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.

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 

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.

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.

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.