Today, the United States Ninth Circuit Court of Appeals denied an en banc request from the plaintiffs in CMA et al. v. Douglas et al. to rehear the case ruled on by a three judge panel of the court in December.

A three judge panel of the Ninth Circuit court overturned a Federal District Court decision to stop a 10% Medi-Cal cut. The Federal District Court’s ruling in February of 2012 stated that “California’s fiscal crisis does not outweigh the serious irreparable injury patients would suffer absent the issuance of an injunction.”

“While we are not surprised by the Ninth Circuit Court ruling, we are certainly disappointed, as the 10% cut to Medi-Cal will have devastating effects on California’s poorest and most vulnerable patients,” said CMA President Paul Phinney, MD. “California already has the lowest Medicaid rates in the nation and with the implementation of health reform, millions of new patients will be enrolled in the program in coming months.”

In spring of 2011, the California Legislature passed and Governor Jerry Brown signed AB 97, which included a 10% reimbursement rate cut for physicians, dentists, pharmacists and other Medi-Cal providers. Federal approval was required before the state could implement its proposed cuts.

“Our fight does not end here,” Dr. Phinney added. “As part of the We Care for California Coalition, we will continue to advocate that these dangerous cuts be stopped. With strong bipartisan support on the issue and on behalf of patients across the state, we intend to make our voices heard on this issue.”

The ruling today makes our efforts as part of the We Care for California coalition that much more meaningful, and to that end, we hope to see you at the coalition’s rally in Sacramento on June 4. Cutting California’s patient safety net will impact access to care, as the State implements health reform.

Click here for more information about the June 4 We Care for California rally.

A loophole in the Affordable Care Act (ACA) could force California physicians to cover the full cost of certain health care services.

Under the ACA, families who obtain subsidized health plans through Covered California—California’s insurance exchange—have a 3-month grace period before the policy is cancelled if they fail to pay their premiums. However, insurers are responsible only for paying claims during the first month of that grace period.

During the other two months, families are asked to pay their doctor’s bill or their insurance premium if they seek health care services. If they do not pay either bill, physicians are left to cover the cost of the treatment. Such families would face a tax penalty for missing payments, but they would not receive a fine, a premium rate increase or a repayment order. In addition, they also would not be barred from purchasing another subsidized plan during the next enrollment period.

Physicians Express Concern

Physicians argue that the loophole might prompt many doctors to avoid participating in Covered California next year. They say that a single prostate cancer patient’s course of treatment can cost $93,000.

CMA President Paul Phinney said the loophole “could be very problematic, even to the extent that it may cause some physicians to have to close their practice.”

Leah Newkirk of the California Academy of Family Physicians said the financial implications of the grace period are especially acute for small or struggling practices, stating “I think in particular it will impact providers in rural areas and providers who are seeing disadvantaged populations, sort of precisely the people we want to encourage to (buy policies)."

State, Federal Response

Diana Dooley, secretary of the state Health and Human Services Agency and Covered California trustee, said, “I do think there’s legitimacy to [physicians'] concerns.” However, she said, “[a]t this point, it’s speculation about how much of a problem it might be.”

Dooley said state officials have discussed such concerns with the federal government, but that federal law provides no flexibility on the issue.

HHS has acknowledged that nonpayment of premiums for certain subsidized policies would “increase uncertainty for providers and increase the burden of uncompensated care.” HHS officials said that the agency will “monitor this issue moving forward and will continue to work on the development of policies to prevent misuse of the grace period.”

Source: California Healthline, May 22, 2013.

On Wednesday, SFMS physicians met with pediatrician and State Assemblymember Richard Pan, MD to discuss the importance of physician representation in Sacramento.

Click here to view photos from the event.

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