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Fall 2013

The Bulletin Inside this Issue: FEATURES: MICRA: As a threat reemerges, physicians stand to defend the law...(page 9) Frequently Asked Questions about California’s Health Benefit Exchange…(page 13) Year of Challenges, Victories...2013 Legislative Wrap-Up...(page 17) HOD 2013...CMA Delegates set policy at Annual Meeting…(page 22) This is Not a Test...Join the Fight Today!…(See page 10) Join Us for our Holiday Party…(See page 24) Meet the New and Returning Members…(See page 25) Research being conducted on the Affordable Care Act…(See page 25) Discounted Coding Books!!!…(See page 26)


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 Samuel B. Tacke, M.D. President Donald P. Carter, M.D. President-Elect Thavalinh Mark Sphabmixay, M.D. Secretary-Treasurer Nirmal Aujla, M.D. Immediate Past-President

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

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

CMA Alternate Delegates Samuel B. Tacke, M.D. Eduardo T. Villarama, M.D.

Staff Chrisy Muchow Executive Director

CONTENTS Meet Your New CMA President—Richard Thorp, M.D. ............................................ 5 Message from your CMA President ......................................................................................... 6

MICRA: As a threat reemerges, physicians stand to defend the law ....................................... 9

Frequently Asked Questions about California’s Health Benefit Exchange for Physicians and their Staff ........... 13

Year of Challenges, Victories The California Medical Association’s 2013 Legislative Wrap-Up ............................ 17

HOD 2013 CMA Delegates set policy at Annual Meeting ............................................................. 22

Meeting Schedule ............................................................................................................ 25 News from the California Medical Association ...................................................... 27 Top News Majority of U.S. House signs bipartisan letter for SGR repeal this year .................. 27 CMA Medi-Cal Survival Guide helps physicians understand numerous program changes ............................................................................................. 27 Covered California releases detailed enrollment data .................................................. 27

Medicare News CMA calls for improvements to the new Medicare SGR reform proposal.............. 28 2014 Medicare fee schedule confirms 24 percent cut ................................................. 29 CMS to implement ordering and referring denial edits beginning in January 2014 ................................................................................................ 29 Are you ready for the new CMS 1500 claim form? ........................................................ 29

Payor News Reminder: Blue Shield fee schedule changes took effect December 1 ................. 30 Anthem Blue Cross moving some inquiry functions to Availity web portal ........... 30 Online payment portals: Physicians beware ..................................................................... 30

Contact Information 2848 Park Avenue, Suite C Merced, CA 95348 (209) 723-2976 Fax: (209) 723-8371 chrisy@mmcms.org www.mmcms.org For Advertising Opportunities Contact Chrisy Muchow at (209) 723-2976 or chrisy@mmcms.org. 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 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 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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MEET YOUR NEW CMA PRESIDENT!

Paradise internist Richard Thorp, M.D., installed as 146th president of the California Medical Association

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n October 12, Richard Thorp, M.D., FACP, became the 146th president of the California Medical Association (CMA) during the association’s annual House of Delegates in Anaheim. Early in his life, Dr. Thorp learned the values he maintains to this day. He was raised in a small community in Washington state, “where people helped each other and looked out” for one another. In addition to the example set by his parents (his mother was a registered nurse, while his father was a dentist), his Seventh Day Adventist upbringing taught him that being of service to his fellow man was more important than self-enrichment. Many years later, Dr. Thorp has carried these values into his practice as an internist. For 37 years, Dr. Thorp has practiced in Paradise, located in rural Northern California. Over those years, he has developed deep ties with his patients. One elderly patient in particular, despite being treated by a specialist, always stops by to visit him. In telling her story, he clearly displays his deep affection and commitment to those he serves. “Medicine is a unique profession where you touch people in ways that very few people can touch others,” he said. “Because you are a doctor, people give you their trust. They tell you personal things they wouldn’t tell their priest.” And, as Dr. Thorp explained, these patients also touch their healers deeply. One of the things he hopes to do during his term as CMA president over the upcoming year is to remind physicians of the “sacred trust and opportunity to care for the people who are our patients.” “We lose that in the details of treatment and paperwork,” he said. “Our patients look to us to intercede and look out for them.” Compared to the past, he says that today “we have a lot we can do for our patients,” whether it is finding them an effective cancer treatment, procuring an eye patch or helping them choose a specialist that will be the right match for that particular patient. Just as he has a passion for helping physicians renew and remember what originally inspired them to become doctors, he also has a passion to help shape public policy for the benefit of patients through organized medicine. Dr. Thorp developed an interest in health policy and health system reform while serving as president of Butte -Glenn Medical Society in 1994, the year of the Clinton health reforms. In 1994, he was also the incorporating agent of a countywide management service organization involving PPO and HMO physician groups and the area hospitals.

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MESSAGE FROM YOUR CMA PRESIDENT, RICHARD THORP, M.D. He continued a leadership role in organized medicine in 1995, serving on CMA’s Committee on Managed Care and subsequently on the Committee on Medical Service. He was the chair of the Committee on Medical Services for 10 years and since 2008, has served as consultant to the committee. Dr. Thorp was also elected to the CMA Board or Trustees in 2009 and is an Alternate Delegate to the American Medical Association House of Delegates, representing a portion of Northern California. In 2011 and 2012, he was the chair of CALPAC, CMA’s political action committee. He has spent the last year serving as president-elect of CMA and as a member of CMA’s Executive Committee. Dr. Thorp, who did his undergraduate work at the University of Washington and then went to medical school at Loma Linda with a residency there as well, has an agenda for his year-long presidency. “I‘d like to tackle the restructuring of CMA, and I know this will be controversial,” he said. “Each year we are spending one-third of the CMA budget ($4.6 million) on governance. We could and should apply more of this money to our state and federal lobbying efforts.” “We also have a board of trustees that is too large to govern (56 members),” he noted. “We need to make sure that everyone in the state is represented, but the board needs to shrink to a more manageable size.” He also sees increasing membership as a priority for him this year. “I want CMA to represent most of the physicians in the state. I think we should set a five-year goal of hitting 50,000 member doctors.” This year, CMA gained almost 5 percent more doctors as members than 2012, bringing statewide membership to 38,000. “We haven’t seen membership like this since the 1990s,” he said. “The MICRA [Medical Injury Compensation Reform Act] fight that is brewing and interest in the Affordable Care Act seem to have pressed doctors into joining us because we have been very successful passing legislation in their favor.” Still, he would like to see membership grow even more to ensure CMA is representing the majority of doctors practicing in the state. Last, but certainly not least on his long list is winning the fight over California’s successful MICRA law. “This is my biggest concern,” he said. “We must make sure that we don’t become too confident or too complacent on this issue.” Recent attacks on outgoing CMA President Paul Phinney, M.D., made by the trial lawyer funded Consumer Watchdog, confirm that the health care community is facing a formidable opponent who will stop at nothing, including lies, to eviscerate MICRA so that they can line their pockets through inflated attorney fees. “We must preserve MICRA and preserve access to care for our patients,” emphasized Dr. Thorp. Dr. Thorp is not only highly regarded by his patients, but also by his colleagues. “We need to speak with a unified voice in order to be heard,” says Sacramento pediatrician and California State Assembly member Richard Pan, M.D. “Dr. Thorp has proven that he can speak with a strong voice for physicians.” Dr. Thorp is the president and CEO of Paradise Medical Group, Inc., a physician-owned multi-specialty primary care group incorporated in 2001. He is also on the active staff of Feather River Page 6

Dear Colleagues – In October, I was honored and humbled to stand before more than 400 delegate physicians from across geographies, specialties and modes of practice at the California Medical Association (CMA) Annual House of Delegates meeting in Anaheim. I want to share with you the messages I shared with our colleagues, as I believe it is important to be unified as one voice moving forward in this tumultuous time of change in health care. First and foremost, we can agree that this is an incredible time to be part of our profession. We are living history as new models of integrated care and innovative technologies become a thing of the present, rather than a dream of the future. Patients will have access to treatment and medicine that they have never been exposed to and with our work and research, we can offer our patients additional years, if not decades, with their loved ones. Although we are at the pinnacle of discovery in the treatment of disease, this profession is also under serious attack, and so we must work more diligently than ever before. We cannot make the mistake of tempting our adversaries with complacency. I practice in Paradise, a small town in Northern California, just a few hours outside of Sacramento. I can tell you first hand, as the medical director of a rural health clinic and as president/CEO of a private multi-specialty Primary Care Group (Internal Medicine, Family Medicine, Hospitalist Medicine and Pediatrics) , that communities like mine are feeling the changes ahead of us the most. Between cuts to California’s Medicaid program (MediCal) and the Congressional stalemate that continually threatens the future of Medicare, running a practice is a constant challenge. As attacks on California’s Medical Injury Compensation Reform Act (MICRA) continue and unknown curveballs are thrown our way, we must stand together with one voice – that is the only way that we will prevail. My hope for us in this next year is that physicians of California remember and are inspired by how far the profession has come as we face the new challenges of the future. We live in the golden age of medicine. A time when the future of medical treatments is bright and getting brighter every day, and when we speak in unison, we have a powerful voice! Offering safe, quality, accessible and affordable health care to our patients is why we joined this noble profession. Whatever fight may come before us this next year, let us stand and live by CMA's mission statement: Promoting 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. Richard Thorp, M.D. CMA President

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Hospital and divides his time between a private general internal medicine practice, service as medical director of a rural health clinic and private practice administration. In 2009, Dr. Thorp was recognized as a fellow by the American College of Physicians (ACP). He also serves on the Governor’s Council for the Northern California Chapter of ACP and has served at the national level of ACP as a committee member. “I will not compromise the honor of this profession for the victory of the moment. I will not capitulate or surrender. I will fight to protect this profession you hold so dear,” Dr. Thorp said as he addressed the 500 physician delegates in attendance at the House of Delegates. “In this critical time, the house of medicine cannot afford to do business as usual. We cannot afford the status quo. We must come with the audacity to create a dream and a vision for the future of medicine and health care in California.” Dr. Thorp told the delegates that he hopes California physicians remember and are inspired by how far the profession has come as we face the new challenges of the future. “When you look at what we’re able to do today, we live in the golden age of medicine,” he said. “A time when the future of medical treatments is bright and getting brighter every day.” “We have serious problems today. But we have incredible opportunities,” said Dr. Thorp. “Although we are at the pinnacle of discovery in the treatment of disease, this profession is at war. More than ever, we cannot make the mistake of tempting our adversaries with complacency.” “This is going to be a hell of a year,” said CMA CEO Dustin Corcoran. “But I cannot think of a better president, better physician to lead us in this time of tumultuous change.”

CMA President Richard Thorp, M.D., and his wife Vicki at the CMA Foundation President’s Reception and Awards Gala.

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MICRA: As a threat reemerges, physicians stand to defend the law By Richard Thorp, CMA President

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hen trial lawyers announced earlier this year that they were working to scrap California’s Medical Injury Compensation Reform Act (MICRA), the California Medical Association (CMA) warned that the campaign would be riddled with lies, misdirection and below-the-belt shots designed to fool the public into thinking the trial lawyers’ efforts were anything more than an outright money grab. Unfortunately, we didn’t know how right that warning would prove to be. Since its passage, MICRA has been under near-constant attack from those who place the prospect of a higher payday above the overall health and well being of California residents. While, time and time again, MICRA has weathered the storm, the law is under siege once again. This time MICRA is facing the greatest threat yet, as trial lawyers aim to put more money in their own pockets at the expense of patients across the state. Driven by greed and the promise of inflated attorney fees, California trial lawyers have renewed their fight to lift MICRA’s cap on speculative, non-economic damages, presenting ballot language that seeks to more than quadruple the maximum award for non-economic damages to roughly $1.1 million. While trial lawyers have postured and threatened major action on MICRA before, this latest effort is made credible by the nearly one million dollars the lawyers recently put into a ballot measure committee. The proposed ballot language, put forward by a trial lawyer front group inappropriately named Consumer Watchdog, was cleared by the Attorney General for MICRA opponents to begin collecting signatures to place the measure on the November 14 ballot. Trial lawyers and their allies are bankrolling the proposed initiative. With money on the table and signature gatherers on the street, it’s clear that MICRA opponents are serious about overturning the law in 2014.


If successful, these efforts would be devastating to California’s health care system. More meritless lawsuits will lead to reduced patient access to our health care professionals – and fewer options for affordable, quality health care – especially in rural and underserved communities. With federal health care reform expanding coverage for millions of additional patients, California is already struggling to provide access to care for the neediest and most vulnerable patients. If this ballot initiative is successful, it will only make the situation worse—even longer lines in emergency rooms, extended waits for appointments with specialists and reduced access to women’s services like OB/GYNs. This measure will make health care professionals including doctors, nurses and other providers less accessible – not more accountable, as claimed by the trial lawyers. A broad-based coalition of nearly 1,000 groups and organizations led by CMA—including doctors, nurses, dentists, hospitals, Planned Parenthood and community health centers and clinics, among others—has emerged to protect access to care across the state. While the latest fight over MICRA has now taken its first steps toward the ballot box, CMA and its allies have already notched several key victories in this fight, and remain committed to defeating the initiative push in its entirety.

THE THREAT EMERGES _______________________________________________________ This latest assault on MICRA began with all the theatrics and deception that has come to be expected from California trial lawyers and their faux-grassroots front group, Consumer Watchdog. In early May, Consumer Watchdog President Jamie Court held a press conference in front of the California Capitol announcing his organization’s intent to overturn MICRA, either through legislation introduced in the final months of the 2013 legislative session, or through a ballot initiative brought before California voters. During the conference, Court nefariously painted physicians as believing they were above the law, and in some cases, completely apathetic to the pain and suffering experienced by victims of medical malpractice. Despite drawing only a small crowd and being unable to expand much upon their intentions during the May press conference, Court and his followers eventually made good on their threat of introducing a ballot measure, submitting language in early July that calls for MICRA’s cap on subjective non-economic damages to be raised from $250,000 to $1.1 million, with automatic annual increases every year thereafter. The ballot measure came only after Consumer Watchdog and others unsuccessfully tried to pressure the legislature to address the issue. The central intent of the proposed ballot language is nothing more than a thinly-veiled money grab by California’s trial attorneys, who stand to make hundreds of thousands of additional dollars on every malpractice case should the cap be changed. However since most voters would not support that provision, it also calls for physician drug testing and a bolstering of the state’s Controlled Substance Utilization Review and Evaluation System (CURES). Currently, MICRA protects patients involved in medical liability lawsuits by allowing unlimited economic compensation for any and all economic or out of pocket costs, including past and future lost income and earning capacity, all necessary medical care, as well as unlimited punitive damages. Under MICRA, patients can also receive up to $250,000 for non-economic pain and suffering damages. This allows legitimate medical liability Fall 2013

cases to move forward while discouraging lawyers from filing frivolous suits. MICRA also limits how much lawyers can take as payment, ensuring more money goes to patients, not lawyers. The trial lawyers’ measure would not only nearly quadruple MICRA’s non-economic damages cap from $250,000 to $1.1 million—it would also triple the legal fees that lawyers receive. While the trial lawyers get rich, everyone else pays. More lawsuits mean higher health care costs for everyone. An analysis by California’s former independent legislative analyst found that this measure would increase health care costs for consumers and taxpayers in California by nearly $10 billion annually.

PANDERING IN THE CAPITOL _______________________________________________________ MICRA opponents also attacked the Capitol, where members of the Legislature were returning from their summer recess and preparing to begin the final legislative push for the 2013 session. Knowing that legislation attempting to scrap MICRA would never survive the vetting process typical of a full session, opponents sought to find an author willing to use the so-called “gut-andamend” action to avoid public scrutiny provided through the regular legislative process to push an anti-MICRA bill through the Legislature in the final days, or even hours, before the Assembly and Senate adjourned for the year. In its effort to locate an author, as well as drum up opposition to MICRA, Consumer Watchdog began conducting daily mail drops featuring their “38 is too late” campaign to legislative offices. The canvassing project targeted physicians as being unsympathetic to their patients’ needs, and portrayed MICRA as a barrier to victims seeking restitution for medical malpractice. Nowhere in Consumer Watchdog’s literature did it mention that medical malpractice victims are entitled to unlimited economic damages— such as lost wages, earning capacity and medical expenses— under California law. Nor did it mention that lawyers would stand to make more money should MICRA be overturned. To combat this effort, CMA and a host of allies—including labor groups, public safety entities, allied health care professionals and municipal interests—inundated members of the Legislature with facts supporting MICRA’s efficacy, warning that altering the cap would adversely impact local governments, community clinics and insurance premiums for all Californians. In the end, MICRA’s supporters emerged victorious, as trial attorneys were unsuccessful in getting anti-MICRA legislation introduced during the most recent session.

CHEAP SHOTS AND SCARE TACTICS _______________________________________________________ Shortly after being defeated in the state Capitol, MICRA opponents decided it was time to start playing dirty. In late September, Consumer Watchdog distributed a mail piece featuring the names of hundreds of California physicians who it claims are afraid to “pee in a cup,” while also personally targeting CMA Past President, Paul Phinney, M.D., asking what he had to hide by opposing the trial attorneys' greed-fueled initiative to gut MICRA. Oddly enough, the trial attorneys' mailer makes no mention of the proposed initiative’s attempt to nearly quadruple MICRA’s cap on non-economic damages and exponentially increase their fees, and sticks to the more voter-friendly provisions regarding substance abuse in the workplace. Page 11


The attack was a brazen one, illustrating that the state’s trial lawyers and their puppet organization, Consumer Watchdog, will stop at nothing to line their pockets through the inflated attorney fees that would be generated from MICRA’s cap being lifted. These cheap shots continued, however, when representatives from Consumer Watchdog crashed CMA’s annual House of Delegates conference in Anaheim, hosting a press conference outside of the conference center before circling the streets with a video truck broadcasting the message that “doctors should pee in a cup.” While these attacks may sting for those who are personally targeted, they also illustrate one fact – MICRA opponents are desperate. In the months since trial lawyers launched their latest assault against MICRA, California physicians and other allies have rallied to MICRA’s defense at a near-historic rate. Funds are being raised at record numbers, and physician engagement with the issue grows every day. As a result, Consumer Watchdog and other MICRA opponents are stooping to new lows in an attempt to intimidate those who have come to MICRA’s defense.

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These deceitful attacks by MICRA opponents will continue, and will get worse as the November 2014 election cycle ramps up. Physicians, however, must continue to advocate for MICRA and ensure that our patients and practices are not jeopardized by the greed of those who would like to see MICRA fall. Rest assured, CMA will win this fight, but will need all physicians in order to do so.

To find out how you can help, visit www.cmanet.org/micra today!!!

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COVERED CALIFORNIA In 2010, Congress passed historic sweeping health care legislation, the Patient Protection and Affordable Care Act (ACA), which reformed the individual and small group health insurance markets and, beginning in 2014, will provide health insurance to much of the nation’s uninsured. Under the ACA, two-thirds of California’s uninsured may be covered by private insurance through a health insurance exchange purchasing pool. California’s exchange, Covered California, began enrollment on October 1, 2013 – with coverage beginning on January 1, 2014. The following FAQ for physicians and their office staff provides answers to the most commonly asked questions about exchange eligibility and enrollment.

What is Covered California?

the health plan in which the patient is enrolled.

Covered California is the new marketplace where Californians can compare and purchase health coverage. Through Covered California, many patients will be eligible for financial assistance to help pay their premiums and even co-pays.

Premium assistance will be adjusted at the end of the benefit year based on the patient’s actual income. A patient may be held accountable for any excess subsidies received when filing that year’s taxes. For this reason, patients should immediately report any changes in income to Covered California that may impact the amount of premium assistance, such as changing jobs, losing a job or receiving a promotion.

Through Covered California, individuals and small businesses can compare different health insurance companies and learn whether they qualify for premium assistance and tax credits. Californians will also be able to find out if they are eligible for low-cost or no-cost health coverage through Medi-Cal.

Which patients can buy coverage through Covered California? Legal California residents, except for currently incarcerated individuals and legal minors, are eligible to buy insurance through Covered California.

Which patients are eligible for subsidies through Covered California to purchase coverage? Premium assistance is available to individuals and families who meet certain income requirements and do not have access to affordable, adequate health insurance through their employers. Eligibility for premium assistance is based on family income and the number of people in the family. The size of the premium assistance is calculated on a sliding scale, with those who make less money getting more financial assistance. Individuals with incomes up to $45,960 and a family of four with an income up to $94,200 may be eligible for premium assistance.

How will patients’ federal premium subsidies work? Federal premium assistance is only available when enrolled in a health plan through Covered California, and it is paid directly to

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How will Covered California impact my practice? The impact on physician practices will vary greatly depending on the mix of patients in your practice and the extent to which you contract with Covered California plans. Millions of previously uninsured Californians will now be eligible for health insurance through Covered California and Medi-Cal. Your patients with employer-sponsored coverage are not likely to see significant changes in their coverage. Small and medium sized physician practices with 50 employees or less are also eligible to participate in the Small Business Health Options Program (SHOP). For more information, visit www.coveredCA.com.

Will my Covered California patient be able to continue to see me? You will have to be contracted with a Covered California plan and your patient will have to select that plan. Each health insurance plan has a specific list of doctors and hospitals that are considered in-network providers for covered services. Directories of doctors and hospitals will be available at www.CoveredCA.com. Patients should be advised to verify with the individual plan that a particular doctor’s or hospital’s services will be covered under that plan. Covered California is providing a searchable online directory so that patients can see which health plan networks contain a particular doctor or hospital.

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How can a patient apply for Covered California coverage or Medi-Cal? Open enrollment will continue until March 31, 2014, but patients must enroll in a plan by December 15, 2013, for coverage to begin January 1, 2014. In subsequent years, open enrollment will run from October 15 through December 7. Patients can apply for a Covered California health insurance plan online at www.CoveredCA.com or by calling (800) 300-1506. In-person assistance is also available from Certified Enrollment Counselors in many communities. Patients can be directed to their nearest Certified Enrollment Counselor by calling (800) 300-1506.

What if I have questions about how my business may be impacted by Covered California or health plan contracting under Covered California? If you have questions related to your business or contracts for providing services to Covered California patients, please refer to the California Medical Association’s (CMA) resource page, “Health Insurance Exchange Resources for Physicians,” at www.cmanet.org/exchange. For further assistance, please contact CMA’s Physician Hotline at (800) 786-4262.

How much should patients expect to pay out of pocket for health care services? Patients’ co-pays and deductibles will vary based on the plan that is selected. (See chart below.)

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EXCHANGE RESOURCES FOR PHYSICIANS The California Medical Association (CMA) has developed several resources to help educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting. Among those resources is "CMA's Got You Covered," a physician's guide to Covered California. This resource is FREE to members and provides a comprehensive overview of the Affordable Care Act and the exchange, key issues to watch and things to consider when deciding whether to contract with an exchange plan. This guide and other exchange-related resources are available at www.cmanet.org/exchange. Additionally, CMA members and their staff have free one-on-one access to CMA's practice management experts through the CMA reimbursement helpline at (888) 401-5911 or economicservices@cmanet.org.

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YEAR OF CHALLENGES, VICTORIES The California Medical Association’s 2013 Legislative Wrap-Up

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By Juan Carlos Torres, CMA Vice President of Government Relations

his year turned out to be a challenging year for the California Medical Association (CMA). We knew going into the legislative session that 2013 would be a historic year, with the implementation of the Affordable Care Act (ACA) and the wave of legislative freshman. It lived up to our expectations. With the beginning of each session, there are new legislators that come to Sacramento from all walks of life. CMA’s government relations team is challenged with getting to know them, educating them on issues of importance to the physician community and identifying the physicians with whom they have— or should have—relationships. While the Legislature has had up to one third of its members turn over in any given year, this year a majority of legislators were new to Sacramento. The challenging task of educating the new class was magnified. In addition, 2013 included 12 special elections that resulted from various vacancies created by departures and resignations. CMA faced an unprecedented number of scope of practice expansion bills introduced in the Legislature. These scope bills were painted by supporters as necessary reforms to help implement the ACA. Those who wanted to expand scope had a Fall 2013

key message: we need allied health professionals, including nurse practitioners, optometrists and pharmacists, to do more in order to prepare for the many Californians added to California’s health care system through the ACA implementation. Our message was simple: we will not jeopardize patient safety and we need to promote integration of allied health professionals, not fragment them as these proposals suggested. We faced a concerted effort by the nurse practitioners, optometrists and pharmacists who joined together to push their agenda collectively. They put in significant resources to mount a public relations campaign and were actively pursuing newspaper editorial boards across the state to promote their agenda. With the help of our specialty partners and our local medical societies, CMA won the argument in the Capitol. We successfully defeated the attempt by nurse practitioners to gain independent practice in California, as well as efforts by optometrists seeking to diagnose and treat diseases in patients. CMA significantly narrowed the pharmacists’ proposal to ensure that they could provide reasonable services in an integrated and safe manner that promoted collaboration with physicians.

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MOVING THE PHYSICIAN AGENDA FORWARD

CMA also tackled the incorrect perception that physicians are at the center of the opioids overdose crisis occurring in California. Physicians recognize the need to help ensure appropriate prescribing and the need to tackle abuse and diversion of prescription drugs. We helped craft a proposal that will ensure that our state’s prescription monitoring program, CURES, will be upgraded and funded. CMA also secured a streamlined application process for CURES, a requirement that a stakeholders group be consulted as the upgrade and maintenance occurs, and a reduced fee impact on physicians. Most importantly, there will be no mandated participation required of physicians. A proposal that would have given the medical board overly broad power to discipline physicians for inappropriate prescribing was soundly defeated by CMA in an overwhelming fashion on the Assembly floor. CMA was also able to garner amendments to a bill that would have required coroners to report overdose deaths due to controlled substances to the medical board, to ensure that any reports submitted by coroners would remain confidential. (This bill, SB 62, was ultimately vetoed.) In addition, an effort to shift the investigative authority from the Medical Board of California to the Department of Justice was defeated. The trial attorneys’ campaign to eviscerate the Medical Injury Compensation Reform Act (MICRA) was also in full gear this year. Trial attorneys invested heavily in three additional lobbyists and launched a public relations campaign titled “38 Is too Late,” and made several attempts to push a bill through the Legislature. All these efforts resulted in no action in the Capitol, not even the introduction of a bill, a major victory for CMA. While CMA is proud of our legislative victories this year, we understand that these battles will continue next year. Trial attorneys are initiating a ballot fight, allied health professionals will continue to call for inappropriate scope expansion and legislators will continue to focus on prescription drug abuses. CMA will continue to be the voice of the physician community and is prepared to take on these challenges. Many of our fights garnered significant media attention. The Sacramento Bee outlined the five major battles facing the Legislature in the closing month of session. Of the five battles, CMA was front and center on two—each of which CMA won!

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CMA didn’t just play defense. CMA made significant progress in moving our proactive agenda forward this year. After several failed attempts in years prior, CMA partnered with local legislators to successfully secure an annual $15 million appropriation to fully fund the University of California, Riverside School of Medicine, which will be the first new four-year medical school established in California in over 40 years. The effort began this year with two CMA-sponsored bills introduced by newly elected Inland Empire legislators (SB 21 and AB 27), but eventually the conversation shifted to the budget process. Following the approval of the funding in the 2013-2014 state budget, the school welcomed its first class of four-year medical students this fall. The budget also included $3.9 million to upgrade the CURES database, $1.6 million of which was from the Medical Board of California contingent fund (licensing fees). The other professional licensing boards contributed the remainder. The funds are one time in nature and are exclusively for the upgrade of the database platform. While this funding was taken from medical board reserves, we were able to defeat attempts to have new licensing fees pay for this upgrade. We also advanced our efforts to prioritize the need to increase Medi-Cal provider rates. There were two bills introduced in each house that called for this increase. A new coalition, We Care for California, was formed to advocate for that increase. With CMA playing a key role and under the new We Care for California banner, thousands of health care providers from across the state converged on the state capitol in the largest ever health care rally in Sacramento. The historic event, called “WE ARE MEDI-CAL,” included administrators, physicians and frontline health workers from every region of the state. CMA sponsored legislation addressing the need to provide incentives to encourage physicians to practice in underserved communities. Addressing workforce issues, not scope expansion of allied professionals, is the long term solution to the physician distribution issues faced in California. Two CMA-sponsored bills (AB 565, AB 1288), both signed by Governor Brown, will encourage physicians to locate their practices in the Central Valley, Inland Empire and other underserved regions of our state. There is no doubt that CMA faced a many battles this year, but thanks to the advocacy of the physician community and our government relations team, we won these battles. Bills that we opposed were either defeated or significantly amended to address our concerns. Our sponsored bills, with the exception of two, advanced to the Governor and have been signed. CMA has again demonstrated the important role it plays in shaping health policy in Sacramento. As always, CMA will be prepared to lead our state forward.

Fall 2013


CMA SPONSORED LEGISLATION SB 21 (Roth): UC Riverside Medical School

AB 565 (Salas): California Physician Corps Program

This bill appropriates $15,000,000 annually from the General Fund to the Regents of the University of California for allocation to the School of Medicine at the University of California, Riverside. According to a 2010 report by the California Health Care Foundation, the Inland Empire has the lowest ratio of primary care physicians and specialists of any region in the state. The Council on Graduate Medical Education, a federally funded and authorized group that assesses the physician workforce and reports to federal policymakers, recommends a minimum of 60 to 80 primary care physicians and 85 to 105 specialists per 100,00 people. Sadly, the physician and specialist ratio in the Inland Empire is barely half of that recommended number. The UC Riverside School of Medicine is a critical factor in addressing this need, and consistent state funding is needed for the school to maintain its accreditation.

Ten years ago, CMA sponsored legislation to create the Steven M. Thompson Physician Corps Loan Repayment Program (STLRP) to increase access to primary care physicians in medically underserved areas. Although the STLRP has awarded more than $17 million to over 220 individuals, the high demand for this program means less than one third of applicants are awarded funding. Given the limited funds in this program, this bill will tighten the eligibility criteria of applicants to the STLRP and help identify gaps in placing physicians in the Central Valley, the Inland Empire and other underserved communities.

Status: Signed by the Governor. SB 640 (Lara): Medi-Cal: Reimbursement Provider Payments This bill seeks to restore the 10 percent Medi-Cal provider rate reductions contained in the 2011-12 state budget. CMA has built a coalition of different providers who have been impacted by the cuts or who, like CMA, are still in court over their implementation. This bill would both eliminate the retroactive portion of the cuts as well as stop them going forward. This will help provide needed stability to the Medi-Cal system as the state prepares for full federal health reform implementation on January 1, 2014.

Status: Signed by the Governor. AB 670 (Atkins): Therapeutic Substitutions This bill would prohibit pharmacists from receiving a financial incentive for recommending a patient receive a drug that is chemically different from the one prescribed by the physician, a practice known as therapeutic substitution. There has been an increase in consulting contracts with pharmacists that carve out a separate fee each time a therapeutic substitution is recommended. Though the medicine may treat the same condition, the chemical ingredients are not the same. This often results in adverse side effects or ineffective treatment. Patients who are on medication to treat epilepsy or mental health conditions are particularly vulnerable. Therapeutic substitutions should be based upon the patient’s best interest, not a financial incentive. Status: Held in Assembly Appropriations Committee.

Status: Held in Senate Appropriations Committee.

Fall 2013

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AB 1003 (Maienschein): Employment of Physical Therapists CMA and the physical therapists had introduced competing bills this session, which were ultimately combined into one cosponsored bill (see AB 1000). CMA’s bill would clarify existing law to explicitly authorize medical corporations to hire persons licensed under the Business and Professions Code, the Chiropractic Act or the Osteopathic Act. In November 2010, the Physical Therapy Board reversed decades-old policy that allowed physical therapy services to be provided by medical corporations. According to the California Employment Development Department, there are over 15,000 practicing physical therapists in California. Furthermore, California adds about 440 new physical therapy jobs each year. Nearly, 80 percent work in medical corporations, hospitals, home health care services and nursing care facilities. As a result, hundreds of physical therapists across California are at risk of losing their jobs. Status: Assembly Business and Professions Committee – Hearing Postponed. AB 1288 (V. M. Perez): Physician Workforce: MedicallyUnderserved Communities Assembly Bill 1288 will require the Medical Board of California and the Osteopathic Medical Board of California to develop a process to give priority review status to the application of an applicant who can demonstrate that he or she intends to practice in a medically underserved area or serve a medically underserved population. AB 1288 will not change the vigorous standards that govern these professions but will instead focus the board’s resources on the areas and populations with the greatest need. Status: Signed by the Governor.

CMA CO-SPONSORED LEGISLATION SB 191 (Padilla): Emergency Room Funding Co-sponsored by the California American College of Emergency Physicians, this bill extends the sunset date to January 1, 2017. The bill raises approximately $50 million to augment local county emergency medical services funds in order to allow counties, hospitals and physicians to continue providing emergency services in their communities with these desperately needed funds. Emergency care in California is in crisis. In the past decade, more than 65 emergency departments (EDs) have closed; ED visits are up; wait times continue to increase, and hospital diversion is on the rise. Without this bill, the law is set to expire on January 1, 2014. Status: Signed by the Governor. AB 1000 (Wieckowski and Maienschein): Physical Therapists: Direct Access to Services and Medical Corporation Employees CMA and the physical therapists had introduced competing bills this session, which were ultimately combined into one cosponsored bill (AB 1000). The joint bill clarifies an existing ambiguity in the law so that physical therapists can continue to work within the legal boundaries of medical corporations as they have for decades (as was the intention of CMA’s solo bill). The combined bill also gives health care consumers the ability to seek treatment from a physical therapist without a physicians’ consent for a limited period of time. Although CMA had previously opposed attempts to authorize such “direct access,” we believe Page 20

that the final language is an acceptable compromise. The bill does not expand or modify the scope of practice for physical therapists, including the existing prohibition on a physical therapists diagnosing disease. Status: Signed by the Governor. AB 1176 (Bocanegra): Primary Care Access: Residency Programs Co-sponsored by the California Academy of Family Physicians, this bill will follow the example of other states and create a funding source for underfunded medical residency training programs by drawing from private payers such as health insurance companies. According to the Council on Graduate Medical Education, 74 percent of California’s 58 counties have an undersupply of primary care physicians, with primary care physicians making up just 34 percent of California’s physician workforce. Status: Held in Assembly Appropriations Committee. AB 1208 (Pan): Insurance Affordability Programs: Application Form The provisions that impacted physicians were deleted. The bill now deals with demographic data collection. Therefore we are no longer co-sponsoring this bill. Status: Vetoed by Governor.

Fall 2013


OPPOSED LEGISLATION SB 117 (Hueso): Integrative Cancer Treatment

SB 492 (Hernandez): Optometric Corporations

This bill would prohibit a physician and surgeon, including an osteopathic physician and surgeon, from recommending, prescribing or providing integrative cancer treatment, as defined, to cancer patients unless certain requirements are met. The bill would specify that a failure of a physician and surgeon to comply with these requirements constitutes unprofessional conduct and cause for discipline by the individual’s licensing entity. The bill would require the State Department of Public Health to investigate violations of these provisions.

This bill allows optometrist to practice ophthalmology. Specifically, allows optometrists to (1) treat and diagnose any disease, condition or disorder of the visual system, the human eye adjacent and related structures, (2) prescribe and administer drugs including controlled substances, (3) perform surgical procedures with local or topical anesthetic, (4) order laboratory and diagnostic tests, (5) administer immunizations, (6) diagnose and initiate treatment for any condition with ocular manifestations.

Status: Author pulled bill from Senate Business and Professions Committee.

Status: Pulled by author in Assembly Business and Professions Committee. AB 591 (Fox): Hospital Emergency Room: Geriatric Physician

SB 266 (Lieu): Health Care Coverage: Out-of-Network Coverage This bill would prohibit a health facility or a provider group from holding itself out as being within a plan network or a provider network unless all of the individual providers providing services at the facility or with the provider group are within their network, or the provider group acknowledges to the patient in writing or verbally that individual providers within the provider group may be outside the patient’s plan network or provider network and the provider group recommends that the patient contact his or her health care service plan or health insurer for information about providers who are within the patient’s plan network or provider network. Those provisions would not apply to emergency services and care. Status: Held in Senate Appropriations Committee. SB 312 (Knight): Absences: Confidential Medical Services: Parent or Guardian Consent This bill would require the governing board of a school district to notify pupils in grades 9 to 12 and their parents or guardians, that school authorities may excuse a pupil from the school for confidential medical services who is 16 years of age or older without parental or guardian consent. Status: Failed in Senate Education Committee. SB 430 (Wright): Pupil Health: Vision Examination: Binocular Function This bill would, before first enrollment in a California school district of a pupil at a California elementary school, and at least every third year thereafter until the pupil has completed the 8th grade, require the pupil’s vision to be examined by an optometrist or ophthalmologist and require the examination to also include a test for binocular function and refraction and eye health evaluations. The binocular function examination does not need to take effect until the pupil has reached the third grade and would require the parent or guardian of the pupil to provide results of the examination to the school district.

This bill would require each general acute care hospital with an emergency department to have, at all times, a geriatric physician serving on an “on-call” basis to that department. Status: Pulled by author. AB 975 (Wieckowski): Health Facilities Community Benefits This bill would declare the necessity of establishing uniform standards for reporting the amount of charity care and community benefits a facility provides to ensure that private nonprofit hospitals and nonprofit multispecialty clinics actually meet the social obligations for which they receive favorable tax treatment. Status: Failed on Assembly Floor. ACA 5 (Grove): Abortion: parental notification This measure, which would be known as the Parental Notification, Child and Teen Safety, Stop Predators Act, would prohibit a physician and surgeon from performing an abortion on an unemancipated minor, as defined, unless the physician and surgeon or his or her agent has delivered written notice to the parent of the unemancipated minor, or until a waiver of that notice has been received from the parent or issued by a court pursuant to a prescribed process. Status: Re-referred to Assembly Health and Assembly Judiciary Committees.

For information on other bills of interest visit CMA’s Legislative Issues Database at http://www.cmanet.org/issues/legislative.

Status: Pulled by author in Assembly Health Committee. SB 491 (Hernandez): Nurse Practitioners This bill gives nurse practitioners independent practice. Under this bill, nurse practitioners will no longer need to work pursuant to standardized protocols and procedures or any supervising physician and would basically give them a plenary license to practice medicine. Status: Held in Assembly Appropriations Committee. Fall 2013

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HOD 2013 M

ore than 500 California physicians convened in Anaheim October 11-13 for the 2013 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 90 resolutions were introduced and debated in reference committees on Friday, October 11. Over the next two days, the complete house met again to debate and vote on reference committee recommendations. A total of 63 resolutions were adopted.

CMA Delegates set policy at Annual Meeting

As a first step toward a “virtual� reference committee process that will enable a shorter, two-day meeting in future years, Reference Committee A (Science and Public Health) conducted all testimony online in advance of the meeting. All CMA members were invited to participate in the debate, and nearly 300 online comments were recorded. The committee members then met via web conference in advance of the meeting to develop their recommendations, which were presented to the House for floor debate on Saturday afternoon. The House also elected a new President, Paradise internist Richard Thorp, M.D., while Humboldt surgeon Luther Cobb, M.D., (pictured at left) was tapped as President-Elect. The following are summaries of some of the resolutions that were adopted as policy. (The full actions of the HOD are available to members at www.cmanet.org/hod, under the "documents" tab.)

District VI Delegation seated on the floor of the House of Delegates

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Increased reporting of immunizations Resolution 104-13 The delegates approved a resolution that encourages increased reporting of patient immunizations to the California Department of Public Health for purposes of vaccination, disease control and prevention.

Fall 2013


DELEGATES WEIGH IN ON EXCHANGE GRACE PERIOD HIV and STDs: Consent requirements for testing Resolution 109-13 The delegates voted to support revision of HIV consent requirements to allow all health care providers to order a test for HIV when appropriate and to encourage routine HIV testing for all patients that are evaluated for other sexually transmitted diseases. Graphic health warnings on tobacco products Resolution 115-13 Delegates called on CMA to support the use of graphic image labeling on cigarette and other tobacco packaging that warns of the health impact of smoking. Legal blood alcohol limit for drivers Resolution 118-13 Delegates endorsed the National Transportation Safety Board’s 2013 recommendation that the legal blood alcohol limit for operating a motor vehicle be decreased from .08 percent to .05 percent or lower. Food insecurity screening Resolution 122-13 The delegates directed CMA to promote that providers need to identify children and adults who are food insecure to avoid detrimental development and co-morbidities and to refer them to appropriate programs and services. Elimination of CMS outpatient observation status Resolution 211-13 The delegates directed CMA to request that the Centers for Medicare and Medicaid Services eliminate its "outpatient patient observation" status, which is placed upon patients whose anticipated hospital stay is 48 hours or less. Delegates noted that this practice places undue financial burden on patients and creates administrative hassles for physicians. Health exchange benefit designs and tax deductibility of out-ofpocket expenses Resolution 401-13 The delegates called on CMA to support efforts to develop benefit designs in the health benefit exchange that appeal to the young and healthy to boost the risk pool; and to support legislation allowing federal and state income tax deductibility of all out-of-pocket health care expenses.

Dr. James Jones and Dr. Pamela Roussos in the background serving as our District VI representatives at Reference Committee F.

M

embers of the CMA House of Delegates took a stance on the 90-day grace period provision called for in the Affordable Care Act (ACA), an issue that has been rapidly evolving in response to CMA's continued advocacy. The resolution (Res. 402-13) was amended by delegates during floor debate this weekend to reflect recent state and federal actions regarding the grace period provision. The resolution, as adopted by the House, calls for heightened standards for information provided to physicians regarding enrollees in the state's health benefit exchange, as well as a provision emphasizing CMA's position that physicians should not be compelled by payors to participate in exchange products. As initially proposed, the ACA's grace period posed considerable risk to physicians participating in exchange products, potentially exposing them to two months of suspended and/or denied claims if a patient is delinquent on their insurance premiums. Recently, however, California's Department of Managed Health Care has asserted that patients falling under the grace period provision would have coverage suspended after the first 30 days, and that insurance companies could not represent this coverage as active to the participating physician. The patient would then have the second and third months to pay the premium balance and have coverage reinstated. Given that the grace period provision has been a concern to physicians across the country and California is the only state thus far to move forward on the suspension of coverage issue, the matter was also referred to the American Medical Association for national action.

Reimbursement for telephone/electronic patient management Resolution 407-13 The delegates asked that CMA support legislation requiring health insurance companies to pay physicians for telephone or other electronic patient management services. National health information exchange Resolution 501-13 The delegates called on CMA to support the development of a secure, interoperable, nationwide health information exchange network. Fall 2013

CMA CEO, Dustin Corcoran

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

You and your spouse/significant other are invited to our annual Holiday Party!

Wednesday, December 11, 2013 at

Bella Luna Bakery Cafe

350 West Main Street, Merced, California

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

The successful candidates for the 2014 Medical Society Officers and Board of Governors will be announced at the party.

Please RSVP by December 4, 2013 We extend a sincere thank you to:

NORCAL Mutual Insurance Company and Foundation for Medical Care

for helping to make our Holiday Party a success.

Phone: (209) 723-2976 Fax: (209) 723-8371 E-mail: chrisy@mmcms.org or Register at our website www.mmcms.org


Meeting Schedule December 11, 2013

6:30 p.m.

Holiday Reception Bella Luna Bakery Cafe

January 27, 2014

6:00 p.m.

Medical Society Board of Governors Medical Society Office

February 27, 2014

6:30 p.m.

General Membership Meeting De Angelo’s Restaurant

March 17, 2014

6:00 p.m.

Medical Society Board of Governors Medical Society Office

Meet the New and Returning Members... Bethany Blacketer, M.D. Family Medicine Livingston Medical Group 1140 Main Street Livingston, California

Taynet T. Febles, M.D. Infectious Disease Internal Medicine 916 I Street Los Banos, California

Abhilasha Sharma, M.D. Family Medicine Golden Valley Health Centers 847 W. Childs Avenue, Suite C Merced, California

Autumn P. Clos, M.D. Pediatrics Livingston Medical Group 1140 Main Street Livingston, California

E-kai Kyle Hsu, M.D. General Surgery Minimally Invasive Surgery 916 I Street Los Banos, California

Carlos G. Teran Miranda, M.D. Pediatrics Golden Valley Health Centers 847 W. Childs Avenue, Suite C Merced, California

Welcome, Drs. Blacketer, Clos, Febles, Hsu, Sharma and Teran Miranda and thank you for your support of organized medicine!

Research being conducted on the Affordable Care Act Participate in a Doctoral Research Study that will examine the direct impact of the Affordable Care Act on private practice physicians. Research will be conducted by Joshua Skunca, a student pursuing his Doctors of Business Administration through Walden University. To participate, contact Joshua at (559) 349-8799. Fall 2013

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DISCOUNTED CPT, ICD-9, ICD-10, HCPCS and RBRVS BOOKS!!! Order your 2014 Editions of CPT, ICD-9, ICD-10 HCPCS and RBRVS books from MMCMS to receive our VERY discounted prices. We are offering FREE SHIPPING and if you are a Merced-Mariposa County Medical Society Member you get an additional 10% off the total order! Books will be shipped directly to you from the distributor as they become available. If you have any questions, please contact Chrisy Muchow at (209) 723-2976 or chrisy@mmcms.org. THIS IS JUST A SAMPLE OF THE BOOKS WE ARE OFFERING. FOR THE COMPLETE LISTING INCLUDING THE ORDER FORM GO TO www.mmcms.org/Membership/MMCMSBenefits.

CPT Plus! 2014 (Softbound) $33.78 PMIC’s best-selling CPT coding reference includes all official CPT codes with full descriptions, coding instructions and parenthetical notes. Plus, it's loaded it with extra features designed to improve the accuracy of your CPT procedure coding

AMA CPT 2014 Standard Edition (Softbound) $73.03 If you want a value-priced CPT book with no special features such as thumb-indexing, tutorial, anatomical illustrations, compact sizing, etc., the CPT standard edition is for you. ICD-9 CM 2014 Office Edition (Softbound) $41.37 PMIC’s best-selling compact, color-coded, thumb-indexed Coder’s Choice® version of ICD-9-CM is loaded with great features to help you code faster and easier! At a convenient 6" x 9" and weighing a little over two pounds, this book is a real desk space and arm saver. Includes all official ICD-9-CM Volume 1 & 2 diagnosis codes in a single, lightweight, compact book. AMA ICD-9-CM Professional Edition for Physicians, Vol. 1 & 2 (Spiral Bound) $85.53 The updated 2014 edition delivers important diagnostic coding and reimbursement information. By integrating the Official Guidelines for Coding and Reporting into the ICD-9-CM code set, this codebook provides the information you need to ensure the most accurate billing for a medical practice. HCPCS 2014 (Softbound) $36.50 Maximize your Medicare reimbursement by using the most current HCPCS Level II codes. These codes must be used to bill Medicare for supplies, materials, injections, DME, rehab, and other services. Our HCPCS includes exclusive features such as thumb indexing, new lay-flat binding and color coding, all designed to make coding faster and easier. AMA HCPCS 2014 Level II Professional Edition (Spiral Bound) $89.21 HCPCS 2014 Level II Professional Edition provides your practice a quick and accurate coding reference. Along with the most current HCPCS codes and regulations included in the codebook, you’ll have everything needed for accurate medical billing and maximum reimbursement. AMA Medicare RBRVS 2014: The Physicians' Guide $65.97 AMA’s Medicare RBRVS: The Physicians' Guide 2014 provides health care professionals with a concise, authoritative text on Medicare’s RBRVS system. This invaluable reference provides the insights, tools and tables needed to understand the RBRVS system and how to easily calculate payment schedules accurately.


News from the California Medical Association Top News Majority of U.S. House signs bipartisan letter calling for SGR repeal this year Nearly 260 members of the U.S. House of Representatives signed a November 20 letter (http://www.ama-assn.org/ resources/doc/washington/sgr-sign-on-letter-to-lettership.pdf) that urges Congress to repeal Medicare’s failed sustainable growth rate (SGR) formula by the year’s end. The letter bears the signatures of the majority of House lawmakers. Among the signatories are 141 republicans and 118 democrats, representing more than half of the members of each party in the House. A majority of the California delegation (including Jim Costa), both Democrats and Republicans signed the letter.

The letter, which is addressed to the Speaker and Minority Leader of the House, cites the current cost of repeal – half of what it was last year – as the “fiscally responsible step” toward Medicare reform and states that Congress “should not pass up this chance to repeal the SGR…and enact a permanent solution.” In November, during the AMA Interim Meeting held in Washington D.C., physician leaders from more than 35 states participated in AMA grassroots advocacy on Capitol Hill, engaging more than 100 of their members of Congress on this issue during face-toface visits.

CMA Medi-Cal Survival Guide helps physicians understand numerous program changes Over the past year, there have been a number of changes for Medi-Cal patients and for the physicians who treat them. There will be more changes in 2014 as well. To help physicians understand the impact these changes will have on their practices, the California Medical Association (CMA) has published a Medi-Cal Survival Toolkit. The toolkit contains a summary on many of the changes, important dates, options for physicians and links to important resources.

The toolkit is available free to members in CMA's online resource library (http://www.cmanet.org/resource-library). Contact: CMA's reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.

Covered California releases detailed enrollment data Covered California, the state’s health benefit exchange, has released a detailed breakdown of the roughly 30,000 individuals who enrolled in exchange plans during the month of October, a massive data dump that contained at least a few surprises. Among these unexpected results was the fact that young enrollees, specifically those between 18 and 34, accounted for 23 percent of the overall enrollment. That same age bracket accounts for roughly 21 percent of the state’s overall population. Individuals between the ages of 55 and 64 accounted for the largest chunk of exchange enrollees, totaling more than one-third (34 percent) of overall enrollment. Prior to the launch of state and federal exchanges there was a concern that young, healthy individuals would not enroll, therefore throwing off the new marketplace’s risk pool. While the recently released data doesn’t reveal much about the health of October’s enrollees, it would appear that at least the “young” portion of “young and healthy” is being satisfied during pre-enrollment. “Not only are we seeing strong enrollment numbers overall, but enrollment in key demographics like the so-called young invincibles is very encouraging,” said Peter Lee, executive director of Covered California.

In terms of geography, Los Angeles County accounts for 22.6 percent of exchange enrollment, but also accounts for 26.4 percent of the state’s population. The nine Bay Area counties accounted for roughly 25 percent of October’s enrollment figures, but only 19 percent of overall population. An overwhelming majority of exchange enrollees were English speakers, which made up more than 85 percent of total enrollment. Meanwhile, Spanish speakers, which account for nearly 29 percent of the state’s population, made up only 3.2 percent of Covered California’s enrollment in October. Finally, it looks as though the exchange’s “big four” insurers were gaining the lion’s share of enrollment, with Anthem Blue Cross, Blue Shield, Health Net and Kaiser Permanente accounting for 27.2 percent, 24.4 percent, 16.1 percent and 28.5 percent of enrollment, respectively. The other seven plans offering products on the exchange collected a combined 3.8 percent of the roughly 30,000 enrollees signing on during October. Additional statistics are expected to be released as Covered California’s enrollment process moves forward.

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Fall 2013

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Medicare News CMA calls for improvements to the new Medicare SGR reform proposal Recently, the Senate Finance Committee and the House Ways and Means Committee released an unprecedented bipartisan and bicameral “discussion draft” proposal to repeal the Medicare sustainable growth rate (SGR) and reform the Medicare payment system. The committees asked health care organizations around the country to comment on its proposal. On Tuesday, November 12, the California Medical Association (CMA) sent its comments on the discussion draft to the leadership of both committees. CMA supports many provisions in the draft, including: the permanent repeal of the SGR; retention of the fee-for-service program; streamlining of current reporting programs; and the addition of a new bonus pool (8-10 percent), incentives to participate in alternative payment models (5 percent), payment for complex chronic care management and funding assistance for small practices in rural or health professional shortage areas (HPSA) areas. Most of CMA’s concerns with the House-Senate proposal are focused on the impact it would have on all small practices and their ability to transition and participate in the new payment systems. “At no other time in our history has there been such a demand for physicians with health care reform covering the uninsured and the baby boomers becoming eligible for Medicare,” says CMA President Richard Thorp, M.D. “Without a bridge to new systems, CMA fears that many small practice physicians will chose to retire early or leave Medicare, causing an access to care crisis in California when physician services are needed the most.”

Payment Updates The draft legislation would not provide automatic payment increases for the first two years. However, starting in 2016 physicians can choose to participate in new payment models (such as medical homes) and qualify for 5 percent annual bonuses. In 2017 and beyond, physicians remaining in the fee-for-service program can participate in a new “value-based performance payment program." It is essentially the same as the current fee-for-service program, but it consolidates the current PQRS quality reporting, value-based modifier and meaningful use programs and adds new clinical improvement activities. Under current law those programs no longer provide bonuses but applies penalties of up to 8 percent. The new proposal would provide a bonus pool of up to 10 percent, with penalties for non performance as well. CMA is concerned that this proposal does not provide updates until the new payment systems start in 2016/2017 and is urging the committees to provide annual payment updates of at least 0.5 percent until those new models begin to help physician practices transition. CMA argued that many physician practices cannot survive at the current payment rates and make the investments in new payment models. “The last decade of failed Medicare payment policy has taken its toll on small physician practices in California," wrote CMA in its comments. "Medicare SGR formula has frozen physician payments for the last decade, yet physician practice costs rose 25 percent during the same period."

Assistance for small physician practices The proposed legislation includes $50 million to help small practices in rural or underserved areas improve performance and facilitate participation in alternative payment models. CMA is urging the committees to provide funding assistance to ALL small practices not just those in rural areas. CMA also asked the committees to set forth a longer transition timeline that gives small physician practices a realistic chance to succeed, including delaying implementation of the alternative payment models and the clinical improvement activities and extending the electronic health record subsidy program. CMA also urged the committees to authorize a variety of alternative payment models, including some that do not initially require physicians to assume financial risk. "Small practices cannot accept full financial risk under the alternative payment model track as proposed," CMA wrote in its comments. "While it may be a worthy goal to encourage physicians to manage global budgets, small practices must develop the data systems and gain the expertise necessary to transition to such risk-bearing payment models." To help physicians manage effectively, CMA is also asking the Centers for Medicare and Medicaid Services (CMS) to release total cost of care data.

Geographic payment updates Finally, CMA is urging the committees to include in this proposal the CMA-sponsored "GPCI fix," which would update the California county-based localities to the same Metropolitan Statistical Areas (MSAs) used to determine payment rates for hospitals and also hold the physicians in rural counties harmless from the corresponding cuts that would otherwise occur. Updating the localities would ensure appropriate payments for many recently urbanized areas like San Diego, Monterey and Sacramento counties. These counties are currently designated as rural, causing some California physicians to be paid up to 10 percent below what they should be paid if the regional designation was correct. The Centers for Medicare and Medicaid Services already continuously updates the hospital MSAs, however, the physician payment localities have not been updated in 16 years. Congress has a short window of opportunity to enact payment reform in this politically-charged austere fiscal environment. CMA was in Washington, D.C., last week meeting with Congressional and Committee leaders to urge them to take advantage of the reduced cost to repeal the SGR and pass comprehensive payment reform this year. "We applaud the Senate and House for working together on a bipartisan basis to repeal the flawed Medicare SGR payment formula. This is an encouraging development and it could be a pivotal step to stabilizing Medicare," said Dr. Thorp. "With the drastically lower price tag and bipartisan support for the necessary policy changes, we must seize the opportunity to set Medicare on a more stable and predictable course for current and future generations of patients and physicians." Click here to read the full text of CMA's comments and CMA’s summary of the legislation. Contact: Elizabeth McNeil, (415) 882-3376 or emcneil@cmanet.org. (Continued on Page 29)

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Fall 2013


Medicare News...continued 2014 Medicare fee schedule confirms 24 percent cut Demonstrating yet again how broken the Medicare sustainable growth rate (SGR) formula is, physicians will face a 24 percent Medicare payment cut next year if Congress does not seize the opportunity to put a stop to the formula's annual threat of drastic payment cuts. This figure was confirmed by the Centers for Medicare and Medicaid Services (CMS) last week, when the agency released its final physician fee schedule for 2014.

The California Medical Association (CMA) is currently reviewing the final rule, which was released much later than usual because of the government shutdown in October. Stay tuned for details. CMA and others in organized medicine continue to press Congress for SGR repeal this year. Contact: Elizabeth McNeil, (800) 786-4262 or emcneil@cmanet.org.

CMS to implement ordering and referring denial edits beginning in January 2014 Physicians who refer or order services for Medicare beneficiaries must be enrolled with Medicare by January 6, 2014. Medicare contractors have been instructed to turn on ordering/referring physician edits on that date, and claims submitted on or after January 6 will be denied if the ordering/referring physician does not have an enrollment record. The Centers for Medicare and Medicaid Services (CMS) began notifying ordering/referring physicians of the need to enroll in Medicare in October 2009. Enrollments can be completed via the online Provider Enrollment, Chain, and Ownership System (PECOS) or by completing a paper enrollment application (applicable CMS-855).

CMS had originally intended to turn on the edits last May, but the agency delayed implementation because of technical issues. Physicians can confirm whether a referring or ordering physician is enrolled by downloading a report of all the eligible physicians and non-physician practitioners who have current enrollment records from the CMS website. The report is updated weekly. Click here for more information or refer to the MLN Matters SE1305 publication on the CMS website (http://www.cms.gov). Contact: Michele Kelly, (213) 226-0338 or mkelly@cmanet.org.

Are you ready for the new CMS 1500 claim form? Earlier this year, the White House Office of Management and Budget (OMB) approved the revised Centers for Medicare & Medicaid Services (CMS) 1500 claim form, version 02/12, OMB control number 0938-1197. The CMS 1500 claim form is the required format for submitting paper claims to Medicare. The revised form adds the following functionality: 

Indicators for differentiating between ICD-9 and ICD-10 diagnosis codes.



Expansion of the number of possible diagnosis codes to 12.



Qualifiers to identify the following provider roles (on item 17):

Medicare anticipates implementing the revised CMS 1500 claim form (version 02/12) as follows: 

January 6, 2014: Medicare begins accepting paper clams submitted on revised CMS 1500 claim form (version 02/12).



January 6 through March 31, 2014: Medicare continues to accept paper claims submitted on the old CMS 1500 claim form (version 08/05).



April 1, 2014: Medicare no longer accepts paper claims on the old form and will only receive and process claims submitted on the revised CMS 1500 claim form (version 02/12).



These dates are tentative and subject to change. CMS will provide more information as it is available.

Ordering Referring Supervising

CMS is updating the Medicare Claims Processing Internet Only Manual (IOM, Pub. 100-04), Chapter 26, with instructions on how to complete the revised form. This information will be posted on the CMS website when it is available.

Physicians should note that while the new claim form includes fields for ICD-10 codes in preparation for the transition in October 2014, practices should continue to submit only ICD-9 codes until notified otherwise by payors. (Continued on Page 30)

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!!! Fall 2013

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Payor News Reminder: Blue Shield fee schedule changes took effect December 1 Blue Shield has announced changes to its physician fee schedule that will take effect December 1, 2013. In a September 23 notice to physicians, the insurer said that it would be increasing payment for evaluation and management services for preventive care. Additionally, Blue Shield notes payment increases for the more commonly billed office visit codes 99204, 99205, 99213 and 99214. The new rates are available on the Blue Shield website (under "Helpful Resources," click “Professional Fee Schedule” then click “Search the Claims Fee Schedule”). Though not indicated in the letter or on the website, in order to access the new fees, practices must change the default date of service on the “Search Fee Schedule” page to December 1, 2013, (effective date of the change) or later. Failure to do so will result in information on the current fee schedule rather than the new fee schedule. Physicians can also request a copy of the new fees by completing the allowance review form enclosed with the notice, or by calling the Blue Shield Provider Services Department at (800) 258-3091.

Physicians are encouraged to carefully review all proposed amendments to health plan or medical group/IPA contracts. The California Medical Association (CMA) reminds physicians that they do not have to accept substandard contracts that are not beneficial to their practice. To help physicians understand their rights when a health plan has sent notice of a material change to a contract, the CMA has published "Contract Amendments: an Action Guide for Physicians," available in the CMA Resource Library. The guide includes a discussion of options available to physicians when presented with a material change to a contract. Additionally, the guide includes a financial impact worksheet that will help physicians calculate the net impact of the fee schedule changes on their practice. Click here to view a copy of the notice that was sent to physicians.

Anthem Blue Cross moving some inquiry functions to Availity web portal Anthem Blue Cross will soon be migrating member eligibility, benefits and claim status inquiry functions from its ProviderAccess portal to the Availity Health Information Network web portal. Citing ease of use, broad functionality and breadth of services provided through the Availity portal, Blue Cross will transition these electronic functions exclusively to Availity in the coming months. Blue Cross has not, however, announced a completion date for the transition.

under privacy and security laws, including HIPAA. CMA contacted Availity to address potentially problematic language in its agreement.

While BlueCard eligibility and benefits functions will transition to Availity, the BlueCard Advisor function that allows practices to determine which Blues plan to send the claim to will continue to be available on the ProviderAccess website.

We are pleased to report that Availity amended its agreement to reflect CMA’s feedback and also released an updated agreement via email on October 21 to those who had signed prior versions. The updated agreement clearly incorporates a business associate agreement and will make it easier for physicians who use Availity to be in compliance with their obligations under the new HIPAA regulations.

In order to access information on the Availity website, practices must first register and sign the Availity Organizational Access Agreement. Earlier this year, the California Medical Association (CMA) received calls from some practices concerned about the security of the Availity website and any potential liability for physicians

CMA’s Center for Economic Services and Legal Counsel worked collaboratively with Availity to address the specific areas of concern within the agreement to ensure that physicians would be able to meet their obligations under HIPAA.

Practices wishing to register for access to the Availity web portal should go to www.availity.com/providers/registration-details. Or, to view the current Availity free training webinar schedule, go to www.rsvpbook.com/AvailityWest.

Online payment portals: Physicians beware Recently, a number of payors have begun to offer online payment portals that allow patients to pay for physician services via the Internet. Physicians should be aware, however, that while these online payment portals typically do not charge setup fees for participating, physicians will be assessed a per transaction fee, similar to the transaction fees associated with credit card or merchant transactions. Aetna, for example, partnered with Citi to provide an online patient health care payment option called Money² for Health. This online payment tool will allow patients to securely pay for physician services through the Aetna Navigator member website. For physicians who have signed up to participate in Money² for Health, patient payments will be electronically transferred into your designated accounts.

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United Healthcare (UHC) has also recently instituted a similar online portal through Instamed. Through the myClaims Manager selection on the www.myuhc.com website, members can now elect to make payments to their medical providers. Physicians should also be aware that non-participation in these programs does not necessarily prohibit patients from continuing to pay through the portal. For instance, the UHC/Instamed program will still allow patients to make payments to physicians who have chosen to not participate in the program. In lieu of an electronic funds transfer to the physician’s bank account, Instamed will issue a hardcopy check to the physician instead. However, the issuance of the hardcopy check does not alleviate the physician from being required to pay a reduced transaction fee. CMA has inquired further with United about physician options to avoid any transaction fees. Fall 2013


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


Fall 2013  

MMCMS's "The Bulletin" Fall 2013 Edition

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