February 2017 | Physician Magazine

T H E CO N N E C T E D P H YS I C I A N | 2 0 1 7 B U Z Z W O R D S YO U N E E D TO K N O W

LACMA’S FIRST-EVER

Thought Leadership

Roundtable

P RES IDEN T ’S LET T ER | VIT O IM B AS C IANI, M D

Leadership

“Physicians have the education, the experience, the interest and the passion to make a positive impact on the lives of the people in the communities they serve. Be a leader — find your voice and speak out.”

I presume, somewhere out there in the world of literature, there is a vision of Utopia where the author has taken pains to create a society without leaders, where citizens lead their lives in the absence of rule-setters. Such a world would be in contradistinction to ones, like the dystopia created by George Orwell in “1984,” in which every aspect of life is governed by authoritarian father figures (or, increasingly in the sci-fi world of cinema, by authoritarian mother figures).

But, let’s face it, we need leaders. We need them at the local, regional, national and international levels, because humanity has not yet evolved to a point where we all agree on what our needs are, let alone agree on the solutions. We have myriad needs, for the maintenance of biological life, for reproduction, for emotional and spiritual health, for peace in the world.

Most leaders are chosen, whether by acclamation (Moses, Spartacus, Supreme Court justices, the pope) or by elections (45 American presidents, 100 senators, county sheriff). Some seize power (Lenin, Castro, Franco). But the most lasting power, in any culture in the last two millennia, seems to invest itself in people of great moral authority. Think Mahatma Gandhi, Martin Luther King, Jr., Nelson Mandela and Mother Teresa.

These leaders are all larger than life, and that epic quality about them can have an unintended negative effect: that of squelching the interest in normal men and women, including physicians, to address the problems, wrongs and inadequacies they see all around them. As it is, physicians are uniquely positioned to occasion great change at many different levels of society. Some see their pediatric patients getting fat, or eating poorly, of living in dangerous situations. So they attend city council meetings to argue for parks, exercise spaces and better food choices in schools. Other physicians, with a broader outlook, identify threats to the communities they serve: gun violence, drug use (including opioids), poor air quality, unsafe drinking water, lack of herd immunity. These doctors, whether individually or in organized groups, lobby at the state Capitol for sane legislation and public health policies, including vaccinations and smoking cessation, and to protect the profession from encroachment by nonprofessionals.

Organized medical societies like the California Medical Association and specialty societies send delegates to the American Medical Association to lead the discussion on national issues, including universal healthcare, control of pandemics, and physician reimbursement.

Finally, a few amongst us step up, suffer the slings and arrows of our increasingly caustic electoral process, and run for public office. (The 114th Congress, which started in January of this year, has 14 physicians in the U.S. House of Representatives and three physicians in the U.S. Senate.)

Physicians have the education, the experience, the interest and the passion to make a positive impact on the lives of the people in the communities they serve. Be a leader — find your voice and speak out. The Internet has made it a trivial exercise to find the name and number of your elected representatives. It’s easy to write a letter to the editor. A physician speaking at city council meetings will be listened to. There is no better time to lead than now.

ON THE INSIDE President’s Letter | Vito Imbasciani, MD 2 Hold On to Your Lab Coat Month Gustavo Friederichsen LACMA’S FIRST EVER

Thought Leadership

4 Thought Leadership Roundtable

Roundtable

8 Dr. Valencia Walker on Leadership 4

8

12 The Connected Physician

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F EB RUA RY 2017 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 1

F EB RU ARY 2 0 1 7 | TAB LE OF C ON T EN T S

Volume 148 Issue 2

Hold On to Your Lab Coat Month AS THI S GO ES TO PRESS, the newly elected

president of the United States will have just been sworn into office. Therefore, I’m officially proclaiming February as Hold On to Your Lab Coat Month. I want to take this historic “CMA and LACMA recognize that the ACA has serious shortcomings that need to be addressed. Nearly one in three Californians are now enrolled on the state’s Medi-Cal program, yet few have true access to a doctor.”

opportunity to share an update, not a biased dissertation of support or opposition to the recent election. As CEO, I lead an agnostic organization that is solely focused on working for physicians and the practice of medicine in anticipation of the virtual avalanche of change that is coming.

On Jan. 13, the U.S. House of Representatives followed the U.S. Senate in passing a non-binding budget resolution (S.Con.Res.3) that sets 2017 spending targets and provides instructions to the congressional policy committees to do the following: 1. Develop a majority-vote budget reconciliation bill that repeals the Affordable Care Act (ACA) by late February 2. Achieve savings from the ACA repeal legislation

The ACA repeal budget reconciliation legislation will likely focus on three issues: 1.

Repeal of the tax penalties on large employers and individuals who do not purchase insurance 2.

Elimination of the subsidies and tax credits provided to individuals to purchase coverage through the ACA exchanges 3. Repeal of the federal Medicaid funding provided to states to expand their Medicaid programs to low-income adults

3. Develop an ACA replacement plan.

The budget reconciliation bill that will be moved in February would repeal the ACA, but it would not take effect for two to three years while Congress works on a replacement plan. Under House and Senate rules, budget reconciliation bills include only budgetary items and can be adopted by a simple majority vote (rather than the usual 60 votes required for passage in the Senate), thereby circumventing a Senate Democrat filibuster.

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There is a debate within the Republican caucus as to the outcome of ACA funding sources, including the medical device tax, the Cadillac tax on health plans offering “rich” benefit packages, increased premiums on high-income seniors and the income tax increase on higher income earners. Some want to immediately repeal the funding sources. Others argue that these funds should be suspended in a special account in case they are needed to finance the ACA replacement plan. Finally, House Speaker

CMA continues the struggle to maintain the hard-fought Paul Ryan and Senate Majority Leader Mitch McConnell have announced that they plan to defund Planned Parenthood in the insurance reforms that require insurers to dedicate 80% of their revenues to direct medical care and to submit premium increases ACA budget reconciliation bill.

Previous bills introduced by Ryan, the Health and Human to regulators. They are also working to prohibit insurers from Services secretary nominee, Tom Price, MD, and Senate Finance placing lifetime or annual limits on benefits, blocking coverage Committee Chairman Orrin Hatch provide insight into the for pre-existing conditions or rescinding coverage when a patient potential healthcare reform legislation that will replace the becomes ill.

As you know, CMA has also fought health plan mergers over ACA. As previously written, none of these proposals provides as much coverage as the ACA. Generally, these proposals repeal the years in an effort to promote an open, competitive healthcare only the ACA insurance provisions, the individual mandate, and marketplace in California.

CMA and LACMA recognize that the ACA has serious the Medicaid expansion for low-income adults. They replace the ACA with a completely private, voluntary health insurance shortcomings that need to be addressed. Nearly one in three marketplace. It is not clear how the individual market would Californians are now enrolled on the state’s Medi-Cal program, yet few have true access to a doctor. successfully operate.

Since Medi-Cal reimbursement Regardless of previous rates are among the lowest in healthcare reform proposals, CMA continues the struggle to maintain the nation, most physicians the Republican leadership the hard-fought insurance reforms that cannot afford to participate. recognizes that a more Moreover, the payment rates comprehensive approach is require insurers to dedicate 80% of their and physician networks in the warranted, and they plan to revenues to direct medical care and to Covered California Exchange take more time to develop a submit premium increases to regulators. are inadequate. And many replacement plan. They have families continue to express also reached out to state concerns about the affordability governors and insurance commissioners for their input on the ACA, the Medicaid of insurance in the Exchanges. The individual market needs more Expansion and the Exchanges. Sixteen Republican governors and stability. While the ACA significantly expanded coverage, it did 14 Democrat governors expanded their Medicaid programs, and not expand access to care for many Californians.

What does all of this mean for MACRA? In an unusual move, the majority of these governors are asking Congress to maintain CMS requested additional comments on the final rule after it was Medicaid funding.

Finally, the ACA replacement legislation will require 60 issued. CMA and AMA submitted lengthy comments. CMA will votes in the Senate. Therefore, Republican leaders will need to continue to advocate for less administrative burden in MACRA compromise with at least a handful of Democrats to gain final and for greater accountability and penalties on EHR vendors that do not meet the requirements. If Dr. Tom Price is confirmed as passage. Stay tuned. Stay committed. And stay informed. next secretary of HHS, organized medicine believes he will be sympathetic to providing additional regulatory relief to physician practices. CMA will continue to seek reform of Medicare RAC and Tobacco Taxes; Healthcare Reform CMA and LACMA and other medical societies across the state prepayment audits.

However, Congress is not likely to take major action on the are actively involved in shaping the future of healthcare reform at the national level. CMA has extensive policy on healthcare bipartisan MACRA law next year because CMS delayed MACRA reform issues. Based on that policy, CMA’s overriding goal will in 2017 and made significant improvements. CMA and AMA be to ensure that Californians who have coverage today do not will continue to be actively engaged with Congress and the lose coverage or access to care. CMA will also be working to administration on MACRA issues. Both CMA and LACMA will protect current state and federal healthcare funding, including the also continue to offer programs to educate and assist our members so they can successfully participate. I encourage you to visit the Proposition 55 and Proposition 56 tobacco taxes.

Current CMA policy opposes Medicaid block grants. Moreover, CMA MACRA Resource Center at www.cmanet.org/MACRA. I CMA will continue to work to ensure that low- and moderate- want to acknowledge CMA’s Elizabeth McNeil for providing us income families can afford coverage. CMA has promoted with the latest information on ACA, MACRA and more. responsible healthcare financing, including use of the tax code, to help Californians purchase insurance and subsidies to help low-income families afford coverage. An underfunded healthcare system places untenable burdens and unfunded mandates on Gustavo Friederichsen physicians. It also creates access to care problems, healthcare Chief Executive Officer delays and economic hardship for patients. CMA will also be a voice for patient choice in the new healthcare system.

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LACMA’S FIRST-EVER

Thought Leadership

Roundtable

L AC M A K I CK E D OFF THE NEW Y EAR with the first Thought Leadership Roundtable. Six physicians met at LACMA headquarters for a quick dinner and chance to connect before sharing their views on the state of healthcare and medicine, the future and challenges the community faces.

The participating were as follows:

physicians

David Aizuss, MD — General ophthalmologist and chair of the CMA Board of Trustees C. Freeman, MD — Geriatric psychiatrist and LACMA treasurer Howard Krauss, MD — Neuroophthalmologist and member of the Medical Board of California Seira Kurian, MD — Deputy medical director of the Department of Public Health and preventative medicine specialist

Frederick Russo, MD — General internist and president/CEO at Facey Medical Group Diana Shiba, MD — General ophthalmologist and director of government relations for Southern California Permanente Medical Group Reo Carr, CEO of Physicians News Network, was the facilitator for the event. He led off by asking each participant to weigh in on the state of healthcare.

4 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2017

Pictured left to right: David Aizuss, MD, Frederick Russo, MD, Seira Kurian, MD, Reo Carr, C. Freeman, MD, Diana Shiba, MD, and Howard Krauss, MD

Dr. Krauss: Probably the number one problem that remains in healthcare in the United States despite the ACA is there still are many people with inadequate access to healthcare. There are perhaps 16 million more people with some health insurance today than there were in 2008, but having health insurance or having Medicaid doesn’t necessarily ensure that one has access to healthcare. That’s a problem that needs to be solved. Hopefully we’ll work toward that goal.

We each have different opinions how to get there, but none of us has the ability to push the levers. We stand by and watch what the government does at both the federal and state level. We stand by and watch what the health insurance and health plan companies do, but one of the things I admire about my colleagues is that they’re not just sitting in their offices taking care of patients. They’re actively engaged and trying to create a better healthcare milieu for society. I commend my colleagues for being very active in their associations and for being leaders in their associations. Unless we physicians — who know what it’s like on the front lines of healthcare — participate in the process, I suspect we’ll end up someplace worse than we would otherwise.

Dr. Freeman: I can’t give a global perspective, but I can give a perspective on the population I serve. Unfortunately many people believe that, because the ACA exists, all of a sudden people have access to care. There are many people who still do not have insurance. There are many people who, even if they have insurance, don’t really know how to maneuver in a very complicated healthcare system.

Dr. Aizuss: I would characterize the state of the healthcare system currently as one of uncertainty and turbulence.

The uncertainty has been created by the change in administration in Washington, D.C., and the desire of the Republicans to repeal the ACA with no replacement in place. The turbulence is created in every state in the country dependent on significant funding for their Medicaid population. That now is being threatened with being terminated.

We each have different opinions how to get there, but none of us has the ability to push the levers. We stand by and watch what the government does at both the federal and state level.

In California we receive about $20 billion as a result of ACA to care for our Medicaid, Medi-Cal population, and there’s a great deal of uncertainty if that funding is going to continue. . . . So we’re in a very difficult time right now. We don’t know how to prepare, and the uncertainty that creates both for the patients and physicians is extraordinarily difficult to deal with.

Dr. Shiba: I echo the concern for the public on access to affordable, high-quality care.

I have personal friends — I know a husband who was able to get hip surgery that he’d been waiting for for years and years and years; now he can walk and run and go on hikes with his wife again. So I think I only echo the concern that I hope with the changes that are likely to come in the future that our patients, the people that I know, continue to have that kind of life-changing care. ACA brought some great changes to a lot of patients’ lives, and I hope that we do continue to have that kind of coverage.

Dr. Russo: I’m concerned about the lack of access to care for patients in the Medi-Cal

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definitely under question. For us, it was sort program in terms of being able to get access of an opportunity to move away from direct to specialists. It’s my understanding that When you add service provision and turn to the role of many of the patients prior to the ACA were health strategist. being moved into Medi-Cal, [and] they another 5 [million] or Beyond access to care, the department is were going to have access to primary care, now looking at a variety of different issues. but I don’t think there was enough funding 6 million patients that In terms of the state of health for LA County, to attract enough specialists. That puts the one of the interesting things we’ve seen is primary care physician in a very difficult ended up on Medi-Cal that we’ve made huge advances in terms of situation in terms of being able to follow the leading causes of mortality. We’ve seen through with the care that’s needed. rolls post-ACA with trends decreasing across all the primary When you add another 5 [million] or 6 reasons that account for mortality, like million patients that ended up on Medi-Cal not a lot of additional rolls post-ACA with not a lot of additional funding, it didn’t really do anything to funding, it didn’t encourage specialists to be available. And really do anything to that’s a key part of the delivery of care.

And I say that as a primary care physician encourage specialists who benefited from having a relatively deep bench of specialists in my particular to be available. And practice setting. That needs to be figured out. To hear Dr. Aizuss talk about the fact that’s a key part of the that we may lose federal dollars and what we achieved with the initiatives of 55 and delivery of care.

56 to try and put another $3 [billion] to $5 Pictured left to right: Howard Krauss, MD, Diana billion on the table, that’s very discouraging Shiba, MD, and Frederick Russo, MD. if in fact the administration is going to rip that aside.

Dr. Kurian: I think I can echo what a lot of you are saying here cardiovascular disease and COPD. But nationally, the interesting in terms of access to care from the standpoint of the Department thing is that we’ve seen a slight uptick in mortality rates, and that of Public Health. Access to care is a concern. We’ve seen a huge seems to be mirrored in LA County as well. Again, our ability to increase in the number of people who have been able to access work as strategists to really identify why this issue is happening and care, but the quality of that care and the extent of the care is to collaborate with other partners to address these issues is a big concern for us.

In terms of funding, the 21st Century Cures bill was signed off by the last administration, which is a huge boon in a lot of different respects, but one of the concerns is that does take about $3.1 billion away from preventive and public health issues. So as a department we’re wondering what this is going to mean in terms of public health and preventive services in the future. So there are concerns across the board in terms of the future and status of health for LA County.

Pictured left to right: David Aizuss, MD, C. Freeman, MD, and Seira Kurian, MD. 6 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2017

The issue of access was touched on throughout the evening and is sure to crop up again in future LACMA discussions.

The video of the evening allows us to hear the full range of the exploration into the state of healthcare in LA County, the state and on a national level. Look for followup reports from the Roundtable and as we expand the Thought Leadership program at LACMA.

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DR. VALENCIA WALKER

ON LEADERSHIP AND ORGANIZED MEDICINE WE’D LIKE TO INTRODUCE YOU to LACMA member Valencia Walker, MD. We’d also

like to congratulate Dr. Walker for her recent Photos by Ari Moshayedi

Dr. Walker is a neonatologist with UCLA hospitals and an assistant professor at the David Geffen School of Medicine at UCLA. She also serves as president of the Black Women Physicians Association. She shared with us her interest in organized medicine, the skill set she’d like to bring to her leadership position and the importance of engaging the next generation of physicians.

The CMA website describes the mission of the Council on Legislation as [formulating] “policy recommendations to the Board of Trustees regarding positions on legislation pending in the State Legislature that impact physicians and the practice of medicine in California.”

There’s the potential for this to be a very busy year for the Council. Dr. Walker pointed out that it’s still too early to know what the issues are going to be, but as policy is enacted on a federal level, it will trickle down to California. The full Council will have its first meeting in March, while leadership will meet in February.

Dr. Walker’s engagement in organized medicine began soon after she completed her medical training, and the chance

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appointment as chair of the California Medical Association (CMA) Council on Legislation.

to chair the Council came as an unexpected opportunity. She says she decided to “be fearless and jump into it” because it represented a chance to work closely with wonderful people and strong leaders. She says she knows there will be a learning curve for her, but she’s looking forward to representing the concerns people have.

In considering the skills that transfer from clinical practice to advocacy work and the skills that she will need to develop, Dr. Walker drew from her experience in crisis medicine. She said that there’s a difference in dealing with emergencies and giving day-to-day care.

LISTENING IS A PRIORITY. “I’m an intensivist, so the idea that I can just go in with the right medication, the right amount of fluids, the right procedure and fix the condition, reverse the situation and everything’s better — that’s great for the crisis. But when it comes to listening and understanding what happens when you transfer that patient and the primary care physicians take over and they’re doing the day-to-day management and chronic care . . .”

“I’ve realized from getting more involved in work in this arena that physicians have been doing this kind of work for hundreds of years.

And [Rudolf] Virchow, everything is named after him — Virchow’s Triad, Virchow’s Node — he was also a very outspoken social advocate. He firmly believed that physicians were politicians. The work that needed to be done needs to be done by physicians.”

COLLABORATION PLAYS A BIG PART AS WELL. “[Understanding the nature of day-to-day care] is an adjustment for me, but I think one of the places where the skills are very similar is making a differential diagnosis, making sure that you’ve looked at all the potential angles and that you’re doing the right tests, that you’re looking at the right data and interpreting it correctly. And do you have the right consultants?

It’s a collaborative process. I tend to deal with really complex patients. I might be in charge of the totality of the patient, but I have to deal with cardiologists, surgeons and putting the whole team together. A lot of those skills are definitely transferable, but I think, more than anything, understanding the team dynamic and how critical it is, understanding that everyone plays a role and that no one can be undervalued or else you’re going to minimize your ability to be effective and have the impact that you want. We all want those good outcomes, right? We all want to meet those benchmarks. So really what you’re doing in this [advocacy] arena is scaling up and not looking at just the patient but, as we like to say, all the other determinants that may have led to your patient ending up in the ICU.”

IT’S IMPORTANT TO SEE THE ENTIRE PICTURE.

outspoken social advocate. He firmly believed that physicians were politicians. The work that needed to be done needs to be done by physicians. We absolutely rely on our critical thinking skills. We absolutely rely on our problem-solving skills. And we have an innate desire to do the best that we can for our patients and for our patients’ families. At the same time we have to figure out how to make our practices run, how to get the bills paid. So many physicians are entrepreneurs or small-business owners or scientists. They are so many things that encompass critical parts of our society.”

Thank you, Dr. Walker, for your service to your patients, LACMA and the physician community. We look forward to checking back with you as the term progresses.

Photos by Ari Moshayedi

“So it’s like having one coin and being able to look at both sides of it at the same time. I love the fact that at least right now I’m very engaged as a clinician, so I see the day-to-day and where the challenges are, but I’m also seeing a lot more of the entire picture.

“I’ve realized from getting more involved in work in this arena that physicians have been doing this kind of work for hundreds of years.

And [Rudolf] Virchow, everything is named after him — Virchow’s Triad, Virchow’s Node — he was also a very

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The Connected Physician

2017 Buzzwords You Need to Know

I N T H E E V E R - C H A N G I N G W O R L D of connected care it is hard to keep up with new technologies or with the new ways in which familiar technologies are being repurposed. While some of the following terms may not be new to you, they are all worthy of a deeper understanding of how they may impact information sharing, data collection and patient care in 2017.

Blockchain

Blockchain is a permanent record of online transactions.

Through the use of cryptography, each transaction is recorded and is considered a block. The ledger that links these transactions can be thought of as the chain. This record can be shared among a network of computers, and users on the network can add to the record of transactions.

All pieces of information in the chain are verified and show the history of transactions. With the potential to change how healthcare information is stored, shared, secured and paid for, blockchain technologies have immense potential to tackle some of the biggest challenges in healthcare information management, according to Forbes.

Internet of Things (IoT)

The internetworking of physical devices (also referred to as “connected devices” and “smart devices”) embedded with electronics, software, sensors, actuators, and network connectivity that enable these objects to collect and exchange data. In healthcare this might include everything from ultrasounds, heart monitors, thermometers, glucose monitors, electrocardiograms and cell phones when used to connect with healthcare providers or mHealth apps.

According to Business Insider Intelligence, the installed base of healthcare IoT devices will grow to more than four devices for every human on Earth by the year 2020. As the IoT market matures, it is expected that healthcare will be a major beneficiary of the technology, and vendors are exploring capabilities and features that can benefit patients and healthcare professionals.

Artificial Intelligence (AI)

While applicable in a variety of settings, AI in healthcare promises a variety of life-enhancing innovations, including clinical decision support, patient monitoring and coaching, automated devices to assist in surgery or patient care, and management of healthcare systems. In essence AI may be more involved in everyday tasks; for example, Forbes predicts that AI will play a big role in diagnostic imaging by complementing radiologists with advanced interpretation and imaging informatics support.

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Augmented Reality (AR)

Virtual additions to the known physical world, often used in fitness and wellness apps, augmented reality is also being utilized for much more complex applications like surgical guidance. AR can also be used in conjunction with AI, allowing physicians to employ machine learning while strategizing an upcoming surgical procedure in a simulation.

Digital Therapeutics

Used to improve health outcomes by addressing chronic conditions through behavioral changes, digital therapeutics refers to the collective developments in behavioral economics, smartphone apps, gamification, biometric sensors, data analytics and artificial intelligence.

Already a-half-billion-dollar market, digital therapeutics is expected to grow into a $6 billion market, according to a research report by Goldman Sachs. Not limited to devices, however, it also encompasses online preventative therapies. Substantiating the digital approach, Medicare recently announced it will cover both bricks-and-mortar and virtually delivered diabetes prevention programs like online courses for pre-diabetes prevention.

Informatics

Informatics is the science behind information technology, communications and healthcare to improve the quality and safety of patient care. This includes the use of electronic health records (EHRs), technology-based patient education, and the exchange of health records between providers. Studies have shown that employing these technologies has resulted in dramatic reductions in malpractice claims and faster lab results after introducing EHRs, which offers the potential for significant cost savings and improved quality of care. In addition to informatics, analytics can be provided by converting big data into actionable insights. Practices can expect to see more informatics and analytics solutions hit the market in 2017.

It will be important to conduct due diligence before investing in an informatics and/or analytics solution.

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