As previously reported, CMA has received numerous complaints from physicians regarding Blue Cross and Blue Shield’s refusal to honor assignment of benefits, highlighting the burden and cost it places on the physician practice to act as debt collectors rather than physicians, and in many cases, this policy has jeopardized the physician-patient relationship.
To address this issue, CMA sponsored AB 1742 (Pan) to shore up this loophole and require Blue Cross and Blue Shield, the major PPOs currently refusing to honor assignment of benefits, to pay physicians directly for out of network services.
Representatives of Blue Cross and Blue Shield were asserting to the legislature a false claim that by removing the incentive of direct pay to the physician for out of network services, there would be a broad erosion of the PPO networks. In other words, they asserted that direct pay is the main reasons physicians decide to contract and if that option is removed, doctors will no longer contract with payors.
CMA/SFMS conducted a survey on criteria physicians consider before signing a contract to be in a payor network. We had an overwhelming response to the survey, gathering over 1,100 responses from physician practices in 43 different counties within a very short period of time. Through the survey results, we were able to highlight the following to the legislature:
Though this specific bill is still in the Assembly Health Committee for reconsideration after failing passage earlier this week, our effort to require Blue Cross and Blue Shield to honor assignment of benefits will continue. The survey results will also aid our legislative efforts in support of physicians and patients on various issues.
Click here to view the comprehensive survey results.
SB 1318 (Wolk), which would require all health care workers in health care facilities, including physicians, to either receive the influenza vaccination or wear a mask in patient care areas during flu season, moved out of the Senate Labor and Industrial Relations Committee this afternoon. The bill is co-sponsored by SFMS/CMA.
Influenza is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness and, at times, can lead to death. Some people, such as seniors, young children and those with certain health conditions, are at high risk for serious flu complications. SB 1318 will help to keep the numbers of hospital-acquired flu fatalities low.
"The bill would protect our most vulnerable patients—infants, seniors and those who are immune-compromised," Wolk said. "It would ensure that health care workers receive the influenza vaccination, or wear a mask during influenza season. It's a choice: Get vaccinated, or wear the mask. We want to decrease the deaths from influenza, and increase the safety at hospitals."
In California, several counties (Sacramento, Yolo and San Francisco) and numerous hospitals have gone beyond state law and have instituted mandatory vaccination policies that include a masking requirement for the unvaccinated. The California hospitals with the highest vaccine compliance rate are those that have such policies in place.
SB 1318 passed the Senate Committee on Health and Labor and Industrial Relations, and is re-referred to the Committee on Appropriations.
On June 1, 2011, California began its transition of seniors and persons with disabilities (SPD) from Medi-Cal fee-for-service program into managed care plans, and will continue over the next several years until complete. Almost immediately, SFMS/CMA began receiving a wide range of complaints and reports of serious problems involving disruption of patient care.
Over 50 percent of Medi-Cal patients involved in the initial phases of the transition had been automatically assigned to health plans due to failure to respond to notices during the enrollment period. Was this truly the patient’s fault? Or was this the result of poor planning, lack of communication or other language barriers? Nonetheless, CMA has received numerous reports of patients losing access to physicians who cared for them for many years, and have also received an increasing number of complaints of plans and IPAs/medical groups refusing to contract with physicians who have been long time Medi-Cal providers.
While CMA has continued to work with the Department of Health Care Services (DHCS) to address those issues, the state now is seeking approval from the Centers for Medicare & Medicaid Services (CMS) to shift “dual eligibles” (persons with Medicare and Medi-Cal coverage) into Medicare and Medi-Cal managed care plans in four counties including Los Angeles, Orange, San Diego and San Mateo on January 1, 2013. If the state plan is approved by CMS, patients will begin receiving enrollment notices on October 1 through November 31 of this year. Furthermore, the state is once again seeking authority to automatically enroll individuals who do not actively enroll or opt-out within the required time frame.
The state’s plan is currently in a thirty (30) day public comment period. CMA is collecting data on the extent of problems and other issue physicians and their patients have experienced thus far. Examples of delayed and/or denied medical treatment, disruption in continuity of care, and other issues that negatively impacted the financial viability of your practice can be extremely powerful.
Your participation in this survey is crucial. The information you provide will be reflected in CMA’s response to the state’s proposal and will help us better advocate for solutions.
By Steve Heilig, SFMS Assistant Executive Director
The New York Times just printed a cover story titled "Tightening the Lid on Pain Prescriptions." The Wall Street Journal printed one on the same topic a week before.
Clearly, we have a serious problem -- two of them, in fact. It's long been demonstrated that pain has been widely under-treated in this country. Efforts to improve that have been underway for some time. But it's also increasingly recognized that unwise use of pain medications is a growing epidemic, with dire results: Fatal, unintentional drug overdoses occur every 19 minutes in this country, and opioid analgesics -- oxycodone, for example -- have been responsible for more of these deaths since 2003 than heroin and cocaine combined. And that's just the tip of the abuse/addiction epidemic. For every such death related to opioid analgesics, 461 people report nonmedical use of these meds, and 35 visit an emergency department. There, doctors learn to dread them -- the patients who might be "drug-seekers," or might be in real physical pain, or might be both.
These are not entirely mutually exclusive diagnoses. Addiction is painful -- it has even been likened to slavery. And many addicts started as honest people in physical pain. Medication diversion and abuse has become a major epidemic. Up to three-quarters of non-medical opioid users report their drugs were prescribed to somebody else -- in other words, they are sharing and selling them.
The April issue of San Francisco Medicine contains authoritative perspectives on some of the issues, including: An overview of the "pain problem", A review of the addiction epidemic and strategies to combat it, A review of the use of cannabinoids for pain, and How yoga can help with pain.
Clearly there is much to be done in terms of addressing both epidemics of under-treated pain and pain medication abuse and addiction. California’s official medical guidelines for managing pain are available online here.
But one important practical tool to help track the prescriptions of pain meds, the Prescription Drug Monitoring Program is going underutilized and unfunded, as noted here.
As noted therein, this "CURES" system allows doctors and pharmacists to "instantly look up the prescription histories of customers and refuse to provide medication to a patient whose drug shopping habits seemed suspicious or out of control. More than 40 states are using similar systems to help curb prescription drug abuse."
The funds needed to upgrade and operate this neglected tracking system would no doubt prevent much higher costs elsewhere. So as is so often the case, the choice is between prevention or playing catch-up, aka, penny-wise or pound-foolish. And unfortunately pinching pennies usually wins out, and then we wonder why the problem is so bad while we try to clean up the consequences. Perhaps California politicians and regulators can see their way to an exception this time, for the benefit of all concerned.
And, I can't help but add, this would seem to be a bigger problem than a few profiteering cannabis clubs, annoying to some politicians as those might be.
Americans work longer hours than workers in most other developed countries. The typical American middle-income family put in an average of 11 more hours a week in 2006 than it did in 1979. Although more than 805,000 people reside in San Francisco, there were no after-hours clinics available to accommodate busy families until the establishment of the After Hours Medical Clinic in March 2012.
Staffed by the Pacific Family Practice Medical Group, the clinic provides much-needed non-office, after-hours medical care at reduced cost for both patients and insurers. The clinic operates from 5:00 pm to 9:00 pm on weekdays and from 10:00 am to 4:00 pm on Saturdays.
An after-hours clinic provides walk-in care that focuses on acute conditions and exacerbations of chronic conditions. In a study done by the California HealthCare Foundation, the most common diagnoses seen in non-emergent and non-primary care settings are upper respiratory infections (60.6 percent); preventive care, such as vaccinations and preventive exams (21.6 percent); other minor conditions such as allergies, insect bites, rashes, and conjunctivitis (9.5 percent); and urinary tract infections (3.7 percent). These four groups of diagnoses accounted for more than 95 percent of all visits to acute care clinic sites.
According to “Health Matters in San Francisco” and the California Office of Statewide Health Planning and Development, 18,000 emergency department visits were preventable. Dr. Robin Weinick of RAND Health, one of the largest private health research groups in the world, estimates that 13.7 to 27.1 percent of all emergency room (ER) visits could occur in less intensive, walk-in-based care facilities. A combination of increased working hours for patients and diminished primary care access result in unnecessary use of emergency departments.
Delays in care and additional costs incurred in ER visits are a drain on health care resources. Several studies have estimated that costs of care in nonemergency, nonprimary care clinics are $279 to $460 less per visit than ER costs for similar cases.
“Extended hours have become a big concept of how to bring our practice to the people, to make it more available to the people,” explained SFMS member Sophia Mirviss, MD. “It’s for existing patients, and also for people who come home and find themselves sick and really want to be seen but had to work all day. And for people who do not have insurance but want to get their strep throat checked but cannot go to the ER because it’s prohibitively expensive.”
The clinic does not provide ongoing primary care services. It transmits all medical encounters to patients’ primary care physicians via an electronic medical records system so that the primary care physicians retain control of all referrals and follow-up.
The community has embraced this concept; many physicians have been strongly positive in their responses. It has also garnered support from Brown & Toland and other insurers as it has the potential for reducing inappropriate ER and hospital use rates.