San Francisco Medical Society Blog

Your Help Needed to Oppose SB 62 (Bill Requiring Medical Board Investigations for Prescription Drug Deaths)

Tue, 21 May 2013 16:43:41 GMT

On Thursday, May 23, the Senate Appropriations Committee will be considering a bill that would require a coroner to file a report with the medical board when a controlled substance is found to be a contributing factor in a death. While well-intentioned, SB 62 simplifies a very complicated issue to the potential detriment of patients.

SFMS/CMA is urging physicians to contact their senators today and ask them to oppose this flawed bill.

SB 62 (Price) would expand provisions to require a coroner to file a report with the Medical Board of California when he or she determines that a Schedule II, III, or IV drug was a contributing factor in a death.

Senator Price's stated assumption that a coroner’s report connects the dots between overdose deaths and so-called physician overprescribing is fundamentally flawed. This bill is a response to growing concern about prescription drug abuse, an issue that is of great concern to SFMS/CMA and physicians across the state. However, the statistics show that the vast majority of people who abuse prescription drugs acquire them from friends and family (often without their knowledge) or from sources other than the prescriber. There are also many circumstances in which individuals with legitimate prescriptions for controlled substances might die, including non-compliance with prescriber's orders or mixing the drugs with other substances like illicit drugs or alcohol.

If this bill is allowed to become law, it will become increasingly more difficult for patients being treated for pain to get appropriate treatment, as physicians will become less likely to prescribe controlled substances for fear of a medical board investigation.

We ask that you and your colleagues call, fax, or email your legislators TODAY.

Call (877) 362-8455 to be connected with your legislator or click here to send an email (sample email via link).

Talking Points

As a physician, I am very concerned about the growth in prescription drug abuse and want to be a partner in addressing it, but SB 62 is an approach that will have significant unintended consequences.
The reports being required under SB 62 will make physicians less likely to prescribe drugs on Schedule II, III, and IV for fear of investigation even in instances when the care is appropriate. Doing so will impact patient’s ability to get appropriate pain management.
There are many circumstances in which a person with a legitimate prescription for a controlled substance may die, including the patient being non-compliant with the prescriber’s orders or mixing the drugs with other substances like illicit drugs or alcohol.
Patients being treated for pain may also have comorbities that could result in death. None of these instances reflect inappropriate practice by a physician and yet all of them could be reported to the medical board for investigation under SB 62.
Further, the vast majority of people (70%) who use drugs for non-medical purposes did not get it from a prescriber, but from other sources.
The risk of negatively impacting patient care must be balanced with the potential benefit. Given all the extenuating factors that exist in assessing overdoses related to controlled substances, SB 62 is not balanced.

Overruns Forcing Lower Payments to Some Providers in Stopgap Health Program

Tue, 21 May 2013 15:41:01 GMT

The Obama administration said Monday that it was cutting payments to doctors and hospitals after finding that cost overruns are threatening to use up the money available in a health insurance program for people with cancer, heart disease, and other serious illnesses.

The administration had predicted that up to 400,000 people would enroll in the program, created by the 2010 health care law. About 135,000 have enrolled, but the cost of their claims has far exceeded White House estimates, exhausting most of the $5 billion provided by Congress.

Under a new policy issued by Kathleen Sebelius, the secretary of health and human services, “health care facilities and providers will get paid less” for providing the same services to patients in the federal program, known as the Pre-Existing Condition Insurance Plan.

Congress established the program to provide coverage to people with pre-existing conditions who had been uninsured for at least six months. The program provides a transition to 2014, when most consumers will be able to obtain insurance regardless of their pre-existing conditions.

In a regulation to be published Wednesday in the Federal Register, the administration says that doctors and hospitals must accept the amounts set by the government as “payment in full” for services in the high-risk pool administered by the federal government. Providers can still collect co-payments from patients, but cannot bill them for more than the “cost-sharing amounts” allowed by the government.

The administration said the restrictions were necessary to prevent “irreparable financial harm” to patients, who might otherwise be “forced to pay substantially higher out-of-pocket costs.”

The government will not set payment rates for prescription drugs, organ transplants or kidney dialysis. Officials did not say why those items and services had been exempted.

When the federal program for people with pre-existing conditions ends on Jan. 1, 2014, many of them are expected to go into private health plans offered through new insurance markets being established in every state. Federal and state officials worry that an influx of people with serious illnesses could destabilize these markets, leading to higher premiums for other subscribers.

For this reason, federal and state officials say, they will try to recruit large numbers of healthy young people to buy insurance. Their premiums would help pay for the care of less healthy people.

Source: New York Times, May 20, 2013

CMS Announces $1 Billion Initiative to Provide Better, Lower-Cost Health Care

Tue, 21 May 2013 12:43:24 GMT

U.S. Health and Human Services Secretary Kathleen Sebelius announced second round of Health Care Innovation Awards, a nearly $1 billion initiative that will fund projects to transform the health care system by delivering better care and lowering costs.

“These awards will continue our work to drive down health care costs while providing high quality care to all Americans, and I’m excited to see the innovative ideas these applicants will bring to the table,” Sebelius said.

Last year, the Centers for Medicare & Medicaid Services (CMS) awarded 107 round one Health Care Innovation Awards (out of nearly 3,000 applications) to organizations that are currently testing innovative solutions to improve outcomes and reduce costs.

This second round of Health Care Innovation Awards differs from the first round in that CMS is specifically seeking innovations in four areas: rapidly reducing costs for patients with Medicare and Medicaid in outpatient hospital and other settings; improving care for populations with specialized needs; testing improved financial and clinical models for specific types of providers, including specialists; and linking clinical care delivery to preventive and population health.Like the first round, these awards will emphasize results and ensure program integrity.

More than 15 innovation awards were given to groups in California in 2012, including:

$4.7 million to the Family Service Agency of San Francisco to expand and test its model for Prevention and Recovery in Early Psychosis (PREP) for low-income, largely Latino counties in the San Francisco area.
$6.9 million to the San Francisco Community College District (City College of San Francisco), in partnership with the University of California San Francisco and Yale University, to address the health care needs of high-risk/high-cost Medicaid and Medicaid-eligible patients released from prison, targeting eleven community health centers in six states.
$13 million to Sutter Health is receiving an award to expand their Advanced Illness Management program (AIM) across the entire Sutter Health system in Northern California, serving patients who have severe chronic illness but are not ready for hospice care, are in clinical, functional, or nutritional decline, and are high-level consumers of health care.

Click here to view the full list of California award recipients.

Physician, Tweet Thyself

Mon, 20 May 2013 15:25:05 GMT

By Kim Newell, MD

Our patients are getting overloaded with health information from more and more sources, and yet they often don’t get to the right answer. Recent studies have shown that more than 98% of the online health-related discussions take place without the input of a health care professional.

How do we make sure that we remain an integral part of our patient’s health care conversations? As a pediatrician in an increasingly complex health care delivery system, in which I must provide more care with higher levels of service to increasingly savvy patients in less time, I have begun to turn to technology, the Internet, and especially social media to help me do my job better.

There are many compelling reasons that I am active in social media.

Social media makes me more efficient: I save time (and my voice) by sending my patients to my website to learn about why their child has green poop or how to tame their diaper rash.
Social media strengthens my connection with my patients: As I write about my joys and foibles in parenting, I become more human, which actually increases my authority with patients.

Social media keeps me up to date: Twitter is now my primary source for news about pediatrics, parenting, and health care policy. Twitter is an information accelerator, and there I get health news hot off the press. It has become the most efficient way for me to keep up both with scientific literature and with the popular media's take on health news (which my patients are reading).

Social media helps me network: Twitter has allowed me to interact with peers and colleagues in ways not previously possible. Just today I conversed with new contacts in three different states about an infant’s undiagnosed GI issue, and then watched a fascinating webcast about social media and health care put on by my own organization that I learned about on Twitter. Through Twitter I have also been asked to write a forward to a parenting book and advise a start-up company on a new mobile health product.
Social media gives me a voice in the sea of health information: Through my blog and Twitter I give scientific, evidence-based, timely and practical guidance on child health and parenting. Without physicians involved, this discussion can be unbalanced. When Jenny McCarthy claims that vaccines are unhealthy for our children on the Oprah Winfrey show and Donald Trump chimes in to agree, we have to get involved in the conversation—otherwise, the conversation is dominated by tweets like this on about the “dangers” of vaccines.

There was a time when we physicians didn’t have to compete for our patients’ attention—we were the one voice in the room. I believe that the core of our healing still happens one on one, with patients in our examining rooms. However, we must also begin to meet our patients where they are: on their smartphones and tablets and computers, doing research and engaging in discussions on Twitter and Facebook and in the blogosphere.

There’s a conversation going on. About health.

If you’re not active in social media, your voice as a physician, a scientist, a healer, and an advocate is likely to be drowned out.

In the end, the key is not in the technology or the tweets: It is in the trust that we build with patients. We, as a medical community, must figure out how to be not only a part of the health-related conversations happening in social media but also to lead those discussions. We can and must use these channels to combat misinformation, promote health, and engage the trust of our patients.

This article originally appeared in the May 2013 issue of San Francisco Medicine.

Dr. Kim Newell is a general pediatrician at Kaiser Permanente and a member of the SFMS board. She began to learn about technology and medicine upon moving to San Francisco for residency at UCSF and is now a technology lead at Kaiser, where she also teaches a class about vaccine safety for parents and helps lead an innovative obesity management program. She tweets at @drkimmd and sometimes blogs at drkimmd.com.

UMVS Indemnification Clause May Limit Coverage for Malpractice Claims

Thu, 16 May 2013 15:58:28 GMT

SFMS/CMA has recently become aware that a broad "indemnification" clause in the UnitedHealth Military & Veterans Services (UMVS) TRICARE provider contracts is causing some professional liability carriers to exclude coverage for services provided to TRICARE beneficiaries.

Although California's Knox Keene Act prohibits indemnification clauses in physician contracts, the contract in question is governed by federal law. Indemnification clauses are not uncommon, and usually are used to restrict liability in the case of willful misconduct. The clause in the UMVS contract, however, is so broad that at least two professional liability carriers have indicated that they would not defend or indemnify the physicians in the event of a claim brought by a TRICARE beneficiary.

SFMS/CMA has escalated this issue to high level contacts at UMVS. We will provide additional information as it becomes available. In the meantime, physicians are urged to reach out to their liability carriers to determine if they are covered when treating TRICARE patients.

SFMS members with reimbursement questions can contact our Member Helpline for one-on-one assistance at (800) 786-4262.

Physician-Lead ACOs Better Model for Health Care Savings

Thu, 16 May 2013 13:48:51 GMT

Physician-led accountable care organizations (ACOs) could have more opportunities to create savings in patient care with a little help from health insurers, a leading health reform expert said Wednesday.

Doctor-centric ACOs can do a better job at controlling costs than hospital-led organizations, Paul Ginsburg, PhD, president of the Center for Studying Health System Change, said at an ACO summit hosted by America's Health Insurance Plans.

Entrepreneurial insurance companies can offer loans to provider groups to expand or re-engineer to become ACOs through Medicare or commercial payers. Others can create innovative programs that have physicians take additional risk to improve outcomes and lower costs for patients.

"I think physician-led ACOs inherently make markets more competitive because they have an opportunity to shift patients toward higher-value hospitals," Ginsburg said. "It means that a hospital market that might not have large competition going, all of a sudden, if there's a physician-led ACO, those hospitals have to compete on price for the allegiance of those physician-led ACOs."

Unlike in hospital-led ACOs, doctor-led ACOs aren't compromised financially by reducing hospital admissions and emergency department visits, he pointed out.

In fact, physician-led ACOs already outnumber their hospital counterparts, the latest data from the Centers for Medicare and Medicaid Services (CMS) show. However, doctor-organized groups typically treat fewer patients than those formed by hospitals.

Charlie Baker, former Secretary of Health and Human Services Secretary in Massachusetts, noted that nearly every shared-risk model in Medicare Advantage is with physician groups and not hospitals, he says, because insurers know that's how to save money.

Baker said he believes there will be more growth in small providers pooling resources to become ACOs. "My big fear is they're starting behind the larger players, way behind," Baker said.

Physician groups are still skeptical of quality metrics used to determine the shared savings in ACOs, Ginsburg said.

However, CMS rules on ACOs favor hospital-led organizations. "The CMS rules are making it exceedingly difficult for an independent physician group to form an ACO," Baker said.

To that point, Ginsburg noted the federal government can play a larger role in facilitating physician-led ACOs.

"I think of the federal support for the HMOs in the 1970s as to whether it'd be feasible to have the federal government support the development of physician organizations as an investment for viable markets in the future," Ginsburg said.

No matter what happens, whatever strategy emerges to control costs must tackle provider payments—an area public and private payers seem to be in agreement on.

Source: MedPage Today, May 15, 2013.

10,000 Health Care Providers to Rally to Stop Medi-Cal Cuts at State Capitol

Mon, 13 May 2013 16:21:30 GMT

SFMS and CMA have joined an unprecedented coalition of physicians, dentists, health care workers and hospitals working to stop the 10% Medi-Cal reimbursement rate cut.

The We Care for California coalition was borne of an effort to build a strong coalition of diverse organizations fighting to ensure that California’s health care system doesn’t continue to get short changed. So often in the past, health care advocates have become divided in their efforts, so focused on individual organizational interests, that the collective strength is weakened. We Care for California intends to stand undivided in using the coalition’s collective influence in defense of health care.

The coalition’s first major effort is to ensure that two CMA-sponsored bills—SB 640 (Lara) and AB 900 (Alejo)—are passed by the Legislature and signed by Governor Brown. Both bills, sponsored by CMA, would stop the 10 percent Medi-Cal rate cut.

Join “We Care for California” in Sacramento on Tuesday, June 4 from 11 am to 4 pm

to call on State Legislators and the Governor to stop the $1 billion reduction in provider rates in the Medi-Cal program. SFMS/CMA physicians will stand with nurses, dentists, and other health care providers as well as patient and consumer groups to advocate for the support of SB 640 and AB 900.

This will be the largest health care gathering ever at the state Capitol, and will send a powerful message that we expect our elected leaders to stand up for quality care in California.

The goal is to bring 10,000 health care providers together from across the state participate.

Buses will be available to transport anyone who wants to participate from hospitals around the state to the Capitol building in Sacramento at no charge to the participant. If you are interested in attending the event, please register at www.wecareforca.org to reserve a seat on the bus nearest you.

Click here for detailed event and RSVP information.

MICRA Under Attack; Changing/Overturning MICRA Impedes Access to Health Care for Californians

Fri, 10 May 2013 10:51:22 GMT

California’s trial attorneys launched an all-out assault on California's historic tort reform law, which since 1975 has helped keep malpractice premiums in-check and ensured that California’s patients have access to affordable health care.

On May 2, 2013, a coalition—including the Consumer Attorneys of California and the trial lawyer-funded Consumer Watchdog group—announced intentions to seek to overturn California's landmark Medical Injury Compensation Reform Act (MICRA) through a ballot initiative. The group has until September to submit a proposed initiative to qualify for the November 2014 general election ballot.

If successful, the trial attorney’s efforts will cause malpractice rates to skyrocket, and recreate the same conditions that threatened to throw California’s health care system into crisis during the early 1970s. Prior to MICRA, out-of-control medical liability costs were forcing community clinics, health centers, physicians and other health care providers out of practice.

California’s MICRA has been a national success story with broad public support and has safeguarded both patients and our health care delivery system for decades. Risky reforms like the ones being threatened by the trial lawyers would severely impede our state’s ability to provide health care to the poorest and most vulnerable patients. At a time when we are trying to implement federal health care reform and provide access to health care to all Californians, this is the worst possible overreach at the worst possible time.

"The threat of a ballot measure is nothing more than a money grab by trial lawyers," says CMA President Paul R. Phinney, MD. "And one that that will come at the expense of higher health costs for all patients and decreased access for patients and clinics already struggling to keep their doors open. We cannot and will not let that happen."

Click here for more information on MICRA, and what you can do to help in the fight.

SFMS/CMA asks California Supreme Court to Depublish Case that Ignores MICRA's Definition of Professional Negligence

Fri, 10 May 2013 10:04:16 GMT

The California Medical Association (CMA), together with other amici, has asked the California Supreme Court to depublish an appellate court opinion that thwarts the long-standing definition of "professional negligence" in California's Medical Injury Compensation Reform Act (MICRA). The ruling, if allowed to stand as precedent for future cases, could be misused to undermine the goals of MICRA and adversely affect the entirety of the health care system and safety net in California.

In Flores vs. Presbyterian Intercommunity Hospital, a hospital inpatient sued for injuries she allegedly sustained from a fall when her hospital bed rail collapsed. The appeals court ruled that the negligence did not occur in the rendering of professional services and as such was subject to the two-year statute of limitations for ordinary negligence rather than the one-year statute of limitations for professional negligence.

CMA, California Dental Association, and California Hospital Association filed a joint amicus letter urging the Supreme Court to depublish the Court of Appeal’s opinion on the grounds that the opinion was wrongly decided, having been based on a poor factual record and consideration of less than all the pertinent authority.

CMA’s letter points out that under the long-standing definitions in MICRA, professional negligence includes any act or omission by a health care provider in the rendering of professional services for which the provider is licensed. Despite this clear definition and the fact that the provision and maintenance of safe hospital beds is a service for which hospitals are licensed, the Court of Appeal’s opinion failed to even address the pertinent licensing laws and regulations.

CMA and the other amici urged depublication because this wrongly decided opinion will not provide meaningful guidance in future cases and obscures the definition of what constitutes professional negligence under MICRA.

MICRA, California’s landmark professional liability reforms, have for nearly 40 years fairly compensated injured parties while protecting access to care for Californians.

Click here for more information on MICRA.

Outdated Communication Technologies Cost U.S. Hospitals More than $8.3 Billion Annually

Thu, 09 May 2013 13:44:41 GMT

U.S. hospitals lose a total of $8.3 billion annually due to inefficient communications technology, according to a new report from the Ponemon Institute the Wall Street Journal's "CIO Journal" reports.

The report was sponsored by Imprivata, a provider of health care security software and services.

For the report, Ponemon surveyed 577 health care and health IT professionals at medical facilities that ranged in size from having fewer than 100 beds to having more than 500 beds.

Findings on Communications Tools

The survey asked participants about the challenges they encounter in using communications tools, finding that:

52% of respondents said that pagers are inefficient
39% said that Wi-Fi is not available
38% said that their email system is inefficient
36% said that text messaging is not allowed
28% said that personal mobile devices are not allowed

Findings on HIPAA's Effects

The survey also asked participants about the effects of complying with HIPAA, finding that:

85% of respondents said that HIPAA reduces the amount of time available for delivering care
79% said that HIPAA makes accessing electronic patient data difficult
59% said that the complexity of HIPAA requirements were a major barrier to modernizing the health care system
56% said that HIPAA restricts the use of electronic communications

Findings on Time Spent Communicating

Survey participants also answered questions related to time spent communicating. The survey found that:

Clinicians said they waste an average of 46 minutes daily as a result of using outdated communications technology
Clinicians estimated that only 45% of each workday is spent with patients, with the remaining 55% being spent communicating and collaborating with other clinicians, as well as using electronic health record systems and other IT tools
65% of respondents said that they believe that secure text messaging could cut patients' discharge time by 50 minutes

Findings on Costs

The report estimated that inefficient communications technology causes the U.S. hospital industry to lose:

More than $5.1 billion annually as a result of decreased physician productivity and the decreased time that physicians have available to spend with patients
About $3.2 billion annually as a result of lengthy patient discharge times

Source: California Healthline, May 9, 2013.

Qing Dong, MD: SFMS April 2013 Member of the Month

Wed, 08 May 2013 11:34:00 GMT

Qing Dong, MD, PhD is a board certified pediatrician who specializes in general pediatrics and endocrinology. She established Sound Pediatrics in 2010 after spending more than 20 years on medical research and clinical practice dedicating to provide comprehensive pediatric care.

Dr. Dong received her medical degree from Tongji Medical University in Wuhan China, and completed a general pediatric residency at Riley Hospital for Children in Indianapolis as well as a clinical fellowship in pediatric endocrinology at UCSF.

A physician scientist at heart, Dr. Dong has published many papers in the field of cancer research, endocrine, and metabolism. Her current research focuses on calcium homeostasis, as she has discovered several novel mutations in the calcium-sensing receptors.

To view Dr. Dong's practice information, please click here.

I am a SFMS member because SFMS is a professional home that unites physicians from all specialties and health care sectors, and provides a venue for independent physicians in private practice like me to stay connected with my colleagues. I joined SFMS at the advice of my practice consultant who teaches practice management for private physicians.

I think the most helpful SFMS member resource is the practice promotion assistance I received through the online Physician Finder tool and the SFMS patient referral hotline.

What are some of the biggest opportunities or challenges you see in health care within the next five years?

I think patients need doctors, not robots. The transformation of health care from volume-based system to a value-based system—with the goal of improving efficiency, access and outcomes while reducing costs—will enable physicians to focus on patient care.

I love practicing Pediatrics because I am able to follow a child from birth to adulthood. Every time I see a newborn, I still feel the excitement of the first time parent. Being able to follow the growth and development of my patients from baby years to adulthood is probably my greatest joy. Also, over time I really feel like I become part of the patient’s extended family. This often gives my well-child-care visits a sense of catching up on life, just like we do with relatives and friends who live many miles away. Since I opened my own private practice, my extended families have been growing exponentially.

What is your favorite restaurant in San Francisco?

This is a tough one. There are too many good ones out there that cater all tastes and budgets. I used to follow Michael Bauer’s top 100 guide when I first moved to the city. Now, I prefer to explore different parts of the city to find small eatery from different regions of the world. I still enjoy reading Michael Bauer’s long and elaborated articles about his restaurant adventures. I always wonder how he makes a living on that.

If I wasn't a physician, I would like to be a stand-up comedian. I memorized every 单口相声 (an equivalent of monologue) available in China when I was a child. When I first came to America, I learned English partly by watching Johnny Carson. I hardly missed his shows. I am always amazed by the creativity and the ability of making people laugh. Life is over when you lose the ability to laugh.

SFDPH Health Advisory: Human Infections with Avian Influenza A: H7N9

Tue, 07 May 2013 11:31:06 GMT

May 1, 2013 (Revised from April 12, 2013)

The U.S. Centers for Disease Control & Prevention (CDC) has updated its interim guidance:

Antiviral Treatment: Due to the potential severity of illness associated with Avian Influenza A:H7N9 virus infection, CDC now recommends that all confirmed, probable, and suspect cases of Avian Influenza A:H7N9, including outpatients with uncomplicated illness, be treated with neuraminidase inhibitors as early as possible, without waiting for laboratory confirmation of influenza before initiating treatment.

Infection Control Guidance has been updated; Droplet precautions are no longer recommended but Standard, Contact and Airborne precautions should be implemented by health care personnel; suggestions are provided for clinics unable to fully implement Airborne Precautions.

Case Definitions: A definition for Suspect cases (Cases Under investigation) has been added, defining Suspect as patients with influenza-like illness (ILI1) with:

Recent contact (within ≤ 10 days of illness onset) with a confirmed or probable case of infection with Avian Influenza A:H7N9 virus; or
Recent travel (within ≤ 10 days of illness onset) to a country where human cases of Avian Influenza A:H7N9 virus have been recently detected or where Avian Influenza A:H7N9 viruses are known to be circulating in animals. (As of 4/29/13, those countries are China and Taiwan).

Actions Requested of Clinicians

IMPLEMENT Standard, Contact and Airborne Precautions2, including eye protection and respirators, for health care personnel caring for patients meeting criteria for a Suspect case of Avian influenza A:H7N9. Place a surgical mask on the patient to reduce spread of respiratory secretions and have the patient avoid public settings (e.g., public transportation). Aerosol-generating procedures should be performed only if they are medically necessary and cannot be postponed.
REPORT suspected Avian influenza A:H7N9 in patients who meet the criteria described in the case definition for case under investigation (CUI). Call the SFDPH Communicable Disease Control Unit at (415) 554-2830; after hours, weekends and holidays press “1” and “1” again to page the on call physician.
COLLECT specimens for testing and, after obtaining approval from SFDPH Communicable Disease Control, send specimens to SFDPH Public Health Laboratory per instructions below.
TREAT empirically with neuraminidase influenza antiviral medications (oral oseltamivir or inhaled zanamivir) as soon as possible, without waiting for laboratory confirmation in all patients who meet the case definition for case under investigation, including outpatients with uncomplicated illness.
CONSULT an infectious disease specialist and/or the CDC webpage3 for updated information

Click here to view the SFDPH health advisory on Avian Influenza A: H7N9.

For more information about health alerts, advisories, and updates from the San Francisco Department of Public Health, please visit http://www.sfcdcp.org/healthalerts.html.

Update on Scope of Practice Legislation

Tue, 30 Apr 2013 13:09:57 GMT

A package of bills aiming to expand or alter the scope of practice for a collection of allied health professionals successfully cleared the Senate Committee on Business, Profession and Economic Development yesterday.

The scope bills—SB 491, 492 and 493—are being authored by Sen. Ed Hernandez (D-West Covina) and deal with the respective scopes of practice for nurse practitioners, optometrists and pharmacists in California.

While all three bills are now heading to the Senate Committee on Appropriations, SFMS/CMA made important headway on these proposals, garnering some significant concessions that we hope to build upon as the legislation moves forward.

This is the first step in a long journey for these bills, and CMA staff will continue to work diligently to ensure that our concerns are addressed. We also expect the proposals to face an enhanced level of scrutiny should they be approved on the Senate floor and enter the Assembly.

Below is an update on where the bills now stand, including highlights of some of the many amendments and revisions that took place in the past few weeks.

SB 491 - Nurse Practioners

This bill would expand the scope of practice for California’s Nurse Practitioners, allowing them to establish independent practices without the supervision of a partner physician. SFMS and CMA have consistently “opposed” this bill.

Our primary concern with this bill continues to center on the issue of patient safety, but also touches upon the increased costs that may come with under qualified health care professionals ordering unnecessary tests or making superfluous recommendations to specialists. In addition, we called attention to the fact that nurse practitioners did not move to medically underserved areas in Arizona, a stat that granted them independent practice in 1985.

SB 492 - Optometric Corporations

SB 492 initially sought to dramatically expand the scope of practice for California’s optometrists, originally asking that they be allowed to diagnose and treat a host of ailments that manifest in the eye, including diabetes and high blood pressure. In its original form, the bill also allowed optometrists to administer surgical procedures current outside their legal scope of practice.

While SFMS/CMA continues to take an opposed position on this bill, significant amendments have taken place in the past few days. As it stands now, all of the surgical procedures and most of the treatments generally reserved for ophthalmologists have been removed from the bill. This represents significant progress and will provide us a place to build from as the bill moves forward.

SFMS/CMA still has considerable concerns regarding primary care responsibilities that would be extended to optometrists if the bill is allowed to move forward, specifically regarding the ability to diagnose, rather than simply screen for, ailments that may manifest in the eye. It should be noted, however, that optometrists have agreed to not include treatment for primary care in the most recent version of their proposal. We remain committed to working with the author to address these concerns.

SB 493 - Pharmacy Practice

SB 493 seeks to expand the existing scope of practice for pharmacists in California, and is perhaps the bill where SFMS/CMA made its greatest progress leading up to Monday’s hearing. As a result, SFMS/CMA originally took an opposed position to the bill, but has since moved to “oppose unless amended” in advance of Monday’s hearing.

Initially, this bill would have expanded pharmacists’ scope in a way that allowed them to prescribe a wide variety of drugs without physician supervision. Following a round of amendments, much of the prescribing authority has been removed from the bill, but there continue to be some major areas of concern for SFMS/CMA.

The major concern deals with the author’s desire to allow pharmacists to prescribe smoking cessation drugs that both the Medical Board of California and SFMS/CMA consider to be psychotropic in nature. We believe this to present a major risk to patient safety and will continue to oppose the bill until these issues are resolved. Several members of the committee also raised this concern, and as a result, the sponsors acknowledged the issue and committed to working with CMA to resolve it.

As mentioned before, all of these bills still face some considerable hurdles before they can become law and we believe the level of scrutiny will increase as they move forward.

Health Care Leaders Expect Shift Toward Outpatient Care

Tue, 30 Apr 2013 12:43:16 GMT

As the care delivery models of hospitals and health systems evolve, health care executives and practice area managers predict a major shift in admissions from inpatient to outpatient settings.

According to Premier Healthcare Alliance's Spring 2013 Economic Outlook, 69% of the survey participants predict that outpatient volume will rise in 2013, as compared to last year's volume. And as outpatient admissions are projected to increase, nearly 24% of respondents suggest that inpatient volume this year will drop.

“With reimbursement cuts and changes in care delivery threatening today's status quo, health care providers face a significant change imperative as they transition toward more accountable, value-based care models,” Mike Alkire, CEO of Premier, said in a news release. “Ensuring patients are cared for in the most efficient manner—without compromising quality—is key to success. This means more care is being shifted to less intensive and expensive outpatient care sites, with lower reimbursement rates.”

In fact, nearly half of survey participants—48%—cited reimbursement cuts as having the greatest impact on their organizations, though the largest expenditures are expected to go toward healthcare information technology and telecommunications, according to 43% of those surveyed. That's up 21% from two years ago.

Respondents also pointed to accountable care organizations as a method for integrating care across the continuum. About 22% are currently involved in an ACO, and that number is expected to more than double by the end of next year.

Source: Modern Healthcare, April 29, 2013.

Medicare MAC Contract Protest Update

Mon, 29 Apr 2013 10:23:10 GMT

The U.S. Court of Federal Claims has denied two protests that were filed challenging a decision by the Centers for Medicare and Medicaid Services (CMS) to award the Medicare Administrative Contractor (MAC) contract for Medicare Parts A and B in Jurisdiction E to Noridian Administrative Services.

CMS and Noridian will now move forward to implement the new contract and expects this process to complete by mid-September 2013. SFMS/CMA has and will continue to work closely with CMS and the new contractor to ensure a smooth transition.

Jurisdiction E (previously called Jurisdiction 1) covers California, Nevada and Hawaii, as well as the U.S. territories of American Samoa, Guam and the Northern Mariana Islands. Jurisdiction E includes over 3.5 million Medicare fee-for-service beneficiaries, 500 Medicare hospitals and 86,500 physicians. MACs process Part A and Part B claims and perform other critical Medicare operational functions, including enrolling, educating and auditing Medicare providers.

SB 304 Would Strip Medical Board of Power To Investigate Physicians

Fri, 26 Apr 2013 11:24:19 GMT

Lawmakers are considering SB 304, a bill that would eliminate the Medical Board of California's authority to investigate physician misconduct.

The board has been criticized for failing to discipline physicians accused of harming patients, particularly doctors suspected of overprescribing addictive pain medications.

According to a December 2012 Los Angeles Times investigation, at least 30 patients in Southern California died of prescription drug overdoses or related causes while their physicians were being investigated by the medical board.

Physicians were reprimanded or placed on probation in 80% of the 190 cases of overprescribing filed by the board since 2005. However, physicians in most of those cases were permitted to continue writing prescriptions with few or no restrictions.

According to the bill authors—Sen. Curren Price (D-Los Angeles) and Assembly member Richard Gordon (D-Menlo Park)—the California attorney general would handle investigations of physician misconduct.

The change would leave the medical board to deal mostly with licensing doctors.

Source: California Healthline, April 26, 2013.

Bipartisan Policy Center Releases Health Care Cost Containment Plan

Fri, 19 Apr 2013 12:09:04 GMT

On Thursday, the Bipartisan Policy Center released a health care cost containment plan that would reduce the federal deficit by about $560 billion over the next decade, including about $300 billion in Medicare savings.

The report was compiled by former Democratic and Republican congressional lawmakers and health care experts, including former Senate Majority Leader Tom Daschle (D-S.D.), former Congressional Budget Office Director Alice Rivlin, and MIT economist Jonathan Gruber.

The plan offers a variety of recommendations to change health care delivery and how it is financed, including the elimination of the sustainable growth rate formula at a cost of $138 billion.

Further, health care providers in areas that have not received a rural exemption from HHS would not receive an increase in their fee-for-service payments. The fixed payments plan was proposed in an effort to drive providers into new "Medicare networks," which build upon the Affordable Care Act's accountable care organizations (ACOs).

According to BPC staff, the proposal is expected to expand the 250 existing ACOs in order to enroll about 40% of all Medicare beneficiaries within the first 10 years. The networks would be offered as a third option for Medicare beneficiaries, alongside traditional fee-for-service and Medicare Advantage. The plans would offer enrollees lower premiums and cost-sharing, while providing financial incentives to providers, hospitals and other health care providers to better coordinate care. However, the plan would equalize office visit payments, regardless of the site of care, which would save about $8.7 billion over 10 years.

In addition, the BPC's plan would combine deductibles for Medicare parts A and B into a single $500 annual deductible, with a $5,315 cap on beneficiary out-of-pocket cost sharing. Further, the report proposes expanding cost-sharing assistance to Medicare beneficiaries with annual incomes of up to 150% of the federal poverty level, or $17,235 for an individual.

The report's authors say the recommendations have been well received by congressional lawmakers and White House staff.

Source: California Healthline, April 19, 2013.

CMS Confirms Sequestration Payment Cuts for EHR Incentive Program

Thu, 18 Apr 2013 16:21:55 GMT

The Centers for Medicare & Medicaid Services (CMS) has confirmed that the Medicare electronic health record (EHR) incentive program payments will be cut by 2% as required by the Sequestration Transparency Act.

The 2% "sequestration" cuts to Medicare are part of the $1.2 trillion in cuts required by the Sequestration Transparency Act, part of a deal worked out to end last year's debt-ceiling crisis.

According to CMS, the 2% reduction will be applied to Medicare EHR incentive payments for reporting periods that end on or after April 1, 2013. If the final day of the reporting period occurs before April 1, 2013, those incentive payments will not be subject to the reduction.

Medicaid (Medi-Cal in California) is exempt from the sequestration cuts.

Click here for more details on the sequestration cut as previously reported by SFMS.

Click here for our Sequestration FAQ.

Physicians and Lawmakers Promote Workforce Legislation

Thu, 18 Apr 2013 15:50:56 GMT

A coalition of physicians, legislators, medical students, and residents gathered on the steps of the Capitol to support several key pieces of legislation that will address California's mounting issues regarding its physician workforce during CMA Lobby Day.

California’s health care industry is expected to see an enormous surge in demand beginning in 2014, when the implementation of the Patient Protection and Affordable Care Act (ACA) begins the process of extending coverage to what many analysts are projecting could be more than 5 million currently uninsured residents. To compound this problem, a large number of these currently uninsured residents live in areas of the state already grappling with long-standing physician shortages.

Several members of the state Legislature have introduced bills dealing to the various stages of physician training and development in California.

The first step, lawmakers agreed, was to ensure that California was taking the necessary measures to educate its future physicians, a goal which Senator Richard Roth (D – Riverside) and Assembly member Jose Medina (D – Riverside) believe would be furthered by funding the University of California, Riverside School of Medicine.

The pair, which has each authored a bill to allocate $15 million annually in state funds to the operation and expansion of the UC Riverside School of Medicine, agreed that the expansion of coverage called for under the ACA was a tremendous first step toward health care reform in California, but that more needed to be done, especially in regions struggling with existing physician shortages.

Other members of the Legislature have directed their attention toward California’s lack of residency slots, a problem which they claims sends California-educated physicians off to neighboring states, while the problem of access to care at home grows worse.

To remedy this issue, Assembly members Raul Bocanegra (D – Pacoima) and Rob Bonta (D – Alameda) have authored AB 1176, which would help fund and expand residency programs in California by placing a small fee on the state’s health plans.

Both Bocanegra and Bonta noted that an overwhelming majority of residents ultimately lay down roots in the state where they complete their residency training, and that California is doing itself a disservice by forcing California-educated physicians to seek programs in other states.

The financial burdens of a medical education also pose an enormous challenge to California’s students, speakers said, adding that the average medical student in California graduates with roughly $150,000-$160,000 in debt.

To relieve some of this burden, Assembly member Rudy Salas (D-Bakersfield) has authored AB 565, which would expand and strengthen the Steve Thompson Loan Repayment Program, which offers repayment assistance to physicians practicing in medically underserved areas of the state.

Together these bills will ensure that California’s physicians can continue to lead a health care model that will fully and adequately serve the state’s population.

AB 1176 passed with a 10-5 vote and AB 565 passed with unanimous support in Assembly Health Committee on Tuesday afternoon.

“Pause Before Posting”: New Ethical Guidelines for Physicians and Social Media Usage

Fri, 12 Apr 2013 14:52:04 GMT

Physicians should exercise caution—and “pause before posting”—when interacting in online settings in order to preserve professionalism and maintain appropriate patient-physician relationships, according to a policy paper released today by the American College of Physicians and the Federation of State Medical Boards.

“Online Medical Professionalism: Patient and Public Relationships” addresses the use of online and social media and electronic communication between physicians and patients. The two organizations looked at opportunities and challenges created by new technologies and online forums, and provided recommendations and strategies for physician behavior in these areas.

Digital communications and social media use continue to increase in popularity among the public and medical profession. The ACP policy paper discusses best practices to inform standards for the professional conduct of physicians online and includes a chart of online activities, potential benefits and dangers, and recommended safeguards for physician behavior.

Notable recommendations from ACP and FSMB include:

Physicians should keep their professional and personal personas separate. Physicians should not “friend” or contact patients through personal social media.
Physicians should not use text messaging for medical interactions even with an established patient except with extreme caution and consent by the patient.
E-mail or other electronic communications should only be used by physicians within an established patient-physician relationship and with patient consent.
Establishing a professional profile so that it “appears” first during a search, instead of a physician ranking site, can provide some measure of control that the information read by patients prior to the initial encounter or thereafter is accurate.

The paper will be published in the April 16 issue of Annals of Internal Medicine, and is authored by ACP’s Ethics, Professionalism and Human Rights Committee; ACP’s Council of Associates; and FSMB’s Committee on Ethics and Professionalism.