The 2012 SFMS delegation to the California Medical Association’s (CMA) annual House of Delegates meeting took a wide range of proposed resolutions for consideration by the statewide gathering. Each resolution, some with modification, moved important health care issues forward in the areas of health care delivery, health care mandates, and pharmaceutical industry issues, including medication disposal and insurance coverage.

Our roster of policy proposals this year, with outcomes, included: 

Tracking Prescriptions to Curtail Medication Abuse (Rokeach, Loring, Turner): CMA supports the development of a fully functional, Web-based prescription drug monitoring program (PDMP), whether it be an improved CURES (Controlled Substances Review and Evaluation System) program or a new one that should be fully funded, including through a fee-per-prescription paid by manufacturers and suppliers of drugs monitored.

Reducing Overutilization: Physician Leadership (Denys, Fung, Eng): CMA supports physician-led, evidence-based efforts to improve appropriate use of medical services and will educate physicians, hospitals, health care leaders, and patients about the need for physician-led, evidence-based efforts to improve appropriate use of medical services. This resolution originally referred to the “Choosing Wisely” effort that will be the topic of the January/February 2013 edition of San Francisco Medicine. 

"Pay for Delay" Practices on Generic Medications (Susens): CMA will ask AMA to support federal legislation that makes tactics delaying conversion of medications to generic status, also known as “pay for delay,” illegal in the United States. As noted in a recent NEJM piece, that might already be the case!

Increasing Utilization of POLST Orders (Newman, Schickedanz, Lopato): CMA encourages physicians to become educated about all aspects of the POLST form and to integrate discussions about, and use, POLST in all appropriate instances where medical services are provided to patients at the end of life. Surprisingly to many, this was perhaps the most hotly debated resolution of the year, as our original allowed for nurse practitioners to fill out POLST forms for physician confirmation, as is done in some other states.

Medical Mandates for Insurance Coverage and Medi-Cal (Chan): CMA supports the principle that mandated coverage for private insurers should also apply to publicly financed entities, when appropriate; and will advocate that the state legislature must budget for the increased cost to Medi-Cal and enrollees of the California Health Benefit Exchange when passing mandated coverage. 

Promoting Quality and Transparency in Graduate Medical Education (Schickedanz): CMA supports efforts to urgently address the anticipated imbalance between the number of medical school graduates and available residency training positions; and greater transparency at all levels in the calculation, distribution, and tracking of graduate medical education (GME) funding; and will petition the Centers for Medicare and Medicaid Services to address perceived disparities in the distribution of GME funding.

Cell Phone Use in Cars (Udovic-Constant, Fouras): CMA will support public education efforts regarding the dangers of distracted driving, particularly activities that take drivers’ eyes off the road, and will ask the AMA to do likewise. Our original was more forceful, asking for more severe penalties and even bans.

There was much more, with something of interest to every specialty, practice setting, and personality.

Click here to view the full list of the new policies adopted at the 2012 CMA House of Delegates.

Interested in submitting a resolution or suggesting a resolution idea for 2013 HOD? Please contact SFMS at membership@sfms.org.

Frustrated with the vagaries of today's health care system? Would you like to see something done to fix it? Do you have some new and/or innovative policy ideas you would like to share? The SFMS delegation to the CMA House of Delegates (HOD) would like your input about issues and concerns you have as a San Francisco physician.

The SFMS delegation has long had a significant impact on CMA policy, which can have a real world influence on state and national policy. We develop resolutions on any issue related to medicine and public health, and welcome ideas from any SFMS member. 

 

Please submit any issues or concerns and potential policy solutions we can bring to the table on your behalf in the comments section at the bottom of this page (comments section) or email Steve Heilig by August 1, 2012.

 

The CMA House of Delegates is the CMA policy-making body that represents physicians statewide. The delegates meet once a year to establish CMA policies on key issues that affect the practice of medicine, from medical ethics to critical matters of public health. SFMS will once again send a full delegation to this year’s meeting. Our delegates share the responsibility of representing the voices of San Francisco family physicians, their patients, and the communities in which they live.

 

Resolutions adopted at past HODs include banning sugar drinks in schools, establishing regulation of e-cigarettes, granting minor access to obtain preventative treatment for STIs without parental consent, and assisting students and residents with medical education debt.

 

Click here to view a list of just last year's successfully-adopted policies.

By Steve Heilig, MPH

Contraception exploded onto the front pages this month. That might seem strange to most people—what is controversial about contraception at this late date? One headline read “Changes to Contraceptive Coverage Rules Draw Mixed Reaction” and that one wins the ‘understatement’ award on this topic.

“Conservatives” seized on the issue as a potentially good wedge issue to attack President Obama on various fronts, and hoped that it would somehow awaken some version of the good old moral majority to political action. Yet almost all women, including Catholics, ignore their putative religious leaders on this issue, and always have—when they have a choice. And most men support that practice. In letters and online comments, the most incisive perspectives seem to come mostly from women—political leaders, doctors, nurses, social workers, and just plain folks. 

The New York Times editors noted that Catholic authorities were trying to have it both ways, claiming all the special financial privileges of a church but wanting to ignore any strings that might be attached, however compassionate those might be. Others observed that behind this debate was specter of abortion politics—even though the one proven way to reduce abortions is to make contraception as easily available as possible.

Amongst politicos, the gender split seemed to hold true as well. Three female senators wrote to the Wall Street Journal defending the contraceptive mandate. Some female politicians even felt compelled to boycott the male-dominated House hearing on the topic.

In the GOP candidate’s race, Romney sought whatever position he could sell to the most people; Santorum, consistent at least, already opposes contraception, perhaps not surprising for a guy who thinks women working is a “radical feminist” plot. Irrelevant cranks Ron Paul and Newt Gingrich made statements that were aptly ignored. 

Kris Long, a nurse writing in the New York Times likely had it best: “As a former employee of a Catholic-run hospital, I find it appalling that the party of ‘individual rights’ would stand up for a religious bias rather than for the non-Catholic employees who are deprived of the right to choose health insurance commensurate with the private needs and beliefs. Why should I not be allowed birth control through my insurance because my boss has a problem with it?”

Strangely enough, organized medical voices have been muted in this heated debate. But the contraceptive mandated did not spring anew out of the White House health reform plan. It is an old idea, long supported among healthcare policy wonks and, last summer, given strong endorsement by perhaps the highest medical authority in the land, the Institute of Medicine (IOM) of the National Academy of Sciences. Their report “Clinical Preventive Services for Women: Closing the Gaps” focuses on preventive care for women, including but not limited to contraception. In medical circles it was hardly controversial and seemed to be greeted in the clinical trenches with an “OK, now make it happen” sentiment, as is often the case with rational, evidence-based medical recommendations.

Given that, and sensing that the IOM recommendations might be more controversial in non-scientific arenas, I thought it might be good to have a strong statement of support from the medical organizations I work with, and drafted the statement below for the San Francisco Medical Society’s policy-making body:

Contraception as a Fully-Covered Health Insurance Benefit

Whereas, the United States Institute of Medicine in July 2011 strongly recommended that “the full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity” be a fully covered benefit of all health insurance plans; and

Whereas, the costs of contraception have long been identified as a barrier to many women’s optimal use of contraception, with negative impacts on their health and in terms of unwanted pregnancies, as well as discriminatory implications; and Whereas, The Federal administration has just mandated that contraception be a covered benefit, but health insurance industry representatives have voiced their opposition to this measure and might try to repeal it; now be it

RESOLVED: That the California Medical Association supports the coverage, without co-payments, of all FDA-approved contraception methods as a mandated health benefit of all health plans.

True to form, this statement was noncontroversial among the 20+ physicians of various specialties who reviewed it and three physicians signed on as co-authors—all of them women (I am omitting their names here to protect them from the scary minority), but we could have added men as well. The statement then went to the annual policy-making meeting of the California Medical Association (CMA)—a much larger and often more conservative bunch, made up of hundreds of doctors from all over the state. 

We thought there might be some opposition there, but in the open debate, the CMA physicians even strengthened the final statement to include voluntary sterilization. Thus, here is one of the nation’s largest state medical association’s concise position on this matter: RESOLVED: That the California Medical Association supports the coverage, without co-payments, of all FDA-approved contraception methods and sterilization as a mandated health benefit of all health plans. Simple, direct, and medically correct, regarding a private medical matter between women and their physicians. 

As for the rest of those pundits weighing in, mostly male and including religious figures and politicians, I can’t help but be again reminded of what pioneering lawyer and yes, feminist Florynce Kennedy once quipped, “If men could get pregnant, abortion would be a sacrament.” The importance of this mandate is highlighted in The New York Times report this week showing that Catholic control of hospitals in some areas is growing, with resultant restrictions on some services. I also can’t help but note that a recent report from the widely-respected group Save the Children confirmed what has long been known—one out of four children already here on this planet are malnourished, and many of them are starving to death around the world, at a rate of one every five minutes. Some would say these issues are related. The Catholic church does much good in the world; some of my best friends are Catholic (seriously). But on this topic, pundits have pointed out that for all the fire and brimstone directed by church leaders against the contraceptive mandate, they tend to be much less vehement when politicians propose policies that seemingly violate other teachings about war, inequality, compassion and empathy for the poor. I respectfully wonder if Catholic and political leaders opposed to contraception could meditate on that for a moment, and instead of fulminating against one of the only solutions we have for helping women live better lives—and to prevent abortions—they might devote their time and energy towards alleviating this ongoing tragedy of suffering in the world. And—a novel idea—perhaps they could listen to what doctors think as well. Once can hope so, but I will not hold my breath.

Originally published on sfgate.com/San Francisco Chronicle blog on February 21, 2012. 

The SFMS Delegation, along with hundreds of California physicians, convened in Anaheim this past weekend for the 2011 CMA House of Delegates. The CMA HOD is an annual conference where all 53 California counties, representing all modes of practice, meet to discuss issues related to health care policy, medicine and patient care, and to elect CMA officers. A shortlist of the newly approved policies are posted below, all of which stemmed from SFMS submitted resolutions.

Generic versus brand medications (Resolution 504-11): The delegates asked CMA to oppose the profit-motivated removal of generic medications from the market in favor of much more expensive brand products and refer for national action. Presumed consent for organ donation (Resolution 509-11): The delegates asked CMA to recognize the worsening shortage of donor organs and to support pilot studies for presumed consent as advocated by the AMA in 2005; The delegates also asked CMA to study “presumed consent” for organ donation to determine how future policy can be implemented in a manner that protects both patient and donor. Oppose legal prohibition of circumcision (Resolution 106-11): The delegates directed CMA to oppose any attempt to legally prohibit male infant circumcision and to refer this for national action. Regulation of electronic cigarettes (Resolution 113-11): The delegates voted to support the prohibition of the use of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids in places where smoking is prohibited by law, and to support requiring a tobacco permit for the sale of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids. Coverage of contraception as health insurance benefit (Resolution 403-11): The delegates directed CMA to support coverage, without copayments, of all FDA-approved contraception methods and sterilization as a mandated health benefit of all health plans. The rest of the actions of the 2011 House of Delegates will be posted later this week to the CMA website.

By Stephen Follansbee, MD and Steve Heilig, MPH The California Medical Association can be a formidable force in Sacramento health policy. The CMA House of Delegations meeting, scheduled for October this year, is the opportunity for physicians to guide the CMA on important issues and set the priority for these efforts. Your elected SFMS delegates have introduced a roster of policy resolutions to be debated at the meeting. As your representatives, we thought you might like to see what we will be addressing – along with the many other resolutions introduced from other delegations throughout the state. The SFMS is a relatively small but relatively “loud” presence each year, with a good track record of successful policies; here is our list. In November we will publish a scorecard on what we were able to get adopted; and then the real work begins in the halls of politics, translating these words into something that benefits patients, the public, and physicians all over our state – and beyond as some of these would then be referred on to the AMA.

SFMS Proposed Policies for 2011 (authors in italics):

Reduction of Subsidies of Tobacco in Films (Fung): Did you know that the movie industry gets big tax credits for filming, including when they portray tobacco use? UCSF researchers have shown this is true – that taxpayers subsidize tobacco marketing, in effect – and we hope to stop that. Unethical Rebates from Pharmaceutical Companies (Susens): Some drug makers still offer money to doctors who prescribe their products. Some doctors take that money. This is against ethical codes and we hope to stop that. Deceptive Pregnancy ‘Crisis/Counseling’ Centers (Lopato): As reported in the Chronicle, certain “clinics” are in fact “pro-life" centers which seek to divert women from considering abortion with misinformation and fear. We would require full disclosure of what is and is not offered at such places. Regulation of Electronic Cigarettes (Fouras, Aragon): These nicotine delivery devices may have their place as harm reduction, but they need more regulation for both users and the public, and this resolution would require that. Supporting The California Cancer Research Act (Margolin): The CRCA will be on the ballot, increasing tobacco taxes for cancer research, and we ask the CMA to join the full-court press to help it pass in this "no new taxes” era. Clinical Research - Banning "Seeding" and Similar Marketing Trials (Susens): Pharmaceutical companies do marketing in the guise of “research” even after the medication is approved, with unwarranted cost and safety implications; we hope to stop that. Healthy Food Marketing for Children (Desai, Schickedanz, Udovic-Constant): The obesity epidemic too often starts in childhood, and better “selling” of healthy food is indicated; this would encourage that on various fronts. Opposing Legal Prohibition of Circumcision (Tabas): This intrusion was blocked from the state ballot, but will likely be back, and we want CMA and AMA on record in opposition for next time. Firearms and Censorship (Follansbee): Another intrusion, courtesy of the gun lobby, prohibits Florida physicians from even talking with patients about the risk of guns in the home. We hope to stop this there and before it spreads. Contraception as a Fully-Covered Health Insurance Benefit (Silverman, Desai, Myers): This has now been adopted as national policy, but attempts to overturn it are already promised. We want CMA and AMA on record in support of full coverage. Increasing Organ Donation via Presumed Consent (Follansbee, Margolin): The waiting lines for organs get longer, and more people die while waiting. It is time for some changes in organ policy and we are asking CMA to weigh in, based upon evidence, ethics, and what some other nations are doing. Clinical Sense and Costs at the FDA; Generic vs. Brand Medications  (Susens): When a generic medication mysteriously goes back to “brand," and the price skyrockets, that seems wrong, and we think the FDA should take a closer look. Vision Screening for School-Aged Children (Leung): Too much pediatric poor vision is missed, and schools may be a good place to screen for that and refer to early intervention. Emergency Department Overcrowding (Maa, Curran): When emergency departments get too crowded, some hospitals have “triaged” based on financial considerations.  That’s not good; there must be better ways, and we'll ask CMA to try to find them. As you can see, it's a full and diverse roster. As already mentioned, there will be much more from other delegates around the state; any CMA member can propose a resolution, and perhaps we can help you bring good ideas forward next year.  As for this year, stay tuned. Stephen Follansbee is an SFMS past-president, chairs the SFMS delegation to the CMA, and is an infectious disease specialist at Kaiser San Francisco and a clinical professor at UCSF. Steve Heilig is on the SFMS staff.