October 2016 | Physician Magazine by Los Angeles County Medical Association

P H Y S I C I A N

S P O T L I G H T

J O N A T H A N

N I S S A N O F F

MOBILIZING ON MACRA PLUS

PATIENTS, PRACTICE & PUBLIC HEALTH

VOTE 2016

OCTOBER 2016

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OCTOB ER 2016 | TA B LE OF CONT ENT S

Volume 147 Issue 10

PATIENTS, PRACTICE & PUBLIC HEALTH

VOTE 2016 FEATURE VOTE

2016

In advance of this important election, this issue of Physician Magazine summarizes eight initiatives for our physician readers, and provides the California Medical Association’s (CMA) stance on each measure.

MOBILIZING ON MACRA 4 President’s Letter | Vito Imbasciani, MD 6 Organized Disruption | Gustavo Friederichsen 20 Talk Is Cheap | Gustavo Friederichsen

ON THE INSIDE 8 Physician Spotlight | Dr. Jonathan Nissanoff 10 The Searing Journey — Step One for LACMAHeals

Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 04 Copyright ©2012 by LACMA Services Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. POSTMASTER: Send address changes to Physician Magazine,801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. Advertising rates and information sent upon request.

O C TO B ER 2016 | 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

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as well as medical students, interns and residents. For more than 100 years, LACMA has

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been at the forefront of current medicine, ensuring that its members are represented in the areas of public policy, government relations and community relations. Through its advocacy efforts in both Los Angeles County and with the statewide California Medical Association, your physician leaders and staff strive toward a common goal— that you might spend more time treating your patients and less time worrying about the challenges of managing a practice.

Vito Imbasciani, MD William Averill, MD C. Freeman, MD Sion Roy, MD Peter Richman, MD

RESIDENT/FELLOW COUNCILOR

CMA TRUSTEE

COUNCILOR – DISTRICT 2

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Jerry Abraham, MD David Aizuss, MD Emil Avanes, MD Erik Berg, MD Robert Bitonte, MD Stephanie Booth, MD Amanda de la Cerda Troy Elander, MD Samuel Fink, MD Hector Flores, MD Sidney Gold, MD Stephanie Hall, MD Po-Yin Samuel Huang, MD David Hopp, MD Marvin Kaplan, MD Kambiz Kosari, MD Jeffery Lee, MD Paul Liu, MD Maria Lymberis, MD Ashish Parekh, MD Jinha Park, MD Anantjit Singh, MD Stacy Songco Heather Silverman, MD Diana Shiba, MD Nhat Tran, MD Omer Deen, MD Theressia Washington, MD

LACMA’s Board of Directors consists of a group of 30 dedicated physicians who are working hard to uphold your rights and the rights of your patients. They always welcome hearing your comments and concerns. You can contact them by emailing or calling Lisa Le, Director of Governance, at lisa@lacmanet.org or 213-226-0304.

SUBSCRIPTIONS Members of the Los Angeles County Medical Association: Physician Magazine is a benefit of your membership. Additional copies and back issues: $3 each. Nonmember subscriptions: $39 per year. Single copies: $5. To order or renew a subscription, make your check payable to Physician Magazine, 801 S. Grand Avenue, Suite 425, Los Angeles, CA 90017. To inform us of a delivery problem, call 213-683-9900. Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

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

MOBILIZING ON MACRA A LETTER TO MY FRIENDS IN PRIVATE PRACTICE

“Now the realization is dawning that MACRA threatens to upset the medical community in profound ways and that damage will be experienced differently by physicians depending on their mode of practice.”

A physician chooses the manner in which he or she wishes to practice for one of myriad reasons. I see one’s choice of practice setting as falling somewhere along a continuum, with the extremes ranging from missionary medicine (done for love of God and not of financial reward) to a pressured business model (think billboards advertising certain surgical procedures). Most of us are in the middle, trying to care for patients while earning enough to employ our staff and pay the bills. Some of us work in large multi-specialty groups, some work alone or with a partner or two. Others work for hospitals, universities, the military or local governments. Even within the solo practitioner community, we see great variety, with some doctors in concierge practices and others with panels full of Medicare patients. All of us, however, are facing the new rules coming soon from CMS. Abbreviated as MACRA, or the Medicare Access and CHIP Reauthorization Act, the new rules were what the medical community settled for in order to end the threatened revenue cuts known as SGR (sustainable growth rate). Now the realization is dawning that MACRA threatens to upset the medical community in profound ways and that damage will be experienced differently by physicians depending on their mode of practice. Physicians in large groups, like myself, have benefited from the electronic infrastructure necessary to achieve the requirements of MACRA and other quality reporting metrics. That investment came at a financial cost that few (if any) small or solo practitioners can afford. Unfortunately, this new MACRA-centered world is a zero-sum game: Approximately half of practicing physicians will garner higher compensation for their services by meeting these new CMS expectations, while the other half — unable to compete effectively on this new playing field — will be docked pay in increasingly higher aliquots with each passing year. To suffer even a small penalty the first year — as little as 2% — will have a noticeable impact on small and fee-for-service practices; larger cuts coming in subsequent years will threaten their very viability. A recent meeting of the entire LACMA Board of Directors discussed this issue at length. The pain in the room was palpable and visceral, and it creates unfortunate divisions within the House of Medicine. The immediate challenge is to forestall MACRA’s implementation (and it looks like there will be some temporary easing this fall), but the ultimate solution cannot be to merely forestall the inevitable, the way we pushed off year after year the SGR threat to physician reimbursement. This can is one we kick down the road only at our own peril. The entire medical community must come together at this crucial time to ensure that all physicians, regardless of their mode of practice, can continue to keep their doors open. Let me remind my brethren in group practices of a salient fact: Our own economic well-being is calculated, specialty by specialty, on how well our colleagues thrive in their respective practices. We are inextricably linked to the fortunes of the larger medical community. No one, medical groups included, is an island in 21st-century America. That is only one of the reasons I advocate so strongly on behalf of my friends in solo practices in Los Angeles County. But the county medical society cannot solve this national problem. Nor can the state medical society working alone. But all the state medical societies can work together at the national level to suggest alternative solutions, resources and implementation schedules. This could give individual specialty societies (such as the Wizard program offered by the American Academy of Physicians that, for a small fee, helps doctors register patients to satisfy PQRS requirements) and entrepreneurs opportunity to create electronic interfaces that are both affordable and easily accessible. The possibility of a HIPAA-secure, cloud-based technology that individual small practices can affordably access cannot be dismissed as a pipe dream. There are likely other suggestions out there that have not yet been articulated. Now is the time to join hands and join in the effort. Communicate your ideas and opinions to your local LACMA leaders. If you are reading this and do not yet belong to your county medical association, this is certainly the time to do so.

4 P H Y S I C I A N M A G A Z I N E | O C TO B ER 2016

CMA/Los Angeles County Medical Association sponsored Health Insurance Program

Is your health insurance open enrollment soon? Are your rates going up? Want to shop? Whether you are an individual policyholder or a member of a group health plan, it’s time to think about your health coverage for 2017. The open enrollment period for individual and family plans starts on November 1, 2016. Many practices have open enrollment periods for small groups on December 1 or January 1. Did you know that you can get the right insurance though the CMA / Los Angeles County Medical Association sponsored Health Insurance program with Mercer? If you are covering yourself, or if you’re responsible for providing coverage for your family or employees, working with Mercer online or in person with a licensed agent, can get you the benefits you need, utilizing the physicians you want to see, at a price that fits your budget. Working with the largest insurers in California, Mercer can help you determine what’s best for you. Call today at 800-842-3761 or visit www.CountyCMAMemberInsurance.com.

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MOBILIZING ON MACRA Call me naïve, uninformed, a dreamer. Soon after I took the job as CEO I began to study all that is MACRA (Medicare Access and CHIP Reauthorization Act). I quickly learned it is the result of a compromise of sorts. A suitable replacement for SGR (sustainable growth rate).

“With MACRA, I will retire early. It will destroy me, force me to essentially leave dozens of patients, many who are low income, and vulnerable patients will have nowhere to go.”

I’ve listened to a diversity of views on it over five months. Debated with some, agreed with others. Some say it’s here to stay and it is physicians who need to adjust. Others say it’s egregious and a practice killer, job killer, that it will have a tsunami effect on communities, families and livelihoods. I’ve come to a similar and, hopefully, supportive conclusion: A collective voice needs to be heard on this issue. As one LACMA physician recently told me, “With MACRA, I will retire early. It will destroy me, force me to essentially leave dozens of patients, many who are low income, and vulnerable patients will have nowhere to go.” Still, another shared this: “I’ve built my practice, cared for hundreds of patients through the years, and now I’m expected, mandated, forced to subscribe to a program that makes me spend less time with patients and more on documentation?” I work for all of you, each of you, whether you are in a group or independent, whether you are in Beverly Hills or Compton, whether you are young or near retirement, male or female. The battle to be waged needs to be about common sense. For several weeks, we’ve been educating members on MACRA — what you need to know, how to prepare, how to survive. It’s time to put down the proverbial checklists, pause the webinars and begin the campaign to change the narrative 180 degrees. We don’t need MACRA Awareness Month; we need severe modification or, if possible, eradication. Simply put: There are too many of you in crisis mode and I feel your anger. Together we will transition to a clearer process. We will “educate” CMS by harnessing your collective voices though various communication channels — social media, print media, letters and email blasts. We will establish a LACMA/MACRA hotline so I can hear your voices and share those opinions every day with the same architects who designed the compromise. We will begin interviewing solo/private practice physicians and sharing video testimonials with media, policy makers, bureaucrats and advocates. No longer will the mantra be “survival”; the mantra will be “organized disruption based on common sense.” I hope you will join me in this effort. As renowned basketball coach Bobby Knight once said, “Most people have the will to win; few have the will to prepare to win.” I want you to know that I’m prepared to defend, represent and illustrate what you’ve built, whom you care for, and together we’ll find a winning solution. Who’s in?

Gustavo Friederichsen Chief Executive Officer

6 P H Y S I C I A N M A G A Z I N E | O C TO B ER 2016

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LACMA Physician Spotlight:

Dr. Jonathan Nissanoff

I T W A S N ’ T T H A T L O N G A G O that orthopedic surgeon Jonathan Nissanoff, MD, found himself in the frustrating position of taking calls in the emergency room for which he wasn’t paid properly because of dealing with non-contracted insurance companies. Today, Dr. Nissanoff said, thanks to ECURE, or Emergency Claims Underpayment Recovery Experts, a Los Angeles-based company he co-founded in 2011, the situation has much improved for him as well as for many other physicians dealing with non-contracted insurers. ECURE’s mission, according to its website, is to ensure that providers are reimbursed “usual customary and reasonable fees” by insurance carriers for emergency services they provide. The company uses federal and state laws that have been put in place to recover these funds and to protect the financial interests of physicians of any specialty who take emergency room calls as well as those of ambulance companies and hospitals. Dr. Nissanoff said he took it upon himself to learn the laws associated with emergency medical claims after having written off significant monies year after year. He also learned that California ER doctors or on-call specialists who don’t have a pre-existing contract with a patient’s insurance company may not “balance bill” the patient — bill the patient for the difference between what the patient’s health insurance chooses to reimburse and what the provider chooses to charge — for emergency services rendered. In 2009, the California Supreme Court declared the practice of socalled “balance billing” in the context of emergency care unlawful. Doctors must resolve billing disputes solely with the health plans; only the health plans are responsible for reimbursing out-of-network providers for emergency care services. And California law limits recovery of non-network providers for ER services rendered to only “reasonable and customary” amounts, not the amount charged by the ER physician, Dr. Nissanoff said. What constitutes “reasonable and customary,” however, is often disputed, since there is no prior agreement in place. In any given case, the “reasonable amount” may be the amount a doctor bills, the amount the HMO chooses to pay or anything in between, according to an article written by attorneys from the California Department of Managed Health Care. The problem, as Dr. Nissanoff sees it, is that health insurers often underpay doctors because they believe that many doctors 8 P H Y S I C I A N M A G A Z I N E | O C TO B ER 2016

are afraid to take legal action. “Even with these laws, the insurance companies realize that it takes a lot of money to litigate them and that providers won’t do anything because they know it would cost more to sue the insurance companies than the value of the underpayments,” Dr. Nissanoff said. “That’s what happens every day.” Dr. Nissanoff said ECURE was formed strictly to take on health insurance firms that underpay clients, who today include California healthcare providers, California urgent care centers, California hospitals and California Emergency Medical Services. This is how the process works, Dr. Nissanoff said. “ECURE essentially buys small amounts of underpayments from many providers and consolidates them, and then goes after the carrier that has been shortchanging providers,” he said. “We litigate as one entity under the Emergency Claims Underpayment Recovery Experts. It’s almost like a mini class action lawsuit.” According to Dr. Nissanoff, the service is essentially risk-free to clients because ECURE absorbs all attorney and court fees. The client gets final closure on all accounts receivable once the case is settled, won or lost. There doesn’t have to be continued appeals and rebillings hoping for additional payment. The judge and jury make it final. “We spend a lot of money fighting the insurance companies,” Dr. Nissanoff said. “We have won or settled 95% of our cases against the insurance companies.” He said since 2011, ECURE has dealt with “hundreds of cases” and currently has 39 cases in the court system. He said because of ECURE’s history, claims are getting settled faster these days, in as short as 30 days. However, on average it takes ECURE 18 to 24 months to settle a case in or out of the courtroom, he said. The company now has 30 employees and six attorneys and opened offices in San Diego and San Francisco. “We are hopeful to get the word out that providers don’t have to accept whatever they get because they have no other choice,” Dr. Nissanoff said. “Our hope is that insurance companies will start paying correctly, and we’re happy to work ourselves out of business by turning the tables on insurance companies.”

LACMA Partner Spotlight:

CapAlt Advantages WHAT DOES AN INSURANCE CAPTIVE have to do with my business? Basil Hantash, MD, PhD, MBA, from Turlock, Calif., realized the greatest threat to his dermatology practice wasn’t medical malpractice. What kept him and so many other doctors up at night were worries over things like loss of license or hospital privilege, a cyber attack, staffing issues, losing a patient referral source or needing to pay out for legal defense. These are problems that could prove catastrophic to any practice. Dr. Hantash did his research and found a solution. Enter CapAlt, a captive insurance company administrator, specializing in protected captives. Working with CapAlt, Dr. Hantash was able to protect his if you’re facing the need to defend your reputation. practice in a way that was not only tailored for his specific CapAlt recognizes that physicians have specific risks they are needs, but would increase his bottom line. It may sound too working to mitigate. In coming on as a partner with CMA and good to be true, but here’s how it works. LACMA, they have developed a comprehensive program for A large commercial insurance company takes your physicians, addressing issues such as HIPAA compliance and premiums and invests those funds, growing the company’s licensing. Mark Sims is VP of Business Development for CapAlt. assets. Through CapAlt, business owners (including physicians) He’s been active in talking to physicians and organizations can set up their own captive insurance company and not only like CMA. If you’d like to find out more about managing risk protect their business, but make money in the process. Allstate and assets through captive insurance, Sims is happy to answer Insurance actually started as a captive. So the idea of a captive questions and help you determine if setting up a captive is right isn’t a new insurance model; CapAlt is a new partner for LACMA for you. You can reach him at msims@captivealternatives.com members. or 404.823.6200. We want you to know that CapAlt went through an extensive vetting process by CMA, the CMA Insurance Committee and LACMA. The result is that, in addition to all the advantages of owning a captive, CapAlt is now offering free LACMA membership to any physician who adopts a captive. The representatives at CapAlt will take you through a fairly painless process with a risk assessment MEDICAL PRACTICE PURCHASES, SALES AND MERGERS questionnaire to help determine

MEDICAL BOARD HOSPITAL STAFF F R A U D / A B U S E MEDI-CAL/M E D I C A R E

your exposure and budget. From there, you’ll determine where to invest your premiums and they’ll do the heavy lifting. You don’t have to become an insurance specialist. You may not have heard of insurance captives or been offered this kind of opportunity because captives don’t work for everyone. Physicians and small physician groups can qualify and really benefit from captives. The premium you pay to your captive is tax-deductible and over time this investment acts almost like a 401(k). Captives usually cover claims that have a high payout but a low occurrence rate. This means that your captive keeps you from paying out of pocket and keeps you protected from high-risk situations such as someone hacking into your computer system or

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The Searing Step One Journey for LACMAHeals C. Freeman, MD

Rick Baker, MD

THE IDEA FOR THE ROUNDTABLE EVENT — African-American Physicians: The Searing Journey — came out of a LACMA staff meeting right after the shooting that took place in Dallas this past July.

Brian Williams, MD, with LACMA members

“It is important for LACMA, as an organization, to not just LACMA’s CEO, Gustavo Friederichsen, shared with his team grieve because of gun violence in this country,” Friederichsen how moved he was to hear Brian Williams, MD, speak about said. “It’s important that LACMA, as an organization, not his experience as the trauma surgeon treating the police officers assume that we understand the struggles of any of our groups who were shot in Dallas. At a press conference that went viral, of physicians. It’s imperative that we provide opportunities for Dr. Williams also found himself talking about what it means to our community to come forward and share. At the roundtable, be a black man, a black doctor in America. Friederichsen and we heard over and over appreciation for team sat around the conference table creating a safe space to share and connect. at the LACMA offices and decided to This is just the first step.” bring Dr. Williams to LA to speak and to While the discussion was wide-ranging open up a conversation so black doctors “I have a young daughand at times intensely personal, there were would have the chance to share their ter. How do I teach a few themes that evolved. Increasing stories, challenges and hopes. her? I come back to this the number of African-American students Five weeks later, on Aug. 31, LACMA question: Am I treating pursuing medical degrees was agreed headquarters was standing room only as others the way I’d want to be imperative. Randy Hawkins, MD, Friederichsen, LACMA President Vito spoke to this issue and continued on to Imbasciani, MD, and Rick Baker, MD, to be treated?” say that black patients will often feel more (African-American Physician Advisory comfortable with black doctors. There’s a Committee) welcomed Dr. Williams. cultural competence that’s important to The result was a three-hour-long recognize. conversation that included residents, Others emphasized micro-aggressions that are still felt daily students, physicians and LACMA staff and sponsors. The in school and in practice. Making changes means addressing conversation reached another 35 people via live stream from these in the moment and over time. It was stressed that joining Periscope. Here are a few quotes from the evening that went organizations like LACMA not only helps individuals strengthen out via social media:

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their voice collectively but also can help some to find their voice and speak up for the first time. Enlarging the circle was seen as a goal. LACMA partners MUN CPAs and JNT Tek were also on hand to join the community and learn more about the specific needs physicians have in running their practices. They represent business support, another integral component to success. Dave Bader of JNT Tek asked, “I have a young daughter. How do I teach her? I come back to this question: Am I treating others the way I’d want to be treated? If so, you’re usually going on the right path. It’s not just that these issues are for that subgroup to deal with. The onus for a solution doesn’t rest with them. We’re all in this together. Rectifying these issues makes things better for everyone.” Next steps for LACMAHeals on issues affecting African-American physicians will include the African-American Physicians Advisory Committee and other volunteers. If you’d like to become involved with this effort or find out more about similar programs at LACMA, please contact ellie@lacmanet.org.

To honor former LACMA President Marshall T. Morgan’s legacy of support for prehospital and emergency medicine, the Los Angeles County Medical Association has established the Marshall T. Morgan, MD, Memorial Scholarship. The awards will be presented at the 2016 Los Angeles Healthcare Awards on Nov. 3 at the Beverly Wilshire Hotel. Awards will be presented to the UCLA Department of Emergency Medicine Residency Program and accepted by Gregory Hendey, MD, inaugural chair of the department; and UCLA Center for Prehospital Care for both Emergency Medicine Technician Education and Paramedic Programs and accepted by Steven Rottman, MD. Dr. Marshall Morgan was a professor of medicine and chief of emergency medicine at UCLA for 34 years and president of the Los Angeles County Medical Association 2013-2014. He was recognized by colleagues, staff and students as an outstanding leader and educator and a compassionate physician who always had a calming voice, inviting smile, gentle demeanor, and an enduring passion for Emergency Medical Services (EMS). Throughout his life, Dr. Morgan was committed to helping the underserved and disenfranchised not only through direct patient care, but also by sharing his wisdom and by supporting the education of students, physicians, nurses and EMS personnel. The funds from this scholarship will commemorate Dr. Morgan’s commitment to emergency medicine residents and the career development of promising Emergency Medical Services providers.

Donations to the scholarship will create and fund: • Awards to enable residents to complete community and international

service projects locally and abroad. • A Humanism Award to recognize a

graduating resident for a unique and outstanding contribution.

• Scholarship support for deserving students to attend either the UCLA

emergency medical technician (EMT) or paramedic education program.

Tax deductible donations may be made by visiting www.lahealthcareawards.org/scholarshipfund/#Morgan.

O C TO B ER 2016 | 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 11

PATIENTS, VOTE PRACTICE & 2016 PUBLIC HEALTH YES

P H Y S I C I A N S A N D H E A LT H C A R E P R O V I D E R S in Los Angeles County and throughout the state face not only the polarizing presidential election this November, but also an unprecedented 18 state ballot initiatives, many of which have direct implications for their patients, practices and public health. At least eight of the ballot measures have the potential to directly impact the local healthcare community. In advance of this important election, this issue of Physician Magazine summarizes these eight initiatives for our physician readers, and provides the California Medical Associationâ&#x20AC;&#x2122;s (CMA) stance on each measure and additional information on the propositions that may be helpful as you head to the polls.

Voter Approval to Divert Hospital Fee Revenue Dedicated to Medi-Cal* State Fees on Hospitals. Federal MediCal Matching Funds. Initiated Statutory and Constitutional Amendment.

YES supports requiring voter approval to change the dedicated use of certain fees from hospitals used to draw matching federal money and fund Medi-Cal services. The initiative was also designed to require a two-thirds majority vote of the Legislature to end the hospital fee program.

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NO opposes this initiative, allowing the Legislature to change, extend or eliminate the hospital fee program with a majority vote. CMA SUPPORTS | Proposition 52 would lock in hospital fees to allow the state to draw down federal healthcare funds. It would add language to the California Constitution requiring voter approval of changes to the hospital fee program. This will prevent diversion of the funds from the original intended purpose of supporting hospital care to Medi-Cal patients and paying for healthcare for low-income children.

MORE INFORMATION | One of the more politically and financially complex issues on the upcoming ballot, Prop. 52 would make permanent the Hospital Quality Assurance Fee, which the state collects from private hospitals to bring in additional federal dollars for Medi-Cal. The federal government matches money that California puts up to fund Medi-Cal services. Hospitals like the fee, which has been in place since 2009, because it gives them a big financial boost in what they say is an underfunded government health program, according to a California Healthline article. In the 2015-2016 fiscal year, hospitals received an additional $3.5 billion to pay for services they provided to Medi-Cal patients, according to the state Legislative Analyst’s Office. According to the California Healthline article, the arcane details of the measure might be too much for many voters to sort out, and a lot of them “won’t do any homework,” said Wesley Hussey, associate professor of government at Sacramento State University. “In general, the more complex an issue is, voters usually respond by either skipping the issue itself . . . or by voting no,” he said. Kevin Riggs, spokesman for the Yes on 52 campaign, which is sponsored by California hospitals, sought to demystify the initiative. “If you care about . . . access to Medi-Cal for kids and old people and working families in California, this is a way to protect [that] program,” he said. The fee is an important part of sustaining hospital care for Medi-Cal enrollees because government payments for patients covered by the program are $8 billion short of what it costs hospitals to provide the services, Riggs said. The revenue generated by the fee totals around $3 billion a year, offsetting about 40% of hospitals’ Medi-Cal losses. Opponents, who include Californians for Hospital Accountability and Quality Care and Libertarian Party of California, make the arguments that the proposition would divert resources from patients and communities to special interests and would not require any sort of accountability for hospital CEOs and lobbyists regarding how money is spent. Additionally, they claim the proposition would not guarantee that funds are spent on healthcare and would only favor corporations and hospital CEOs.

Voter Approval Requirement for Revenue Bonds above $2 Billion Revenue Bonds. Infrastructure Projects. State Legislature and Voter Approval. Initiated Constitutional Amendment.

YES will be a vote in favor of requiring voter approval before the state could issue more than $2 billion in public infrastructure bonds that would require an increase in taxes or fees for repayment.

NO will be a vote against the voter approval requirement and in favor of continuing to allow the state to issue new debt without voter approval. CMA OPPOSES | Proposition 53 would require voter approval before the state could issue more than $2 billion in public infrastructure bonds that would require an increase in taxes or fees for repayment. This initiative could impact medical care by curtailing the ability of the State of California and local government entities to build or rebuild major infrastructure projects. MORE INFORMATION | California sells two types of bonds. General obligation bonds are repaid by using revenue in the General Fund. Revenue in the fund comes mostly from state taxes. The California Constitution requires voter approval before the state can issue general obligation bonds, according to Ballotpedia.com. Revenue bonds, on the other hand, are repaid using revenue from fees or other charges paid by the users of the project. For example, a revenue bond issued to build a highway could be repaid by mandating a toll for users of the highway. Under existing state law, revenue bonds do not require voter approval. Prop. 53 would require voter approval for infrastructurerelated revenue bonds totaling $2 billion, adjusted for inflation, or more. Supporters, who include the California Republican Party and several Northern California taxpayers associations, say politicians and state agencies are currently allowed to borrow billions of dollars in state revenue bond debt without getting voters’ approval. Proposition 53 would hold politicians accountable and would induce them to provide accurate estimates of how much a project would cost. Opponents joining CMA include Gov. Jerry Brown, the California Democratic Party, the Los Angeles County Democratic Party and the Los Angeles County Metropolitan Transportation Authority.

Extension of the Proposition 30 Income Tax Increase Tax Extension to Fund Education and Healthcare. Initiated Constitutional Amendment.

YES supports extending for 12 years the personal income tax increases on incomes over $250,000 approved in 2012 in order to fund education and healthcare. NO opposes extending for 12 years the personal income tax increases on incomes over $250,000 approved in 2012, allowing the tax increase to expire in 2019.

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CMA SUPPORTS | Proposition 55 would extend the current income tax rates on the wealthiest 2 percent of Californians — singles earning more than $250,000 and couples earning more than $500,000 a year — for 12 years. Funding would provide local school districts the money needed to hire teachers and reduce class sizes and improve access to healthcare services for low-income children so they can stay healthy and thrive. MORE INFORMATION | Along with CMA, the California Hospital Association, the California Teachers Association and SEIU (Service Employees International Union) California State Council are all backing Prop. 55 to prevent billions of dollars in funding cuts for public education and healthcare services. “Doctors and other healthcare providers across the state are supporting this initiative because it will provide critical funds to improve access to healthcare for low-income children and their families,” said CMA President-elect Ruth Haskins, MD. “This initiative will help our state provide the care vulnerable kids need to stay healthy and thrive.” According to a recent article in Capitol Weekly, three ballot measures, Propositions 55, 56 and 52, could yield about $7.6 billion for Medi-Cal, the state’s healthcare program for lowincome families, the disabled and children. Props. 55 and 56 could provide up to $3.6 billion for MediCal, an amount that is eligible for matching funds. “Medi-Cal is a lifeline for almost 14 million Californians and a pillar in the healthcare we all rely on. But it’s underfunded,” Anthony Wright, executive director of Health Access California, which advocates for expanded healthcare, told Capitol Weekly. “We have yet to restore the cuts from the last recession,” added Wright, whose group supports Props. 55 and 56. CMA President Steven Larson, MD, a primary care and infectious disease physician who practices in Riverside, told California Healthline that CMA is looking to the state’s initiative process for relief on Medi-Cal reimbursement rates for physicians for good reason. “We have to do it on our own because the state government is not very sympathetic,” Dr. Larson said in the article. There are roughly 80% Medi-Cal enrollees in managed care, and their numbers are rising. Yet, managed care reimbursement to Medi-Cal providers is much lower than commercial rates, Dr. Larson told California Healthline. Indeed, he said, the rates are so low that they are not sustainable for most physician practices. A recent Public Policy Institute of California poll reportedly found that 61% of Californians support extending the income tax rates on the wealthiest individuals and couples to spare education and vital health services from a repeat round of devastating budget cuts. In 2012 Gov. Brown backed and campaigned for the passage of Proposition 30 to raise taxes to prevent $6 billion in cuts to the education budget for California state schools. The measure was approved by California voters 55% to 45%.

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Tobacco Tax Increase Cigarette Tax to Fund Healthcare, Tobacco Use Prevention, Research, and Law Enforcement. Combined Initiated Constitutional Amendment and State Statute.

YES favors increasing the cigarette tax by $2 per pack, with equivalent increases on other tobacco products and electronic cigarettes. NO opposes increasing the cigarette tax by $2 per pack, with equivalent increases on other tobacco products and electronic cigarettes. CMA SUPPORTS | Supported by a broad alliance of physicians, healthcare advocates, educators and others, Proposition 56 would raise California’s tobacco tax, which is currently among the lowest in the country, to $2.87 a pack. Designed as a user fee on cigarettes and other tobacco products, the majority of the money would be used for existing health programs and research into cures for cancer and other illnesses caused by smoking and tobacco products. MORE INFORMATION | Supporters of Prop. 56 tout the measure as a way to fund existing health programs as well as research to find much needed treatments for cancer and other illnesses caused by smoking and tobacco products. “Sadly, we see tobacco’s deadly and costly toll every day in our hospitals and clinics. Cancer and other tobacco-related diseases kill more people than car accidents, murder, suicide, alcohol, illegal drugs and AIDS combined,” said CMA’s Dr. Larson. “The heart of this initiative is simple: Taxing tobacco saves lives by getting people to quit or never start smoking. The only people who will pay are those who smoke. If you don’t smoke, you don’t pay.” California taxpayers pay $3.5 billion annually to treat cancer and other tobacco-related diseases through Medi-Cal. Proponents of Prop. 56 see a user fee on cigarettes as only being fair since it shifts the fiscal burden for these medical programs, smoking prevention and research to smokers. Prop. 56 would generate up to $1.4 billion in tax revenue its first year. The funds would go into a special fund to help pay for Medi-Cal rather than into the General Fund, according to PolitifactCalifornia.com. Opponents of Prop. 56, including the No on 56 campaign funded by tobacco companies Philip Morris and R.J. Reynolds, argue that this aspect of the measure “cheats schools out of at least $600 million a year.” However, experts interviewed by PolitifactCalifornia said that this proposal is nothing new. In 1988 and 1998 tobacco taxes also established special funds rather than sending money to the General Fund. State Superintendent of Public Instruction Tom Torlakson also rejected the claim that the new tax measure cheats schools, writing in a letter that “Proposition 56 will not divert a dime

away from schools. Rather it will raise revenues for school-based tobacco prevention and intervention programs.” The CMA reported that despite years of progress in education and research about the dangers of tobacco, nearly 17,000 California kids get hooked on smoking every year; one-third of them will eventually die from tobacco-related illnesses. Prop. 56 is backed by Save Lives California, a coalition of health advocates and others that include the CMA, the American Cancer Society Cancer Action Network, American Lung Association in California, American Heart Association, California Dental Association, California Hospital Association, SEIU California, Blue Shield of California and philanthropist Tom Steyer.

Non-English Languages Allowed in Public Education California Non-English Languages Allowed in Public Education Act.

YES is a vote in favor of repealing most of the 1998 Proposition 227, the “English in Public Schools” Initiative, thus effectively allowing non-English languages to be used in public educational instruction. NO is a vote against repealing most of the “English in Public Schools” Initiative, which was designed to prohibit non-English languages from being used in public schools. CMA SUPPORTS | Proposition 58 would give local school districts and their academic staff the option of providing bilingual education. California needs a well-prepared and educated healthcare workforce that reflects our diverse society. Prop. 58 would break down barriers by removing outdated mandates, helping physicians provide the best patient care for all Californians.

Drug Price Standards State Prescription Drug Purchases. Pricing Standards. Initiated State Statute.

YES supports regulating drug prices by requiring state agencies to pay the same prices that the U.S. Department of Veterans Affairs (USDVA) pays for prescription drugs. NO opposes regulating drug prices by requiring state agencies to pay the same prices that the U.S. Department of Veterans Affairs (USDVA) pays for prescription drugs.

CMA OPPOSES | Proposition 61 would prevent certain state agencies from entering into contracts for the purchase of prescription drugs unless the price paid is the same as or lower than the special discounts provided to the U.S. Department of Veterans Affairs. The measure could result in the invalidation of existing agreements between the state and pharmaceutical companies that already provide significant discounts to the state. MORE INFORMATION | CMA is joined by some of the largest drug makers in opposing Prop. 61. “While California’s physicians are profoundly concerned about the affordability of prescription drugs, we evaluated this measure and have concluded it is deeply flawed and unworkable,” said Dr. Larson. “We believe the measure would likely increase — not lower — state prescription drug costs. Of greatest concern to doctors is that the measure would result in a new bureaucratic prior approval process that could interfere with patient access to the medicines they need.” The cancellation of contracts would remove many drugs from the Medi-Cal list of pre-approved medicines, creating a new prior authorization hurdle for patients and their physicians. “CMA supports real reforms to protect consumers and lower drug costs, but this ballot measure is the wrong prescription,” Dr. Larson added. According to the Los Angeles Times, the campaign against Prop. 61 had $65.9 million in cash as of June 30, far outpacing supporters of the measure, whose campaign filing reported just over $7 million. In August Prop. 61 supporters lost a state court bid to alter the wording of a key analysis that may affect the outcome of Prop. 61. Supporters of the measure, launched by the AIDS Healthcare Foundation, which operates clinics and pharmacies in multiple states, argue that a leading industry “scare tactic” is to warn that the measure will hurt veterans because drug makers will raise prices rather than agree to provide the state with prices offered to the VA. A consumer activist argued that federal law already protects veterans and that the state analysis didn’t mention that federal law “restrains” VA drug pricing. He reportedly asked a state court judge to order the Legislative Analyst’s Office to add the phrase “drug manufacturers might choose to raise VA drug prices, subject to federal price caps on brand-name drugs” rather than simply stating that “drug manufacturers might choose to raise VA drug prices.” But California Superior Court Judge Christopher Krueger denied the petition saying, “The Court finds it sufficient to inform voters that although drug manufacturers might choose to raise VA drug prices, there are federally imposed ‘upper limits’ on their ability to do so. Particularly given the Legislative Analyst’s considerable latitude in preparing the analysis, the court finds that this is not the type of clear case where the failure to specifically state that the VA price increases would be ‘subject to federal price caps’ renders the analysis misleading.”

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Background Checks for Ammunition Purchases and Large-Capacity Ammunition Magazine Ban Firearms. Ammunition Sales. Initiated State Statute.

YES will be a vote in favor of prohibiting the possession of large-capacity ammunition magazines. NO will be a vote against prohibiting the possession of large-capacity ammunition magazines. CMA SUPPORTS | Proposition 63 would prohibit the possession of large-capacity ammunition magazines and would require most individuals to pass a background check and obtain authorization from the California Department of Justice to purchase ammunition. CMA supports Prop. 63 to ensure our communities are safe and healthy places to live.

Marijuana Legalization Marijuana Legalization. Initiated State Statute.

YES supports legalizing recreational marijuana and hemp under state law and enacting certain sales and cultivation taxes. NO opposes legalizing recreational marijuana and hemp under state law and enacting certain sales and cultivation taxes, thereby continuing to only allow the use of medical marijuana. CMA SUPPORTS | Proposition 64 would regulate and control the cultivation and use of non-medical cannabis. The proposal would generate up to $1 billion in taxes for state and local governments, according to a fiscal analysis of the proposal. CMA believes that the most effective way to protect public health is to tightly control, track and regulate cannabis, as well as comprehensively research and educate the public on its health impacts. MORE INFORMATION | In a statement, CMA said that under a legal market, cannabis can be monitored, researched,

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regulated and mitigated to protect the public health and improper diversion by healthy patients into the medical marijuana system could be reduced. At the same time, CMA doesn’t encourage its use or smoking. “The California Medical Association believes the Adult Use of Marijuana Act is a comprehensive and thoughtfully constructed measure that will allow state officials to better protect public health by clarifying the role of physicians, controlling and regulating marijuana use by responsible adults and keeping it out of the hands of children,” Dr. Larson told the Sacramento Bee. “Medical marijuana should be strictly regulated like medicine to ensure safe and appropriate use by patients with legitimate health conditions, and adult-use marijuana should be regulated like alcohol,” Dr. Larson added. “This measure — along with the recently passed medical marijuana bills — will ensure the State of California does both while keeping the public health and public interest as paramount concerns.” Dr. Larson also told California Healthline that, currently, medical marijuana is “terribly abused and misused and puts physicians in the middle.” “I’m a practicing physician and some patients inappropriately want a diagnosis to obtain marijuana,” he said. In July, the California Academy of Preventive Medicine (CAPM) became the second statewide physicians group to endorse Prop. 64, the LA Weekly reported. “Proposition 64 is a thoughtful, comprehensive measure based on sound, evidence-based science that will protect public health and fund vital health programs for California’s youth,” said CAPM’s legislative director, Donald Lyman, according to LA Weekly. Other proponents of Prop. 64 include the California Democratic Party, state Lt. Gov. Gavin Newsom, former Democratic presidential candidate Bernie Sanders and Napster co-founder Sean Parker. Supporters reportedly raised $11.5 million through August, including $3.3 million from Parker. Opponents, which include the California Republican Party, the California Hospital Association, the California Police Chiefs Association and the California Libertarian Party, reportedly raised $229,385. The Libertarians say on their website that the measure “does more harm than good, damaging medical availability, and creating additional criminal offenses and regulations.”

*Source for ballot measure names, voting descriptions: Ballotpedia.com

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MOBILIZING ON MACRA

We all know the catchphrase and it’s something I want to make sure I never exhibit with any of you. I’ve been actively listening to our membership for six months now. I’ve promised some of you privately and many of you publicly that I will fight for you - whether the issues can have minimal impact or catastrophic results and whether you are in private practice or part of a group. Based on what I’ve heard, MACRA represents that one issue that keeps some of you awake at night. For others, it’s just another challenge to prepare for and manage. I’ve been counseled by some who say we need to simply educate our members on what MACRA is. But it’s the not-so-silent minority solo and small group physicians who have shared their pain and concerns. These doctors feel powerless (and sometimes neglected) and they need to be heard, not placated.

This is why I am asking you to join me in the fight to share our collective voice. In the days and weeks ahead I’ll be collecting your opinions regarding MACRA: • Why it is destructive and punitive for some, manageable for others. • How this will affect patients. • Why the architects of value-based medicine need to know what healthcare reform means to private practice physicians.

On Monday, October 3, at LACMA headquarters we will

be conducting video interviews with members all day until 10 p.m. I will share these personal testimonials with targeted constituencies, opinion makers, policy leaders and fellow LACMA members via social media, print and digital channels. October 3 is the day to tell your story, and I can guarantee you that it will be shared far and wide. I can only share what I hear. Remember, talk doesn’t need to be cheap. It can be powerful. Especially when we join together.

MACRA Video Session Date Monday, October 3, 2016 LACMA Headquarters 801 S. Grand Avenue Suite 425 Los Angeles, CA 90017 If you can’t make the video sessions, email me at Gustavo@lacmanet.org to discuss other possible arrangements. You can also call my office line at 213-226-0337 to leave a brief summary of your specific concerns about MACRA. We’re thinking of this as the LACMA MACRA Hotline. I look forward to hearing from you. Thank you, Gustavo Friederichsen Chief Executive Officer Los Angeles County Medical Association “If it matters to our LACMA members, it matters to me.”

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