dhcs.ca.gov/ services/hf/Pages/HFPFAQ.aspx. Contact: CMA reimbursement help line, (888) 401-5911 or economicservices@cmanet.org.

(See News, Page 21)


You and your spouse/significant other are invited to a

[ÉÄ|wtç ctÜàç hosted by the Merced-Mariposa County Medical Society

Wednesday, December 12, 2012 at

De Angelo’s Restaurant

2000 East Childs Avenue, Merced, California

Hosted cocktails and hors d’ oeuvres will be served from 6:30 to 8:30 p.m.

The successful candidates for the 2013 Medical Society Officers and Board of Governors will be announced at the party.

We extend a sincere thank you to

Please RSVP to the Medical Society by December 5, 2012

for helping to make our Holiday Party a success.

Phone: (209) 723-2976 Fax: (209) 723-8371 E-mail: chrisym@pacbell.net

NORCAL Mutual Insurance Company and Foundation for Medical Care


Fall 2012

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News (Continued from page 19)

Anthem Blue Cross Physicians who wish to opt out of new Blue Cross network must act soon Over the past month, Blue Cross sent notices to physician practices advising them of the insurer’s new “Anthem Individual/ Exchange Network.” The new network will serve both individuals who purchase coverage through the California Health Benefits Exchange and individuals who purchase coverage from Anthem Blue Cross in the individual market outside of the exchange. In other words, the fee schedule would apply to all individual business, whether bought on or off of the exchange. The physicians who received the notices include more than 10,000 who are part of Blue Cross’s Select PPO network, 200 practices who are part of the Blue Cross Medi-Cal managed care network, and 69 practices who participate solely in the Blue Cross Healthy Families program. The letter states that Blue Cross is amending the physician’s Blue Cross Prudent Buyer Agreement to automatically include the new individual/exchange network, effective January 1, 2014. The new fee schedule associated with this product was included with the notice. Physicians who do not wish to participate in this network must notify Blue Cross of their intent to opt out by December 31, 2012 (for letters dated October 24) or January 31 (for letters dated November 15). Opt out notices should be in writing and sent via certified mail with return receipt to the address specified in Section VI of the amendment. Blue Cross has confirmed that a decision to opt out of the individual/exchange product will not affect a physician’s participation status with the Prudent Buyer PPO network. In response to the California Medical Association’s (CMA) inquiry about the amendment, Blue Cross has provided the following clarifications:  While Section IV of the amendment states physicians must provide for the availability of emergency services 24-hours-aday, seven-days-a-week, Blue Cross has clarified that a voicemail message or answering service guidance directing patients to the emergency room or to call 911 in the event of an emergency will satisfy this requirement.

 Section IX of the amendment, which addresses compensation, does not clearly indicate reimbursement rates for immune globulins, vaccines and toxoids. Rather, the language states, “The statewide maximum allowable for immune globulins, vaccines and toxoids will be established by Blue Cross and considers claims and/or external data, including AWP, which will be updated quarterly.” Blue Cross has clarified that immune globulins, vaccines and toxoids will be reimbursed at the commercial Prudent Buyer fee schedule.  Blue Cross has also clarified that this fee schedule change will not apply to Small Business Health Options Program (SHOP) business purchased through the exchange. Please note that a small subset of Select PPO Network physicians did not receive a notice automatically opting them into the individual/exchange network. This subset of physicians received a notice from Blue Cross dated October 9 regarding fee schedule reductions. Physicians who choose to discontinue participation in the Select PPO network at the reduced rates have until December 14 to notify Blue Cross in writing. As always, physicians are encouraged to carefully review all proposed amendments to payor contracts. You do not have to accept substandard contracts that are not beneficial to your practice. Physicians who did not receive a letter, are unsure whether they are affected by this change, or those who have general questions about the amendment can contact Blue Cross’s Network Relations Department at (855) 238-0095 or network relations@wellpoint.com. Contact: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.

(See News, Page 22)


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News (Continued from page 21)

EHR CMA publishes handy guide to EHR meaningful use, stage 2 As previously reported, the Centers for Medicare & Medicaid Services (CMS) has released the final rule for stage 2 of "meaningful use." The rule is part of a federal incentive program for Medicare and Medicaid physicians who adopt and achieve "meaningful use" of electronic health records (EHR). The final rule also lays out the timelines physicians will have to follow in order to avoid payment reductions in 2015.

Webinar to explain recent changes to meaningful use rules

In addition to detailing the stage 2 requirements, the rule also includes changes to stage 1, some of which will go into effect as soon as January 1, 2013.

The webinar, “2013 Updates to Meaningful Use” is now available on demand and is free for members and their staff. To access the webinar, visit CMA's online resource library, www.cmanet.org/ resource-library.

The California Medical Association (CMA) has analyzed the CMS reporting requirements for physicians and created a fact sheet about the final rule. The fact sheet, "Federal EHR Incentive Programs: Stage 2 of Meaningful Use and Changes to Stage 1," is available to members in CMA's online resource library, www.cmanet.org/resource-library.

In November, David Ford from CMA's Center for Medical and Regulatory Policy held a webinar to explain recent changes to meaningful use that go into effect January 1, 2013. Participants learned more about the measures on which physicians will have to report in order to receive their incentive payments.

Contact: CMA member help center, (800) 786-4262 or memberservice@cmanet.org.

Medicare CMA joins amicus brief challenging Medicare RAC's ability to reopen paid claims The California Medical Association (CMA) has joined the American Medical Association (AMA) and the medical associations from all other states in the Ninth Circuit (Alaska, Arizona, California, Hawaii, Idaho, Montana, and Oregon) in an amicus curiae brief in a case with far-reaching implications for providers’ financial stability and patient care. The case, Palomar Medical Center (Escondido) v. Sebelius, turns on the actions of a Medicare Recovery Audit Contractor (RAC) that reopened a paid claim submitted by Palomar after more than one year had lapsed. Palomar challenged the reopening for failure to show good cause. A Medicare Appeals Counsel held that even though federal regulations require a showing of good cause to reopen a claim, the regulations do not permit a challenge of the failure to make that showing. A federal district court judge granted summary judgment to the Department of Health & Human Services (HHS). Palomar appealed the decision. After oral arguments in the Ninth Circuit Court of Appeals on March 7, 2012, the court invited amicus briefs to address whether federal regulations bar administrative challenge of a decision by a RAC to reopen a claim, despite a failure to show good cause, and if an administrative challenge is barred, whether federal courts have jurisdiction to enforce compliance with the good-cause requirement. According to the brief, the ability of a RAC to reopen a paid claim without cause puts physicians and hospitals at risk for fiscal

uncertainty. “Doctors cannot move forward with hiring and purchasing decisions if they do not have confidence in their financial situation.” In this event, most physicians (and hospitals) will act cautiously to avoid financial shortfalls with respect to planning and will decide not to make “critical investments in their health care infrastructure, which results in the diminishment of care for patients.” With no oversight of RACs, the brief argues, they are liable to “pursue goals inconsistent” with those of HHS and violate the statutory rules because they are “paid between 9 and 12.5 percent of any amounts they recover.” The brief reviews several studies that appear to prove this point. “In over 50 administrative cases reviewed by the California Hospital Association, an administrative law judge found that RAC’s lacked good cause to reopen well over half of the claims considered.” A CMS-authored study found that “as of March 2010, an astonishing 64.4 percent of appealed RAC re-openings resulted in decisions favorable to the provider.” And while the judicial panel that heard the Palomar case felt confident that CMS’ regulatory limits could be enforced adequately by evaluation and audits of the contractors’ performance, the brief continues, “the Secretary failed to point to a single instance in which a RAC was reprimanded for reopening a claim older than a year without good cause.”

(See News, Page 23)


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News (Continued from page 22)

Medicare continued... 2013 Medicare fee schedules posted The 2013 Medicare fee schedule has been posted on Palmetto GBA’s website. The fee schedule includes the 26.5 percent sustainable growth rate (SGR) cut that is scheduled to take effect on January 1, 2013. There is unanimous agreement in Congress that cuts of this magnitude would result in serious disruptions in care for the nation’s elderly and disabled populations, and cannot be allowed to occur. The California Medical Association (CMA) has been working with Congress to stop the SGR cut and the additional 2 percent sequestration cut during the lame duck session in December. If Congress passes legislation stopping the cut, new fee schedules will be posted. CMA encourages members to periodically check the Palmetto website for changes to the fee schedules before January 1, 2013.

Should Congress fail to act on the SGR before the end of the year, the Centers for Medicare & Medicaid Services (CMS) may instruct Medicare contractors to hold claims for 2013 services for the first 10 business days of January, as they have in the past. Physicians should be aware of the possibility of delays in claims processing as a result of any late fee schedule changes and may want to establish a contingency plan in the event of such cash flow disruptions. For more information on the 2013 payment rule, go to http:// www.cmanet.org/news/detail/?article=cms-releases-2013medicare-physician-fee. Contact: Michele Kelly, (213) 226-0338 or mkelly@cmanet.org.

All of the CMA News articles are reprinted from CMA’s biweekly e-newsletter, CMA Alert. CMA publishes Alert to keep members up-to-date on critical issues affecting the practice of medicine in California. What you see here is a very small sample of the sometimes critical information that CMA publishes in Alert. If you are not receiving Alert, PLEASE VISIT THE CMA WEBSITE AT www.cmanet.org TO SIGN UP TODAY!!! LAWS (Continued from page 6)

cancer which include mastectomies, dissections, prosthetics or reconstructive surgery. Revises definition of mastectomy to specify that the partial removal of a breast includes, but is not limited to, lumpectomy, which includes surgical removal of the tumor with clear margins. Requires a consultation regarding the length of any postsurgical hospital stay. (Knox-Keene Health Care Service Plan Act of 1975) SB 1196 (Hernandez, E.) – Claims Data Disclosure Provides that no contract in existence or issued, amended or renewed between a health care service plan or health insurer and a provider or supplier shall prohibit, condition or in any way restrict the disclosure of claims data to a qualified entity related to health care services provided to specified individuals. Requires the plan or insurer to comply with all state and federal laws and regulations regarding the protection of data privacy and security. Requires error correction for claims data received. (Civil Code add Part 2.7, commencing with §57, to Division 1; Health & Safety Code §1367.50; Insurance Code §10117.52)

Health Care Facilities and Financing AB 1803 (Mitchell) – Medi-Cal: Emergency Medical Conditions Provides that emergency services and care that are necessary for the treatment of an emergency medical condition are a covered benefit in the fee-for-service (FFS) Medi-Cal program. Defines "emergency services and care," "emergency medical condition" and other related definitions. Specifies that this bill shall not be construed to change the obligation of a Medi-Cal Managed Care (MCMC) plan to provide emergency services and care. Provides that the "reasonable layperson standard" applies for emergency medical services for persons in the Medi-Cal fee-for-service program creating a uniform standard of patient protection. (Welfare & Institutions Code §14132)

Medical Education AB 589 (Perea) – Medical School Scholarships Establishes the Steven M. Thompson Medical School Scholarship Program within the Health Professions Education Foundation to promote the education of medical doctors and doctors of osteopathy. Provides up to a specified sum per recipient in scholarships to selected participants who agree in writing prior to (See LAWS, Page 24)


Fall 2012

LAWS (Continued from page 23)

completing an accredited medical or osteopathic school based in the United States to serve in an eligible setting. Establishes a related account within the Health Professions Education Fund. (CMA Position: Sponsor) (Health & Safety Code add Article 6 (commencing with §128560) to Chapter 5 of Part 3 of Division 107) AB 1533 (Mitchell) – Medicine: Trainees: International Medical Graduates Amends the Medical Practice Act. Authorizes a clinical instruction pilot program for certain bilingual international medical graduates at the David Geffen School of Medicine of the University of California at Los Angeles as part of an existing preresidency training program, at the option of the university. Authorizes the state medical board to consider participation in the program as remediation for deficiencies in a participant's subsequent application for licensure as a physician and surgeon. (Business & Professions Code §2066.5)

Medical Practice and Ethics AB 1731 (Block) – Newborn Screening Program: Congenital Heart Disease Requires a general acute care hospital that has a licensed perinatal service to offer to parents a pulse oximetry test for the identification of critical congenital heart disease (CCHD) and would require the department to issue guidance stating that hospitals perform this test in a manner consistent with the federal Centers for Disease Control and Prevention guidelines. Requires these hospitals to develop a CCHD screening program. (Health & Safety Code add Article 6.6, commencing with §124121, to Chapter 3 of Part 2 of Division 106) SB 1172 (Lieu) – Sexual Orientation Change Efforts Prohibits a mental health provider from engaging in sexual orientation change efforts with a patient under 18 years of age. Provides that any sexual orientation change efforts attempted on a patient under 18 years of age by a mental health provider shall be considered unprofessional conduct and subjects the provider to discipline by the licensing entity. (Business & Professions Code add Article 15, commencing with §865, to Chapter 1 of Division 2) SB 1538 (Simitian) – Mammograms Requires, under specified circumstances, a health facility at which a mammography examination is performed to include in the summary of the written report that is sent to the patient a prescribed notice on breast density. (Health & Safety Code §123222.3)

Organ and Tissue Donation AB 2356 (Skinner) – Tissue Donation Amends existing law that prohibits the transfer of any tissues into the body of another person by means of transplantation, unless the donor of the tissues has been screened and found nonreactive for evidence of infection of specified viruses. Excepts a donation by a sexually intimate partner of the recipient from second or repeat testing if the recipient signs a waiver. Provides a liability exclusion for a physician or surgeon for

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insemination and assisted reproductive services under certain conditions. (Health & Safety Code §§1644.5 and 1644.6)

Public Health AB 472 (Ammiano) – Controlled Substances: Overdose: Punishment Provides it shall not be a crime for any person who experiences a drug-related overdose, who, in good faith, seeks medical assistance, or any other person who, in good faith, seeks medical assistance for that person, to be under the influence of, or to possess for personal use, a controlled substance, controlled substance analog, or drug paraphernalia, under certain circumstances related to the overdose that prompted seeking medical assistance if the person does not obstruct response personnel. (CMA Position: Support) (Health & Safety Code §11376.5) AB 1301 (Hill) – Retail Tobacco Sales: Stake Act Amends the Stop Tobacco Access to Kids Enforcement Act. Removes the schedule for State Board of Equalization action in response to the occurrence of a violation of the Act or the related misdemeanor provision. Requires the board to assess a civil penalty and suspend or revoke a retailer's license for subsequent violations. Requires the assessment of an additional civil penalty to be deposited in the existing Cigarette and Tobacco Products Compliance Fund to fund suspension and revocation activities. (CMA Position: Support) (Business & Professions Code §§22958 and 22974.8; Penal Code §308) AB 2109 (Pan) – Communicable Disease: Immunization Exemption Requires on and after January 1, 2014, a separate form prescribed by the Department of Public Health (CDPH) to accompany a letter or affidavit to exempt a child from immunization requirements under existing law on the basis that an immunization is contrary to beliefs of the child's parent or guardian. Requires the letter or affidavit to include a signed attestation from a health practitioner that the parent was informed of the benefits and risks of the immunization and the risks of specified communicable diseases and to document which immunizations have or have not been given. Relates to emancipated minors. (CMA Position: Sponsored) (Health & Safety Code §120365) These are just a sampling of the new laws impacting health care in 2013 and beyond. For a complete list, see "Significant New California Laws of Interest to Physicians for 2013," in the California Medical Association's online resource library.


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House of Delegates 2012 ACA topic of heated debate at House of Delegates Since the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, it’s been virtually a certainty that delegates at the annual House of Delegates meeting would debate to influence policy regarding the landmark reform bill. This year’s gathering was no exception, as resolutions touching upon various aspects of the ACA were introduced, and in some cases, adopted as official California Medical Association (CMA) policy. Of the resolutions introduced and debated over the weekend, it appears that Resolution 202-12 will produce some of the most immediate results. The resolution, which deals with the California Health Benefits Exchange, asks that CMA support several actions that will help ease the transition of roughly 1.6 million new enrollees to the state’s Medi-Cal program, as well as a list of requirements that will help protect physicians when contracting with plans offered through the exchange’s online marketplace. Specifically, the resolution asks that county and state funding sources that currently help provide care for medically indigent adults follow those individuals when Medi-Cal is expanded in 2014, and that the exchange takes a more active role in monitoring network adequacy of its offered plans. The issue of network adequacy has already garnered a significant amount of attention from CMA staff, but an agreeable solution has yet to be reached with exchange leadership. A separate resolution, 201-12, reaffirmed CMA’s position of continuing to work toward amending the ACA to “address issues of concern to the practice of medicine,” and was adopted by the House. Finally, two resolutions, 204-12 and 205-12, launched the seemingly annual debate over single payor coverage in California. During the reference committee hearings, supporters and opponents of single payor in California took to the microphone to voice their opinions on the matter, providing some of the most passionate and ideologically divided debate of the weekend. Ultimately, reference committee members recommended that delegates disapprove both resolution, noting that CMA has “well thought out and longstanding” policy on the issue of single payor. (CMA's Policy Compendium is available to members at www.cmanet.org/policies. The new policies passed this year will be added to the compendium soon.) For more information on any of these resolutions, or general reform activities in California, please subscribe to CMA’s regular reform newsletter, CMA Reform Essentials at http:// www.cmanet.org/cma-reform-essentials.

CALPAC, CMA’s political action committee, carried two things into the 2012 House of Delegates meeting—last year’s three-day fundraising record of $110,000 and a fully mustached Chair posing a challenge to delegates in attendance. In a record-setting show of support for CALPAC, CMA members contributed a total of roughly $152,000, besting last year’s mark while also exceeding the $150,000 goal established before the House of Delegates. Throughout the weekend, attendees were informed that, should the goal be met, outgoing CALPAC Chair and new CMA President-Elect Richard Thorp, M.D., would shave his mustache during the full House session held on Monday morning. (Check out the photos on CMA’s FaceBook page, www.facebook.com/cmaphysicians.)

CMA delegates call for increased advocacy on duals transition Recognizing the challenges that California’s planned shift of Medicare and Medi-Cal dual eligible patients to managed care plans will pose to patients and the physicians that serve them, the California Medical Association (CMA) has adopted policy to help keep physician concerns in clear view of the agencies orchestrating the transition. The policy (Resolution 208-12), which was adopted at the CMA's annual House of Delegates meeting, calls on the association to collect data from its membership regarding difficulties with the planned duals transition and, if difficulties are found to be widespread, report them to the California Department of Health Care Services, the California Department of Managed Health Care and the federal Centers for Medicare and Medicaid Services. During the floor debate regarding the issue, delegates noted that the state's Coordinated Care Initiative, which includes a pilot program to passively enroll patients eligible for both Medicare and Medi-Cal in eight of California's largest counties, would see more than 75 percent of the state's dual eligibles transitioned to managed care plans. The shift, speakers said, would likely lead to considerable confusion among patients and almost certainly interrupt relationships that have been established with their existing physicians. Under the pilot program, patients will be enrolled in a managed care plan unless they actively opt out. In addition to asking that CMA monitor the transition, the newly adopted policy also requests that the association advocate that the appropriate state agencies provide "full and clear disclosure" on options and consequences facing patients affected by the pilot program. More information regarding the dual eligible transition can be found in CMA's online duals resource center, at www.cmanet.org/duals.


Fall 2012

Wrap-Up (Continued from page 11)

joined by Saturday Night Live alum Rob Schneider. Now armed with "celebrity" status, the opposition was able to secure public rallies, television time and spread of social media to oppose our efforts. Despite attempts at negative media attention by the opposition, Governor Brown signed AB 2109 into law hours before the deadline. The year wouldn’t be complete without CMA revisiting some oldies but goodies, physical therapy and MICRA being no exceptions. Unfinished business from 2011, SB 924 (Steinberg/ Price) would have fixed the ambiguity in law as to whether or not medical corporations can legally employ physical therapists, but it would have also allowed patients to directly access physical therapy treatment for 30 business days, at which time a physician would have to sign off on a physical therapy treatment plan. CMA had an official "Oppose unless Amended" position on the bill, asking for amendments that would have required a medical diagnosis after 30 days of direct treatment. The Assembly Appropriations Committee passed the bill, adding in medical diagnosis as a requirement for direct access. The California Physical Therapy Association again amended the bill on the floor, changing the language so that instead of requiring a diagnosis it would require an examination or a diagnosis…and as the game of semantics wore on, the bill was quickly sent to Assembly Rules Committee where it stayed until its demise. Two bills that would have weakened the protections of MICRA,

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SB 1528 (Steinberg) and AB 1062 (Dickenson) were amended the last week of session adding to the flurry of the chaos in the final days. The provider community strongly opposed both bills and thanks to letters and phone calls from physicians across the state, they were ultimately killed with astoundingly low vote counts. The legislative session officially ended early Saturday morning, September 1, 2012, and CMA’s Government Relations team was at the Capitol until the very end. In the waning hours of the 2011 -2012 Legislative Session, CMA successfully negotiated key amendments into the Worker’s Compensation bill and proudly fought to reinstate the Healthy Families program as part of a multi-part deal that died sometime after 1:00 am. Despite bipartisan support for our efforts, the Healthy Families program became collateral damage to partisan politics. CMA continues to work with stakeholders on the transition of kids to Medi-Cal. "The Myth of Sisyphus" tells us that toil is not futile, and hard work can be noble. CMA toiled throughout the year for physicians, honoring the labor physicians do for their patients every day. The struggle to push those legislative rocks up the hill was performed with pride, and as the essay reads, "The struggle itself toward the heights is enough to fill a man’s heart. One must imagine Sisyphus happy." Of course, Sisyphus was not pushing the rock while simultaneously fighting labor lobbyists or Rob Schneider–but I still imagine him happy. For details on the major bills that CMA followed this year, see www.cal.md/legwrap2012.


Fall 2012

Credit Cards (Continued from page 13)

contract, you may be treated the same as a higher level merchant and be required to conduct annual on-site assessments and validation by a Qualified Security Assessor. Expect the annual on-site assessments to cost in the $10,000– 20,000 range or more. You will be required to remediate any inadequacies discovered during the annual assessments at your own expense.

Who enforces compliance of the PCI DSS? American Express, Discover Financial Services, JCB International, MasterCard Worldwide, and Visa Inc. Each of these institutions posts compliance guidance which may be slightly different from the others. Before going to each credit card company website, read, understand, and follow all guidelines provided by PCI.

Why aren’t card readers or software applications safe enough from hackers? According to the PCI, there are many reasons credit card readers or applications may not be secure. Card readers may inadvertently store magnetic stripe data which contains Sensitive Authentication Data or card verification codes; they may not be installed properly or securely and might be easily compromised; default settings or passwords may not have been changed on readers or in applications; security patches were not kept updated; the credit card data on the network is not properly segregated to be secure; data may not be properly encrypted; web applications may not be hardened against vulnerabilities.

What if I complete a self-assessment and uncover deficiencies? If the self-assessment uncovers deficiencies, remediation is necessary. A remediation plan, known as an Action Plan for NonCompliant Status, should be completed. PCI allows 12 months to

Roadmap (Continued from page 17)

epileptic patient had a seizure, was brought to the emergency department, and follows up with you the next week, you should report the incident if you don’t see documentation of reporting in the emergency department records. Similarly, if a patient with dementia transfers to your care, you must report them to the DHS, unless the prior records reflect notification in your state. As mandated reporters, we are required to report lapses of consciousness, but we can reassure our patients that this does not equal the loss of one’s driving privilege, as only the DMV is authorized to make this determination. The DMV wants to hear about all reportable LOC, but makes a decision on each driver after conducting a thorough investigation that will include additional medical information, usually obtained through DMV form DS 326 (www.dmv.ca.gov/forms/ds/ds326.pdf), and may include interviews, vision and written exams, and on-the-road testing. In patients with mild dementia, for example, the DMV may determine that they are safe to continue driving for an abbreviated period of time, with close monitoring.

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remediate, but progress must be demonstrable. All remediation is at the expense of the merchant. If your practice is very large and you process many transactions, you will need to work with a data security firm. PCI provides a list of qualified assessors on its website.

How do I avoid the need for assessments altogether? If you accept credit cards for payment, an annual assessment is required. But if you successfully follow these guidelines, the selfassessment questionnaire is short and painless:         

Secure your credit card readers. Use a virtual terminal solution provider validated by the PCI. Do not store credit card numbers, or any of the information from the credit card on any computer or system. Do not store the Primary Account Number (PAN) commonly known as the credit card number. Never store sensitive authentication data. If the PAN is displayed, it must be masked. Only the first six and last four digits may be displayed. Never store the data from the magnetic stripe or, if present, the chip. Never store the Personal Identification Number (PIN). Never store the card security code, the 3-digit number on the back of most credit cards or the 4-digit code on the front of American Express cards.

Now that you know some of the risks and requirements of storing credit card information, do you really need them on file? For more information, visit the Payment Card Industry website at www.pcisecuritystandards.org.

Fran Cain is the Network Systems Manager for NORCAL Mutual Insurance Company. Copyright 2012 NORCAL Mutual Insurance Company. All rights reserved.

Identification of age-related driving disorders includes the screening and diagnosis of lapses of consciousness, frailty, vision deficits, and other medical conditions (e.g., use of medications that impair cognition) that influence driving abilities. AMA has provided guidelines for screening at www.ama-assn.org/ ama/pub/physician-resources/public-health/promoting-healthylifestyles/geriatric-health/older-driver-safety/assessingcounseling-older-drivers.page. Of the disorders identified through this screening, only lapses of consciousness require reporting. Keeping our patients and the public safe requires attention to driving safety, including compliance with noncommunicable-disease mandated reporting laws. More information on the physician’s role in older driver safety can be found on the TREDS website (treds.ucsd.edu).

Dr. Hill, SDCMS-CMA member since 2010, is a Professor in the Department of Family and Preventive Medicine at UCSD, Director of the UCSD/SDSU General Preventive Medicine Residency, and the Director of TREDS (Training, Research, and Education for Driving Safety).


The Bulletin 2848 Park Avenue, Suite C â—? Merced, California 95348


Fall 2012