November 2013

• The Big 3: Medicare, Obamacare, MICRA

• Partnership HealthPlan to absorb Medi-Cal rate cuts to local physicians

• Physicians urged to refer prediabetic patients to YMCA prevention program

• CMA delegates meet to discuss critical health care issues, set policy

• Message from CMA President Dr. Richard Thorp

• POLST: Improving patient care in the emergency department

• PEOPLE

• MEDICAL ORGANIZATIONS

• RESOURCES AND EVENTS

• CLASSIFIEDS

• APPLICANTS

• ABOUT MMS

The Big 3: Medicare, Obamacare, MICRA

The current federal and state landscape for healthcare has three dominant features, according to chief CMA lobbyist Elizabeth McNeil: Medicare payment reform, implementation of Obamacare, and a nascent attempt to gut California’s Medical Injury Compensation Reform Act (MICRA). Speaking to about 80 physicians, spouses and guests at the Fountaingrove Inn in Santa Rosa on Oct. 23, McNeil offered a whirlwind tour of all three features, pausing at times to describe some of their intricate details.

McNeil was formally introduced to the crowd by local CMA Trustee Dr. Peter Bretan, a urologist with offices in Novato and Sebastopol. Encouraging his colleagues to be more politically active, Dr. Bretan observed that modern life is no longer “survival of the fittest,” but rather “survival of the most politically allied.”

McNeil began with a recap of the recent government shutdown, expressing the view that Congress is even worse than it looks, and that it’s not fixing anyone’s problems. The challenge, she said, is getting Congress to do something productive, particularly in the face of determined Tea Party activists who are trying to dismantle the government. She praised local congressmen Jared Huffman and Mike Thompson, noting that Thompson serves on the powerful Ways & Means Committee and is a Medicare expert.

The House Energy & Commerce Committee did unanimously pass a Medicare SGR (sustainable growth rate) overhaul in July, explained McNeil, but the legislation has been languishing, with several obstacles to clear before it can come to a vote in the full House and Senate. McNeil emphasized that without the overhaul, physicians may face up to a 30% pay cut from Medicare. The bill also includes the long-awaited “GPCI fix” that would raise Medicare reimbursement rates in Marin County by at least 5%, and in Sonoma County by at least 3%.

Turning to the Affordable Care Act, better known as Obamacare, McNeil noted that the Covered California website is faring significantly better than its much-maligned federal cousin, www.healthcare.gov. Nonetheless, the initial physician directory on Covered California was rife with errors and has been taken down until mid-November. She offered the example of one doctor who was incorrectly listed as speaking Arabic, Turkish, Spanish, Russian and Farsi, and she urged physicians to check their listings once the directory goes back up.

McNeil’s tour concluded with a MICRA update. Trial lawyers have begun collecting signatures to put their anti-MICRA initiative on the November 2014 ballot. Besides raising the current $250,000 cap on non-economic damages to more than $1.1 million, the measure would mandate physician drug testing. The anti-MICRA campaign has already turned vicious, said McNeil, describing how one group recently circulated a flyer accusing recent CMA President Dr. Paul Phinney, a Sacramento pediatrician, of being a drug addict.

Both McNeil and Dr. Bretan urged physicians to donate to the pro-MICRA campaign. Dr. Bretan explained that if donations are made via medical staff organizations, hospitals will match them two for one. Donations can also be made to the Californians Allied for Patient Protection website at www.micra.org.

McNeil’s speech was followed by a lively question-and-answer session, with topics ranging from the role of specialty societies to implementation of a single-payer system.

Partnership HealthPlan to absorb Medi-Cal rate cuts to local physicians

Partnership HealthPlan, which operates the managed Medi-Cal program throughout the North Bay, will absorb the mandated Medi-Cal rate cuts to physicians during the next year. “The state’s fiscal crunch has always been a challenge to us,” said Partnership CEO Jack Horn, “but we’re very happy that we can keep these cuts away from our doctors for the time being.”

Legislation mandating the cuts was signed by Gov. Jerry Brown in 2011, but they are only now being implemented. Because Partnership is a county-organized health system, it can use its resources to absorb some of the cuts. The state has also exempted certain specialties from the cuts. “Moving forward,” said Horn, “we’re confident that our managed care initiatives will bring even more savings which we can use to help our providers.”

Physicians urged to refer prediabetic patients to YMCA prevention program

Physicians throughout Marin County are urged to refer prediabetic patients to the YMCA Diabetes Prevention Program, which will be launching locally in January. The program helps those at high risk for developing type 2 diabetes adopt and maintain healthy lifestyles by eating healthier, increasing physical activity and losing a modest amount of weight. Program participants work together in a small group led by a trained lifestyle coach over a 12-month period, beginning with 16 weekly sessions and continuing with monthly maintenance.

Research has shown that prevention programs can reduce the number of cases of type 2 diabetes by 58%. The reduction is even greater, 71%, for people 60 or older.

To qualify for the program, participants must be at least 18 years old, overweight (BMI ≥ 25), and at high risk for developing type 2 diabetes or have been diagnosed with prediabetes. Patients who have already been diagnosed with either type 1 or type 2 diabetes do not qualify for the program.

The cost is $429 per year, but financial assistance is available. Health insurers may also pay for the program, depending on the patient’s coverage.

For more information, or to refer patients, contact the YMCA’s Elizabeth Bachrad at 415-281-6702 or ebachrad@ymcasf.org, or visit www.ymcasf.org/diabetesprevention. A patient flyer and a program application form are attached below.

Diabetes Prevention Program flyer

Program application form

CMA delegates meet to discuss critical health care issues, set policy

More than 500 California physicians convened in the Disneyland Hotel in Anaheim on Oct. 11-13 for the 2013 House of Delegates, the annual meeting of the California Medical Association. Each year, physicians from all 53 California counties, representing all modes of practice, meet to debate resolutions related to healthcare policy and to elect CMA officers. Delegates at this year’s meeting:

• Approved a resolution that encourages increased reporting of patient immunizations to the California Department of Public Health for purposes of vaccination, disease control and prevention.

• Voted to support revision of HIV consent requirements to allow all health care providers to order a test for HIV when appropriate and to encourage routine HIV testing for all patients who are evaluated for other sexually transmitted diseases.

• Called on CMA to support the use of graphic image labeling on cigarette and other tobacco packaging that warns of the health impact of smoking.

• Endorsed the National Transportation Safety Board’s 2013 recommendation that the legal blood alcohol limit for operating a motor vehicle be decreased from .08 percent to .05 percent or lower.

• Directed CMA to promote that providers need to identify children and adults who are food insecure to avoid detrimental development and comorbidities and refer them to appropriate programs and services.

• Directed CMA to request that the Centers for Medicare and Medicaid Services eliminate its “outpatient patient observation” status, which is placed upon patients whose anticipated hospital stay is 48 hours or less. Delegates noted that this practice places undue financial burden on patients and creates administrative hassles for physicians.

• Called on CMA to support efforts to develop benefit designs in the health benefit exchange that appeal to the young and healthy to boost the risk pool; and to support legislation allowing federal and state income tax deductibility of all out-of-pocket health care expenses.

• Asked that CMA support legislation requiring health insurance companies to pay physicians for telephone or other electronic patient management services.

• Called on CMA to support the development of a secure, interoperable, nationwide health information exchange network.

The full actions of the House of Delegates are available to members on the Documents tab at www.cmanet.org/hod.

Message from CMA President Dr. Richard Thorp

[Dr. Thorp, a Paradise internist, was installed as CMA president during the recent House of Delegates meeting in Anaheim.]

In October, I was honored and humbled to stand before more than 400 delegate physicians from across geographies, specialties and modes of practice at the California Medical Association (CMA) Annual House of Delegates meeting in Anaheim. I want to share with you the messages I shared with our colleagues, as I believe it is important to be unified as one voice moving forward in this tumultuous time of change in healthcare.

First and foremost, we can agree that this is an incredible time to be part of our profession. We are living history as new models of integrated care and innovative technologies become a thing of the present, rather than a dream of the future. Patients will have access to treatment and medicine that they have never been exposed to, and with our work and research, we can offer our patients additional years, if not decades, with their loved ones.

Although we are at the pinnacle of discovery in the treatment of disease, this profession is also under serious attack, and so we must work more diligently than ever before. We cannot make the mistake of tempting our adversaries with complacency.

I practice in Paradise, a small town in Northern California, just a few hours outside of Sacramento. I can tell you first hand, as the medical director of a rural health clinic and as president/CEO of a private multispecialty primary care group (internal medicine, family medicine, hospitalist medicine and pediatrics), that communities like mine are feeling the changes ahead of us the most.

Between cuts to California’s Medicaid program (Medi-Cal) and the Congressional stalemate that continually threatens the future of Medicare, running a practice is a constant challenge. As attacks on California’s Medical Injury Compensation Reform Act (MICRA) continue and unknown curveballs are thrown our way, we must stand together with one voice--that is the only way that we will prevail.

My hope for us in this next year is that physicians of California remember and are inspired by how far the profession has come as we face the new challenges of the future. We live in the golden age of medicine: a time when the future of medical treatments is bright and getting brighter every day, and when we speak in unison, we have a powerful voice!

Offering safe, quality, accessible and affordable health care to our patients is why we joined this noble profession. Whatever fight may come before us this next year, let us stand and live by CMA's mission statement: Promoting the science and art of medicine, the care and well-being of patients, the protection of the public health and the betterment of the medical profession.

POLST: Improving patient care in the emergency department

True McMahan, MD

[Dr. McMahan is associate medical director of emergency services for Monarch Health Care.]

Emergency department (ED) physicians are a diverse group of providers. Some of us are cavalier, shooting from the hip as called for by the situation at hand. Others are meticulous and obsessive planners, taking no chances and casting a wide net of differential diagnoses. But MOST, if not all of us, work in a daily melee of balancing a multitude of patients with emergency medical conditions, all the while putting out administrative fires and juggling family and visitors. Is it any wonder then that we crave simplicity? Why not have one less decision, one less stack of nursing home records and advance directive jargon to sift through? That is the beauty of the bright pink POLST form that I have come to know and love.

POLST stands for Physicians Orders for Life Sustaining Treatment. Since 2010, when I first learned of this initiative to simplify and standardize end-of-life wishes, I have been a passionate supporter of its implementation. My hope is that by the end of this article, a few more physicians will be persuaded to join with me in promoting this valuable tool.

First of all, what is it? The POLST form is a doctor’s order that delineates specific medically appropriate measures desired by the patient or his/her surrogate decision maker should the patient become seriously ill, mostly what we ED physicians and providers call “code three” patients. It is a single piece of paper and is bright pink so that it is easily recognized in a stack of medical records. When used correctly, the POLST form follows the patient from acute care to primary care. Stories of its utility include EMS finding it hanging from a patient’s refrigerator when neighbors called 911 and the patient lived alone, and designated health care agents having electronic versions and emailing or faxing a copy to the ED while they are en route.

I challenge all providers in the ED and acute care setting that as physicians we not only have a duty to treat, but only to treat as the patient’s dignity and health goals require. Paternalistic medicine serves to help no one. Non-beneficial care leads to more emotional pain and financial devastation than we realize. As for the ED practitioner, taking a few seconds to find that POLST form, even if hidden in the stack of papers brought in by the paramedics, may mean the difference of peace for patients and their survivors or end-of-life trauma and havoc.

Because the POLST form requires the patient or family to have the courageous conversation about end-of-life wishes BEFORE the crisis, it allows that moment of crisis to be expected, allows us emergency providers to be facilitators of thoughtful care, while taking the guesswork out of hectic, desperate situations. For me, finding that pink POLST form brings calmness to the gathered team of resuscitators. As I read aloud the wishes delineated on that form, I am able to provide care as if I had just consulted the patient and family, and I can perform that care under the grace of the Hippocratic Oath and with the grace of a doctor who cares about what the patient or family would want.

The California Medical Association (CMA) publishes a POLST kit, available in English and Spanish, that includes legal forms and wallet identification cards, and answers many of the most frequently asked questions about end-of-life issues. These kits are available in CMA's online resource library at www.cmanet.org/resource-library.

For more information on palliative care and POLST, visit www.coalitionccc.org and www.capc.org.

PEOPLE

Drs. Irina deFischer, Jeff Stevenson, Cuyler Goodwin and Peter Bretan represented MMS at the recent CMA House of Delegates meeting in Anaheim (see accompanying story). During the meeting, delegates approved the following local appointments to CMA committees: Dr. deFischer, to the Council on Legislation; Dr. Bretan, to the Council on Ethical Affairs, the Committee on Medical Services and the Committee on Nominations; Dr. Michael Rokeach, to the Council on Judicial Affairs; and Dr. Anne Cummings, to the Medicare Reform Technical Advisory Committee.

MEDICAL ORGANIZATIONS

Marin General Hospital, which recently received a $4 million anonymous gift for its radiation oncology department, is using new technology in its cardiac catheterization lab to unblock chronic total occlusions. Dr. Brian Strunk, chief of cardiology at the hospital, explained that the new catheter-based technology makes slits in the artery wall, allowing cardiologists to guide wires around the blockage, move the plaque, and create new channels for blood flow. “The procedure is difficult and time-consuming,” said Dr. Strunk, “but we are committed to making it more widely available to those patients whose conditions warrant it and whose quality of life will greatly benefit.” Cardiologists at the hospital have performed 10 of the minimally invasive procedures over the past three months, with a 90% success rate; the national average is 75%.

RESOURCES AND EVENTS

CMA’s Institute for Medical Quality and the PACE program at UC San Diego are cosponsoring a Stepping Up to Leadership conference in San Antonio, Texas, on Nov. 7-9. The conference trains medical staff leaders in issues of communication, problem solving, and improving outcomes for patients and staff. Because of a grant from the Physicians Foundation, cost is as low as $595 for all three days. To register, visit www.physician-leadership.org.

MMS members can get registration discounts for the Napa Primary Care Conference: Caring for the Active and Athletic Patient, to be held at the Napa Valley Marriott from Nov. 6 to 10. The conference is designed for physicians and medical professionals who care for active and athletic patients or who themselves lead such a lifestyle. Topics include common medical and musculoskeletal problems, healthy lifestyles and personal wellness. The conference offers up to 16 hours of CME. To register, visit the conference website.

Physicians and staff are invited to attend an Open Payments Sunshine Rule Webinar sponsored by Medicare from noon to 1 p.m. on Nov. 14. The webinar will cover the new Sunshine Rule, intended to increase public awareness of financial relationships between drug and device manufacturers and certain healthcare providers. To attend, visit https://webinar.cms.hhs.gov/ro9-10openpayment/ or call 877-267-1577. The meeting ID number is 994-209-357, and no password is required.

The following CMA webinars are scheduled for November and December. Webinars, which are typically worth one CEU credit, begin at 12:15 p.m. and run until 1:15 or later. To register, visit www.cmanet.org. Seminars are free for CMA members and their staff; cost for nonmembers is $99 per person.

• Managing Difficult Employees and Reducing Conflict (Nov. 13)

• ICD-10 Documentation for Physicians: Part 1 (Dec. 5)

• ICD-10 Documentation for Physicians: Part 2 (Dec. 12)

• ICD-10 Documentation for Physicians: Part 3 (Dec. 19)

CLASSIFIEDS

Primary care/immediate care physicians needed

Physicians and MD medical director needed for new primary care/immediate care facilities located in Pittsburg/Antioch and San Rafael. Ideal for semi-retired MDs or if part time work desired. 6 hr shifts--7 a.m. to 1 p.m. or 1-7 p.m. Prior supervision of NP/PAs and Medi-Cal existing provider credentialing a plus. Send CV and inquires to MD@practiceconsultants.net.

MMS members get free classifieds!

MMS members can place free classified ads in News Briefs or Marin Medicine. Cost for nonmember physicians and the general public is $1 per word. To place a classified ad, contact Linda McLaughlin at Linda@scma.org or 707-525-4359.

APPLICANTS

David Palestrant, MD, Critical Care Medicine, 7 Circle Way, Mill Valley 94941, Univ Arizona 1996

Peter Uzelac, MD, Obstetrics & Gynecology*, Reproductive Endocrinology, 1100 S. Eliseo Dr. #107, Greenbrae 94904, St. George’s Univ 1998

* = board certified; italics = special medical interest

ABOUT MMS

The Marin Medical Society, a 501(c)(6) nonprofit association, supports local physicians and their efforts to enhance the health of the community. We are affiliated with the California Medical Association and the American Medical Association.

© 2013 MMS, PO Box 246, Corte Madera, CA 94976