VOLUME 1-NUMBER 3

Merced Mariposa

Physician Volume 1 | Number 3

2019 House of Delegates:

CMA Tackles 21st Century Health Care Dilemmas including A.I., Homelessness, Cannabis and Adverse Childhood Experiences

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…

Merced Mariposa

Physician

MMCMS Leadership Officers

Tahir Yaqub, M.D. President Timothy S. Johnston, M.D. President-Elect Oscar V. Ramos, M.D. Secretary-Treasurer

5 2019 House of Delegates: CMA Tackles 21st Century Health Care Dilemmas

Eduardo T. Villarama, M.D. Immediate Past-President

Governors

11

Thomas A. Barrett, M.D. Gabriel Garcia-Diaz, M.D.

SURPRISE BILLING

Alfred B. Johnson, M.D. Atul T. Roy, M.D. Ajinder Singh, M.D. Glen A. Villanueva, D.O.

CMA Delegates

17

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

Congenital Syphilis

CMA Alternate Delegates Leena Chaudhury, M.D.

An Unfortunate Burden

Timothy S. Johnston, M.D.

Staff

Chrisy Muchow Executive Director

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

Merced Mariposa Physician is published quarterly by the Merced-Mariposa County Medical Society 2848 Park Avenue, Suite C | Merced, CA 95348 P (209) 723-2976 | F (209) 723-8371 E chrisy@mmcms.org | W www.mmcms.org Merced Mariposa Physician does not assume responsibility for author’s statements or opinions; opinions expressed are not necessarily those of Merced Mariposa Physician or the MercedMariposa County Medical Society.

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

21 WINNING THE FIGHTS THAT MUST BE FOUGHT CMA’s 2019 Legislative Wrap-Up

MORE ARTICLES, EVENTS & RESOURCES: 6

UPCOMING EVENT:

14

EVENT RECAP:

MEDICARE CHANGES:

MMCMS HOLIDAY PARTY

2020 AND BEYOND

Pictures and Appreciation for Years of Membership

10

ANNUAL RECAP: CMA’S 2019 YEAR IN REVIEW

20

PRACTICE MANAGEMENT: 2020 DISCOUNTED CODING BOOKS

2019 House of Delegates:

CMA Tackles 21st Century Health Care Dilemmas including A.I., Homelessness, Cannabis and Adverse Childhood Experiences

T

he California Medical Association (CMA) recently convened its 148th annual House of Delegates (HOD) meeting in Anaheim.

Over 500 California physicians debated and outlined a policy agenda on major issues that have been determined to be the most important issues affecting members, the association and the practice of medicine.

The association also installed its new officers, including new CMA President Peter N. Bretan, Jr., M.D., a urologist and transplant surgeon who gave up his Bay Area practice to serve patients at a safety net hospital in Watsonville. >>>

MEDICARE CHANGES: 2020 AND BEYOND T h u r s d a y, J a n u a r y 2 3 , 2 0 2 0 Location: Bella Luna Bistro & Bar 350 W. Main Street, Merced, CA

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

This presentation focuses on changes to the Medicare program in 2020, including the 2020 Medicare physician fee schedule, annual updates and reducing the burden of Medicare paperwork. Presented by one of CMA’s experienced practice management experts, the presentation will review the Quality Payment Program (QPP) Year 3, streamlining evaluation and management documentation guidelines, avoiding common mistakes and compliance with the current Medicare Administrative Contractor. CMA will also share how you can access the impact of key initiatives on your practice and walk away with educational resources that will help you maximize reimbursement.

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

Registration Required | COST (includes lunch):

Please complete a separate registration for each individual attending:

MMCMS Member: $40.00

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All Others: $80.00

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MAJOR ISSUES: THE MAJOR ISSUES THE DELEGATES FOCUSED ON THIS YEAR AUGMENTED INTELLIGENCE (A.I.)

CANNABIS

The delegates explored pragmatic solutions that address medical decision-making, new liabilities and privacy concerns inherent with augmented and artificial intelligence in health care, with a focus on keeping physicians at the center of health care delivery.

The delegates weighed in on pressing issues, including health impacts associated with cannabis use, public health protections, federal legalization, data and surveillance efforts, high-quality research, marketing and advertising practices, cannabis equity programs and more.

HOMELESSNESS Physicians witness the homelessness crisis in emergency rooms, clinics and on the streets of our communities.

The delegates declared that stable and affordable housing is an essential community priority and an important social determinant of health. They also discussed evidence-based solutions that address the health care and social needs of those at risk of or experiencing homelessness.

ADVERSE CHILDHOOD EXPERIENCES (ACE) Recognizing that ACEs have a strong and life-long correlation to numerous health, social and behavioral problems, the delegates learned more about data collection, research and incorporating ACE screening practices into routine care.

The final actions of the House of Delegates, including newly established policies, are now posted at cmadocs.org/hod.

ELECTIONS: WATSONVILLE UROLOGIST AND TRANSPLANT SURGEON INSTALLED AS CMA PRESIDENT Peter N. Bretan, Jr., M.D., a urologist and kidney transplant surgeon who gave up his Bay Area practice to serve patients at a safety net hospital in Watsonville., was elected as the 152nd president of the California Medical Association. Dr. Bretan is the first Filipino-American physician to serve as president.

“The most important goal, not just in this year of my presidency, but always, is to take back our profession by enabling physicians to lead the struggle to protect, expand and make universal access to health care for all of our patients in California,” said Dr. Bretan. “If we are successful in this state, it will lead the way for sustainable universal health care for all of America.”

Dr. Bretan is the founder and CEO of LifePlant International, a charitable organization that furnishes lifesaving transplants in developing countries, for which

he was recognized by the American Medical Association with the Benjamin Rush Award for Citizenship and Community Service. Dr. Bretan has also provided care around the world on medical missions.

“I grew up as a child farm laborer, and I know what it is to be without adequate health care. My greatest motivation is in service to give back to society for my good fortune,” said Dr. Bretan.

After years of practice in Marin and Sonoma counties, Dr. Bretan now provides urologic and laparoscopic surgical care at a safety net hospital in Santa Cruz County. Most of his patients speak no English and have no medical insurance.

(Continued on page 8)

(Continued from page 7)

“My presidency will be dedicated to giving these patients, and the millions of hard-working Californians like them, a voice,” said Dr. Bretan. “We have an incredible opportunity to boldly change the way health care is delivered. We know that to best serve patients, health care must be physician-led.”

Dr. Bretan has served as a CMA trustee and delegate, and is a three-time county medical society president. He is the current president of the California Urological Association and serves as an adjunct clinical professor at Touro University, where he has taught classes in health care policy for the past 16 years.

Dr. Bretan earned his B.S. degree in physiology from UC Berkeley and his medical degree from UC San Francisco, where he completed residencies in general surgery and urology, as well as a fellowship in radiology. He also completed a fellowship at The Cleveland Clinic Foundation in transplantation and renovascular surgery. Dr. Bretan is a member of the San Francisco Marin Medical Society and the Mendocino-Lake County Medical Society.

SACRAMENTO PAIN SPECIALIST NAMED CMA PRESIDENT-ELECT Sacramento pain specialist Lee T. Snook, Jr., M.D., was named president-elect of CMA. He will serve on the Executive Committee as president-elect for one year. Dr. Snook will be installed as president following next year’s House of Delegates.

A CMA member since 1985, Dr. Snook has served as speaker and vice speaker of the CMA House of Delegates. He has also served as chair of the CMA Worker's Compensation Technical Advisory Committee for the past eight years and as a member of CMA's Board of Trustees for the past 10 years. Dr. Snook is a member of the Sierra Sacramento Valley Medical Society.

Dr. Snook is an outspoken advocate for physician wellness and was an advocate for approaches to preventing physician burnout long before it became a popular thing to talk about. He has spent the past 25 years working to develop policies and programs that have achieved positive results for the health and wellness of all physicians and for the practice of medicine.

Dr. Snook is a medical director, president and founder of the Metropolitan Pain Management Consultants, Inc., in Sacramento. He is board-certified in anesthesiology, internal medicine, addiction medicine and pain medicine.

He is a fellow of the American College of Physicians and the American Society of Addiction Medicine. Dr. Snook is also a certified medical review officer and a qualified medical evaluator.

Dr. Snook graduated from the University of Nevada School of Medicine in Reno, NV. He did his internal medicine and anesthesiology residencies at the University of Wisconsin Hospitals and Clinics in Madison, WI. He is an American Medical Association delegate for the American Society of Interventional Pain Physicians and an alternate delegate for the California Society of Anesthesiologists. He is also a board member at California Public Protection and Physician Health, Inc.

Reliving House of Delegates 2019 Couldn’t get enough of HOD? Check out our Flickr page for photos of HOD 2019 and relive all the glory and memories!

Flickr.com/californiamedicalassociation

Staying Involved Already have ideas for next year’s House of Delegates or want to continue the fight to support CMA? Even though HOD might be over, there are plenty of ways to stay involved and dedicated to CMA.

GRASSROOTS ACTION CENTER

CMA boasts some of the best advocates and lawyers in the capital - but YOU are the most powerful advocate.

As someone who serves on the front lines of health care delivery, elected officials and policymakers need to hear your voice to make informed policy, legislation and regulations. Visit cmadocs.org/grassroots to see how you can get involved.

SUBMIT A RESOLUTION

CMA is proud of its resolutions process because it preserves the value of each member's perspectives and experiences, and empowers physicians to shape the ever-changing health care landscape and ensure that CMA is speaking with its members’ voices in its advocacy.

From internal governance to ambitious statewide advocacy, every policy is crafted, reviewed and approved by the dedicated team of physician leaders that make up CMA's organizational structure. Visit cmadocs.org/resolutions to submit a resolution.

NOMINATE YOURSELF OR A COLLEAGUE

Members of CMA councils and subcommittees play crucial roles in shaping health care policy. You can find out more about available opportunities and awards at cmadocs.org/nominations.

SURPRISE BILLING

By Elizabeth McNeil, Vice President CMA Federal Government Relations

CMA Physicians Fight Harmful Surprise Billing Proposal in Final Year-End Legislation Important health care programs funded through 2020 Mid December, the U.S. House and Senate passed year-end legislative packages that would fund the government through the end of the 2020 fiscal year (HR 1865, HR 1158, HR 965) and extend other important health programs until May 22, 2020. All legislation is expected to be signed by the President.

Notably missing from the package was legislation to address surprise medical bills which Congress worked on all year. CMA and organized medicine joined together to promote surprise billing legislation that would protect patients from surprise bills but establish a fair process for physicians and insurers to resolve billing disputes with reasonable payment rates to protect long-term access to doctors.

In the final weeks of the session, CMA, the AMA, the national specialties, and a handful of state medical associations, successfully fought-off the bipartisan, bicameral Senate HELP and House Energy Commerce (E&C) Committee proposals that would have imposed more than 20% payment cuts on non-contracting, as well as contracting, physicians and negatively impacted access to in-network physicians, and on-call physician specialists caring for patients in emergencies.

While CMA successfully fought the Senate HELP/House E&C plan, Congressional leaders have set a May 22, 2020 deadline to address surprise billing. The House Ways and Means Committee just announced plans to move their new proposal in late January. While few details on the plan have been released, the basic framework appears to be an improvement. It does not set a benchmark payment rate but rather allows it to be determined in an independent dispute resolution (IDR)

process and without a monetary threshold for accessing IDR. It also addresses network adequacy. Two other committees that hold ERISA self-insured plan jurisdiction may also weigh-in. Once the House Committees finish their work, all of the bills will be reconciled for final passage. CMA will continue to aggressively advocate for a balanced solution.

OTHER HEALTH CARE IMPROVEMENTS For the first-time in two decades, the bill includes $25 billion for the National Institutes of Health (NIH) and the CDC to perform firearm violence research related to behavioral, prevention and safety issues.

The bill also raises the national legal age to purchase tobacco and e-cigarette related products to age 21, though unfortunately, it did not include a ban on flavored products which target children.

A final provision would make it easier for generic drug companies to access samples of brand-name drugs.

The year-end legislation also includes a funding extension until May 22, 2020 for important expiring health care programs, including the community health centers (FQHCs), the Teaching Health Center Primary Care GME Program, the National Health Service Corps, Disproportionate Share Hospital payments, and other programs within Medicare. The grand plan is for all of these programs to be included in one legislative vehicle with a solution to surprise billing and Medicare drug pricing legislation.

(Continued on page 13)

(Continued from page 11)

CMA strongly supports HR 3 (Pelosi) which recently passed the House and would authorize Medicare to negotiate drug prices with the pharmaceutical companies.

However, three ACA taxes that had previously been delayed were fully repealed – the medical device tax, the Cadillac tax on high-benefit health plans, and a fee on insurers.

Democrats won several ACA-related provisions that would protect automatic re-enrollment in plans purchased on the exchanges if a consumer does not select a new plan during open enrollment. It would also allow insurance plans to add costs on to the Exchange silver-tiered insurance plans that are tied to the tax credits that help people afford their premiums. This practice keeps costs lower for patients.

CMA thanks the County Medical Societies and physicians across the state for their work to support these important health care programs and to advocate for a balanced solution to surprise billing.

Contact: Elizabeth McNeil, Vice President Federal Government Relations, emcneil@cmadocs.org

Learn more about MMCMS at our website!

MMCMS.ORG

www.mercedradiology.com

PROVIDING PROFESSIONAL RADIOLOGY SERVICES TO Castle Family Health Centers • Patient’s First Medical Center and other Health Care Providers in the Greater Merced Area P.O. Box 3649 • Merced, CA 95344 209-722-9729 (722-XRAY) • Fax: 209-384-9729

Our Holiday Party in Pictures and...

Thank you, Dr. Yaqub for your service as President for 2019 and your willingness to continue as President for 2020.

5 Year Appreciation Awards Pictured:

Oscar V. Ramos, MD

10 Year Appreciation Awards Pictured:

Thanh D. Nguyen, MD

Not Pictured:

Not Pictured:

Mimi E. Carter, MD Theresa A. Schill, MD Muhammad Shabbir, MD Brian K. Sugimoto, MD

Christian A. Gallery, MD Vikram Lakireddy, MD Kristina M. Sogocio, MD Thavalinh Mark Sphabmixay, MD

Appreciation for Years of Membership 15 Year Appreciation Awards

30 Year Appreciation Awards 25 Year Appreciation Awards Not Pictured:

George W. Nevatt, MD

Pictured:

Gundala S. Reddy, MD Pictured Left to Right:

Nirmal S. Aujla, MD and Mani Nallasivan, MD

Not Pictured:

Sivakumar R. Munnangi, MD

35 Year Appreciation Awards Pictured Left to Right:

Ravi Kumar, MD Kin C. Chan, MD

40 Year Appreciation Awards Not Pictured:

Annapurna M. Reddy, MD Salvador Sandoval, Jr., MD, MPH

Stratford Evans Merced Funeral Home

1490 B Street Merced, California 95341 Phone: (209) 722-4191 Fax: (209) 722-4198 www.stratfordevansfunerals.com KENT FLORO Location Manager

FD #538 kent.floro@dignitymemorial.com

PUBLIC HEALTH

UPDATE

Congenital Syphilis An Unfortunate Burden

By Gordon Arakawa, MD PhD, Merced County Health Officer

I

n 1520, many years after King Charles’ army was beset by a devastating affliction during its invasion of Naples, Desiderius Erasmus wrote: “If I were asked which is the most destructive of all diseases I should unhesitatingly reply, it is that which for some years has been raging with impunity … What contagion does thus invade the whole body, so much resist medical art, becomes inoculated so readily, and so cruelly tortures the patient?”1

The disease described by Erasmus: syphilis. Approximately one year following the invasion, King Charles had to abandon his conquest of Naples, in large part, due to the fact that many of his soldiers became so ill from the disease they were no longer able to fight.

Syphilis, caused by the bacteria Treponema pallidum, is a highly contagious disease that spreads primarily through sexual activity. Cure can be readily achieved by appropriate antibiotic therapy.

However, without treatment, it can lead to disability, neurological disorders, and even death.

Congenital syphilis is an infection that develops in utero and is present at birth. It is due to transmission of a syphilis infection in the mother to her fetus during pregnancy. Congenital syphilis is a devastating disease that can cause premature birth, low birth weight, birth defects, and can lead to stillbirth and early infant death.

Syphilis: A Brief Clinical Review The primary stage of syphilis is largely localized; classic signs include the chancre or “syphilis sore.”

The secondary stage usually begins 4-8 weeks after the primary stage and is characterized by disseminated disease with rash (classically involving the palms and soles of the feet), fever and lymphadenopathy. The secondary stage is often followed by a latent stage of syphilis infection in which there are no signs and symptoms. The latent stage is often divided into early and late/unknown duration phases. The early latent phase is defined as lab-confirmed infection or unequivocal signs/symptoms of syphilis within the last 12 months.

The late/unknown duration phase is defined as labconfirmed infection AND no clinical evidence of syphilis infection acquired during the past 12 months.

The tertiary stage of syphilis, which can begin as early as one year following initial infection, involves inflammatory lesions of the skin (“gummata”), cardiovascular system, and skeletal system.

The tertiary stage is often associated with serious complications such as cardiovascular disease and generalized weakness.

Neurosyphilis refers to neurological involvement manifested by syphilitic meningitis, ocular syphilis and/or otosyphilis. Late manifestations of neurosyphilis include dementia and paresthesia and gait abnormalities. It is important to note neurosyphilis can occur during any stage of syphilis infection.

(Continued on page 18)

Congenital Syphilis continued... (from page 17)

Treatment of syphilis depends upon the stage of infection. The primary, secondary, and early latent stages of syphilis are treated with a single dose of penicillin G administered intramuscularly. The late/unknown duration latent phase and tertiary stage are treated with penicillin G administered intramuscularly once per week for three weeks.

Treatment of neurosyphilis includes penicillin G administered intravenously every four hours (or continuous infusion) for 10-14 days.

Figure 1. Female Syphilis Rate/Congenital Syphilis Cases 2018-2019. Adapted from “Concerning Increases in Syphilis in Women and Congenital Syphilis: An Update for Providers from CDPH, 2018.

Burden of Disease Since 2010, there has been a drastic increase in the number of congenital syphilis cases in California (Figure 1). For the most part, this increase in cases parallels the increase in the rate of early syphilis infection in females of childbearing age.2 Several factors have been implicated for the increase in cases of early syphilis infection in females.3 Budget cuts in public health have led to closings of public health clinics which serve the lower socio-economic populations. Those same budget cuts have decreased the outreach and education provided by public health with regards to syphilis and other sexually transmitted infections (STIs). Social factors such as dating apps (e.g. Tinder), drug abuse, and reduced condom use have also contributed to the increase in syphilis infections.

Defeating Congenital Syphilis There are two actions to be taken to address congenital syphilis (Figure 2). The first action involves primary prevention of congenital infection in the pregnant woman. The second action takes place if primary prevention has failed. The second action involves assessment of infection in the neonate and timely and appropriate treatment if evidence of infection is confirmed.

(Continued on page 19)

Figure 2. Actions taken to address Congenital Syphilis: Prevention & Evaluation/Treatment.

Prevention action involves the pregnant mother while the Evaluation/ Treatment action involves the neonate.

Prevention Maternal

Evaluation/Treatment Neonatal

30 Days Prior to Birth

Congenital Syphilis continued... (from page 18)

Prevention The most significant and effective action to combat congenital syphilis is prevention of syphilis infection in the fetus.

Prevention is composed of two steps: 1) maternal screening for syphilis infection and 2) effective treatment of maternal infection when discovered.

In California, it is required by law that all pregnant women undergo screening for syphilis during the first prenatal visit, as recommended by the Centers for Disease Control (CDC). Pregnant women who may be at higher risk for syphilis infection should undergo additional screening for syphilis infection in the third trimester, at birth, and after exposure to an infected partner. Pregnant women who are at higher risk include those who have a history of substance abuse, incarceration, STI diagnosis, and those who did not get tested for syphilis in the 1st or 2nd trimesters of pregnancy.

If screening suggests the presence of infection, followup tests can confirm the stage of infection in the mother. Once maternal syphilis infection is confirmed, the mother must receive antibiotic treatment appropriate for stage of infection. In general, timely, appropriate treatment of syphilis in the mother serves as adequate treatment of the fetus. However, treatment of the fetus is NOT considered adequate if maternal treatment begins less than 30 days prior to delivery.

Assessment of Infection in the Infant Congenital syphilis screening4 of the mother and infant must take place at birth if: 1) the mother has a history of STI, 2) was diagnosed with syphilis during pregnancy, or 3) is considered at high risk for syphilis infection at delivery. Both mother and infant should have serum RPR or VRDL titer drawn at delivery, and a neonatal physical examination must be performed to look for signs of congenital syphilis (e.g. hepatomegaly, jaundice, non-immune hydrops). PCR testing of any suspicious lesion or bodily fluid in the neonate must also be performed.

If no abnormalities are found in the initial neonatal screening, then further congenital syphilis classification

References 1.

Firth J. (2012) Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins. Journal of Military and Veterans’ Health, 20(4), 49-58.

2.

Concerning Increases in Syphilis in Women and Congenital Syphilis – An Update for California Health Care Physicians, CDPH, 2018.

3.

Sharp, N. (2015) The Return of Syphilis, The Atlantic, December Issue.

4.

Congenital Syphilis: Evaluation & Treatment of Infants Born to Women with Syphilis during Pregnancy, CDPH, 2018.

depends upon the mother’s syphilis status. The neonate may be classified as low risk for congenital syphilis if the mother received adequate, documented treatment for syphilis more than four weeks prior to delivery AND there was no concern for reinfection during pregnancy.

If the mother received no treatment or inadequate treatment for syphilis, or received treatment for syphilis less than four weeks prior to delivery, then the neonate must undergo supplemental evaluation with CSF analysis, CBC and long-bone radiographs. The neonate is classified as having possible congenital syphilis if no abnormalities are found in the supplemental evaluation.

The neonate is classified as having probable congenital syphilis if abnormalities are identified in the supplemental examination.

If any abnormality is found in the initial neonatal screening, the neonate is classified as having proven or highly probable congenital syphilis. In this scenario, a complete evaluation of the neonate includes CSF analysis, CBC, long-bone radiographs and other tests as necessary based on the physical exam (e.g. abdominal ultrasound for suspected hepatomegaly).

Treatment of Infection in the Infant Unlike cases of syphilis in an adult in which treatment choice depends upon stage of infection, treatment selection for congenital syphilis in newborns depends upon the likelihood of syphilis infection. When newborn screening and evaluation indicates proven or probable congenital syphilis, then penicillin G is administered intravenously twice daily for seven days and then three times a day for 10 days thereafter. If congenital infection is classified as possible but all elements of the neonate’s workup are otherwise negative or if there is a low risk classification for congenital syphilis but clinical follow up is uncertain, then a single dose of penicillin G administered intramuscularly is recommended.

Finally, if congenital syphilis is considered unlikely, then no treatment is necessary; however, follow up lab tests confirming lack of infection is recommended.

Congenital syphilis can only be defeated with a concerted effort amongst the health care system, public health, social services, and community outreach. When evaluating a pregnant woman in the office, think syphilis. While we might not be able to stop syphilis from hindering King Charles’ army, we must make every effort to prevent syphilis from affecting our most vulnerable populations, the fetus and neonate.

2020 DISCOUNTED CODING BOOKS Order your 2020 coding books from MMCMS to receive our discounted prices!

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Our coding book discounts are only offered to physicians in Merced and Mariposa Counties.

Books will be shipped directly to you from the distributor as they become available.

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WINNING THE FIGHTS THAT MUST BE FOUGHT

California Medical Association’s 2019 Legislative Wrap-Up

I

n January, California witnessed something completely new. The swearing in of Governor Gavin Newson marked the first time in state history that a Democratic governor was succeeded by another Democratic governor. Political history is flush with examples of challenges facing the incumbent party attempting to hold on to statewide power. Typically, voters seize the opportunity for change by electing a leader of a different party. But this time, voters chose to move from a moderate Democrat (Jerry Brown) to a progressive Democrat (Gavin Newsom).

The transition from Brown, who retained tight control of the state’s budget and legislative process, to a first-time governor provided the legislature with an opportunity to reshape California’s policy landscape. >>>

Discussion, debate, dialogue and compromise were the overwhelming themes of the 2019 session. Since Governor Newsom did not have a public veto or signing history, his policy perspective was not yet set in stone.

Legislators saw this as an opportunity to bring nearly every recycled and newly minted policy idea to the proverbial table.

The tone of the 2019 legislative session was overall one of unbridled optimism. Such political environments pose many risks and opportunities, with many competing

interest groups jockeying to raise their priorities.

The California Medical Association (CMA) successfully collaborated with the legislature on proactive efforts to expand public health initiatives, reduce administrative burdens, increase physician reimbursements and strengthen the physician workforce. However, over the course of the legislative year, additional reactive efforts emerged as various stakeholders launched unmerited attacks against the profession.

RELIEVING ADMINISTRATIVE BURDENS In January 2019, CMA was faced with an immediate crisis: flawed implementation of a new state law— intended to improve the security of physician prescription pads as a solution to the opioid crisis—left pharmacies unable to fill prescriptions and patients being refused necessary medications.

CMA quickly worked with the Newsom Administration, the California Department of Justice and the legislature to resolve the matter. The result was the swift approval and enactment of CMA-sponsored AB 149 (COOPER), which allowed patients to immediately start receiving their prescriptions and physicians to utilize their existing prescription pads until July 2021.

CMA also sponsored AB 744 (AGUIAR-CURRY) to revamp the rules regarding the payment of health care services provided via telehealth in order to increase access to care. Under existing law, physicians are incentivized to require patients to physically enter medical offices for services that could otherwise be delivered utilizing telehealth. Health plans sought to maintain existing law as a means of creating barriers to care. However, CMA worked with legislators from both rural and urban areas, showcasing the benefits of telehealth and the necessity for plans to pay for physician expertise regardless of the modality under which it is delivered. Despite the opposition of the health insurer lobby, the measure received only one “no” vote throughout the entire process.

During the last weeks of the legislative session, the United Healthcare Workers Union went after the

physician community and sought to shame physicians for the compensation they receive. CMA successfully stopped the union’s sponsored bill, AB 1404 (SANTIAGO), which would have required targeted physician groups to disclose the total compensation of their physician partners as a means of creating leverage in union contract negotiations. Such attacks don’t belong in the health care legislative space; they increase the difficulty of recruiting the quantity of physicians needed to serve patients and negatively impact efforts to constrain health care costs.

In addition to the above, CMA took the following actions to either relieve existing administrative burdens or stop the creation of new burdens: 

PASSED legislation to alleviate burdens associated with mandatory use of the CURES database

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DEFEATED legislation to change prescription labeling requirements

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DEFEATED legislation to require referral to alternative medicine practitioners prior to prescribing an opioid

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DEFEATED an attempt to dramatically increase physician licensing fees

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DEFEATED multiple attempts to publicly disclose physician reimbursement and contracted rates

This year’s budget contained $120 MILLION to support loan repayment programs for physicians and dentists (administered by Physicians for a Healthy California).

Want to Know More?

For more details on the major bills that CMA followed this year, visit cmadocs.org/leg-wrap-2019.

Subscribe to CMA’s free biweekly Newswire and stay informed on CMA’s legislative efforts and other issues critical to the practice of medicine at cmadocs.org/subscribe.

ACCESS TO CARE In June, Governor Newsom signed his first state budget. The process for the 2019-2020 budget was dramatically different than prior years. Consistent with his campaign promises, Newsom prioritized health care. Not only did he expand health care insurance coverage, he was equally committed to funding access to care. This year’s budget contained: 

$2.2 BILLION for provider rate increases funded by the Proposition 56 tobacco tax

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$120 MILLION to support loan repayment programs for physicians and dentists (administered by Physicians for a Healthy California)

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$250 MILLION for the creation of a Value-Based Payment Program within Medi-Cal

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$150 MILLION for developmental and trauma screening supplemental payments

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EXPANDED MEDI-CAL ELIGIBILITY, which now includes all young adults aged 19-25, regardless of their immigration status

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A STATE-LEVEL INDIVIDUAL MANDATE to obtain health coverage

PUBLIC HEALTH AND POLICING THE PROFESSION The physician members of CMA hold sacred the trust patients and communities have in the medical profession. On countless occasions, the leaders of state, county and specialty societies wrestle with a variety of policy questions. And while there are many perspectives from which a policy can be debated, inevitably the question will be asked: how will this impact our patients and the trust the public places in physicians to look after their best interest and health?

In 2015, CMA sponsored Senator RICHARD PAN, M.D.’S SB 277 to eliminate the personal belief exemption from the statutory requirements for childhood vaccinations.

The fight to enact SB 277 was fierce. Thousands of antivaxxers flooded the hallways of the Capitol. New security protocols were required for Senator Pan and CMA headquarters. The bill was heavily protested at the Capitol and in local districts; thousands of rabid antivaxxers spewed inflammatory rhetoric and threats of bodily harm. When Governor Jerry Brown signed that measure into law, Sacramento assumed the chapter on vaccines was closed.

The result of SB 277 was positive overall, and statewide vaccination rates improved. However, a number of geographic pockets of unvaccinated children emerged due to vaccine hesitancy and a few physicians willing to inappropriately monetize the moment by providing vaccine exemptions with questionable medical rationales. While some abuse was anticipated, the quantity of exemptions issued by a few physicians was alarming. On social media, parents openly discussed how to purchase exemptions, which physicians were open to such transactions and what medical symptoms to highlight in the visit. As such behavior persisted, Senator Pan and CMA faced a dilemma: how to respond to physicians whose actions threaten to erode public trust in the physician community?

Courage! CMA and Dr. Pan chose to once again brave the turbulence and introduced legislation (SB 276) to increase vaccination rates by cracking down on inappropriate physician behavior. The reaction of the opposition exceeded our expectations. We knew there would be threats and a high number of anti-vaxxers protesting at the State Capitol and in the districts. We did not expect blood to be thrown onto the Senate floor from the gallery or parents forming chains to block the entrance of the Capitol.

CMA’s obligation to protect the integrity of the profession and the public trust in the physician community outweighed the fear of facing fierce, threatening opposition.

Similar courage was necessary on other fronts, including the legislature’s response to the sexual misconduct of gynecologist George Tyndall in student health centers at the University of Southern California. CMA ensured important due process protections for physicians remained, while not protecting the deplorable behavior of a specific physician. Navigating such troubling matters is complex, and CMA successfully preserved fundamental protections, while building our creditability with the legislature that CMA is an association that stands for quality physicians with the ability to self-police the profession.

Courage to fight for patients, courage to fight for the betterment of the profession and courage to fight for the public’s health is why CMA is the most effective advocacy organization in the Golden State!

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

Merced Mariposa

2848 Park Avenue, Suite C | Merced, CA 95348