California Medical Association

Friday, May 22, 2015

San Francisco Medical Society Blog


Providing news to the San Francisco Medical Community.

California Medical Association Removes Opposition to Physician Aid in Dying Bill; SFMS Advocacy Initiates New Discussion on PAD

The California Medical Association (CMA) announced in today’s San Francisco Chronicle that it has become the first state medical association in the nation to change its position on the long-debated issue of physician-assisted dying (PAD).

SFMS has been a long-time advocate on this difficult topic. Our delegation asked CMA to consider neutrality at least three times in the past 15 years. The latest SFMS effort was a letter submitted to the CMA board in January 2015 urging a more open consideration, and after much debate the CMA Council on Legislation voted overwhelmingly in favor of neutrality.

By removing decades-old organizational policy, CMA has eliminated its historic opposition and is now officially neutral on SB 128 (Monning/Wolk), the End of Life Option Act.

“As physicians, we want to provide the best care possible for our patients. However, despite the remarkable medical breakthroughs we’ve made and the world-class hospice or palliative care we can provide, it isn’t always enough,” said CMA President Luther F. Cobb, MD. “The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options. We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage. Protecting that physician-patient relationship is essential.”

CMA's amendments to SB 128 have been accepted by the authoring Senators, and are partly based upon clinical guidelines/safeguards developed at SFMS (and published in the April issue of San Francisco Medicine). Physicians would be explicitly protected from any sanctions for either participating or declining to participate in PAD.

Click here for a full statement from the authors of SB 128. 

Click here for the Chronicle's coverage of this historic development.

UnitedHealthcare to Alter Premium Designation Criteria

UnitedHealthcare (UHC) has altered the criteria for meeting the physician cost efficiency component of its Premium Designation program. UHC will now designate a physician as “Cost Efficient” when he or she has met the episodic cost benchmark, even if the physician did not achieve the population cost benchmark. The change only impacts those physician specialties that are evaluated on both population cost and episode cost, which include:

  • Family medicine
  • Internal medicine
  • Pediatrics
  • OB/GYN
  • Allergy
  • Cardiology
  • Endocrinology
  • Nephrology
  • Neurology
  • Pulmonology
  • Rheumatology

Surgical specialties are all excluded.

Previously, physicians who met episodic cost but failed to meet the population cost component did not receive the UHC Cost Efficiency designation in the Premium Designation assessment. The results of the modified criteria were communicated to affected physicians in a letter in March and are also available on the UHC website. This designation includes data from January 1, 2011, through February 28, 2014.

In 2014, CMA raised multiple concerns with the payor’s criteria for evaluating physician cost efficiency and urged the payor to make changes.

Physicians who have questions or concerns with their physician assessment reports or their Premium Designation can contact UHC at (866) 270-5588. Practices that are unable to obtain answers to their questions or resolve the issue with UnitedHealthcare directly should contact CMA at (916) 551-2865.

For more information on the Premium Designation program, visit the UnitedHealthcare website at

Governor Brown’s 2015-16 Revised Budget Proposal and Its Impact on Health Care

Governor Brown released a revised budget proposal for fiscal year 2015-16, commonly referred to as the “May Revise.

The budget revision includes an increase in overall expenditures from the General Fund to $115.3 billion, an increase of approximately $2 billion (.06% increase) from his January proposal. Total proposed spending for the budget year is projected to be $169 billion, taking into account federal and special fund sources.


The Governor’s revised Budget contains no significant increases to Medi-Cal provider reimbursement rates. SFMS/CMA and other stakeholders have continued to point out major deficiencies in the Medi-Cal program, most notably the serious challenges that many Medi-Cal beneficiaries have accessing care.

Despite these concerns, the Governor is proposing an additional $200 million to provide full-scope Medi-Cal coverage, In-Home Supportive Services, and other benefits for the individuals who are covered by President Obama’s executive orders relating to certain undocumented immigrants. Under existing California law, an individual who is lawfully present in the state is entitled to certain health and social services. The May Revise assumes the legal challenges surrounding the President’s actions will ultimately be unsuccessful and sets aside an additional $200 million for this purpose.

The Governor is now estimating that the Medi-Cal program will serve 12.4 million people, an increase of 200,000 people since January. The May Revise assumes a $2.9 billion increase to provide coverage for Medi-Cal beneficiaries under the mandatory expansion, which would be split evenly between the state and the federal government under the traditional Medicaid financing structure. The May Revise also includes costs of $14 billion for the “optional expansion” – adults without children and parents/caretakers with incomes up to 138% of the federal poverty level. However, this population is financed entirely by the federal government until the 2016-17 fiscal year.

The Governor’s May Revise includes $341 million to cover increased mental health and substance use disorder benefits available to Medi-Cal enrollees. 

Controlled Substance Utilization Review and Evaluation System (CURES)

The administration is proposing an appropriation of $1.1 million to fund five positions for the ongoing maintenance and operations of the CURES prescription drug monitoring database. In January, SFMS/CMA urged the Legislature to continue its oversight over the CURES upgrade to ensure that the project is completed in a timely fashion and that the Department of Justice has adequate staff resources to, in a timely manner, enroll the thousands of licensees now required to apply to CURES by January 1, 2016.

High-cost Drugs

The January Budget proposal reserved $300 million to pay for several new drugs for Hepatitis C for individuals in the Medi-Cal Program, the AIDS Drug Assistance Program, inmates in state prisons, and patients in state hospitals. In the May Revise, the Budget allocates $228 million of that $300 million to the Department of Health Care Services, the Department of State Hospitals, and the Department of Corrections and Rehabilitation. Additionally, the State will convene two workgroups: one to examine high-cost drugs that are pending federal approval and how they could affect existing clinical guidelines, and another procurement workgroup that will examine pharmacy benefit manager contracts, drug pricing information, and the ability to negotiate prices and rebates.

Next Steps

The Legislature is constitutionally required to pass a balanced budget by June 15, leaving the Governor until June 30 to sign, veto, or approve the Budget with reduced expenditures (line-item veto). Both houses of the Legislature will continue to hold committee hearings on the various proposals and assumptions contained in the May Revision. Meanwhile, the Legislative leaders will begin negotiation on some of the major aspects of the Budget directly with the Governor and his administration. CMA has put several hundred hours into our advocacy surrounding Medi-Cal reimbursement rates and will ramp up those advocacy efforts over the next month.

Click here to view the 106-page May Revise. 

Application Cycle Starts Next Week for Primary Care Physicians Interested in Steven M. Thompson Physician Corps Loan Repayment Award

The Health Professions Education Foundation (HPEF), a division of the Office of Statewide Health Planning and Development, has announced a special application cycle for the Steven M. Thompson Loan Repayment Program award. Applicants for this award could receive up to $105,000 for loan repayments in exchange for a service obligation in California’s medically underserved areas or public mental health system.

HPEF will accept applications from May 18 through June 26. Primary care physicians specializing in family medicine, internal medicine, obstetrics and gynecology, and pediatrics are eligible to apply. This cycle is only open to applicants in the following 17 counties: Alameda, Kings, Orange, Stanislaus, Contra Costa, Los Angeles, Riverside, Tulare, Del Norte, Madera, Sacramento, Fresno, Merced, San Diego, Kern, Monterey, and San Joaquin.   

HPEF contracts directly with recipients and does not require employers to provide or match funds.

Click here for more information and to apply.

SFDPH Health Update: Increase in Reported Cryptosporidiosis Cases

During January through April 2015, SFDPH received an unusually high number of case reports of Cryptosporidiosis. Most cases were homeless, many were HIV positive. Although several were hospitalized, there were no deaths or severe complications reported, and no common source of infection was identified. In recent weeks, reports of Cryptosporidiosis have declined to more typical rates. The first quarter increase in reports may have been due to increased stool testing associated with a recent outbreak of Shigella diarrhea affecting the homeless population. The water supply in San Francisco is safe to drink due to the San Francisco Public Utilities Commission’s watershed protection, treatment including ultraviolet light disinfection that specifically targets Cryptosporidium, and monitoring programs.


Cryptosporidiosis infection may be sub-clinical, a mild diarrheal illness, or a severe enteritis with or without biliary tract involvement. Diarrhea may be associated with malaise, nausea, anorexia, abdominal cramping, and low fever. The illness usually resolves in 10-14 days without specific therapy. However, infection in elderly patients can lead to severe volume depletion and high case-fatality rates.  In immune compromised hosts, especially those with CD4 <200/L, the illness is more likely to be protracted and severe and can lead to malabsorption with significant wasting and hepatobiliary disease (cholecystitis, cholangitis, hepatitis, pancreatitis).


Diagnosis is typically based on stool microscopy. Stool diagnostic testing with PCR or ELISA may also be available through commercial laboratories. If Cryptosporidiosis is suspected, the laboratory should be alerted to look specifically for Cryptosporidium, as routine stool O&P testing may not include the specific stains required to detect the spores.

For immunologically healthy children and for adults with persistent symptoms, treatment with nitazoxanide may be appropriate. Patients with severe diarrhea may need aggressive replacement of fluid and electrolyte losses. For HIV-infected patients, immune reconstitution with antiretroviral therapy is central to recovery; treatment with nitazoxanide or paramomycin may also be considered.

Prevention involves good hand washing before eating or preparing food, proper disposal or disinfection of contaminated materials such as soiled bedding, and avoidance of unprotected direct oral/anal contact. Immunocompromised patients should avoid oral exposure to water from lakes, streams, and public pools or hot tubs. People with Cryptosporidiosis should avoid using public pools or hot tubs for at least 2 weeks after symptoms have resolved.

Click here to view the SFDPH Health Update issued on May 13, 2015.

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