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What You Can Do

PLUS

A Warm Welcome to Our 141st President, Dr. Samuel Fink How To Terminate a Patient Relationship— Legally What You Need to Know Before Entering a Lease

July 2012

About It

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Volume 143 Issue 07 July 2012

18

FEATURES 18 Physician Burnout: The Rising Cost of Stress With increasing demands on their time, physicians are feeling more stressed than ever. But help may soon be on the way. 22 A Warm Welcome Welcoming our 141st president, Samuel Fink, MD. 24 A Tribute to a Leader in Organized Medicine Thanking James Hinesdale, MD, for all he has done.

every issue 4 Front Office Tips, hints, advice and resources to make your practice run more smoothly. 12 CMA The latest update on regulations. 36 Just the Facts This month we focus on Hepatitis C.

From Your Association 2 CEO’s Letter An update on how your association works for you from Rocky Delgadillo. 26 Member Benefits Find out how to get the absolute most from your membership. 30 Association Happenings Presenting to the Korean American Graduate Medical Association • Medi-Medi educational seminars • Talking Tours go full steam ahead • July and August events • Welcome to our new members!

Southern California Physician (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 07 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 Southern California Physician, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 9001 7. Advertising rates and information sent upon request.

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CEO’ S L E T T E R | ROCK Y D E LGAD I L LO

Everyone On Board: it’s Time for Change

A

S i W R i T E this in late June, physicians across the country are waiting for the U.S. Supreme Court decision on the Obama administration’s health care reform law. The impact that California physicians and their patients will feel depends on how the Justices rule—they could throw out the law entirely, declare it all constitutional, or reject portions of it, such as mandated insurance for most Americans. It remains to be seen what message the decision will send to Americans. Meanwhile, the Los Angeles County Medical Association has a different sort of message for physicians—it’s high time to get on board with organized medicine. When I first started as LACMA’s CEO, I initiated “talking tours” to meet with physicians and to hear their concerns. At the beginning, the tours provided a way for me to get to know our members better and for members to find out more about what LACMA was doing for them. Over time, however, the tours evolved. While we still listen avidly to what our members have to say, we’ve also crafted a stronger message to them showing just how important it is that they step up to the plate and step up now to advocate for the medical practice and patients. This month, Southern California Physician magazine features a cover story on stress—and it is quite timely if not overdue. Physicians are getting challenged on every angle simply because they haven’t done a good job of organizing and standing up for themselves. Insurers are certainly organized and, in the medical arena, the nursing association is the second most powerful group in California. Why isn’t that spot—or even the top spot—held by physicians? LACMA is working to mend the situation. We are helping physicians land positions with powerful, prestigious civic organizations around the county such as the fire commission or the police commission. We are initiating media training so that physicians know how to speak to the press and make their voices better heard. And we are encouraging all physicians to tell us their story so that we can highlight them in the media and with key decision makers in the county and state. If enough stories point to a common thread, public opinion will change in our favor and physicians will be the primary voice for healthcare. Here’s an analogy I like to use. If someone is hit by car, the physician is the first on the scene, taking charge and using their bravery, skills and training to save a life. But when Blue Cross denies a claim, they aren’t brave or trained to stand up to the consequences. It’s high time for that to change. With every good wish,

PU BLISH ER /EDITOR

Cheryl England

213-226-0335 | cheryle@lacmanet.org

ART & EDiTORiAL ART DIR EC TOR

Thomas Miller

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Russell A. Jackson, David Reynolds

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Christina Correia

213-226-0325 | christinac@lacmanet.org D I S P L AY/ C L A S S I F I E D A D S A L E S

Karen Heger

213-226-0393 | karenh@lacmanet.org ADVERTISING SALE S

Dari Pebdani

858-231-1231 | dpebdani@gmail.com

EDiTORiAL ADviSORy BOARD David H. Aizuss, MD Troy Elander, MD Thomas Horowitz, DO Robert J. Rogers, MD

LOS AnGELES COUnTy MEDiCAL ASSOCiATiOn OFFiCERS CEO

Rocky Delgadillo PRESIDENT

Samuel I. Fink, MD P R E S I D E N T- E L E C T

Marshall Morgan, MD TREASURER

Pedram Salimpour, MD S E C R E TA R Y

Peter Richman, MD I M M E D I AT E P A S T P R E S I D E N T

Troy Elander, MD

HEADQUARTERS

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Members of the los angeles county Medical association: Southern California Physician 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 Southern California Physician, 707 wilshire Boulevard, suite 3800, los angeles, ca 90017. to inform us of a delivery problem, call 213683-9900. acceptance of advertising in Southern California Physician 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 Southern California Physician, lacMa services inc. or the los angeles county Medical association. Southern California Physician reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. scp is not responsible for unsolicited manuscripts.


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f ro n t o f fi ce | pr ac ti ce ti ps

hey Coach! Yes, physicians, that’s you!

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By JUdy CaPKo

h e n yo U think coach, you think team. Unfortunately, you might be thinking about a sports team instead of the practice. In reality, every practice needs a coach to guide team performance and come out a winner. The coach might be a high level administrator, manager or a direct supervisor, it might even be the physician in a smaller practice. In a practice with little structure it could be someone that has assumed the role because he or she just has the knack—someone everyone feels good about and trusts. If the coach is doing a great job the practice runs well and everyone is happy. If you are someone else’s boss or responsible for someone else’s performance, coaching is your way creating an awesome team. So, hey coach, how are you doing? Let’s take a look at what the

successful coach really does:

1 2

Create a constructive, winning climate for your team.

Lead your team to improved performance by providing encouragement, feedback and recognition.

3 4

Take action with people on the team who don’t carry their load. Take charge and set the tone for your team to be successful.

Coaching is not just dealing with poor performance issues, it’s staying in touch with the entire team (including the best performers) and providing them with tools to be even more successful. You have the opportunity to create a positive, winning climate by staying in

touch. Concrete things to think about in your role of coach include clarifying goals, brainstorming with the team and providing recognition. If your team feels you value and respect each of the them, they will go to the mat for you— and that’s a very big deal. You have the power to make this a reality. You can guide people to go from where they are to where they want to be—and that is powerful! Judy Capko is the founder of Capko & Company (www.capko.com) and author of the popular book Secrets of the BestRun Practices. She has specialized in medical practice operations and marketing for more than 20 years, and is a certified risk management specialist. Her emphasis is on building patientcentered strategies and valuing staff ’s contribution.

Physician Compensation Models Evolve New MGMA survey shows that varying responsibilities and time commitments yield differences in stipend amounts for directorship activities i n M a n y h e a lT h care organizations, physicians play an administrative role that is increasingly complex and changing in scope. As such, stipend amounts for nonclinical effort continue to evolve as a component of many physicians’ total compensation plans. The MGMA Medical Directorship and On-Call Compensation Survey: 2012 Report Based on 2011 Data, provides benchmark information that is reflective of the primary compensation drivers for directorship activities. A directorship’s scope of responsibilities and duties impacts stipend amounts. According to the report, primary care directorships responsible for community relations or strategic development reported a higher median annualized stipend ($25,000) than their peers who were responsible for other directorship duties. Surgical specialty directors responsible for documentation and care planning, monitoring quality and appropriate4 s o u t h e r n c a l i f o r n i a p h ys i c i a n | j u ly 2 0 1 2

ness of medical care, or physician relations and/or representation reported an annualized stipend of $36,000. Nonsurgical subspecialists with provider of last resort/call availability or regulation, licensure, and credentialing responsibilities earned a higher median annualized stipend ($44,586) than their peers with other duties. Time spent on directorship activities varies greatly. The majority of respondents to this survey reported that their duties were only a component of total work time. Almost 50 percent indicated they spent fewer than six hours per week on directorship activities. As such, benchmark data reflected stipend amounts for non-clinical effort. Over time, MGMA-ACMPE staff expects the growth of the survey to allow for the depiction of compensation benchmarks for medical directors working in a predominately nonclinical capacity. As the health care reimbursement paradigm changes, quality measures

will become increasingly important. In light of this, the survey began asking this year’s participants to report total annualized stipend amounts by quality metrics tied to their directorships. Those in pulmonary medicine indicated an 80 percent difference in annualized stipend based on whether or not quality metrics were tied to their duties. “It appears that reimbursement for medical practices will be more closely tied to quality metrics in the future, so the medical director’s most important duty will likely be that of the ‘quality monitor,’” explained Jeffrey W. Smith, CEO, Pottstown Medical Specialists Inc. “As practices enhance the way they gather data through their electronic health records and practice management systems, the medical director, along with practice administrators, can review data tied to their quality metrics and be instrumental in monitoring the practice’s efforts, which could ultimately improve care and reduce costs.”


pr ac ti ce ti ps | f ro n t o f fi ce

Physician Practices Revisit Telemedicine Advances are allowing physicians to revisit this potential differentiation By Lonnie Hirsch and Stewart Gandolf, MBA

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h e S i n g l e biggest barrier to the adoption of telemedicine is financial. Physicians, hospitals and other providers have resisted “telehealth” because there’s no obvious way to monetize the time and effort. That’s still an issue, but it’s changing. Some practitioners and health care delivery systems are finding solutions that make telemedicine financially realistic. What’s more, these approaches offer benefits in quality of care, marketing, patient experience and outcomes. By its various names and definitions, telehealth is being recognized as a means for physicians, hospitals and others to enhance their services, either by reaching more patients or by expanding what they provide. By some definitions, it’s home health… remote telemonitoring of patient data. More broadly, it’s physician-patient communications via a live video connection. Physicians are looking at online services for different reasons, according to Healthcare Finance News. “Some want to launch concierge medicine services, offering more or directed services for a higher fee. Others want to expand their practice to bring in more clients or take advantage of their specialties. Still others see telemedicine as an important tool to becoming part of an accountable care organization or patientcentered medical home.”

From a marketing point of view, the prospective benefits of telemedicine can be significant. Earlyadopters that capture a differentiation can control an increasingly valuable market. Four forces that are driving change:

1

resources) are sought-after by physicians, departments and programs. What’s more, large national pharmacy chains and insurance plans provide a means to consult a physician, nurse practitioner or triage nurse online. 


3

Technology explosion. Digital technology has expanded dramatically. Broadband and high-speed Internet connections are mainstream in America. Online, twoway communications is well supported. And software for secure physician-patient connectivity is commonly available and user-friendly. Smartphones and wireless tablet devices are widely available. Nearly half of U.S. adults are smartphone owners, according to a Pew Internet report. “Nearly every major demographic group— men and women, younger and middleaged adults, urban and rural residents, the wealthy and the less well-off—experienced a notable uptick in smartphone

penetration over the last year.” And peripheral devices for monitoring patient data—from wearable biometric sensors to testing and diagnostic plug-ins—are widely available and often connect via increasingly powerful smartphones. Juniper Research projects more than three million patients will use smartphone-connected monitoring devices in the next few years.

4

Patients expect a digital dividend.

The Internet-infused public looks online for medical, health and physician information and services. Consumer surveys indicate that, in addition to information, they also appreciate online convenience appointments and administrative tasks. Further, patients want their physicians to be available via email for questions. Lonnie Hirsch and Stewart Gandolf are founding partners for Healthcare Success Strategies (www.healthcaresuccess.com), a health care marketing firm.

Physicians are restructuring their business model. Health care reform has

changed the nation’s health care delivery system dramatically. And physicians, who have been wary of telehealth in the past, are reexamining this and other options for their business potential. The objective—the necessity for many—is to find new ways to increase revenue and/or reduce costs.


2

Competition. The competitive land-

scape is shifting and aggressively growing for private practices and specialty physician groups. The same is true for hospitals and health systems. Finite resources (particularly marketing j u ly 20 1 2 | w w w. s o c a l p h ys i c i a n . n e t 5


f ro n t o f fi ce | pr ac ti ce ti ps

how to Terminate the PhysicianPatient Relationship The ins and outs of handling a sticky situation

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ne of The MoST important aspects of a successful medical practice is building a large and loyal patient base. However, in certain circumstances you may need to terminate the physician-patient relationship. There are a number of reasons why a physician may want to terminate the physician/patient relationship. In some cases, a patient may refuse to pay bills or follow his or her physician’s medical advice. Alternatively, a physician may be concerned that a patient is misusing prescription medication or misrepresenting his or her symptoms. Whatever the reason (and, in fact, a specific reason to terminate the physician/patient relationship is not necessary), it is important to terminate each physician/relationship appropriately to avoid any complaints of patient abandonment. What is patient abandonment? In general, once a physician/patient relationship begins, the physician has an obligation to continue to provide care to his or her patient until the relationship is formally terminated. This includes providing alternative coverage when the physician is out of town or unable to provide care. Patient abandonment occurs when a

By BenJaMin J. fenTon

physician terminates the physician-patient relationship without appropriate written notice to the patient. Patient abandonment may be a basis for a malpractice lawsuit or a Medical Board accusation. How to draft a termination letter. In order to minimize any potential liability for patient abandonment, the relationship must be terminated appropriately. Ideally, this involves written correspondence via certified mail to the patient advising him or her that the relationship is being terminated. It is not necessary to include reasons for the termination, but in some cases a physician may want to discuss the underlying cause for the termination in order to establish a record of what has occurred. In all cases the letter should be polite and respectful so as to avoid complicating an already delicate situation. It is also important that a physician give his or her patient sufficient notice of the termination so that the patient has adequate time to find alternative care. The Medical Board of California advises physicians to provide their patients at least fifteen days of treatment, including prescriptions, before the termination goes into effect. In more rural areas, where a patient may have trouble finding alterna-

tive care, more notice may be appropriate. In our practice, we typically advise physicians to provide between 20 and 30 days notice. The termination letter should also direct the patient to alternative sources of medical care. Ideally, the letter should list a few other physicians (with their contact information included) in the same specialty and geographic area who can continue treatment for the patient. At the very least, the letter should advise the patient to contact the local medical referral association or the California Medical Association. Finally, a termination letter must advise the patient of his or her right to the medical records and how the patient can request the transfer of his or her records to a new medical provider. While these are general guidelines to consider when terminating the physicianpatient relationship, it is also advisable to consult a healthcare attorney in order minimize any potential fallout from a patient termination. Benjamin J. Fenton is a litigator at Fenton Nelson (www.fentonnelson.com) with significant trial and appellate work experience.

New Tool Helps Physicians Address Driving Safety Older patients often need help with driving abilities T h e a M e R i C a n Medical Association now offers a free web-based educational course to help physicians address the driving safety of their older patients. “Medical Fitness to Drive: Is your Patient at Risk?” was created by the AMA in collaboration with the National Highway Traffic Safety Administration to help physicians identify when medical conditions may impair their patients’ ability to drive. The AMA encourages physicians to 6 s o u t h e r n c a l i f o r n i a p h ys i c i a n | j u ly 2 0 1 2

make driver safety a routine part of their geriatric medical services. “Medical Fitness to Drive” provides assessment tools, case studies and additional resources for physicians to better evaluate and counsel older drivers. The AMA conducted a pilot study for this web-based course and 87 percent of physicians who participated said that they learned specific techniques or tools that will enhance their practices regarding older drivers. Motor vehicle injuries are a leading

cause of injury-related death in adults over 65. Older drivers have a higher risk of traffic fatalities because they are considerably more fragile and more likely to suffer a fatal injury in the event of a crash than their younger counterparts. “Medical Fitness to Drive” will be available for continuing educational credits for physicians and other health care professionals. For more information, visit www.ama-assn. org/go/olderdrivers.


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f ro n t o f fi ce | pr ac ti ce ti ps

Risk Tip Properly implemented checklists prevent patient injuries

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h e U S e o f C h e C K l i S T S to help prevent fatal and nonfatal injuries originated with the aviation industry. In the mid1930s a Boeing 299 crashed after takeoff, and the investigation revealed that the pilot neglected to release the elevator lock prior to takeoff. Reducing the probability of pilot error became an immediate priority and, in 1937, separate checklists were developed for takeoff, flight, before landing and after landing, to decrease incidence of human error. Checklists are not new to medicine either; however, a renewed emphasis on checklists, specifically for use in surgery, continues to evolve. The World Health Organization piloted their Surgical Safety Checklist in 2007 and 2008 in eight sites throughout the world. The results, published in the New England Journal of Medicine in 2009, showed that the use of the checklist reduced complications and mortality in surgery by greater than 30 percent. The tool, Safe Surgery Saves Lives, developed by WHO, was created by a group of international experts including anesthesiologists, nurses, surgeons,

By daVid o. heSTeR

and patients to foster communication between members of the surgical suite and keep patients safe during all phases of the procedure. In addition to the WHO surgical safety checklist, other organizations including the Association of periOperative Registered Nurses, Veterans Affairs Hospitals, and The John Hopkins Hospital have developed and implemented successful checklists that start with addressing issues related to organizational culture, hierarchy and leadership. Surgical checklists should be comprised of detailed tasks for each member of the surgical team and broken into the following sections: • Pre-procedure verification process checklist. • Procedure area time out checklist inclusive of the immediate members of the surgical team, standardized by the facility and initiated by a designated member of the surgical team. • Verbal confirmation checklist at the conclusion of the surgery, initiated by a designated member of the team as

defined by the facility. • Team confirmation checklist to address key concerns for the recovery and management of the patient. It is important to note that when two or more procedures are being performed on the same patient, by different surgeons, another time out should be initiated prior to skin incision for the next procedure. The purpose of a checklist is to remind health care providers of the importance of certain details, not to shame or blame a member of the health care team when things don’t go according to plan. Unlike other checklists, forgetting or disregarding certain details when treating patients, can and does result in injury or death. Thorough checklists used in hospitals, ambulatory surgery centers, and physician offices that have fostered and created a culture of patient safety are a valuable tool. David O. Hester, BS, is the Patient Safety/ Risk Management Account Executive at The Doctors Company. For more Patient Safety articles and practice tips, visit www.thedoctors.com.

take the Mystery out of insurerprovided profile reports New teaching guide helps physicians understand data T h e a M e R i C a n Medical Association has introduced a new teaching guide to help physicians review insurer-provided practice data and use the information for practice improvement. “Take Charge of Your Data” is designed to help physicians understand and verify the accuracy of complex profile reports provided by public and private health insurers and based on collected claims data. Using practical information and instructions, the guide will simplify the process of reviewing profile reports and help physicians better use the data to provide patients with the highest quality of care. 8 s o u t h e r n c a l i f o r n i a p h ys i c i a n | j u ly 2 0 1 2

By aMa STaff

“It is increasingly important that physicians be able to confirm the accuracy of the practice data collected by insurers because that information is used to drive public reporting, pay-for-performance, physician tiering and narrow-network programs,” notes AMA president Peter W. Carmel, MD. “Practice data must be accurate to be actionable, and the AMA’s new guide will help physicians ensure that only reliable information is the basis of any profile report.” “Take Charge of Your Data” was created to be used in tandem with a Standardized Physicians Data Report created by the AMA to

encourage insurers to adopt a uniform format for physician data reports. The standardized report serves as a model reference for the AMA’s new guidebook. When used together, the resources will teach physicians how to extract information and patterns from their own data reports provided by insurers. The new AMA guidebook and the supplementary standard report are available free to all physicians. For other innovative AMA resources that promote the accuracy and transparency of physician profiling activities, visit the AMA’s newly updated Practice Management Center website.


MANN • URRUTIA • NELSON CPAs M U N CPAs •

Conference on a Critical Issue that will Impact Your Medical Practice in a Profound Way Invites You to a

TOPIC: How Will the U.S. Supreme Court Decision on the Affordable Care Act Impact Your Practice? WHEN: Thursday, August 23, 2012, 6:00 – 9:00PM WHERE: Glendale Hilton, 100 West Glenoaks Blvd., Glendale, CA SPEAKERS:

Mark Ashlock, CPA, Senior Vice President, Network & Physician Strategy, Adventist Health William Barcellona, Esq., Vice President for Government Affairs, CAPG Micah Weinberg, PhD, President, Healthy Systems Project; Senior Advisor, Bay Area Council

Space is limited so contact us NOW! RSVP to Diane Robarts at drs@muncpas.com or call (818) 956-1681


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Taking the Path of “Lease” Resistance How to negotiate physician leases in a commercial space

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i t h a l l of the things that need to be addressed when setting up a new medical practice or relocating an existing practice, it is easy to overlook some seemingly commonplace items that require specialized attention solely due to the fact that a medical practice is involved. One area where this can lead to significant issues is with respect to office leases. Physicians often spend a significant amount of time and energy finding just the right location. Once that location is identified, many physicians understandably want to sign a lease as quickly as possible just to secure the space. In many commercial office lease situations it is not unusual to have a broker present a “standard form” commercial lease to the physician. Unfortunately, that broker may or may not have any health care specific experience. And without careful analysis of the lease arrangement, the physician may unknowingly be exposing themselves to potential liability. Regardless of whether the lease is for space in a commercial building or in a hospital, physicians need to make sure that any leases they sign provide adequate protection for their rights as tenants. A common mistake physicians make is letting the landlord rush them into signing a lease agreement that is incomplete. Even if the parties have verbally agreed to certain terms, it will be very difficult to enforce those terms if they are not included in the lease agreement. Some basic items that should be addressed in every medical lease include: • Clear identification of the landlord and the tenant (including signatures from both parties). • A specific term for the lease that is at least one year. • Rent clearly set forth, along with a procedure for changing the rent amount. (Note: additional requirements apply if the landlord is also a health care provider, as discussed below). • Clear definition of the rental space. • Clear delineation of landlord and tenant responsibilities.

By Shara A. Lerman

• Allowance for amendments to comply with regulations. • Provisions to address HIPAA and HITECH Act privacy and security concerns (including requiring Business Associate Agreements where appropriate). • Renewal provisions and language that addresses the situation where the lease has expired and the parties are negotiating for a new lease. There are additional concerns when the landlord is a physician or other health care provider (such as a hospital). In these situations, physicians must take care to ensure that they do not enter into an arrangement that violates the Stark Law or the Anti-Kickback Statute. The hospital lease is a classic example where the referral issues arise, as physicians are likely to refer their patients to the hospital for designated health services, such as diagnostic testing. The Stark Law prohibits a physician from making a referral for certain designated health services to an entity with which they have a financial relationship, and a leasing arrangement qualifies as a financial arrangement. The Anti-Kickback Statute prohibits remuneration to induce or reward referrals of items or services that are reimbursable by a federal health care program (not just designated health services). To avoid liability under these regulations, the physicians must make sure the lease arrangements meet the office rental exception under the Stark Law (if designated health services are involved) and the space rental safe harbor for the Anti-Kickback Statute. To qualify for these safe harbors, the lease arrangement must meet the following conditions: • The lease must be in writing signed by the parties and specify all of the rental space to be covered by the lease. • Lease term must be at least one year, and if the lease is terminated during the term (regardless of the reason for termination), the parties cannot enter into a new agreement during the first year of the original term of the lease. • The rent must be set in advance and

1 0 s o u t h e r n c a l i f o r n i a p h ys i c i a n | J u ly 2 0 1 2

must be consistent with fair market value, not taking into account the volume or value of any referrals or other business generated between the parties. (Note: fair market value cannot be determined in a manner that is based on revenue or business generated by the tenant) • The space must not exceed that which is reasonable and necessary for the legitimate business purpose of the lessee and must be used exclusively by the lessee when leased by the lessee. Any common area lease payments must not exceed the lessee’ pro rata share of expenses for the space. • The lease must be commercially reasonable even if no referrals existed between the parties. • A holdover tenant can maintain a month-to-month rental for up to six months immediately following the expiration of the lease, provided that the prior lease was for a term of at least one year and that the holdover rental is on the same terms and conditions of the prior lease. This is a very general overview of the types of issues that should be addressed in medical leases. There are many other items that may need to be addressed to meet the needs of each individual situation. In addition, there are specific regulations that apply to amendments to the lease agreement, most notably to any amendments changing the rent amount. Although it is tempting to sign a lease right away, physicians must take care when entering into these agreements. And although it may seem intimidating at times to propose changes when the landlord seems to hold all of the bargaining power, it should be noted that these provisions provide protection to both parties, not just the physician lessee. Shara Lerman is an attorney with Fenton Nelson (www.fentonnelson.com) where she focuses on advising health care providers, provider groups, and facility owners in connection with formation, financing, acquisitions and divestitures, restructuring, licensing, operational and general corporate matters.


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Cm a | qu i ck list

Regulations Quick List The latest news on medical regulations

By CMA Staff

Loss Ratio Regulation for Individual Health Insurance Policies Department of Insurance This regulation conforms state law to the 80 percent medical loss ratio requirement under the federal Patient Protection and Affordable Care Act. The CMA supports the regulation because it will ensure that consumers receive the maximum health benefit value for their premium. The CMA submitted comments generally supporting conformity to federal law, but raised concerns about misleading health plan information regarding premium rate increases. Currently, the DOI and Department of Managed Health Care are accepting pre-notice comments regarding their implementation of Senate Bill 51, which would bring California in conformity with the federal 85 percent MLR requirement for large group insurers in addition to the 80 percent MLR requirement discussed above. The CMA submitted pre-notice comments reflecting concerns similar to those on the initial DOI regulation, as well as calling for an application of the MLR rule that would not result in excessive administrative burdens for physicians. Status: Pre-notice comments submitted 2/9/12.

Paid Surrogacy Arrangement Benefits Exclusion Managed Risk Medical Insurance Board On November 18, 2011, the MRMIB provided advance notice that it intended to use the emergency rulemaking process to promulgate regulations to exclude maternity care in connection to paid surrogacy from the Access for Infants and Mothers program. The CMA submitted comments expressing our concern with the MRMIB’s abuse of the emergency rulemaking authority. On February 10, 2012, the MRMIB followed up by posting two similar proposed rules on paid surrogacy, one making changes to AIM and the other to the Major Risk Medical Insurance Program. The CMA requested amendments to the regulation to ensure that physician reimbursement is protected if they were not made aware of a paid surrogacy arrangement by the patient. The MRMIB recently released an updated version of the regulation with language very similar to that requested by the CMA and the CMA filed comments thanking the board The MRIB approved the regulations at their May 9 board meeting. As emergency regulations, they were effective immediately upon approval. Status: Effective 5/9/12.

Requirements for Preceptors Physician Assistant Committee Existing regulations permit only physicians to act as preceptors for the training and education of physician assistant preceptees. This proposal would expand the type of licensed health care providers who may act as preceptors to include physicians and surgeons, PAs, registered nurses who have been certified in advanced practice, certified nurse midwives, licensed clinical social workers, marriage and family therapists, licensed educational psychologists, and licensed psychologists. 1 2 s o u t h e r n c a l i f o r n i a p h ys i c i a n | J u ly 2 0 1 2

The CMA submitted comments and substitute language that would maintain the requirement that PAs receive supervised clinical training from physicians, but allow other health care providers to serve as supplemental preceptors. The changes were not made at the February 6 hearing, but the CMA and the California Academy of Physician Assistants were encouraged to submit additional language changes for future consideration. The CMA and CAPA sent a joint letter with agreed upon language changes for the PAC to consider at their May 7 meeting. At the May meeting, the PAC accepted and approved the language recommended by the CMA and CAPA and will be updating the proposed regulation’s language to maintain the requirement that preceptees receive supervised clinical training from physicians. Status: CMA/CAPA letter sent 4/10/12.

Chiropractic Use of Lasers Board of Chiropractic Examiners The proposed regulation allows chiropractors to use lasers that have been approved by the FDA and indicates that they may not use lasers for ablation or surgery. It also states that they may not treat allergies where there is a known risk of anaphylaxis. The CMA submitted comments calling for no chiropractic laser treatment of allergies under any circumstances, clarifying that cosmetic medical laser procedures, including ablative and nonablative procedures are also prohibited, and declaring that the only lasers appropriate for chiropractors use are FDAapproved devices available over-the-counter. At their March meeting, the BCE accepted the amendment that prohibits chiropractic use of lasers to treat allergies under any circumstances, but did not accept the other changes. The CMA reiterated the unaddressed issues in a letter submitted during the 15-day comment period. The BCE made no further changes before submitting the regulation to the Office of Administrative Law. Status: OAL decision expected 6/17/12.

Federal Regulations Medicare Fee Schedule – Revisions to Part B for CY 2011 Centers for Medicare and Medicaid Services The CMS published the 2011 Medicare Physician Fee Schedule for comment along with changes required by the ACA. The CMS also solicited comments on physician payment programs to be implemented in future years, including the Physician Value-Based Payment Modifier. The CMA opposed the reductions to California physicians as a result of the changes to the Medicare Economic Index and the Geographic Practice Cost Index practice expense factor. The CMA also commented on the proposed payment rates for the newly covered preventive services, the bonus payments for primary care and general surgery, e-prescribing, the Physician Quality Reporting Initiative, consultation codes and the need to update geographic payment localities. Status: Finalized 12/10. Long term ACA payment reform still pending.


qu i ck list | cm a Coverage of Preventative Services: Group Health Plans and Health Insurance Issuers Department of Health and Human Services The Department of Health and Human Services issued an interim final rule implementing coverage for preventive services such as immunizations, obesity screening, and tobacco cessation counseling. CMA comments supported the proposed standards as a means to provide more Americans with basic preventive services that are covered by their health insurance, but cautioned that adequate provider reimbursement must be provided for these services to ensure access to care. Status: Still pending as of 2/18/12.

Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections HHS Center for Consumer Information and Insurance Oversight The HHS issued regulations to implement the ACA health insurance market reforms, including banning preexisting conditions exclusions or denials, lifetime dollar limits on benefits and rescissions except in clear cases of fraud, along with patient protections with respect to choice of physicians and no prior authorization requirements for emergency care. The CMA submitted comments on August 27, 2010 in conjunction with the AMA. Comments supported these market reforms and expressed concern over the emergency care provisions. Status: In effect.

Medicare Physician Value-Based Payment Modifier Centers for Medicare and Medicaid Services

The ACA establishes a new Medicare payment methodology called the “Physician Value-Based Payment Modifier,” which would pay physicians a higher rate if they successfully spend less than the national average per Medicare beneficiary. It reduces payments to physicians who do not successfully report on quality measures and spend more than the national per capita average. The Value Index takes effect January 1, 2015. The CMA generally opposes the value index because it is not workable under CMS’ current systems and will not produce accurate individual physician quality information. While the CMA won amendments in the ACA to ensure that the new formula adjusts physician payments based on geographic practice expenses (rent and wages) and the socioeconomic and health status of the patients, the CMA is concerned about its implementation and impact on access to care. Status: Long term ACA payment reform still pending.

Health Insurance Issuers Implementing Medical Loss Ratio Requirement Under ACA HHS Center for Consumer Information & Insurance Oversight The HHS issued an Interim Final Rule implementing the requirements for health plan medical loss. The regulation requires insurers to dedicate 80-85 percent of their revenues to direct patient care depending on the type of plan. It outlines the specific categories for defining medical treatment—direct patient care, quality improvement activities and administration. It also specifies the requirements for transparency of health plan financial information. The CMA submitted comments in

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Cm a | qu i ck list with the AMA generally supporting the final regulations. Status: In effect.

Nutrition Labeling of Standard Menu Items in Restaurants Food and Drug Administration The ACA requires restaurants with 20 or more locations to list calorie content information for standard menu items. The ACA also requires vending machine operators who operate 20 or more vending machines to disclose calorie content for certain items. These regulations provide further direction on what is required to comply with the standards. The CMA submitted comments in support of the standards. Status: Still pending as of 1/23/12.

Medicaid: Methods for Assuring Access to Covered Medicaid Services Centers for Medicare and Medicaid Services Under federal law, states must ensure that payments in their Medicaid (Medi-Cal) programs are “sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.” The CMA has used this provision of law to argue against cuts to MediCal reimbursement. These regulations clarify the process states must use to prove compliance with the federal standard. This is very important for physicians, since it will cause the state to be more transparent in their Medi-Cal rate setting. Status: CMA comments submitted 7/5/11.

Medicare and Medicaid: Opportunities for Alignment Under Medicaid and Medicare Centers for Medicare and Medicaid Services Under the provisions of the ACA, the CMS will work with state Medicaid (Medi-Cal) programs to redesign the care and treatment of Medicare-Medicaid “dual eligibles.” In this request for information, the CMS solicited comments from all stakeholders about how best to coordinate benefits for the dual eligibles, and what opportunities are available to better align the two programs. The CMA filed a formal response highlighting the need for adequate physician and patient protections and the importance of coordinating care for this vulnerable population. Status: CMA comments submitted 7/11/11.

Medicaid: Eligibility Changes Under the ACA of 2010 Centers for Medicare and Medicaid Services This regulation implements the Medicaid (Medi-Cal) expansion as part of the ACA. Under the ACA, all persons under 133 percent of the federal poverty level will be eligible for Medicaid. The federal government will fund care for newly eligible persons, but states will have to follow federal guidelines to claim the funding. The CMA filed comments emphasizing the importance of ensuring that Medicaid recipients have access to care after the expansion of the program. The CMA further commented that recently-enacted rate cuts will greatly complicate the expansion of the program. The CMS recently published a final rule clarifying how new eligibility standards will be applied and clarifying how state Medicaid programs are expected to work with insurance exchanges and CHIP (Healthy Families) programs. The final rule was limited to addressing eligibility determinations, and thus did not address the CMA’s comments. Status: Final rule published 3/23/12. Effective 1/1/14. 1 4 s o u t h e r n c a l i f o r n i a p h ys i c i a n | J u ly 2 0 1 2

Medicare Physician Fee Schedule for 2012 Centers for Medicare and Medicaid Services The CMS published the 2012 Medicare physician payment rule and asked for preliminary comments on provisions of the ACA that take effect in future years, including the Value Modifier and the Physician Compare Website. Most significant for California physicians, in last year’s proposed rule, the CMA successfully killed the CMS’ plan to reduce geographic adjustments by 4 percent. The 2012 proposed rule includes the CMA’s advocate position to increase the geographic adjustment by 3 percent to truly ref lect the geographic differences in the cost to practice medicine. The CMA opposed the proposed dates for applying penalties for e-prescribing and the value modifier. The CMA urged the CMS to coordinate the PQRS and EHR programs, and provide more guidance to physicians and patients about the new Annual Wellness Visit. The CMA provided detailed comments on the physician confidential feedback report program, the PQRS, e-prescribing, and the Value Modifier. The CMS continues to ignore the Geographic Payment Locality problems. Status: Final rule published 11/28/11. Long term ACA payment reform still pending.

Medicare and Medicaid: Reform of Hospital and Critical Access Hospital Conditions of Participation Centers for Medicare and Medicaid Services The CMS published an updated se t of requirements that hospitals must meet in order to participate in the Medicare and Medicaid programs. The major changes to the requirements, known as conditions of participation, that could impact medical staffs and scope of practice within hospitals include: • Creating an option that allows a single governing body in a multi-hospital system to oversee multiple hospitals. • Allowing hospitals to broaden the definition of “medical staff” to other practitioners (e.g. advanced practice registered nurses, physician assistants, pharmacists) as eligible candidates for privileges required by the state to practice in a hospital. • Allowing for drugs and biologicals to be prepared and administered on the orders of practitioners (other than a doctor), in accordance with hospital policy and State law. The amendment also allows orders for drugs and biologicals to be documented and signed by practitioners (other than a doctor), in accordance with hospital policy and State law (which is specified to include medical staff bylaws, rules and regulations). • Eliminating the requirement for authentication of verbal orders within 48-hours and have deferred to applicable State law to establish authentications timeframes. Late last year, the CMA submitted comments objecting to several amendments in the proposed regulations. The CMA supported the elimination of the federal requirement that verbal orders be authenticated within 48 hours. With regard to authentication of verbal orders, California law still requires such authentication to take place within 48 hours, but the elimination of the federal requirement on this issue could potentially lead to changes in state law. The CMA will be reviewing the final rule in further detail and will take the appropriate legislative and regulatory action to ensure that state laws continue to


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Cm a | qu i ck list protect patients and ensure quality of care. Status: Final rule published 5/16/2012. Effective 7/16/12.

Smoking of Electronic Cigarettes on Aircraft Department of Transportation This rule would amend existing airline smoking regulations to explicitly ban the use of electronic cigarettes on all aircraft in scheduled passenger interstate, intrastate and foreign air transportation. The CMA submitted comments in support of the rule. Status: Still pending as of 6/11/12.

Medicare, Medicaid, SCHIP: Transparency Reports and Reporting of Physician Ownership or Investment Interests Centers for Medicare and Medicaid Services This rule requires applicable manufacturers of drugs, devices, biologicals, or medical supplies covered by Medicare, Medicaid or the Children’s Health Insurance Program to report annually certain payments or transfers of value provided to physicians or teaching hospitals. In addition, applicable manufacturers and group purchasing organizations are required to report annually certain physician ownership or investment interests. The Secretary must publish applicable manufacturers’ and GPOs’ submitted payment and ownership information on a public website. While the CMA supports the disclosure of financial relationships between physicians, pharmaceutical interests, and medical device manufacturers, the CMA co-signed a letter with the AMA that expresses concern with the lack of due process for physicians who dispute the accuracy of information, the record-keeping burden, and the scope of the value that must be reported. Without significant modifications, the regulation will result in the publication of misleading information and impose burdensome paperwork requirements on physicians while shedding very little light on actual physician-industry interactions. Status: CMA/AMA comments submitted 2/17/12.

Medicare: Emergency Medical Treatment and Labor Act: Applicability to Hospital Inpatients and Hospitals with Specialized Capabilities Centers for Medicare and Medicaid Services EMTALA was passed to ensure that any individual with an emergency medical condition, regardless of insurance coverage, is not denied essential lifesaving services. This request for comments addresses the applicability of EMTALA to hospital inpatients. The CMS states that it is maintaining its current policy that EMTALA does not extend to inpatients or to the transfer of inpatients to hospitals with specialized capabilities. The CMS says it will continue to monitor whether it may be appropriate in the future to reconsider the inapplicability of EMTALA to the transfer of inpatients to hospitals with specialized capabilities. The AMA and CMA determined there was no need for comment at this stage. Status: Comment period 2/2/12 – 4/2/12.

Medicaid: Covered Outpatient Drugs Centers for Medicare and Medicaid Services This rule implements several sections of the ACA related to prescription drug pricing in the Medicaid (Medi-Cal) program. The regulations would increase minimum drug rebates paid by manufacturers, add new reporting requirements on pharmaceutical companies, and review upper payment limits allowed under federal law. The CMA reviewed the regulations to ensure 1 6 s o u t h e r n c a l i f o r n i a p h ys i c i a n | J u ly 2 0 1 2

that they do not hamper access to, for example, vaccinations and chemotherapy. Physician administered drugs are not addressed, and there is no apparent connection to the practice of medicine, so the CMA will not comment. Status: Comment period 2/2/12 – 4/2/12.

Medicare and Medicaid EHR Incentives – Stage 2 Centers for Medicare and Medicaid Services This rule defines “Stage 2” of meaningful use, which many physicians would have to demonstrate in the EHR incentive programs beginning in 2014. As drafted, the rule would require physicians to report on 17 required objectives, and 3 selected from a menu of 5. It would further require physicians to report on as many as 12 clinical quality measures. The CMA Information Technology Council is reviewing the rule, and the CMA will submit formal comments requesting that the CMS not impose any new requirements that would be overly burdensome on physicians, or which involve infrastructure physicians cannot control (such as public health registries). Status: Final rule expected in late 2012.

ACA: Certain Preventive Services Under the ACA Department of Labor This announces the DOL’s intention to amend federal preventive services regulations around the mandated provision of contraceptive services coverage in employee health insurance. Specifically, the proposed amendments would shift the requirement to provide such coverage from the employer to the insurance issuer or plan, leaving the religious exemption largely unchanged. The CMA submitted comments supporting the federal position that such preventive services provisions serve as a floor so as to not reduce the current level of access to contraceptive services coverage in states like California. Status: CMA comments submitted 6/5/12.

Medicare: Reporting and Returning of Overpayments Centers for Medicare and Medicaid Services Physicians are currently obligated to return overpayments to Medicare. The CMS recently issued further guidance on how physicians may comply. However, the rule fails to clarify key elements of the obligation and contradicts other existing CMS overpayment rules. The CMA joined the AMA in sending a joint response to the CMS. The CMA/AMA opposed the 10-year look back period for overpayments and requested a three year look back starting in 2010; the CMA/AMA also asked for the following clarifications: Asked CMS to clarify that physicians are not obliged to search for overpayments; Requested that the CMS provide the same due process and appeal rights to physicians for overpayments as apply for other payment related issues. Status: CMA/AMA comments submitted 4/16/12.

Medicare ICD -10 Coding System Implementation Regulations Centers for Medicare and Medicaid Services In response to organized medicine’s advocacy, the CMS’ regulations delay the implementation of the ICD-10 coding system until October 1, 2014. The regulation also simplifies administrative processes for physicians by proposing that health plans have a unique identifier of a standard length and format. In a letter to the CMS, the CMA expressed strong support of the decision to delay the implementation of ICD-10 and asked for further delays. Status: CMA Comments submitted 5/10/12.


! s s e r t s Physician Burnout:

The rising ess r t s f o t s Co emands d With increasing physicians on their time, re stressed o m g n li e fe re a han ever. t t u o d e n r u b and oon be But help may s on the way. G LA N D By C H ery L eN

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st r e ss | f e at u r e

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e A LT H C A r e reform, the dual eligible pilot program, ever-changing formularies, insurer denials—it’s enough to make a physician scream. And those problems are only the tip of the iceberg. It seems that everywhere physicians turn these days, there’s a new demand on their already-pressured time. As a result, physicians are, as a group, under an incredible amount of stress. According to a new survey by Physician Wellness Services and Cejka Search, almost 87 percent of all respondents say they are moderately to severely stressed and/or burned out on an average day; 37.7 percent say they suffer severe stress and/or burnout. More telling, 63 percent of physicians said they were more stressed and/or burned out than three years ago. To make matters worse, the stress can lead to all sorts of problems from venting anger at staff and peers to substance abuse to thoughts of suicide. Fortunately, there are programs that can help. The programs range from self-help resources provided by the California Medical Association and the American Medical Association to private consultancies to hospital or large group sponsored options. But, perhaps, the most promising source for physicians is a proposed confidential, non-punitive State funded program that is currently making its way through the legislature.

The Core Issues

“We uncovered through our survey that physicians are clearly under a lot of stress,” says Alan Rosenstein, MD, an internal medicine physician in the San Francisco Bay Area and the medical director for Physician Wellness Services. “Burn out and frustration can lead to anger and disruptive behaviors where physicians, their co-workers and possibly even their patients are getting physically or emotionally hurt. And that’s not going away. It’s not a user friendly environment for physicians these days and their stress levels continue to rise.” But while a majority of physicians are more stressed than ever, only a minority seek help from professional resources such as Physician Wellness Services. “There’s a great resistance on the part of physicians to seek help,” continues Dr. Rosenstein. “All of their training during medical school and residency has made them believe that stress is simply a part

of life and that they can handle it.” And while many physicians recognize that they need to get a grip on their stress levels by getting enough sleep, eating right, exercising and balancing their work with their personal time—advice they frequently give their patients—not many can actually do so on their own. “It’s similar to an overweight person who knows they need to go on a diet,” continues Dr. Rosenstein. “If you leave them on their own to do it, only a very few will follow through.” Fortunately, there are some resources for physicians who do not want to go it alone. For example, independent companies such as Physician Wellness Services offer programs that use dedicated staff members or physician peers who are trained to coach physicians on how to handle their stress or substance abuse problems. “The goal,” says Dr. Rosenstein, “is for the physician to become better adjusted and, therefore, able to provide better care.” The Physician Assessment and Clinical Education program from the University of California, San Diego, also

courage to come forward and talk about her own issues with depression and mental health,” says Dr. Hafner-Fogarty. “She teamed up with a chaplain in the hospital and began reaching out to physicians they had reason to believe were having problems.” Before long the two had created a support group of eight or so physicians in all specialties who met monthly to discuss their struggles with stress, burnout, and mental health. “It is a safe place for physicians to come and be human and talk about the problem areas of their lives,” continues Dr. HafnerFogarty. “It’s confidential not punitive; it’s not regulatory.” So far, the program has worked very well and has grown so much that it will be split into two groups to keep it small. “It has earned the credibility of the medical staff so that physicians know there is a safe place to turn,” says Dr. Hafner. “My personal belief is that those kinds of support structures can help keep physicians from bottoming out and engaging in dysfunctional behavior that can lead to a report to the state medical board.”

“Burn out and frustration can lead to anger and disruptive behaviors where physicians, their co-workers and possibly patients are hurt.” offers similar assistance to physicians who are suffering from stress, burn out or substance abuse, with the goal being to make physicians able to once again perform at their peak. Some hospitals and large group practices also offer loosely defined physician wellness programs. These programs run the gamut from having a workout room on site to offering presentations for physicians several times a year to innovative one-on-one programs for physician peers. Becki Hafner-Fogarty, MD, a physician consultant for Physician Wellness Services and practicing physician who is also on the board of directors for the Federation of State Medical Boards Foundation, gives an example of one very innovative—and grass roots—program at Lake Region Hospital and Clinic in Fergus Falls, MN. “The physician wellness program there was started by a physician who had the

Leaving Physicians to Cope

At one point, California’s medical board had a diversion program for physicians with harmful behaviors; it was designed to divert them from disciplinary action. But that program was abolished in 2008 (see “A History of the Diversion Program”). Since then, California physicians have been mostly on their own to deal with stress, mental disorders or an addiction problem. Of course, any physician can elect to enroll in a treatment center and have the matter kept confidential unless a patient complaint is filed with the medical board. But the problem is that California doctors no longer have a safe way to undergo treatment for substance abuse while maintaining their license if they end up in the disciplinary system. If the medical board finds clear and convincing evidence that a violation of J u ly 20 1 2 | W W W. s o c a l p h ys i c i a n . n e t 1 9


f e at u r e | st r e ss the Medical Practice Act occurred, the case is referred to the California Attorney General’s Office for filing. The result could be revocation or surrendering of the license, probation or some other action. Upon filing, a copy of the accusation is automatically made public on the Board’s web site. If placed on probation, the physician must submit to random drug screening, refrain from using drugs or drinking alcohol, and submit to psychiatric evaluation. Regulations enacted a couple of years ago mandate a minimum of 104 tests the first year and at least 50 tests a year thereafter, for an

Proposed Legislation Offers New Hope

Enter Senate Bill 1483, authored by Senate President pro Tempore, Darrell Steinberg. The bill proposes a State funded, voluntary program based on referrals for physicians with disruptive behaviors. The scenario is this: A physician comes into the program and, together with qualified counselors, develops a treatment plan. A contract is drawn up and the program staff helps the physician find quality resources to lead their rehabilitation. The medical board is not involved in the treatment plan and it is completely confidential.

“The bill proposes a State funded, voluntary program based on referrals for physicians with disruptive behaviors.” indefinite period of time. Physicians will no longer be able to craft a strategy to avoid testing; the board must give approval for alternate drug testing locations when going on vacation or leaving town. A positive drug test will mean an immediate month’s suspension from work and a change in license status to “inactive,” which will be disclosed publicly. Without a viable discipline diversion program, experts fear that California doctors with substance abuse issues will stay hidden until they eventually harm a patient.

“The first thing to know is that this is not a diversion program,” says Randall Hagar, the Government Affairs Director for the California Psychiatric Association and a board member for the California Public Protection and Physician Health non-profit organization. “There’s no relation to the medical board except the medical board will collect further fees from physicians to help fund the program. You can’t have an effective program that is connected with a disciplinary board.” Ironically, the bill has its roots in the

collapse of California’s medical diversion program. After the diversion program folded, the CMA developed a workgroup of all relevant stakeholders in the physician community and also included national experts such as the national Federation of State Physician Health Programs. The workgroup fashioned the idea of the bill and, upon deciding that it needed something in place to be ready to roll should the legislation be signed formed a non-profit organization, California Public Protection and Physician Health (informally called C3PH). Today, C3PH has many influential organizations actively on board, including the CMA, the California Society of Addiction Medicine, the California Psychiatric Association, and the California Hospital Association.  And the group is the key driver behind SB1483. It also serves an educational function; currently the group is hosting a series of regional educational workshops on physician well-being for hospital medical staff committees, medical groups, specialty societies and county medical associations. It is the growing influence that the group has fostered, however, that makes it most likely that SB1483 will be signed into law. C3PH has submitted two prior bills: the first was vetoed and the second stalled because no one in Gov. Schwarzenegger’s office could agree on where within the government bureaucracy the program belonged. “For the third bill, we decided to reinvigorate our lobbying group,” says Hagar. “We got specialty societies to do a line-by-line review of the second bill to create new, third

And the Survey Says… A 2 0 1 1 s u rv e y conducted by Physician Wellness Services and Cejka Search showed that almost 87 percent of all respondents say they are moderately to severely stressed and/or burned out on an average day. Here are more results from the survey: • The top three external factors that created stress were the state of the U.S. economy in general, health care reform and the Centers for Medicare and Medicaid policies. • The top three work-related factors were

paperwork and administrative demands, too many hours of work and on-call schedules and expectations. • The top three personal life-related factors were not enough time to relax, not enough time for exercise and concerns about work/life balance in general. • The top two impacts of stress on physicians’ work lives were lower job satisfaction and a desire to work fewer hours. • The top two choices among respondents for dealing with stress were exercise and spending time with family and friends.

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• The top choice for what organizationsponsored things might help address stress was more ancillary support for dealing with things like paperwork and charting. • The top three things physicians felt would help reduce stress and burnout in their lives was better work hours and less on-call, more or better work/life balance, improved finances, compensation and reimbursement, greater levels of respect and support from administration and patients and more time and support for self-care such as exercise and more sleep.


st r e ss | f e at u r e bill. The third bill didn’t end up being that different but it got the associations invested. We’ve also formed a tight group of lobbyists from the CMA, California Psychiatric Association, California Society of Addiction Medicine, and the California Hospital Association. The weight of these lobbyist groups cannot be underestimated. In addition, C3PH was successful in getting political heavyweight Darrell Steinberg to author and champion the bill. Senator Steinberg is a longterm mental health champion and understands the need for treatment. If the bill is successful, as many expect it to be, the group would be authorized to begin January 1, 2013; the timeline calls for the initial physician participants to be enrolled in late 2013. But make no mistake—while the bill proposes a program that is standalone and separate from the medical board, there is a point at which a risk assessment may be called for because a physician is breaking their contract with the program. “Relapses are common in drug and alcohol abuse cases,” says Hagar. “So one bad drug or alcohol test doesn’t get someone kicked out of the program. But

if there is a serious breach of the contract and there is risk to a patient, then the program will be obligated to report a physician immediately to medical board. If there is no danger and the physician is a voluntary patient then there is confidentiality because they are treated just like any patient.” Hagar repeats that the program the bill proposes is designed to get physicians back on their feet, practicing medicine safely. “The program will do early intervention,” he says. “It will help to catch people before they have an issue that has to be brought to medical board. The idea is that there is less wear and tear on the physicians and we can catch the problem before it gets worse and patients are harmed.”

An Important Issue

“Physician wellness” is a vague term that sugar coats the serious implications behind it. Thus, it’s critical for physicians to get the help they need, when they need it. Many physicians are reluctant to approach their peers whom they suspect may be suffering. That’s understandable—but there are other

avenues such as asking a human relations person to help out. But even more effective is for physicians to know that there are resources available—they don’t need to go it alone. And, hospitals, clinics and group practices need to become more accountable for helping their most important asset—their physicians. “It’s important, not just for physicians, but also for hospitals and clinics to pay attention to the issue of physician wellness,” says Dr. Hafner-Fogarty. “There are issues of patient safety and satisfaction as well as financial issues for some of the hospitals and clinics. Support for physicians is money well spent, as there are data that show stressed, burned out physicians are more likely to make errors and have lower patient satisfaction scores.” “For the most part,” she continues, “medicine is practiced by good people who are trying to do good things for their patients. In a climate where physicians are overwhelmed by too much paperwork, too many patients, and too many regulations, it behooves us to look at what help physicians need in order to practice medicine to the best of their ability.”

A History of the Diversion Program I n 2 0 02 , the Orange County Register published a series of articles that disclosed to the public instances of major physician wrongdoing that had gone unaddressed by the California Medical Board. As a result of the expose, an independent monitor was appointed by the California legislature to audit the Board’s enforcement practices. In November 2005, a report was published that specifically addressed the flaws in the physician addiction diversion program. In 2007, the Bureau of State Audits conducted its own investigation and found, in sum, that diversion neither rehabilitated doctors nor protected the public. “The diversion program diverted physicians from a medical board disciplinary tract,” says Randall Hagar, the Government Affairs Director for the California Psychiatric Association and a board member for the California Public Protection and Physician Health non-profit organization. Three or four audits that were conducted in the last ten years revealed that the program was ineffective, mismanaged, underfunded and simply not doing well.

The medical board threw up its hands in the end, finding the program inconsistent with its mission of protecting physicians and patients.” Hagar goes on to note that in the diversion program’s early days, about 30 years ago, it was fairly well-respected. But, he claims, it didn’t get the right people or, due to underfunding, enough people. “One audit found that the person who was responsible for random drug testing had only two hours per month to devote to the task,” he says. “And that was supposed to cover some 250 physicians.” The audits revealed other problems as well. For instance, physicians were not always required to stop treating patients if they failed a drug test even though policy required it. In addition, the evaluation committee often determined that a drug-test failure did not constitute a relapse without feeling the need to explain their position or have the results reviewed by a medical officer. In short, the program did not adequately and consistently monitor substance-abusing doctors. Problems ranged

from the staffing deficiencies to failure of the board to oversee administration of the program. The study found that drug tests were only conducted on weekdays, possibly enabling “weekend” abusers to avoid detection. While it was thought that confidentiality would encourage voluntary participation, it didn’t work out that way; the majority of physicians participated simply to avoid disciplinary action. By January 1, 2008 all physicians were released from the program ad in June 2008 the diversion program was abolished. “I attended a medical board meeting where, after extensive discussion, the board decided to scrap the program,” says Becki Hafner-Fogarty, MD, a practicing physician who is also on the board of directors for the Federation of State Medical Boards Foundation. “Like many states the diversion program in California was underfunded and understaffed; people were falling through the cracks. The end result is that now a physician really doesn’t have a place to go within the board process to self-report and get help.” j u ly 20 1 2 | www. s o c a l p h ys i c i a n . n e t 2 1


A Warm Welcome Introducing Samuel Fink, MD, LACMA’s 141st President

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h e n Sa m u e l F in k , M D, went into practice in 1988 it was status quo to join the Los Angeles County Medical Association. “Every physician at the time joined LACMA,” he says. “In fact, you were considered a little weird if you did not join.” Now, 24 years later, Dr. Fink knows just how important the association is—and, as the group’s 141st president, he wants to make sure other physicians feel the same way. A Los Angeles native, Dr. Fink graduated from Grant High School in Van Nuys and attended Pomona College in Claremont, where he graduated with honors in biochemistry. He then spent an additional year of research during the infancy of computerassisted drug design, working with Corwin Hansch, PhD, one of the world’s foremost medicinal chemists at the time. Next up was medical school at the University of Texas Medical Branch in Galveston, where he dodged hurricanes and tornados, and learned about the subtleties inherent in chicken-fried steak. It was also here that his poker skills were finely honed as a member of the Phi Chi Medical Fraternity and also where he got his start in “medical politics,” as Student Body President of UTMB. These days, Dr. Fink is an internist in private practice in Tarzana, after doing his residency at Huntington Memorial Hospital in Pasadena. He is an active member of the medical staff of the Providence Tarzana Medical Center, and has previously served as the Chair of the Critical Care Committee, as well as the Vice-Chief of Internal Medicine. Currently, Dr. Fink is the Chair of the Institutional Review Board, a position that he has held since 1994. His background serves him well in becoming LACMA’s newest leader. He has been a member for almost thirty years, and has served as the President of the San Fernando Valley/Santa Clarita Medical Society, as well as Chair of the LACMA delegation to the California Medical Association. In addition, Dr. Fink has chaired the Public Health reference committee at the CMA House of Delegates, and is a current member of the Council on Legislation, as well as the President’s Forum. “I’ve led multiple organizations within LACMA and the CMA, chaired committees at Tarzana and I was also president of my synagogue for three years,” he says. “I’m organized and focused and I will push hard to meet our goals. I hope that if I lead others will follow.”

Goals for the Year

Dr. Fink plans to focus on membership growth during the coming year. “We need to address the membership decline that has occurred over the last 20 years,” he says. “We need to change the way we communicate with members. We are now on Facebook and Twitter and Southern California Physician is now available in digital format. We need to communicate with our members like they do with each other.” Dr. Fink also points out that LACMA CEO Rocky Delgadillo has held meetings in every area of Los Angeles County listening to member needs and reminding them that LACMA advocates for them and their patients daily. “There is a lot of noise out there,” he continues. “I get 300 emails a day. Our emails need to be more focused and direct. We can communicate a lot of information in just 100 words.” Dr. Fink also plans to use the combined purchasing power of member physicians as leverage to get significant discounts 2 2 s o u t h e r n c a l i f o r n i a p h ys i c i a n | J u ly 2 0 1 2

By Cheryl England

for members on the products and services that really make a difference to them such as medical waste disposal services, office and medical supplies, phone systems, billing and IT services and more. “As a group, we should be able to get rates that other organizations can’t touch,” he says. “We want to have best of class products and services available to our physicians at substantial discounts.” Part of the discount strategy, Dr. Fink explains, is to combat the common—if misconstrued—complaint that membership is too expensive. “We need to make it so that a physician can’t afford not to join LACMA. When I joined in the late ‘80s, a medical association could sell memberships based on a mission,” he says. “But we can’t do that anymore. We are still going to advocate for key legislation, we are still going to staunchly support MICRA, and we are going to continue to be committed to anti-smoking causes—physicians perceive that as “free”. Also, twenty years ago, medical associations were the primary source of information that directly affected physicians. I remember when LACMA and the CMA had excellent scientific meetings. But now, information is free… use Google and you’ll instantly have at least 100,000 free references.” Other hot button items for Dr. Fink include getting LACMA physicians more prominently featured in the media, forming an ethnic physicians committee, and reenergizing the political action committee to take a more active role locally. And, he can’t stress the importance of unity enough. “If our organization is to continue to grow, then it has to be important to its members that your unaffiliated colleagues also be in LACMA. We need your personal help in recruiting the rest of your medical community,” he states. “When you are referring patients, a gentle—or even a not so gentle—reminder about the importance of LACMA and the CMA would be very much appreciated.”

In His Off-Work Time

While Dr. Fink is deadly serious about the importance of LACMA, he also has a very humane side. First and foremost, he enjoys spending time with his family. Despite pleas from other physicians over the years to become an executive officer, Dr. Fink waited until his children got older so that he wouldn’t miss their growing up years. While his family remains crucial to him, Dr. Fink feels confident that they can weather—and, in fact, support—his time commitment to LACMA. Beloria, his wife of 26 years is the owner of Corevita Health, a health care consulting firm. They have four children—Jonathan (21), Zachary (20), Sarrica (18) and Benji (13). Jonathan is a junior at Northridge, Zachary is a sophomore at Yeshiva University in New York, Sarrica just graduated from YULA High School in L.A. where she served as Student Body President and will be leaving shortly to study in Israel for a year. Benji just finished seventh grade at the Emek Hebrew Academy in Sherman Oaks. Aside from his family, Dr. Fink spends his precious free time playing league basketball, and he loves to go skiing and hiking. He follows the Lakers, Dodgers, and the Kings too closely… even the Clippers sometimes. He has coached youth baseball for fifteen years, and has not been thrown out of any games—yet. Please welcome our new president! He certainly welcomes your comments at president@lacmanet.org!


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A Tribute to a Leader in Organized Medicine LACMA offers a hearty thanks for all he has done to James G. Hinsdale, MD By Cheryl England

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h e n Ja m e s G. Hinsdale, MD, took over as President of the California Medical Association at the beginning of October 2010, he made one thing very clear: he believed physician autonomy was crucial in providing excellent patient care. “I can say the one thing that binds doctors together is this: We

Hinsdale-isms “Jim is a real interesting character,” says Bill Parrish, CEO and Executive Director of the Santa Clara Medical Association. “He says a lot of really funny things that most people can’t get away with. And also lots of things that strike straight to the heart of what it means to practice medicine.” Herewith is Parrish’s list of what he terms “Hinsdale-isms.” The first nail in the physician-patient relationship coffin was Medicare. If you can avoid contracting at all, do so. My personal basic stance on contracting is three words: TERMINATE, TERMINATE, TERMINATE. It went over like a fart in church. Would you have Bill Gates take out your appendix?

I’m proud of what I do. I save lives. I help people. I improve someone’s quality of life. I have never heard the Catholic church use the term ‘scandal’ in reference to any other of its major problems— such as pedophile priests—and now a poor woman desirous of a tubal ligation is inviting ‘scandal’? I must confess, as a Catholic (I am on inactive reserve) even I can’t understand it. The neat thing about organized medicine is to look out over the landscape, see the diversity of practitioners, both in types of specialties and in ways of practicing, and be able to savor those things that unite us as physicians. It doesn’t mean we can’t be different as individuals. But it does mean that we, as individuals, should temper the selfinterest that naturally occurs within us at times to achieve value-oriented goals that are for the better of our patients and society.

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would just like everyone to stay out of our way and let us practice medicine,” he said in his acceptance speech. “It isn’t about money. It’s about being a professional and having the autonomy needed to heal our patients.” “No one in this state can deny that the CMA has, and always will, put the care and well being of the residents of California first,” Dr. Hinsdale continued. “Who can forget the CMA’s leadership in health care reform? All of it was devoted to guaranteeing access to care for patients and stopping insurance abuses such as dropping coverage for patients who get sick.” Two years later, although his latest stint as the Immediate Past President for the CMA is nearing an end, Dr. Hinsdale is still a strong advocate for physicians, patients and organized medicine. “Jim Hinsdale is an independent thinker who always cares about what is best for the physicians and their patients,” says David Aizuss, MD, a former president of the Los Angeles County Medical Association. “He is one of the few leaders willing to oppose typical organized medicine group-think. When LACMA was being investigated by the CMA charter commission he strongly and consistently defended us.” George Ma, another former LACMA president agrees wholeheartedly. “It was during my LACMA presidency that Dr. Hinsdale became president of the CMA,” he says. “He came to our defense and that gave me time to start my membership drive. Otherwise, I would have been spending all my time with the charter commission and not with furthering LACMA’s goals. I am very grateful to him for his leadership.” A board-certified surgeon and Executive Director of Trauma at Regional Medical Center in San Jose, Dr. Hinsdale has always found the time to devote to organized medicine and other causes that he truly believes in. He has been active with the CMA for 25 years. In March 2005, he was elected Vice Chair of the CMA’s Board of


Trustees. He has also served as a CMA Trustee and Chairman of the Board of Trustees. In addition to his activities at the state level, Dr. Hinsdale is a past president of the Santa Clara County Medical Association. He is currently Assistant Clinical Professor of Surgery at Stanford University School of Medicine and Medical Director of California Shock/Trauma Air Rescue (CALSTAR), a public, nonprofit rescue service. Bill Parrish, the CEO and Executive Director for the Santa Clara County Medical Association, has worked with Dr. Hinsdale since 1995 and has nothing but glowing praise for him. “I’m a big supporter of Jim’s,” says Parrish. “Jim is a doer; he’s a fighter. He is the single highest donor to CALPAC so he truly puts his money where his mouth is. You want to be on Jim’s side—it’s the winning side.” Parrish goes on to point out how much Dr. Hinsdale truly cares about his patients. “He saved my life,” says Parrish. When Parrish’s ankle swelled up, but wasn’t painful, he went to see his physician thinking it was probably a hypothyroid condition. His physician did blood tests and increased his medication but the condition persisted for more than six weeks. His joints began to ache and then his other ankle swelled. About that time he ran into Dr. Hinsdale at a meeting. Dr. Hinsdale began quizzing him about the ankle and upon finding out how long it had been swollen declared “Enough of this” and made sure Parrish got a CAT scan that day and rounded up a radiologist to read it. When the news came back that Parrish had lymphoma, Dr. Hinsdale wasted no time getting a more detailed diagnosis. He managed to get a radiologist, a pathologist and a CT scan all lined up on a weekend. When the diagnosis came back inconclusive, Dr. Hinsdale cancelled his cases the next day in order to do a biopsy for Parrish. The lymphoma turned out to be Stage 3. “He checked on me every day at home,” says Parrish. “And then he wouldn’t take a penny. That’s the kind of guy he is as a friend.” His generosity goes beyond friends, however. At the CMA’s House of Delegates meeting, he’s been known to raffle off a round trip air flight and the use of his condo in Hawaii to a lucky medical student. And all for free, of course. Dr. Hinsdale has been married to Elizabeth “Bonnie” Mulshine for 41 years. They have two adult children—William and Catherine—and four grandchildren—Clara, Rose, Charlotte, and Calvin. The Hinsdales’ live in Saratoga in Northern California. A native of Chicago, he attended St. Ignatius College Prep high school there and then Holy Cross College in Worcester, Mass. He received a medical degree from the University of Illinois College of Medicine in 1974. He served his internship, residency and surgical gastroenterological fellowship at Stanford

University Hospital from 1974 to 1980. He is a fellow of the American Association for Surgery of Trauma and the American College of Surgeons, and he is a member of Alpha Omega Alpha Honor Society. He is founder and President of the Northern California Trauma Medical Group, a group of 18 practicing trauma surgeons in the San Francisco Bay Area. He is also a six-time winner of the Physician’s Recognition Award from the American Medical Association. While Dr. Hinsdale’s stint as President and Immediate Past President of the CMA is ending in the all-too-quickly-coming fall, we don’t for one minute think that it is the last we will hear from him when it comes to organized medicine. We appreciate all that he has done for physicians and their patients throughout California over the years and the ways he has helped strengthen LACMA. And we look forward to seeing what he has up his sleeve in the coming years.

A true friend to organized medicine, Dr. James Hinsdale will be ending his term as Immediate Past President of the California Medical Association this fall. We can’t wait to see what he’ll be up to next.

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m e m b e r b e n e fits | at wo r k fo r yo u

reimbursement Advocacy and Assistance t h E C M A established the center for economic services to support physicians—especially those in solo practice, partnership, or small group settings—who face increasing financial pressures due to ongoing changes in the health care delivery system. we recognize that physicians like you are under constant pressure to streamline your business operations while continuing to provide access and quality care to patients. it is often a struggle to implement changes in stringent federal and state regulations and grapple with health plans that employ confusing, inconsistent, and unfair payment practices. we offer hands-on support to physician members in a variety of areas relating to practice management and a healthy bottom line: • Reimbursement assistance, which can help you recoup thousands of dollars by showing you how to appropriately respond to health plans through efficient appeals processes and claims reconsideration. • Direct assistance with resolving reimbursement issues. • numerous workshops and seminars that teach physicians and their staffs how to maximize reimbursements. • Various toolkits to help you better manage your finances. • cMa payor contract analysis, which is a free guide to contracting with payors. the educational guide helps members thoughtfully consider whether and when to enter into agreements with payors and how to prepare for negotiations when a payor relationship is desired. • assistance with federal and state pre- and post-payment audits and compliance. • information on health care issues, mandates and new policies to keep members informed about day-to-day reimbursement issues. • work with public and private payors to prevent onerous provisions from getting into contracts in the first place. For more information, contact the CMA’s Center for Economic Services at 1-800-786-4262.

At Work for You

LACMA offers a wide array of benefits designed to enhance your practice and protect your autonomy BY CAroL ChAKEr

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h E r E h A S N E V E r been a more important time to be a member of the Los Angeles County Medical Association and the California Medical Association. When you join LACMA and the CMA, you join a dedicated network of over 6,000 Los Angeles County physicians and over 35,000 California physicians who are working together to achieve a unified health care front and fight against unfair insurer reimbursement practices, restrictions on physician autonomy and the erosion of valuable legislation that protects physicians’ practices. LACMA and the CMA can help enhance your practice, improve your bottom line and protect your autonomy as a physician. Read on to discover the many benefits of membership.

Your Membership, Your Benefits

Since 1871, the Los Angeles County Medical Association has been at the forefront of medicine in L.A. County, ensuring that our members are represented in the areas of public policy, government relations and community relations. Through our advocacy efforts in both Los Angeles County and with the statewide California Medical Association, our physician leaders and staff strive toward a common vision—that you might spend more time treating your patients and less time navigating the obstacles that threaten your autonomy and undermine your practice of medicine. When you join LACMA and the CMA, you have access to these member-only benefits: • legislative advocacy

• • • • • •

Reimbursement advocacy and assistance Free legal consulting jury duty assistance Free publications hit resources Free access to educational events, webinars, and cMe programs • partnerships and discounts As a member of LACMA and CMA, these benefits can: • provide visibility with patients and the community. • help improve your bottom line. • provide access to networks of peer physicians and elected officials. • Give you a powerful platform to advocate for meaningful reform of the health care system and to protect your rights as a physician. • put valuable resources on topics ranging form practice management to legal issues at your fingertips. Most importantly, your membership works for you. As a member, you get access to an equally committed professional staff that will stop at nothing to protect the way you practice medicine from legal, regulatory and legislative intrusions. Your membership lets you focus on what’s really important: providing exceptional care to your patients. Recognizing the diverse membership needs of our prospective members, we offer specialized memberships for physicians, practicing residents and medical students. For additional information on the benefits of membership or to apply, please visit www.lacmanet.org or call us at 213-226-0313.

Jury Duty W h E t h E r Yo u P r AC t i C E in a solo/small group setting, a large hospital group, or anything in between, jury duty service can conflict with your important daily obligations and disrupt patient access to care. lacMa understands how valuable your time is and has developed a solution to provide you with maximum flexibility in scheduling jury duty service. our program even reduces the chance that you will have to report. please call 213-226-0304 if you need further assistance or have additional questions.

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Legislative Advocacy

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i t h o u r influential Government Affairs program, LACMA and the CMA build coalitions of engaged physicians and establish meaningful relationships with legislators and other decision makers to impact public policy for the benefit of physicians and their patients. Working in partnership with the CMA, LACMA is actively involved in legislation at the federal, state, and local levels. While the vision for our Government Affairs program is ambitious and sweeping, our work has a tangible impact on the day-to-day practices of our members.

Shaping Health Care Legislation

Critical issues affecting today’s physicians are being decided in the legislative arena at a fast and furious pace. The most powerful weapon in advancing the cause of physicians and their patients is you. Hearing from a physician with experience from the frontlines of medicine can

make all the difference for a legislator facing a complicated health care issue. As a physician, you are in a unique position to offer advice to lawmakers about specific legislation affecting the medical profession and to share the concerns and challenges you face in your everyday. You can also help increase patient access to the important services that physicians provide. It is not only the right thing to do so that your patients’ interests are best served, but it is also good for the stability of the medical profession.

LACMA PACs

LACMA PAC and the LA County Physicians Action Committee are LACMA’s political action committees. Their mutual goal is to support and elect pro-medicine candidates at the state level by directly contributing to candidates seeking election to the State Legislature and other local offices. Anybody can support LACPAC.

LACPAC has a powerful role to play in shaping state health care policy since about one-third of the California Legislature respresents L.A. County. Many of these legislators hold key leadership positions, including five past speakers of the State Assembly. Active participation in every election cycle ensures the election of candidates who share our philosophy toward the future of medicine.

Continual Protection of MICRA

The CMA and LACMA continue to defend against attacks by personal injury lawyers on the Medical Injury Compensation Reform Act of 1975, which is California’s landmark medical malpractice reform law that keeps doctors’ medical liability premiums low and thus also keeps health care costs in check. We continuously defend the constitutionality of MICRA in court. The CMA and LACMA also work to ensure that federal health care reform efforts do not undermine MICRA.

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Apply Now for Fall 2012 – merage.uci.edu/go/HCEMBA Contact us to attend an Information Session or schedule a personal consultation.

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Free Access to Events and Educational Programs L AC M A A N D t h E C M A regularly host seminars, cMe programs, webinars, conferences, meetings, and educational workshops on a variety of topics essential to running the business side of your practice. you’ll find seminars on: • implementing electronic medical records. • proper coding, billing and collection. • Managing Medicare. • practice management techniques. • understanding and implementing legislative and policy regulations. • and much, much more.

Benefits and Discounts

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L AC M A A N D C M A membership offers you exclusive, time- and moneysaving benefits. By taking advantage of these discounts and services, you can earn back more than the investment of your dues dollars. Products include discounts on billing and collections services, malpractice insurance, group practice insurance and HSAs, investment services, auto insurance discounts and more. Highlighted programs include: • Bank of America Affinity Card: a member-only credit card that offers reduced rates, premium service and a generous rewards program. • Marsh insurance Services: Marsh offers members a variety of insurance programs including high deductible health plans and health savings accounts, employment practices liability insurance, workers’ compensation, term life, business owners package, long term care, long term disability, business overhead expense, dental and more. • AAA Auto insurance Discounts: save hundreds annually. • CME tracking/Credentialing: cMa’s institute for Medical Quality, certifies cMe activity for credentialing purposes to the Medical Board of california, as well as to hospitals, health plans, specialty societies, and others. • heartland Payment Systems: Members receive exclusive discounts and a three-year rate guarantee on heartland payment system’s suite of financial services, which includes credit card processing, payroll services, check management and real time health benefits eligibility verification. Other discounted resources for you include:

events are held throughout the county and state. please view the calendar at www.lacmanet.org.

hit resources A S o F 2 0 1 1 , the federal economic stimulus package provides approximately $19 billion over five years for health information technology, including direct bonus payments upwards of $44,000 for qualifying physicians who demonstrate “meaningful use” of electronic health records systems. since eligibility is based on usage, even physicians who already use ehR systems are eligible. whether you already use an ehR system or are just starting to survey the landscape, lacMa and the cMa are ready to help you navigate this process. as a lacMa-cMa member, you will receive free access to health information technology resources.

• Epocrates: cMa members get a discount on all epocrates mobile and online products. save 30 percent on subscriptions to epocrates products such as the #1 rated epocrates essentials. epocrates provides point-of-care access (via mobile devices and the web) to information on drugs, diseases and diagnostics. call 1-800-786-4262 to access this benefit. • Staples: save up to 80 percent on office supplies and equipment from staples, inc. call 1-800-786-4262 to access this benefit. • MedicAlert: Medicalert is a nonprofit foundation with over 50 years of lifesaving experience identifying and providing vital medical information to emergency personnel for over 4 million members worldwide. cMa members and their patients save $10 on new adult enrollments and $2.95 on Kid smart enrollments. call 1-800-253-7880 to access this benefit. • Magazine Subscriptions: 50 percent off subscriptions to hundreds of popular magazines, with a best price match guarantee. call 1-800-289-6247 to access this benefit. • Car rentals: save up to 25 percent on car rentals for business or personal travel. Membersonly coupon codes are required to access this benefit. Get your code by calling the cMa’s Member help center 1-800-786-4262.

Legal Assistance t h E C M A’ S L E G A L help line provides immediate assistance for hR, medical, regulatory or legal questions. this resource is free to members. in addition, members have access to cMa on-call, the california Medical association’s online library of medical-legal and other information of importance to physicians. the library includes most of the center for legal affairs’ annual publication, the california physician’s legal handbook, as well as more specialized information on peer review and other topics, including information from the cMa’s center for Medical policy and economics. please call 1-800-786-4262 to access the legal help line. to access cMa on-call, please visit www.cmanet.org.

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Benefit of the Month H i g h L i m i t Supplemental Disability insurance is an exciting new benefit for Los Angeles County Medical Association members. Many physicians find they have a significant gap between the level of disability insurance needed and the level of coverage available to them, leaving them at risk for financial hardship should a disability occur. High limit supplemental disability insurance is designed to cover the loss of income that results from having only traditional disability policies in place to protect you. Whether you have your own disability insurance or it is provided by your group, this plan is something you should consider for your own protection. The purpose of disability insurance is to replace a portion of the income a physician loses when unable to work due to a disability. The monthly benefit amount is typically limited to a percentage of your monthly income, up to a maximum monthly benefit cap that can vary by insurer. The result: high income earners

have a decreased amount of replacement income. High Limit Supplemental Disability insurance bridges the gap by providing coverage above and beyond the limits of standard disability insurance. For example: A physician earning $200,000 per year would very likely qualify for an average maximum disability benefit of $120,000 per year or $10,000 per month, replacing 60 percent of his or her income. In some cases it might be higher at 66-2/3 percent. But as you earn more, the maximum disability benefit available in any one plan, or together with all plans, is capped at lower percentage thresholds. This prevents you from protecting your income at proper levels. Here are the benefits you should look for in a High Limit Disability Plan: • High Limits—For instance, high limit plans offer additional protection of up to $25,000 per month.

• Own occupation definition policy—This means underwriters will recognize your medical specialty or sub-specialty that is widely recognized by the medical profession and that you are practicing in prior to a disability. • Premium guarantees—Premiums should be guaranteed during the term of each policy. • Guaranteed Issue—Is the policy available without medical underwriting requirements? Marsh is pleased to announce a new program for LACMA members who have existing monthly disability benefits of $7,500 per month and need higher monthly benefits. To find out more, and receive a premium indication with a 20 percent premium discount, please call a Client Service Representative at 800-842-3761, or e-mail CMACounty. Insurance@marsh.com. Roy S. Lyons is the Managing Director of Marsh.

Meet Your Board! L AC M A’ 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, Executive Assistant, at lisa@lacmanet.org or 213-226-0304. Officers Samuel Fink, MD

Erik Berg

Lawrence Kneisley, MD

Heidi Reich, MD

Councilor-at-Large

Resident/Fellow Councilor

President

Medical Student Councilor / USC Keck

Marshall Morgan, MD

Stephanie Booth, MD

Howard Krauss, MD

Susan Reynolds, MD

Councilor

Councilor

President-Elect

Councilor-at-Large

Pedram Salimpour, MD

Jack Chou, MD

Gideon Lowe, MD

Bob Rogers, MD

Councilor

Councilor

Treasurer

CMA Trustee

Peter Richman, MD

Sidney Gold, MD

Secretary

Councilor

Troy Elander, MD

William Hale, MD

Immediate Past President

Councilor

Board of Directors David Aizuss, MD

Shelley Han

CMA Trustee

Medical Student Councilor / UCLA David Geffen

William Averill, MD

Vito Imbasciani, MD

Councilor

Councilor

Paul Kirz, MD

Jonathan Macy, MD

Sion Roy, MD

Councilor-at-Large

Resident/Fellow Councilor (Alternate)

Carlos E. Martinez, MD Councilor

Nassim Moradi, MD Councilor

Ashish Parekh, MD Councilor

Jeffrey Penso, MD

Pejman Salimpour, MD Councilor

Shuo Steven Wang, MD Councilor-at-Large

Erin Wilkes, MD CMA Trustee (Resident)

Councilor-at-Large

Chair of LACMA Delegation j u ly 20 1 2 | w w w. s o c a l p h ys i c i a n . n e t 2 9


asso ciati o n happe n i n gs | n e ws & e ve n ts

July and August Events JuLY EVENtS 11 2012 Legislative update Free webinar. This webinar will provide physicians and their staff with the latest information on the bills that made their way through the State Legislature this year. Topics that will be discussed include immunizations, children’s health, physical therapists, physician health and much more. 12:15 p.m. - 1:15 p.m. Contact: 800-786-4262 or memberservice@cmanet.org.

12 Latino Physician Empowerment Dinner Free. Hosted by LACMA CEO Rocky Delgadillo, this second in a set of Latino Physician Empowerment Dinners is back by popular demand. Hear from other Latino physicians regarding their thoughts on the changes affecting health care, the way the practice medicine, and LACMA’s vision for becoming a more interactive player amongst the physicians in the Latino community. 6:00 p.m. Tamayo’s, 5300 E. Olympic Blvd., Los Angeles. Contact: Lisa Le at 213-2260304 or lisa@lacmanet.org.

18 Preparing for a Medicare and/or MediCal Audit Free webinar for members

and staff; $99 for nonmembers. All third-party payers, including government health plans, have stepped up their audit activity. It is no longer a matter of “if” you go through an audit, but a matter of “when” you are selected for an audit. It is always preferential to be prepared. This webinar will discuss recognizing those things that put your practice at risk for an audit, how to know when you are being audited, handling a request for records, and what to do with your results. 1 CEU credit. 12:15 p.m. - 1:15 p.m. Contact: 800-786-4262 or memberservice@cmanet.org.

AuGuSt EVENtS 1 Coding for Medical Necessity Free webinar for members and staff; $99 for nonmembers. Medicare and private payers all recognize medical necessity as a deciding factor for claims payment and it is important that all practices know the rules. We will discuss applying the rules to your patient encounters, medical decision making and medical necessity, importance of diagnosis coding, coverage determination policies, using an electronic health record, how

to respond to requests for records, and how to appeal if you disagree with decisions from outside reviewers. 1 CEU credit. 12:15 p.m. - 1:15 p.m. Contact: 800-786-4262 or memberservice@ cmanet.org.

8 CMA and the Courts / Accessing CMA’s Legal Library Free webinar. Learn about the CMA’s role in important litigation in California and nationwide and learn how to navigate the CMA’s health law library. The Legal hotline staff will provide and overview of the wide array of topics covered in the CMA’s online library. 12:15 p.m. -1:15 p.m. Contact: 800-786-4262 or memberservice@cmanet.org.

15 Program integrity in Medicare and Medi-Cal—the Physician’s role Free webinar for members and staff; $99 for nonmembers. This session provides physicians with information about the risks of becoming a victim of fraud and how to take preventative action. It also covers compliance with Medicare and Medi-Cal documentation requirements. 1 CEU credit. 12:15 p.m. - 1:15 p.m. Contact: 800-786-4262 or memberservice@ cmanet.org.

In mid-June, Los Angeles County Medical Association President Troy Elander, MD, presented the benefits of a LACMA membership to the Korean American Graduate Medical Association. About 50 people from this group composed of young physicians attended to learn more about how the Association can help their careers as physicians and help them advocate for their patients.

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N e ws & e ve n ts | associati o n happe n i n gs

Welcome to Our New Members! Please offer a warm welcome to our new members. Organized medicine is now 57 voices stronger thanks to them! Metropolitan District 1 Sang Hoon Ahn, MD Hematology / Oncology

Stephen Carney, MD Emergency Medicine

Min Cha, MD Pediatrics

Andrew Cho, MD Ophthalmology

Kyung Han, MD Internal Medicine

George In, MD Family Practice

Hans Kim, MD Ophthalmology

Kenneth Kim, MD Plastic Surgery

Lisa Masson, MD Family Practice

Pasadena / San Gabriel Valley District 2 Armen Cherik, MD Neurology

Joseph Davidson, MD Ophthalmology

Fowrooz Joolhar, MD Cardiology

Eli Baron, MD

Sam Seelig, MD

Neurosurgery

Anesthesiology

Arthur Benjamin, MD

Rebecca Slomovic, MD

Ophthalmology

Gastroenterology

Eduardo Besser, MD

Mitchell Spirt, MD

Ophthalmology

Gastroenterology

Gary Brazina, MD

Stuart Stoll, MD

Orthopedic Surgery

Ophthalmology

Edward Carden, MD

David Wallace, MD

Pain Medicine

Ophthalmology

Uday Devgan, MD

Philip Werthman, MD

Ophthalmology

Urology

Moses Fallas, MD

Graham Woolf, MD

General Surgery

Gastroenterology

Philip Fleshner, MD

Kenneth Wright, MD

General Surgery

Ophthalmology

Jerome Goldwasser, MD

Southwest District 9 Ripu Arora, MD

Gastroenerology

Robert Gross, MD Gastroenerology

Jayson Hymes, MD Pain Medicine

Afshin Khodabakhsh, MD Ophthalmology

Robert Klapper, MD Orthopedic Surgery

Long Beach District 3 Lars Hertzog, MD

Mari Madsen, MD

Ophthalmology

Colon and Rectal Surgery

Janita Russo, MD

Samuel Masket, MD

Nephrology

Ophthalmology

Bay District 5 Michael Gorin, MD

Gil Melmed, MD

Ophthalmology

Parrish Sadeghi, MD Dermatology

Beverly Hills District 7 Robert Katz, MD Obstetrics / Gynecology

David Alessi, MD Facial Plastic Surgery

Gastroenterology

Frederic Nicola, MD Orthopedic Surgery

John Reinisch, MD Plastic Surgery

James Salz, MD Ophthalmology

Anesthesiology

Kamran Ghadimi, MD Anesthesiology

Yousef Hendizadeh, MD Psychiatry

Gregory Keese, MD Orthopedic Surgeon

James London, MD Orthopedic Surgeon

Huong-Anh Long, MD Physical Medicine

Alexander Nemirovsky, MD Anesthesiology

Lalitha Ramanna, MD Nuclear Medicine

Southeast District 10 Dong Kim, MD Pediatrics

Carolina Vazquez, MD Family Practice

Nicholas Schenck, MD

East San Fernando Valley District 17 Shahan Yacoubian, MD

Otolaryngology

Orthopedic Surgery

j u ly 20 1 2 | w w w. s o c a l p h ys i c i a n . n e t 3 1


asso ciati o n happe n i n gs | N e ws & e ve n ts

Get Ready for Medi-Medi Seminar series helps physicians prepare The Los Angeles County Medical Association was pleased to host a series of educational seminars from the California Medical Association regarding dual eligible patients from Medicare and Medi-Cal. Frank Navarro, Director of Economic Services, and Jay Hansen, Chief Strategy Officer, from the CMA spoke to hospitals and ethnic groups, which are the groups most affected by the Medi-Medi pilot project since they deal largely with underserved populations, regarding how the Medi-Medi pilot program will happen and how physicians should prepare. The group somehow managed to squeeze in six seminars in L.A. County during the month of June. Venues included Good Samaritan Hospital, the American Armenian Medical Society, the Long Beach Memorial Medical Center, the Valley Presbyterian Medical Center, the St. Vincent Medical Center and the Providence St. Joseph Medical Center.

Onward and Upward Talking Tours go full steam In J u ne , the Talking Tours initiated by LACMA CEO Rocky Delgadillo continued in force with seven new locations including the Pomona Valley

Hosptial, the St. Francis Medical Center and the Brotman Medical Center and many more. And there were a slew of new announcements. Attendance at each

3 2 s o u t h e r n c a l i f o r n i a p h ys i c i a n | J u ly 2 0 1 2

event was large, and as always, vocal with physicians expressing their concerns and opinions. LACMA had its share of announcements to make including its plans to provide media training to physicians so that they can skillfully speak to the press about issues that concern them and legislation on the rise. In addition, LACMA will work to ensure that physicians land powerful, prestigious positions on leadership boards around the county such as the fire department commission and the police commission. The bottom line message from Delgadillo that each attendee came away with was that physicians need to unite, as an organized group, in order to make their voices heard in Los Angeles County and beyond. To make your voice count, be sure attend our events. You can find them at www.lacmanet.org. You won’t want to miss these events!


Los Angeles County Medical Association Bay District 5

District 5 Annual Summer Beach Picnic Bel-Air Bay Club Saturday, July 14, 2012 12:00 PM - 3:00 PM

Please join your fellow physicians and families from LACMA’s Bay District, and enjoy an afternoon picnic on the beach at the beautiful Bel-Air Bay Club.

Picnic Activities Mix and mingle with your local colleagues Barbecue favorites including burgers, hot dogs, and chicken Children’s menu Volleyball Playground and inflatable jumping castle Refreshing beverages including iced teas, sodas, margaritas, beer and wine Sun, sand and surf LACMA Member families: No Charge Non-Member families: $50.00/family Details Where: Bel-Air Bay Club, Lower Clubhouse, Palapa Area 16800 Pacific Coast Highway Pacific Palisades, CA 90272 R.S.V.P: Carolina Vasquez 213-683-9900/ carolvelaz03@gmail.com Parking: Available in the Will Rogers State Beach parking lot just east (south) of the Lower Clubhouse.(parking fees not covered). The entrance to the Will Rogers State beach parking lot is located at the intersection of Temescal Canyon Road and Pacific Coast Highway. Once parked, guests should walk west (north) along the seaward sidewalk, down the sandy hill and onto Club property. .


cl assi fi e ds / jo b boar d To place a classifieds ad, contact Karen Heger at karenh@lacmanet.org or 213-226-0393 118

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VINELAND & MOORPARK MEDICAL OFFICES AVAILABLE 1,100-2,806sqft. Prestigious high visibility corner location, many recent renovations, onsite surface parking, close to freeways and hospitals, many long term satisfied tenants. LEASE WITH OPTION TO BUY. Daniel 310268-7770 ext 111 or daniel@ PacificRealtyVentures.com

130

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135

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REDONDO BEACH ARTESIA CORRIDOR 144-2,382 sq. ft. Professional and medical offices, some views, near freeways, restaurants and shops. Parking + ADA elevator at 2512 Artesia Blvd. 310-5690384 Email: maryannejankovic@ hotmail.com or visit: http://pike. nsicorp.net.

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REDONDO BEACH RIVIERA VILLAGE 145 – 2,017 sq. ft. Some views, balconies, impressively near restaurants, shops and beach! Medical parking + ADA elevator, at 1611 S. Catalina Ave. 310-5690384 Email: maryannejankovic@ hotmail.com or visit us at www. plazariviera.nsicorp.net. newport beach SUITES FOR LEASE 1,240 and 1,000 sq. ft. Ground or 2nd floor, 1 block to Hoag Hospital, plenty of parking, low rent. Call 949-645-6665. See: wrmorganmd.org/sfl.htm. 610

medical practice for sale

PEDIATRIC PRACTICE FOR SALE Sole practice over 30 years in Upland, CA. Doctor planning to retire soon. E-mail: uplandped39@ yahoo.com.

3 4 s o u t h e r n c a l i f o r n i a p h ys i c i a n | J u ly 2 0 1 2

IMMEDIATE OPENINGS FOR EXPERIENCED PHYSICIANS Great opportunity for Family Physician, Neurologist, etc. Seeking specialists for expansion. The clinic is suitable for multispecialist or urgent care clinic. Call 310-273-6060, or fax: 310273-6097. job board

testimonial “I rely on the doctor-to-doctor ads for medical equipment and leasing space. It’s a great resource.” Wayne Gradman, MD


jo b boar d / cm e / m ar ke t pl ace / ad i n d e X To place a cme lisTing, conTacT K aren Heger aT K arenH@lacmaneT.org or 213 -226 - 0393 film reading Carl H. Boatright, MD, DABR, 30 years’ experience, rapid turnaround. We are now accepting Teleradiographs for General X-ray and General Ultrasound examinations. 866-723-2081. 535

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CME 5TH annual ciTy of Hope conference on HemaTologic malignancies September 13 – 15, 2012, Hotel Casa Del Mar, Santa Monica, CA

Learn about recent advances in the treatment of multiple myeloma, lymphoma and leukemia in a highly interactive environment while engaging in one-on-one dialogue with renowned experts. Updates on improved curative and palliative treatments, evolving molecular and immunologically based systemic therapies, and important, completed or ongoing clinical trials will all be profiled. REGISTER TODAY at www.cityofhope.org/hematologicconference2012

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to place a marketplace ad, contact Karen heger at karenh@lacmanet.org or 213-226-0393. j u ly 20 1 2 | w w w. s o c a l p h ys i c i a n . n e t 3 5


4 million The number of the U.S. population that are, or have been, infected with hepatitis C—that’s 1.8%. (2)

70% 90% How many people that become infected will develop chronic liver disease. (2)

Sou rCE S

1 centers for Disease control and prevention 2 american liver Foundation 3 arizona Department of health services

How many liver transplants were performed in the U.S. in 2005. (3)

The annual number of chronic liver disease deaths associated with hepatitis C. (1)

6,500

12,000 j ust t h e fac t s | h e patitis c

Amount of decline in the incidence of acute hepatitis C since 1992; however, a large burden of disease caused by chronic hepatitis C virus infection remains. (1)

10-20%

How many people that become infected will develop cirrhosis. (3)

2.7 TO 3.9 MILLION Number of people living with chronic hepatitis C. (1)

3 6 s o u t h e R n c a l i F o R n i a p h ys i c i a n | j u ly 2 0 1 2


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July 2012