coastal medicine: winter 2014

Coastal MedicineThe magazine of the Santa Cruz County Medical Society

Winter 2014Volume 2/Number 3

2015 Health CareLeadership Forum

presented by the

Santa Cruz County Medical Society

Join us to welcome

Wendell Potterto Santa Cruz

February 19, 2015Location and time to be announced

Following a 20-year career as a corporate public relations execu-tive, Wendell Potter left his position as head of communications for CIGNA, one of the nation’s largest health insurers, to help socially responsible organizations — including those advocating for meaningful health care reform — achieve their goals.

Wendell is currently a senior analyst at the The Center for Public Integrity, a non-partisan nonprofit that produces original, re-sponsible investigative journalism on issues of public concern; the senior fellow on health care for the Center for Media and Democracy, an independent, non-partisan public interest or-ganization; and speaks out on both the need for a fundamental overhaul of the American health care system and on the dangers to American democracy and society of the decline of the media as watchdog, which has contributed to the growing and increas-ingly unchecked influence of corporate PR. He also serves as a consumer liaison representative for the National Association of Insurance Commissioners.

Winter 2014 • COASTAL MEDICINE • 3


5The President’s DeskBrian Brunelli, MD,SCCMS President

8Public Health ReportLisa Hernandez, MD, MPHCounty Health Officer

9Action Steps for a Suspect Ebola Case

10The Legislative ReportSergio Klor da AlvaSCCMS Advocacy & Public Policy Intern

13Welcome New SCCMS/CMA Members

20Executive Director’s MessageDonna Odryna

21The Ultimate MeasureCMA's 2014 Legislative Wrap UpJanus Norman, CMA Senior Vice President

27Advertisers / Classifieds; Key Dates / Calendar

14Achieving the Impossible:The 12-Year Battle for Fair Geographic Payments for Medicare Physicians

6Vote No on 46 -- Victory

4 • COASTAL MEDICINE • Winter 2014

SANTA CRUZ COUNTYMEDICAL SOCIETY

PRESIDENT Brian Brunelli MDPRESIDENT-ELECT Juan Rodriguez, MDPAST-PRESIDENT Jeannine Rodems, MD

SECRETARY Christopher O’Grady, MDTREASURER Patrick Meehan, MD

BOARD MEMBERSDavid Benjamin, MD; John Christensen, MD

W. Richard Hencke, MD; Donaldo Hernandez, MD Lisa Hernandez, MD; Dawn Motyka, MD

John Pestaner, MD; Rosalind Shorenstein, MDMichelle Simon, MD; Jack Watson, MD

COMMITTEE/PROJECT CHAIRS & RREPSFINANCE Juan Rodriguez, MD

HEALTH SCIENCES MENTORSHIP (UCSC) Jack Watson, MDLEGISLATIVE OUTREACH Tim Allari, MD; Jack Watson, MD

MEMBERSHIP Dawn Motyka, MDMRAC Tobias Yeh, MD

NOMINATING Brian Brunelli, MD; Juan Rodriguez, MDNORCAP COUNCIL Rosalind Shorenstein, MD

PHYSICIAN WELL-BEING John Gillette, MDand Martina Nicholson, MD

PRACTICE MANAGERS NETWORK Mary ChamplinQA, CONDUCT, & ETHICS Robert Jones, MD

CMA HOUSE OF DELEGATES REPRESENTATIVESJohn Christensen, MD; W. Richard Hencke, MD;

Christopher O’Grady, MD; John Pestaner, MDJeannine Rodems, MD; Juan Rodriguez, MD

Rosalind Shorenstein, MD; Jack R. Watson, MD

COMMUNITY ENGAGEMENT/PARTNERSCMA Richard Thorp, MD, President

CRUZMED FOUNDATION Jeannine Rodems, MD, PresidentEMERGENCY MANAGEMENT COUNCIL David McNutt, MD,

SCCMS RepresentativeEMERGENCY MEDICAL CARE COMMISSION Marc Yellin, MD,

SCCMS RepresentativeHEALTH IMPROVEMENT PARTNERSHIP Donna Odryna, Board

SSC MEDICAL RESERVE CORPS Jeff Terpstra, Chair

COVER PHOTOFrom iStockPhoto.com, “Surf board on the beach, Santa Cruz,

California”. Photo by Jason Rothe Photo/Media, www.jasonrothe.com.

Coastal Medicine magazine

EDITORIAL COMMITTEE Brian Brunelli, MD; Jeannine Rodems, MD and Donaldo Hernandez, MD

MANAGING EDITOR Donna Odryna

CONTRIBUTING WRITERS Brian Brunelli, MD; Lisa Her-nandez, MD; Elizabeth Zima; Sergio Klor de Alva; Janus Norman, and CMA staff

COPY EDITOR/LAYOUT Mary Champlin

Coastal Medicine magazine is produced by the Santa Cruz County Medical Society.

OPINIONS expressed by authors are their own and not necessar-ily those of Coastal Medicine magazine or SCCMS. Coastal Medicine reserves the right to edit all contributions for clarity and length and to reject any material submittedin whoe or in part. Acceptance of adertis-ing in Coastal Medicine is no way constitutes approval or endorsemennt by SCCMS of products or services advertised. Coastal Medicine and SCCMS reserve the right to reject any advertising.

SUGGESTIONS, story ideas, or completed stories written by current Santa Cruz County Medical Society members are welcome and will be reviewd by the Editoral Committee.

DIRECT all inquiries, submissions, and advertising to:Coastal Medicine Magazine1975 Soquel Dr #215Santa Cruz CA 95065-1821Phone: (831) 479-7226Fax: (831) 479-7223Email: [email protected]

MEDICAL SOCIETY STAFFEXECUTIVE DIRECTOR Donna J. OdrynaMEMBER SERVICES COORD/OFFICE MANAGER Mary ChamplinBOOKKEEPER Christie Hicks

Copyright ©2014 Santa Cruz County Medical SocietyAll rights reserved. Reproduction in whole or in part withoutwritten permission is prohibited.

POSTMASTERSend address changes to:Coastal Medicine Magazine1975 Soquel Dr #215Santa Cruz CA 95065-1821


The President’s DeskDr. Brian Brunelli is the SCCMS President, serving 2014-2016. He is a Neurologist with the Palo Alto Medical Foundation Santa Cruz. Dr. Brunelli is married and has two children.

The last few months have gone by in a whirlwind. At the Santa Cruz County Medical Society (SCCMS), most of our time and effort in 2014 went toward campaign activities focused on defeating Proposition 46. These included presentations to physicians, groups, medical staff, health care and community organizations, and the community-at-large. The No On Prop 46 Coalition was the largest assembled for a single ballot measure in California. In collaboration with and the help of the SCCMS, the Cali-fornia Medical Association (CMA), and the No On 46 Campaign Coali-tion, California voters saw through the trial lawyers’ attack on MICRA, sending Proposition 46 to a shattering defeat. On behalf of the SCCMS, I want to thank everyone who engaged in and supported these efforts.

Hopefully this defeat has sent the message from the voters that they cannot be fooled and will slow down future attacks from trial attorneys. We will be ready for them when they return.

Going forward, the SCCMS membership continues to grow. We are the largest and strongest in our history at 315 active members and 86 retired members. As a result, we will be sending an additional delegate to the annual CMA House of Delegates in 2015, helping craft the agenda of the CMA for years to come.

Nominations for the 2014 Excellence In Health Care Award are now open. A call for nominations was recently sent via the SCCMS Med-E-Mail Newsletter to all members to nominate candidates for this prestigious physi-cian of the year award – see also the call for nominations on the back cover of this issue of Coastal Medicine.

We are excited to be inviting Dr. Wendell Potter to deliver the keynote address at the 2015 SCCMS Health Care Leadership Forum on February 19, 2015 – see details on the inside cover of this issue. Dr. Potter is author of Deadly Spin – An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans, and Obamacare: What’s in It for Me? What Everyone Needs to Know About the Af-fordable Care Act. He is a former CIGNA executive-turned-whistleblower and is writing about the health care industry and the ongoing battle for health reform. His columns are published every Monday and they can be found at http://www.publicintegrity.org/health/wendell-potter. This is an event you will want to attend.

And finally, your delegate representatives just returned from the 2014 House of Delegates, convened in San Di-ego. Included among the many resolutions that were vetted and voted on at this HOD is on CMA’s governance system including a refocusing of the role of the House of Delegates, delegation of greater policy-making re-sponsibilities to the Board of Trustees, and revamping of CMA’s council and committee structure to equip these bodies for a greater role as drivers of CMA policy making. While there was a great deal of debate in committees and on the floor of the House, Governance Reform Resolutions and the related Bylaw changes required passed. A more thorough recap of the 2014 HOD will be published in the January/February issue of Coastal Medicine.

With that, I think 2014 is officially a wrap! So to you and yours I wish you a healthy, and safe holiday season. ❧


VICTORYOn November 4,the voters of California

spoke loudly AND DEFINITIVELY, SENDING THE TRIAL LAWYERS’ PROPOSITION 46 TO DEFEAT BY A VOTE OF

67 TO 33. THE MESSAGE IS CLEAR – CALIFORNIANS SIMPLY DON’T WANT TO INCREASE HEALTH CARE COSTS AND REDUCE HEALTH ACCESS SO TRIAL ATTORNEYS CAN FILE MORE LAWSUITS.

An increase in the Medical Injury Compensation Reform Act (MICRA) cap on non-economic damages has been rejected in

California again and again: 10 times in court, 5 times in the Legislature and now overwhelmingly by voters. This idea now has its own dedicated spot in California’s political trash heap.

VICTORY


WINTER 2014 SAN JOAQUIN PHYSICIAN 45

SEPTEMBER 13, 2014

“…this measure

overreached in a decidedly

cynical way.”

AUGUST 11, 2014

“…the initiative…has

three distinct provisions

packaged together as a

take-it-or-leave-it deal.”

SEPTEMBER 23, 2014

“Prop 46: Trial lawyers’

pathetic scam”

SEPTEMBER 25, 2014

“Proponents…are trying

to trick voters into raising

malpractice awards.”

SEPTEMBER 25, 2014

“The statewide database

is nowhere near complete,

and data in it is unreliable.

It’s not ready for prime

time…”

AUGUST 7, 2014

“Unfortunately, they

added the random

drug testing because

it reportedly tested

well in focus groups

to boost support for

the measure.”

AUGUST 31, 2014

“…would disrupt health

care in California...”

VICTORYBut this time, we energized the membership of CMA as a whole to fight the fight together, as one unified voice of medicine, representing the patients we so deeply care about and the care that we have committed to provide them.

Despite the trial attorney proponents’ attempt to sweeten the deal by adding provisions that polled well– physician drug testing and mandatory checking of a prescription database – voters said NO on Election Night. As people throughout the state heard from physicians and No on 46 coalition members about the real intentions of the measure’s proponents, there was resounding opposition. One of the secret weapons of this effort was the size and diversity of our coalition. We helped amass one of the largest and most diverse campaigns in California history. The breadth of the coalition — which

includes labor, business, local government, health providers, community clinics, Planned Parenthood, ACLU, NAACP, taxpayers, teachers, firefighters and more – underscores just how important affordable, accessible health care is to every Californian.

In addition to the groups on the ground talking to voters about the deception and trickery behind Prop. 46, every major editorial board in California opposed the initiative.

The Los Angeles Times said, “As worthwhile as [Proposition 46’s] goals may be, the methods the measure would use to achieve them are too flawed to be enacted into law.”

The San Francisco Chronicle decried Prop. 46 saying that the measure, “overreached in a decidedly cynical

way.”

The Orange County Register, UT San Diego, San Jose Mercury News, Monterey County Herald, Sacramento

Bee and dozens of other newspapers echoed these sentiments.

The efforts of the California Medical Association and the county medical associations across the state is a tremendous showing of what we can do for the future of health care, the quality of medicine and the dedication to patients everywhere. Working together to spread the truth about Prop. 46, building

coalitions across communities and standing strong as one united voice is what

helped carry us to victory.

This was one of the most contentious and high-stakes ballot fights in California history and we rose to the occasion. We must use this unity moving forward and showcase to our colleagues the value the California Medical Association brings to

our great profession and stay united for whatever comes our way next.


Reconstructive surgeons who really listen. Our surgeons are here to help you look (and feel) your best. They perform a variety of procedures, such as facial, hand, and post-mastectomy breast reconstruction. Achieve the most natural look possible with highly trained, board-certified plastic and reconstructive surgeons. Call 831-464-8880 to schedule a consultation.

dominicanmedicalgroup.org

The Public Health Division of the Santa Cruz County Health Services Agency has been working towards preparing the healthcare providers in our community for Ebola response since August 13, 2014 when the first Public Health Advisory was distributed. Since that time, Public

Health has worked closely with hospitals, clinics, Emergency Medical Services and the California De-partment of Public Health to develop protocols which protect healthcare workers and ensure proper care, transport and testing for suspect Ebola cases. Additionally, they have published a new Ebola web page (www.santacruzhealth.org) which not only contains information for the public but also for provid-ers, including all of the Public Health Advisories and Updates sent since August 2014. Public Health is confident that, working together, we will be able to respond appropriately to the Ebola threat and protect our community from communicable disease.

Public Health ReportDr. Lisa Hernandez, MPH is the Health Officer and Medical Services Director for the County of Santa Cruz Health Services Agency. During her 20 years in medicine and public health she has become familiar with the health concerns of populations and the challenges the Nation, California and Santa Cruz County currently experience and will face in the future. Dr. Hernandez holds a BA from Yale University, an MD from Georgetown University School of Medicine, and an MPH from University of California, Berkeley.


Actio

n St

eps

for a

Sus

pect

Ebo

la C

ase

Cou

nty

of S

anta

Cru

z, P

ublic

Hea

lth D

ivis

ion

Epid

emio

logi

c R

isk

Fact

ors

to C

onsi

der w

hen

Eval

uatin

g a

Pers

on fo

r Exp

osur

e to

Ebo

la V

irus

Upd

ated

: Oct

ober

27,

201

4 by

U.S

.A. C

ente

rs fo

r Dis

ease

Con

trol a

nd P

reve

ntio

n

1. H

igh

risk

inclu

des

any

of th

e fo

llow

ing:

•

Perc

utan

eous

(e.g

., ne

edle

stic

k) o

r muc

ous

mem

bran

e ex

posu

re to

blo

od o

r bod

y flu

ids

of a

per

son

with

Ebo

la w

hile

the

pers

on w

as

sym

ptom

atic

,•

Expo

sure

to th

e bl

ood

or b

ody

fluid

s (in

clud

ing

but n

ot li

mite

d to

fece

s, s

aliv

a, s

wea

t, ur

ine,

vom

it, a

nd s

emen

) of a

per

son

with

Ebo

la w

hile

the

pers

on w

as s

ympt

omat

ic w

ithou

t app

ropr

iate

per

sona

l pro

tect

ive

equi

pmen

t (PP

E),

•Pr

oces

sing

blo

od o

r bod

y flu

ids

of a

per

son

with

Ebo

la w

hile

the

pers

on w

as s

ympt

omat

ic w

ithou

t app

ropr

iate

PPE

or s

tand

ard

bios

afet

y pr

ecau

tions

,•

Dire

ct c

onta

ct w

ith a

dea

d bo

dy w

ithou

t app

ropr

iate

PPE

in a

cou

ntry

with

wid

espr

ead

Ebol

a vir

us tr

ansm

issi

on,

•H

avin

g liv

ed in

the

imm

edia

te h

ouse

hold

and

pro

vide

d di

rect

car

e to

a p

erso

n wi

th E

bola

whi

le th

e pe

rson

was

sym

ptom

atic

2. S

ome

risk

inclu

des

any

of th

e fo

llow

ing:

•

In c

ount

ries

with

wid

espr

ead

Ebol

a vi

rus

trans

mis

sion

: dire

ct c

onta

ct w

hile

usin

g ap

prop

riate

PPE

with

a p

erso

n w

ith E

bola

whi

le th

e pe

rson

w

as s

ympt

omat

ic•

Clo

se c

onta

ct in

hou

seho

lds,

hea

lth c

are

faci

litie

s, o

r com

mun

ity s

ettin

gs w

ith a

per

son

with

Ebo

la w

hile

the

pers

on w

as s

ympt

omat

ic

C

lose

con

tact

is d

efin

ed a

s be

ing

for a

pro

long

ed p

erio

d of

tim

e w

hile

not

wea

ring

appr

opria

te P

PE w

ithin

app

roxi

mat

ely

3 fe

et (1

m

eter

) of a

per

son

with

Ebo

la w

hile

the

pers

on w

as s

ympt

omat

ic

3. L

ow (b

ut n

ot z

ero)

risk

inclu

des

any

of th

e fo

llow

ing:

•

Hav

ing

been

in a

cou

ntry

with

wid

espr

ead

Ebol

a vi

rus

trans

mis

sion

with

in th

e pa

st 2

1 da

ys a

nd h

avin

g ha

d no

kno

wn

expo

sure

s•

Hav

ing

brie

f dire

ct c

onta

ct (e

.g.,

shak

ing

hand

s) w

hile

not

wea

ring

appr

opria

te P

PE, w

ith a

per

son

with

Ebo

la w

hile

the

pers

on w

as in

the

early

st

age

of d

iseas

e•

Brie

f pro

xim

ity, s

uch

as b

eing

in th

e sa

me

room

for a

brie

f per

iod

of ti

me,

with

a p

erso

n w

ith E

bola

whi

le th

e pe

rson

was

sym

ptom

atic

•In

cou

ntrie

s w

ithou

t wid

espr

ead

Ebol

a vi

rus

trans

mis

sion:

dire

ct c

onta

ct w

hile

usi

ng a

ppro

pria

te P

PE w

ith a

per

son

with

Ebo

la w

hile

the

pers

on

was

sym

ptom

atic

•Tr

avel

ed o

n an

airc

raft

with

a p

erso

n w

ith E

bola

whi

le th

e pe

rson

was

sym

ptom

atic

.

4. N

o id

entif

iabl

e ris

k in

clude

s:

•C

onta

ct w

ith a

n as

ympt

omat

ic p

erso

n w

ho h

ad c

onta

ct w

ith p

erso

n w

ith E

bola

•C

onta

ct w

ith a

per

son

with

Ebo

la b

efor

e th

e pe

rson

dev

elop

ed s

ympt

oms

•H

avin

g be

en m

ore

than

21

days

pre

vious

ly in

a c

ount

ry w

ith w

ides

prea

d Eb

ola

virus

tran

smis

sion

•H

avin

g be

en in

a c

ount

ry w

ithou

t wid

espr

ead

Ebol

a vir

us tr

ansm

issi

on a

nd n

ot h

avin

g an

y ot

her e

xpos

ures

as

defin

ed a

bove

Oct

ober

27,

201

4


After an emphatic defeat in the November 4 Gen-eral Election, Consumer Watchdog and other Prop. 46 proponents announced that they will continue to vie for what they term “increased patient safety,” the central message that was promoted by the Yes on 46 campaign[1]. However, many saw Prop. 46 as a clear attempt to raise the non-economic cap rate on medical lawsuits solely in order to increase potential gains by trial attorneys, rather than to improve patient safety. So why was the message of increasing patient safety not received by many voters?

Ballot initiatives are ultimately judged in two separate but inherently interconnected ways: what they are truly trying to accomplish and which messages they are sending to voters when attempting to garner support for their measure.

BackgroundProposition 46, which supporters refer to as the Troy and Alana Pack Patient Safety Act of 2014, was initially created with the intention of reforming the Medical Injury Compensation Reform Act of 1975 (MICRA) to drastically increase the state’s cap on non-economic damages (grief, pain, and suffering) from medical neg-ligence lawsuits from $250,000 to almost $1.1 million which would then be subject to change based on infla-tion[2]. Other provisions were also introduced, with opponents believing they warranted inclusion solely because they piqued the interests of potential voters (especially in reference to the random drug-testing mandate)[3].

Bob Pack, the sponsor and leader of the initiative, de-cided to try to reform MICRA in order to, as he argues, “hold doctors accountable” after his young children,

Troy and Alana Pack, were killed in a horrific hit-and-run accident by a driver who was under the influence of alcohol and doctor-prescribed pain pills Vicodin and Flexeril (a muscle relaxant)[4]. Soon after, Pack founded the Troy and Alana Pack Foundation to work with political actors, advocacy groups, and police on public safety legislation and anti-drug efforts[5].

He also designed an electronic update to the Con-trolled Substance Utilization Review and Evaluation System (CURES) database, which allows doctors to view the medical prescription history of patients and automatically alerts the Justice Department of pos-sible drug abuse[6]. After seven years of working with the bill’s author, Sen. Mark DeSaulnier (D-Concord), Pack’s brainchild, SB 809, was signed into law by Gov-ernor Jerry Brown on Sept. 27, 2013, ensuring that the database will receive funding to maintain and to make improvements to CURES (using fees paid for by doc-tors and pharmacists)[7].

His efforts found support from the Consumer At-torneys of California and from Consumer Watchdog, a nonprofit advocacy group based in Southern Cali-fornia, that helped fund and mobilize support for his cause[8]. While I am sure these groups do have con-sumers’ interests in mind, I cannot help but make the logical connection that their enthusiasm for Pack’s movement was driven at least in part by the millions of dollars trial attorneys stood to make if the proposition passed and medical lawsuits become more expensive.

Also included in Prop. 46 was a provision that had been dropped from Pack’s SB 809, a mandate that would require doctors to consult the CURES database before prescribing potentially addictive narcotics to patients[9]. A mandate requiring physicians to undergo

Proposition 46: The Rise and Fall/Birth and Defeat of a Controversial

Ballot Measure

The Legislative ReportSergio Klor de Alva is a student in his last quarter at the University of California, Santa Cruz, where he will earn B.A.s in Politics and Combined Sociology/Latin American & Latino Studies. He currently works as the Advocacy and Public Policy Intern for the Santa Cruz County Medical Society. He plans to attend law school and pursue public policy work in the Bay Area, Sacramen-to, and Washington, D.C.


random drug tests, and targeted tests following unfa-vorable medical events, was also part of the initiative and spawned a series of comical musical campaign ads on YouTube promoting the ballot measure[10].

ControversyThe controversial drug testing component of the initia-tive was sold by proponents of the initiative as another way to promote patient safety, because, as Bob Pack argues, “You should have a 100 percent assured feel-ing your doctor is not abusing drugs and alcohol”[11]. While few would argue that physicians, especially those performing surgeries, should not be under the influence of narcotics on the job, dissenters offer a dif-ferent opinion as to why the provision was included as part of the Prop. 46 package.

Opponents of the initiative contest that the provision warranted inclusion because it was an appeal to vot-ers’ emotions, polled well, and masked the true intent of the proposition: reforming MICRA[12]. They also point out that Jamie Court, the head of Consumer Watchdog, even referred to the provision as the “ulti-mate sweetener” in a Dec. 10, 2013 LA Times article by Michael Hiltzik[13]. In the article, Court also men-tions that the provision was the only component of the proposal that sparked the interests of various focus groups[14].

All About the Money?The concept of money is at the heart of arguments made by both proponents and dissenters of Prop. 46. Proponents of the measure note that the cap on pain-and-suffering has not risen since MICRA’s inception in 1975, and thus should be updated for inflation.[15]Supporters also point out that insurance companies spent almost $100 million to defeat the measure and argue that their greed is motivating them to promote anti-Prop 46 messages.[16] Bob Pack also believes that making the use of CURES mandatory will save the state hundreds of millions of dollars, while opponents contend that the database is not well funded and will result in breaches of privacy for patients who will have their medical records exposed to the public.[17]

However, opponents of Prop. 46 argued that the main goal of the proposition was to increase monetary gains of trial attorneys and that increasing patient safety was a secondary goal, if one at all. Tom Scott, executive director for California Citizens Against Lawsuit Abuse,

argued that the proposition used “smoke and mirrors” to distract voters with trivial provisions that tested well but would not dramatically increase patient safety.[18] According to Scott, “This is not about victims -- it’s about money.”[19] Kim Stone, president of the Civil Justice Association of California, echoed this notion, contending that “the true intent is to give lawyers more money at the expense of patients and doctors.”[20] Lawyers take a 40% cut from medical negligence law-suits and, if the proposition had passed and the cap on pain-and-suffering had been inflated, lawyers would have seen their gains rise from $100,000 to $440,000 per lawsuit.[21] Bob Pack, meanwhile, does not believe these potential gains would “enrich the attorney” and believes the compensation would have been fair.[22]

Ultimately, the voters spoke loud and clear in defeating the ballot measure. However, it is unlikely that Prop. 46 supporters will quietly drop the issue and I would guess that the topic, in some controversial form or an-other, will reappear in the years to come. Make sure to stay informed about new ballot measures as they arise and be conscious about the messages they send to the public and the true motivations behind them. ❧

[1] http://www.californiahealthline.org/articles/2014/11/6/prop-46-proponents-vow-to-continue-to-push-for-changes[2] http://www.voterguide.sos.ca.gov/en/propositions/46/[3] http://www.noon46.com/get-the-facts/question-and-answers/ [4-9], http://www.contracostatimes.com/contra-costa-times/ci_24357077/decade-after-death-his-children-dan-ville-man-tenacious[10-14]http://www.washingtonexaminer.com/advocate-de-fends-ballot-measure-that-mixes-doctor-drug-testing-with-increase-of-med-mal-caps/article/feed/2152745[15]http://www.washingtonexaminer.com/advocate-de-fends-ballot-measure-that-mixes-doctor-drug-testing-with-increase-of-med-mal-caps/article/feed/2152745[16] http://www.mercedsunstar.com/opinion/editorials/ar-ticle3304850.html[17-20]http://www.washingtonexaminer.com/advocate-de-fends-ballot-measure-that-mixes-doctor-drug-testing-with-increase-of-med-mal-caps/article/feed/2152745[21] http://www.mercedsunstar.com/opinion/editorials/ar-ticle3304850.html[22]http://www.washingtonexaminer.com/advocate-de-fends-ballot-measure-that-mixes-doctor-drug-testing-with-increase-of-med-mal-caps/article/feed/2152745

12 • COASTAL MEDICINE • Winter 2014 © 2014 NORCAL Mutual Insurance Company

Our beats in

Our heart beats in California … and has for almost 4 decades.

Since 1975 NORCAL Mutual has served healthcare professionals throughout the Golden State.

Strength, stability and innovative products are just a few reasons why physicians continue to

look to us for their medical professional liability insurance. We provide you:

Industry-leading claims and risk solutions support 24/7

Full access to our interactive risk management library

Flexible coverage options tailored to your needs

California is important to us. So is your peace of mind. Come see how homegrown strength

can help protect your practice.

Visit heart.norcalmutual.com or call your agent/broker today.


as of 12/1/14

Prachi Jog, M.D.NephrologyPalo Alto Med Foundation2025 Soquel AveSanta Cruz 95062458-5597

David Beck, M.D.Family MedicinePalo Alto Med Foundation2025 Soquel AveSanta Cruz 95062458-5524

Cesar Castillo, M.D.HospitalistPalo Alto Med Foundation1661-D Soquel Dr Santa Cruz 95065423-4111

Grant de la Motte, M.D.NeurologyPalo Alto Med Foundation1661-D Soquel DrSanta Cruz 95065460-6041

James J. Gallagher, M.D.Family Medicine268 Green Valley RdFreedom 95018728-0440

Ryan Kau, M.D.OtolaryngologyPalo Alto Med Foundation2950 Research ParkSoquel 95073458-6272

Lawrence Spingola, M.D.Surgical Associates of Monterey BayRetired October 8, 2014Member 2000-2014

Andrea Ling, M.D.Pulmonary, Critial CareSC Pulmonary Med Group700 Frederick St #203Santa Cruz 95065425-1906

Nicole Marsico, M.D.PediatricsPalo Alto Med Foundation2025 Soquel AveSanta Cruz 95062458-5555

William Morris, M.D.Geriatric/PalliativePalo Alto Med Foundation2850 Commercial CrossingSanta Cruz 95065458-5511

Matthew Reimert, M.D.RheumatologyPalo Alto Med Foundation2025 Soquel AveSanta Cruz 95062458-5524

Kuntal Thaker, M.D.GastroenterologyPalo Alto Med Foundation1662 Dominican WaySanta Cruz 95065460-7350

Janet Wang, M.D.Hematology/OncologyPalo Alto Med Foundation2850 Commercial CrossingSanta Cruz 95065460-7355

James Maguire, M.D.PediatricsPalo Alto Med Foundation550 S Green ValleyWatsonville 95076458-5860

New and Rejoin Members

Retired Members


In 2002, Larry De Ghet-aldi, M.D., met with his Congresswoman, Anna

G. Eshoo (CA-18), to see if he could enlist her help in changing the way that Medicare reimbursed physicians in Santa Cruz County.

S o m e t h i n g was wrong with the M e d i c a r e ge o g r aph i c payment re-gions tied to the re-i m b u r s e -ment for-mula known as the Geographic Practice Cost Index (GPCI). In his own Santa Cruz County, physicians were paid by Medicare approximately 20 percent less than in the next county north, Santa Clara, while the cost of providing care in both counties was essentially the same. The reason? Santa Cruz County was designated as "rural," while Santa Clara County was not.

In fact, the sixth largest city in the United States, San Diego, was also designated by Medicare as rural. Consequently, physi-cians seeing Medicare patients in San Diego were paid about 10 percent less than physicians in neighboring Orange County.

Since the 1990s, hospitals have been paid according to the local costs in their Metropolitan Statistical Areas (MSAs). The MSAs are defined by the federal Office of Management and Budget and annually updated by the Centers for Medicare and Medicaid Services (CMS), so that reimbursement accurately reflects local costs to deliver care. But for physicians, CMS used county-based localities, and these localities have not been updated in 17 years. As a result, 14 recently urbanized Cali-fornia counties, such as San Diego, Santa Cruz and Sacramento, were still designated as rural. This caused many California physicians to be paid up to 13 percent per year below what Medicare says they should be paid if they were correctly classified.

Because physicians were paid less in Santa Cruz County, Dr. De Ghetaldi noted that many Medicare patients were having problems finding phy-sicians to care for them. In fact, no physician group in Santa Cruz was accepting new Medicare patients.

For this reason, he asked Congress-woman Eshoo to help him convince CMS to reconsider the payment re-gions it used to reimburse doctors.

“This was a week after Congress voted to go to war in Iraq,” Dr. De Ghetaldi said. “We had already spent several hours with CMS trying to

get them to change the formula, but they had little incentive to do so.”

After explaining the issue to Es-hoo, she told him: “Larry, it is easier to go to war, than to change this. We will leave Iraq before this fix is in place.” She said it with such certainty that Dr. De Ghet-aldi was stunned – he didn’t want to believe that she was correct.

The Long HaulWhat followed was a 12-year od-yssey that included divisive de-bates within the California Medi-

cal Association (CMA) House of Delegates (HOD); changes in administration from the Bush White House to the Obama White House; several changes in leader-ship of key congressional com-mittees and their staff; innumer-able frustrating meetings between CMA and CMS; and countless

Achieving the ImpossibleHow one “prick of conscience” launched a12-year fight for fair geographic payments

for Medicare physiciansBy Elizabeth Zima, CMA Staff Writer

Something was wrong with the Medicare geographic payment regions tied to the reim-bursement formula known as the Geo-graphic Practice Cost Index (GPCI).

Dr. Larry de Ghetaldi


rounds of relentless Congressio-nal lobbying by CMA leadership.

What began for Dr. De Ghetaldi as a “prick of conscience” about the lack of care for seniors in his county became an obsession. He, in turn, found a small cadre of activ-ists who formed a team that could not look away from what turned out to be a problem for the whole country – the fact that many areas that CMS had judged as rural in 1997 had become more urbanized with changing costs and demo-graphics, but had not been updated to accurately reimburse physicians. This, in turn, was stymieing seniors from getting the care they needed. It was a huge national problem, and unconscionable that CMS had not kept pace with physician payments.

The team for the long haul was composed of physicians, lobby-ists and Members of Congress and their staff. The key players that took the issue from the CMA HOD floor to the national stage included Dr. De Ghetaldi; Edward Bentley, M.D.; Theodore Mazer, M.D.; Rep-resentative Sam Farr (D-Monterey, Santa Cruz) and his chief of staff, Rochelle Dornatt; and Elizabeth McNeil, CMA Vice President of Federal Government Relations. Dr. Bentley, an internist with a specialty in gastroenterology, was president-elect of the Santa Bar-bara Medical Society in 2002 when he became aware of the GPCI locality issue. “I had been in practice in Ventura County, so I knew that reimbursements were lower (in Santa Barbara Coun-ty).” But, he didn’t know why.

“I approached Dr. George Wolf [a CMA delegate] from Santa Cruz

County and asked him to put for-ward a resolution asking CMA to do something about the prob-lem,” said Dr. Bentley. This caused a ruckus the first time the motion

was introduced at HOD. “It was a divisive resolution," he said. Part of the problem was that CMS re-quired that the fix be accomplished in a budget-neutral way. Unfortu-nately, this meant that in order to raise reimbursement levels for the underpaid counties, other coun-ties would have to foot the bill.

To get to some agreement on the is-sue, a CMA task force was formed. It was headed by current CMA President, Richard Thorp, M.D. “He lived in a county that benefitted from the locality arrangement that had been established by CMS, so he was in a difficult position,” said Dr. Bentley. Trying to put together a compromise that would gain con-sensus from all counties turned out to be so contentious it took three years to pass through the HOD.

When the task force looked at the issue, there were “clear winners and losers.” The other requirement CMS had for action on this issue was that there had to be 100 per-cent approval from the state medi-cal association to make changes.

For McNeil, who says a substan-

tial part of her job at CMA for the past 12 years has been focused on a solution to the locality problem, the CMS requirement for con-sensus was a tactic to discourage

change. But, instead, she says, it served to galvanize the group to come up with a solution for the state that would promote una-nimity and justice in payments.

What CMS had wrought when it created the California localities in 1966, and further distorted them in 1997, was a mishmash of counties grouped together. In 1997, Local-ity 99 was comprised of 47 rural counties, but over the last decade at least 13 had become more urban. Payments for all counties within Locality 99 are averaged, which produces inaccurate payments not based on local costs to provide care. CMS had failed to keep pace with the changing demographics. “Our objective (in the task force) was to improve the accuracy of the pay-ments,” said Dr. Bentley. It turned out to be very hard to do because Medicare is a budget-neutral pro-gram, where any payment change produces winners and losers.

While the task force worked on a solution to the problem, the group had restarted talks with CMS to see if it would take into consid-eration some creative plans

“Our objective (in the task force) was to improve the accuracy of the payments,” said Dr. Bentley. It turned out to be very hard to do because Medicare is a budget-neutral program, where any payment change produces winners and losers.


to refine the payment regions.

CMA, Rep. Farr and Dornatt started working with the power-

ful then-Chairman of the House Ways and Means Committee, Rep-resentative Bill Thomas (R-Bakers-field). He fully agreed with CMA about the problem and said he would help to fix it. Yet year after year, he stalled any action on a fix.

In 2003, during markup of the Medicare Part D bill in the Ways and Means Committee, Rep. Farr tried to introduce language to fix the locality problem, but Rep. Thomas blocked the move. It was then that the “famous $100 bet” was struck on the House floor. Frustrated and ready to take a swing at Thomas, Farr instead bet Thomas that he would never permit a solution to the locality problem in California to pass. Thomas took the bet, telling him he would get it through. When Thomas retired in 2007, he made good on the bet, paying Farr $100.

Meanwhile, the CMA task force had achieved near consensus across the state that all California

physicians would take a one-time, 1 percent cut to pay for the update without harming the rural physi-cians. “We presented the idea to CMS and their lawyers were afraid they would get sued. So we pro-posed a pilot project that had to go through public hearings, but CMS wouldn’t budge,” said McNeil.

In 2005, CMS proposed to update the payment regions and thus, the payments for the most harmed counties in California — Santa Cruz and Sonoma counties. The an-nouncement disappointed doctors in other impacted counties and cre-ated angst throughout CMA mem-bership because some physicians would see a small payment cut. The proposed regulation died because there wasn’t 100 percent consensus within CMA. “I thought CMA’s fail-ure to reach consensus on this pro-posal was a real set-back, because we could have updated a few coun-ties every two years until all were updated," McNeil lamented. "We might have actu-ally gotten it done before 2014!”

Dead EndThe group had reached a dead end. “We had tried the regu-latory path and then realized the only way to solve it was through an act of Con-gress,” said Dr. Bentley. CMS can only change payments in a budget-neutral manner with winners and losers, so any change that holds rural physicians harmless from

cuts requires additional fund-ing and Congressional action.

Up to this point, CMS had been keeping private its cost inputs for the locality payments. In 2004, a staffer leaked the information to Dr. Bentley. He quickly went through the data and discovered that this problem was not confined to Cali-fornia. “The payment disparities were a national problem,” he said.

Working with CMA, Rep. Farr in-troduced several bills over the com-ing years, some with his Republican counterpart Representative Brian Bilbray (R-San Diego), but noth-ing moved. CMA tried to educate the other negatively impacted state medical associations and get them on board. "It was like herding cats," McNeil recalls. "It was an extreme-ly difficult process. In the end, we were afraid it would take more time to bring on 10 medical associations than it would take to get the bill through Congress for California

only." In the 2014 legislation that ultimately passed, CMA attempted to insert a national study to help the other states. But in the end, Con-

Rep. Sam Farr

In 2005, CMS proposed to up-date the payment regions and thus, the payments for the most harmed counties in Cali-fornia—Santa Cruz and Sonoma counties. The announcement disappointed doctors in other impacted counties and created angst throughout CMA member-ship because some physicians would see a small payment cut.


gress only chose to help California.Rep. Thomas did, however, do the group one favor. Before he retired, he asked the U.S. General Account-ing Office (GAO) to study the prob-lem. In 2006, Drs. Bentley and De Ghetaldi prepared a white paper for the Medicare Payment Advisory Commission (MedPAC), an inde-pendent body established to advise Congress on Medicare payment is-sues. “They acknowledged the prob-lem,” said Dr. Bentley. The same pa-per was presented to the GAO who took up the problem and studied it. “The GAO issued a report that vali-dated our white paper,” he added.

In 2008, when California Represen-tative Pete Stark (D-Fremont) be-came Chair of the House Ways and Means Subcommittee on Health, he (at the urging of Rep Farr, CMA and other representatives) included a California GPCI solu-tion in the Children’s Health and Medicare Protection (CHAMP) Act, which passed the House in 2008. He used the GAO report to justify its inclusion. Unfortu-nately, it did not pass the Senate.

Another turning point came in 2009, when CMA hosted a Con-gressional “GPCI Summit” be-tween the House, Senate, CMS and MedPAC. All of the House and Senate committee leaders were in a neutral meeting place in the base-ment of the Capitol. This summit is where CMA started to gain general buy-in that the problem needed to be fixed, particularly from the Sen-ate. In 2010, both Drs. Bentley and DeGhetaldi were invited to testify on behalf of CMA before the Insti-tute of Medicine (IOM). "We pre-sented the white paper,” said Dr. Bentley. “I presented the data that

demonstrated the payment inac-curacies. The IOM took our pre-sentation and the white paper and refined it.” The IOM report con-firmed the locality prob-lem and recommended the CMA proposed solution to move localities to Met-ropolitan Statistical Areas consistent with the hospi-tal payment regions. It was at this point that Congress began to really listen to the group. “When you have the backing of the IOM, the GAO and MedPAC, they will listen,” Dr. Bentley said.

In 2009-10, Chairman Stark in-serted the California locality up-date into the House’s version of the Affordable Care Act (ACA). The House passed it, but the Sen-ate version did not include the fix. Although the GPCI fix was adopted during the House-Senate Confer-ence Committee on health care re-form, when the Senate Democrats lost the majority, Congress was eventually forced to accept the Sen-ate version of the bill without the California GPCI provision. “I felt like a beaten dog, at this point,” said Dornatt. But the problem was still there. “Doctors were still coming in the door [complaining]; and ben-eficiaries complained they could not find doctors to care for them.”

Starting OverThe group started over again look-ing for a solution that would pass both Houses of Congress. The Sen-ate had been extremely critical of a California-only solution. Some called it the “California gold rush.” CMA and Rep. Farr enlisted the help of Representative Darrell Issa

(R-San Diego). Issa, the powerful Chairman of the House Oversight and Government Reform Com-mittee, agreed to work with Farr

to push their respective leaders to include the GPCI fix in any bud-get or Medicare legislative pack-ages moving through Congress.

At the same time, California Sena-tor Dianne Feinstein found a Cal-ifornia-only funding source for the locality legislation that would diminish the California “pork bar-rel” criticisms. Unfortunately, after the passage of the ACA, Congress became even more dysfunction-al; the only Medicare bills mov-ing through Congress were the last-minute Medicare sustainable growth rate (SGR) short-term patch bills. Congressional leadership told the CMA team that no new policy issues would be included in those patch bills, which once again nixed CMA’s chances to achieve California locality reform in 2011 and 2012. However, that didn’t stop Farr and CMA from trying. In early February of 2013, both the House and Senate began working on bills to solve the Medicare SGR issue. In 2012, the Republicans took control of the House with new lead-ership. Representative Kevin Mc-Carthy (R-Bakersfield), who had replaced his mentor, Bill Thomas, became the House Majority


Whip. Under his leadership, the House Republican Committee leaders renewed the call to fix the SGR. Their Democratic predeces-sors in the House had repealed the SGR twice, only to fail in the Sen-ate. “We knew that both the House and the Senate wanted to fix the SGR because the cost of the fix had dropped dramatically,” Dornatt said. “The Medicare bill was intend-ed to be a comprehensive payment reform bill, so we knew we had a shot at getting the California local-ity reform in,” said McNeil. Dornatt and McNeil began to push for the insertion of a GPCI fix for California. The proposal updated the California Medicare physician payment regions. It increased payments in the new urban areas and pre-vented payment re-ductions to California rural physicians, by using a hold harmless provision that was fi-nanced with adminis-trative savings from the formation of a Medicaid County Organized Health System in Alameda County.

But, said Dr. Bentley, “no one likes to do a one-state deal; it is considered pork. This was a sen-sitive issue, and we were try-ing to run under the radar.”

Several committees in both the House and Senate were working on an unprecedented bipartisan, bicameral solution to the Medi-care payment reform issue. With the help of Rep. Henry Waxman (D-Los Angeles), who was the Ranking Democrat on the House Energy Commerce Committee,

and Committee Chair Fred Upton (R- Michigan), Dornatt and Mc-Neil managed to insert language to update the California localities into the bipartisan Energy and Commerce Medicare SGR pay-ment reform legislation (H.R. 2810), which unanimously passed the Committee on July 31, 2013. “We were frantically still negotiat-ing language the morning of the mark-up,” recalled McNeil. “And we were literally one of the last amendments accepted into the bill. It was incredibly stressful. I knew we had to get GPCI into the

first policy committee bill. Other-wise, we would be fighting an up-hill battle the rest of the way, par-ticularly going into the Senate."

This version of the locality up-date was a compromise between Reps. Upton and Waxman. It was based on legislation proposed by Reps. Farr and Issa. House Ma-jority Whip Rep. McCarthy was key to the agreement, with CMS also stepping in to assist. Califor-nia Energy Commerce Commit-tee members Reps. Anna Eshoo, Lois Capps and Doris Matsui, who all have impacted districts, also helped to push the solution.

Doing the UnthinkableIn the fall of 2013, it looked like Congress would do the unthink-able — solve the flawed Medicare SGR. Two other powerful com-mittees were expected to introduce versions of the SGR bill: the House Ways and Means Committee and the Senate Finance Committee. “There was unprecedented una-nimity in Congress that the time was now to fix the Medicare reim-bursement problem,” said McNeil.

While the SGR reform policy bill passed out of these committees before the winter holidays, there was no consensus on how to pay for it. The House Republicans and the Senate Dem-ocrats couldn’t agree on the funding sourc-es, so they passed a policy-only bill.

On February 7, 2014, the three congres-sional committees

announced a final joint biparti-san, bicameral agreement on the Medicare SGR repeal and payment reform legislation, H.R. 4015/S. 2000. Now Congress just needed to marry the policy to the funding sources to the tune of $150 billion.

The California GPCI fix had made it into the final compromise bill, and the group worked feverishly to get the bill passed. But as the SGR deadline grew closer, the group realized there would be no com-promise on the funding sources, and that Congress would yet again — for the 17th time in a decade — pass a short-term patch to stop the double-digit SGR reimbursements

This is a particularly sweet victory be-cause it was so difficult and achieved during one of the most contentious times in Congress. This was a hard-won geographic formula fight between physicians, involving an agency that never takes risk, a dysfunctional Con-gress and a state unpopular in Congress that was singled out for assistance.


cuts. McNeil and Dornatt swung into action to see if they could at least insert the California GPCI fix into the patch legislation.“When we knew there was the po-tential for a patch, we went to the top players in the House and Sen-ate to get the California GPCI into

it,” McNeil said. “Because of our lobbying efforts over the years, our relationships with the Congressio-nal leadership and the committee staffers, they legitimately listened and were interested in helping.”

“However, a special California provision would never make it into such a small bill, so we had to find a larger, more national ar-gument," said McNeil "When the Committee staff revealed to us that the SGR patch bill would in-clude an extension of the national Medicare work GPCI payment floor, I knew we had an angle."

Nearly every other state in the country except California bene-fits from the work GPCI payment floor, so if physicians in other states were receiving an extension, Mc-Neil and Dornatt argued that Con-gress should do something to help California physicians and patients.

"California doesn’t benefit from the work GPCI floor because our local-ities are so out of whack," said Mc-Neil. "We urged GPCI payment par-ity for California and, incredibly, the

leaders agreed. It was incredible!” One day before the patch bill was up for a vote, McNeil was given a heads up that the Cali-fornia GPCI fix was in thelegislation. “CMA didn’t want the SGR patch; we wanted compre-hensive reform, but we wanted the

GPCI fix to come through. CMA was i n c r e d i b l y c on f l i c t e d ,” she said.

Dr. deGhet-aldi said he felt once again like the San Francisco Giants had won the World Series. “I felt chills when I watched the Senate vote,” he said. Then he went numb. He de-cided he couldn’t celebrate what had been a long, hard-fought battle, until President Obama signed the measure into law.

Dr. Bentley felt the same way. “Ev-ery time we thought it was a done deal, something happened at the last minute to prevent its passage. After so many years, you somehow don’t believe it is actually happening. I was preparing myself for more work.”

In the end, Dr. De Ghetaldi said, Es-hoo was right. “It took us much lon-ger than the Iraqi war to pass the fix.”

The GPCI fix was ultimately signed by the president and requires the reimbursement formula to be calculated based on same Met-ropolitan Statistical Areas used to pay hospitals, which more ac-curately reflect the cost of prac-ticing medicine. The higher pay-ments will be phased in over a six year period starting in 2017.

McNeil says, she has to take the long view on some of the issues she works on. “It takes at least five to 10 years to pass a bill through Con-gress. Especially if it is a new idea and only affects a subset of people, so I suppose we are on track. This is a particularly sweet victory because it was so difficult and achieved during one of the most conten-tious times in Congress. This was a hard-won geographic formula fight between physicians, involv-ing an agency that never takes risk, a dysfunctional Congress and a state unpopular in Congress that was singled out for assistance. The odds were definitely against us. But CMA was fortunate to have a team of wise and relentless physi-cian leaders who never gave up.”

“It is safe to say that everyone on Capitol Hill is grateful and re-lieved that they will never hear CMA utter the word 'GPCI' ever again," laughs McNeil. ❧

“It is safe to say that every-one on Capitol Hill is grate-ful and relieved that they will never hear CMA utter the word ‘GPCI’ ever again,” laughs McNeil.

Elizabeth McNeil, CMA Vice President of Federal Government Relations


The CruzMed Foundation (CMF) was formed in 2012 to support the community works that have been within the strategic plans and part of the Santa Cruz County Medical Society (SCCMS) since it began in the early 1900’s. CMF acts as a bridge linking physicians and other medical and public health professionals in programs that improve the health and quality of life for everyone in our community. We partner and work in collaboration with community organizations in 3 key focus areas: Pipeline, Public Health, and Preparedness.

by Donna Odryna, Executive Director, CruzMed Foundation & Santa Cruz County Medical Society

CruzMed Foundation Partners with Go For Health! Collaborative#Palo Alto Medical Foundation (PAMF) awards $42,000 grant to CMF for the relaunch of 5210+! Numbers to live by! Program in Santa Cruz County

Reducing Obesity 10% by 2020! In 2013, the SCCMS & CMF accepted the call to action

from Second Harvest Food Bank of Santa Cruz County and joined them in adopting a very audacious goal of reducing obesity 10% by 2020. This year, several key organizations and collaborations have done the same including the Go For Health! Collaborative of United Way in Santa Cruz. As an active member and partner organization of the 5210+ program, CMF has developed and launched the 5210+ website, www.5210plus.org, and we are honored to have been awarded a grant from PAMF to roll out the new 5210+ program in preschools, elementary schools and after school programs throughout the county in 2015. The 5210+ program is a public education campaign to bring awareness to the daily guidelines for nutrition and physical activity. Physicians are encouraged to participate in the campaign by using the 5210+! Numbers to live by! program resources in their practice with their patients. Opportunities to participate in classroom and after school activities are also available. For more information, contact SCCMS/CMF at 831-479-7226.

PAMF is delighted to contribute 5210+ program curriculum and seed funding for a position that will leverage all the great work of the Go For Health! Collaborative in local schools. ~ Kathy Kelly, Health Education Manager, PAMF

The combination of CMF leadership to create a public 5210+ website and PAMF funding for a Health Education Specialist will provide the ingredients to effect change in our community and create the perfect storm to move the needle forward in the reduction of obesity. ~ Shelley Wingert, MSRD, Safety Net Program Coordinator, HIP and 5210+ Education Committee Chair L-R: Kathy Kelly, Donna Odryna, & Shelly Wingert


The fight to defend the Medical Injury Compensation Reform Act (MIRCA) may have ended with a ballot box victory in

November, but the threat of a statewide ballot measure loomed heavily from the onset of the 2014 Legislative Session. The

leader of Senate, President Pro Tempore Darrell Steinberg, introduced Senate Bill 1429 as vehicle to execute the strong-arm

strategy of the plaintiffs bar attorneys to eliminate MIRCA’s cap on non-economic damages. Tremendous political pressure and

immature bullying tactics were employed in an attempt to force CMA to the bargaining table, but the association held fast to its

principle of working to create an economic environment that allows physicians in all specialties the ability to practice throughout

California. Rejecting the false choices presented by opponents of MICRA and choosing to make our case before the people

of California, CMA united its political allies to ensure Senate Bill 1429 never received a hearing, leaving the trial attorneys’

Proposition 46 ballot measure the only available avenue for overturning MICRA.

CM A’S 2014 Leg ISL AT I ve WR AP UP

The Ultimate

MeasureBy Janus L. Norman, CMA Senior Vice President

For more than 150 years, the California Medical Association has upheld the banner for practicing physicians. Year after year, the state medical society has partnered with the local medical societies to diligently strive to ensure the care and well-being of patients and to protect public health by working for the betterment of the profession. In years of prosperity, the challenge of carrying out this duty is restrained. In years of controversy, the same duty is laborious. This year was full of controversies.


Senator Mark DeSaulnier’s Senate Bill 1258 contained another component of Proposition 46: the requirement for Schedule V controlled substance prescriptions to be reported to the Controlled Substance Utilization, Review and Evaluation (CURES) database. The bill also would have required the electronic prescribing of controlled substances, expanded government access to CUR ES and dictated the quantity of controlled substances allowed to be prescribed. Like the mandatory checking of CUR ES inserted into Prop. 46, SB 1258 was touted as a bill to address prescription drug abuse. However, the impact would have been to legislate the practice of medicine, undermine the patient/physician relationship and reduce patient access to care. CMA was instrumental in killing the bill, which was held in the Senate Appropriations Committee. The committee’s action prevented passage of bad policy and also extinguished Bob Pack’s ability to use the bill as a platform from which to campaign against CM A in the months leading up to the November vote on Prop. 46.

Senate Bill 492, authored by Senator Ed Hernandez, sought to expand to scope of practice of optometrists to included surgical procedures and primary care services. Senator Hernandez, a practicing optometrist and Chair of the powerful Senate Health Committee, worked feverously toward the passage of Senate Bill 492, which passed out of the Senate in 2013 and was resting in the Assembly. Utilizing his great inf luence and charm, Senator Hernandez, along with the Optometric Association, battled with CMA, the California Academy of Eye Physicians and Surgeons, the California Academy of Family Physicians and the California Society of Plastic Surgeons to win the votes of the members of State Assembly. Hundreds of CMA members made phone calls and wrote emails and letters outlining the f laws within Senate Bill 492 and urging legislators to vote no on the measure. As the coordinated statewide effort moved forward, members of the Assembly began to acknowledge the harm that would have resulted from

irresponsibly expanding the scope of optometrists to perform surgeries and provide primary care services by publicly committing to stand with the physician community in opposition to Senate Bill 492. With a majority of the members poised to oppose the measure, Senator Hernandez and the optometrists agreed to drop the bill and allow it die quietly on the Assembly Floor.

California’s physician shortage is consistently utilized as an argument for expansion the scope of allied health professionals. To combat this argument and the increase access to quality care, CMA has prioritized improving our state’s physician workforce by increasing the number of residency slots for medical school graduates. Studies have indicated that where a physician completes his or her residency is a primary indicator of where the physician will practice. CMA pushed the state to make an initial investment in its future medical workforce. The 2014-15 Budget Act signed by Governor Brown included $7 million to support primary care residency slots through the state’s Song-Brown program. Of that $7 million, $4 million will be prioritized to residency programs that wish to expand and train additional residents in internal medicine, pediatrics, obstetrics-gynecology and family medicine.

The 2014-15 state budget also provided significant resources to physicians. Specifically, the budget includes $3.7 million to draw down $37.5 million in federal funds for technical assistance to Medi-Cal providers on implementing and achieving meaningful use of electronic health records (EHRs). The 10 percent contribution from the state will allow an additional estimated 7,500 Medi-Cal providers to participate in the Medi-Cal meaningful use incentive program and receive the necessary training from the existing technical assistance infrastructure. In addition, CMA convinced the Governor to forgive the retroactive Medi-Cal cuts contained in AB 97 (Chapter 3, Statutes of 2011), which reduced Medi-Cal provider cuts by 10 percent.

For the last several years, CMA led the effort to seek an injunction to invalidate and stop the implementation of the 10 percent Medi-Cal cuts, arguing that this reduction would threaten the ability of physicians to continue to treat Medi-Cal beneficiaries and would create significant gaps in access to care for this population. The legal process ran its course when the U.S. Supreme Court declined to hear our appeal. CMA was, however, able to convince Governor Brown to not attempt to retroactively collect the portion of the cuts during the period of time the injunction was in place. As a result, physicians will be able to retain $218 million in Medi-Cal payments.

During the last months of the 2014 legislative session, CMA learned of the imminent closure of Doctors Medical Center in Contra Costa County. Doctors Medical Center (DMC) is the area’s main medical facility, serving over 250,000 patients in west Contra Costa County, including the city of Richmond and surrounding areas. Even though over 80 percent of its patient population is insured through Medi-Cal or Medicare, low reimbursement rates prevent DMC from creating a business model that would allow for sustained financial viability. CMA sponsored Senate Bill 883 (Hancock) to appropriate $3 million from the Major Risk Medical Insurance Fund to DMC to provide bridge funding to secure additional avenues of finance and create a new and viable business model for the facility going forward.

CMA sponsored and strongly supported additional legislation that addresses the daily challenges faced by physicians and raised public awareness surrounding critical health care issues. Assembly Bill 1755, authored by Assembly Member Jimmy Gomez and co-sponsored by CMA and Planned Parenthood Affiliates of California, was signed by Governor Jerry Brown. The bill will improve California’s notice requirement specific to breaches of medical information in order to reduce administrative burdens on providers and health facilities, while also ensuring accurate notification to patients, thereby


allowing health care providers to put those resources back into patient care.

CMA, joined by various patient advocacy groups, worked with the Legislature and Governor to secure the enactment of Senate Bill 964 (Hernandez), which required Medi-Cal managed plans and insurers offering individual plans through Covered California to provide annual reports to the California Department of Managed Health Care (DMHC) about the adequacy of their provider networks and to make the reports available online.

Our successful advocacy did not come without sacrifices. As CMA battled in the Assembly to defeat Senate Bill 492, Senator Hernandez, Chair of Senate Health, held two CMA sponsored bills hostage in the Senate: Assembly Bill 2400 (Ridley-Thomas), which reintroduced an important discussion in the Legislature about the contracting relationship between physicians and health care plans and health care insurers, and Assembly Bill 1771 (Pérez), which would have ensured physician reimbursement for

non-face-to-face patient management services to help increase patient access to care. Ultimately, CM A stood strong in the midst of controversy and held to its core principle of ensuring the safety of patients, and as a result both measures were held in the Senate. However, CMA was able to convincingly make the policy argument for both measures and to secure bipartisan support for the underling policy, for which we will be advocating again in the near future.

In its first year, the “My CMA Idea” contest produced one of the most hotly debated topics of the year: the negative impact of sugary drinks. CM A co-sponsored SB 1000 (Monning), which would have required warning labels on sugary drinks. A strategy to help educate consumers about the risks associated with consuming sugary drinks, the bill was the first of its kind in the country. It generated unprecedented media attention, including coverage by international media outlets. Twenty-four California papers editorialized in support of the bill. Scholastic News magazine, a teaching

tool distributed throughout the country, included stories on the bill in a way that encouraged classroom debate on the issue. SB 1000 was even referenced in the nationally syndicated cartoon strip “Drabble.”

SB 1000 faced a tough political environment from the outset, with the soda industry pulling out all the stops to defeat it. Though the bill died in the Assembly Health Committee, the campaign supporting the bill showed CMA’s strong commitment to reducing obesity, our willingness to pursue innovative public health policy and – most importantly – helped educate people about the risks associated with consuming sugary drinks.

As Martin Luther King, Jr. famously said, “The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.” In 2014, I am proud to say, CMA measured up!

Below are details on the major Bills that Cma followed this year.

CMA-Sponsored LegislationAB 1755 (Gomez): Medical Information Status: Signed by the Governor.This bill improves California’s notice requirement specific

to breaches of medical information to reduce administrative burdens on health facilities and ensure accurate notification to patients. Currently, health facilities in the state must report any unauthorized access of a patient’s medical information to the California Department of Public Health (CDPH) and directly to the patient within five business days or face a penalty. This bill makes three small changes to the law: it extends the notification timelines from 5 to 15 business days, providing a longer time frame for health facilities to complete an internal investigation before notifying the patient of the incident; allows patients to designate and alternate address or means for notification rather than the patient’s last known address, as required by current law; and lastly, provides CDPH with discretion on when to investigate a report of unauthorized access rather than requiring investigation of each and every incident no matter how minor.

AB 1771 (V.M. Pérez): Medical Information Status: Held in Senate Appropriations Committee.This bill would have required health insurance companies

licensed in the State of California to pay contracted physicians and qualified nonphysician health care providers for telephone patient management services.

AB 1805 (Skinner and Pan): Medi-Cal Reimbursement – Provider PaymentsStatus: This bill was an advocacy vehicle. Budget eliminated the retro-cut, which eliminated need for the bill. This bill sought to restore the 10 percent cut to Medi-Cal

provider reimbursement rates that was enacted as part of the 2011 State Budget Act.

The Governor presented a budget that included the elimination of the retroactive clawback, which eliminated any attempt to collect the uncollected 10 percent Medi-Cal reimbursement cuts in prior fiscal years, a savings of nearly $42.1 million for all Medi-Cal providers.


AB 2400 (Ridley-Thomas): Health Care Coverage – Provider ContractsStatus: Author pulled bill from Senate Health Committee.This bill would have prohibited health

plan and health insurer contracts issued, amended or renewed on or after January 1, 2015, from containing the following terms: (1) Termination of the health care provider’s contract or participation status in the contract or the provider’s eligibility to participate in other product networks, if the provider exercises the right to negotiate, accept or refuse a material change to the existing contract. Physicians and physician groups and should not be forced to assume such obligations as a condition of maintaining access to their patients covered by commercial plans. (2) A requirement that a health care provider agree to accept or participate in other products or product networks, including future products that have not yet been developed or adopted by the plan, unless the plan discloses the reimbursement rate, method of payment and any other materially different contract terms for those products from the underlying agreement.

The bill also would have extended to health plan and insurer contracts through a preferred provider arrangement (PPO) the existing prohibition on contract provisions allowing for material changes without the changes first having been negotiated and agreed to by the health care provider. It would also have increased from 45 days to 90 days the advance notice a health plan or insurer must give a provider before implementing a material change to the provider’s contract, where the changes are made by amending a manual, policy or procedure document referenced in the contract which, under existing law, triggers the provider’s right

to negotiate and agree to the change or, if agreement is not reached, the right to terminate the contract.

SB 883 (Hancock): West Contra Costa Healthcare DistrictStatus: Signed by the Governor.This bill allocates $3 million in bridge

funding from the Proposition 99 Special Fund to Doctors Medical Center in order to allow the hospital to develop a viable financial model for operations.

SB 1000 (Monning): Sugar-Sweetened BeveragesStatus: Held in Assembly Health Committee.This bill would have prohibited the

sale of most non-alcoholic beverages with added sugar and over 75 calories per 12 f luid ounces without the following warning label: “STATE OF CALIFORNIA SAFETY WARNING: Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay.” In the last thirty years, Americans’ daily calorie consumption has increased by 250-300 calories. Sugary drinks represented the largest single source of that increase. This bill would have helped to alert consumers about the health risks associated with consuming the empty calories in these types of beverages.

Strongly Supported LegislationAB 357 (Pan): Medi-Cal Children’s Health Advisory PanelStatus: Signed by the Governor.This bill renames the Healthy Families

Advisory Board as the Children’s Health Advisory Board and transfers the panel’s advisory and reporting capacity from Managed Risk Medical Insurance Board

to the Director of the Department of Health Care Services on matters relevant to all children enrolled in Medi-Cal and their families.

AB 1522 (Gonzalez): Employment – Paid Sick DaysStatus: Signed by the Governor.This bill requires most California

employers to provide paid sick leave from commencement of employment to employees who work 30 or more days within a year. Employees will earn a minimum of one hour of paid sick leave for every 30 hours worked. Expanding paid sick leave coverage will help workers avoid going to work when they are most likely to transmit communicable diseases, a public health intervention also supported by leading national public health organizations, the American Public Health Association and the National Association of County and City Health Officials.

AB 1743 (Ting): Hypodermic Needles and SyringesStatus: Signed by the Governor.This bill extends by six years the current

sunset of pharmacists’ authority to sell hypodermic needles and syringes without a prescription. It also removes the existing 30 syringe limit. Finally, it establishes a sunset date of January 1, 2018, for the hypodermic needle/syringe exemption in the law that makes possession of drug paraphernalia illegal.

SB 964 (Hernandez): Health Care CoverageStatus: Signed by the Governor.This bill requires all Medi-Cal managed

care plans to be surveyed on quality management, utilization review, timely access and network adequacy.

opposed legislationAB 1886 (Eggman): Medical Board of California (Neutral)Status: Signed by the Governor.The original language of AB 1886 would have required

the Medical Board of California to post indefinitely all the

information it posts online about physician discipline, criminal convictions, and reportable malpractice settlements. After negotiations, the author accepted amendments that addressed CMA’s concerns. The amendments allowed for indefinite posting


of most disciplinary actions (suspension, revocation, surrender, probation), but continued to maintain the current posting limit of 10 years for letters of public reprimand. It also reduced the posting of citations from five years to three years. Additionally, it provided physicians a 30-day window to resolve or appeal a citation before it is posted to the website. Under current law, citations are posted immediately.

A mendments also reduced the posting requirements for malpractice settlements. The amendments limit the posting of settlement information to when a physician has 3 or 4 settlements (the threshold is based on low vs. high risk specialties) over $30,000 in the last five years and those settlements would be posted for five years. This is a decrease from current law, which requires posting when a physician has 3 or 4 settlements of over $30,000 in a 10 year period. Current posting requirements are 10 years for this settlement information. The amendments ref lect the concern that settlements are not a reliable measure of a physician’s competence. They also avoid indefinite posting of less severe disciplinary actions.

AB 2015 (Chau): Health Care Coverage – Discrimination Status: Failed in Assembly Appropriations Committee.The bill would have required health

plans to reimburse for services from alternative practitioners such as naturopaths and traditional Chinese medicine without referral from a physician.

AB 2406 (Rodriguez): Emergency Medical Services Authority – Abuse of Emergency Medical Services Status: Failed in Senate Public Safety Committee.This bill would have expanded the

scope of paramedics in the field and would have required Emergency Medical Services Authority to submit a report to the Legislature identifying programs that have been implemented by local

emergency medical services agencies to address “misuse and abuse” of emergency medical services. Due to the vague nature of the proposed language, there was concern that the “misuse and abuse” requirement of the report would have negatively affected physicians’ ability to provide care because they would be subject to state reporting on certain aspects of the emergency room.

AB 2533 (Ammiano): Health Care Coverage – Noncontracting Providers Status: Failed on the Senate Floor.The bill would have prohibited a

non-contracting provider that agrees to provide services under these provisions from billing an enrollee or insured for any amount in excess of the in-network reimbursement rate.

SB 492 (Hernandez): Optometrist – Licensure Status: Held on the Assembly FloorThis bill would have expanded

optometrists’ scope by authorizing them to perform a range of therapeutic laser and scalpel procedures for superficial lesions of the eyelid and adnexa, as well as certain injections and immunizations.

SB 1215 (Hernandez): Healing Arts Licensees – Referrals Status: Failed in Senate Business, Professions and Economic Development Committee.This bill would have eliminated the

in-office exception to the self-referral law. In general, existing law prohibits physicians from referring patients for specified goods or services in which the physician or physician’s immediate family has a financial interest. However, there is an exception to this general prohibition that allows physicians to refer patients for goods or services that are supplied in the physician’s office or the office of a group practice. This bill would have amended existing law to eliminate this exception for in-office referrals for advanced imaging, anatomic pathology, radiation therapy and

physical therapy.

SB 1258 (DeSaulnier): Controlled Substances Prescriptions – Reporting Status: Held in Assembly Appropriations Committee.In its earlier iterations, SB 1258

required reporting to CUR ES of Schedule V controlled substances, created authority for non-sworn investigators who do investigations for Department of Consumer Affairs Boards to request reports from the database to investigate allegations of substance abuse of licensees, and mandated electronic prescribing of controlled substances. It also included a provision that limited controlled substance prescriptions to 30-day supplies unless prescribed for panic disorders, attention deficit disorder, chronic debilitating neurological condition, pain in patients with conditions known to be chronic or incurable or narcolepsy. The bill would have allowed controlled substance prescriptions associated with these conditions to be issued for a 90-day supply. It also prohibited prescriptions for controlled substances within 30 days of a patient receiving a controlled substance prescription, unless the patient has used all but a seven-day supply of the previous prescription. CM A requested the complete deletion of the sections being amended because the issues with them are so significant. The author did amend the bill in an effort to address our concerns, however the amendments were not negotiated with us and were so poorly crafted that they created more issues than they solved.

SB 1303 (Torres): Public Health – Hepatitis C Status: Held in Senate Health Committee.This bill would have required health

care providers to offer a Hepatitis C screening to individuals meeting certain criteria. The bill would have legislated the practice of medicine.


You and your family are eligible to enroll in the SCCMS-sponsoreddental plan only during open enrollment periods.

Apply by December 31, 2014! To be eligible for coverage, applications must bereceived during the special open enrollment period ending on December 31, 2014.

For more information... Call a Client Advisor at 800-842-3761 for more information.Or visit www.CountyCMAMemberInsurance.com to download a brochure and application.

Sponsored by:

Open enrollment for theSanta Cruz CountyMedical Society-sponsored dental planhas started!

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • [email protected] (12/14) www.CountyCMAMemberInsurance.com • Copyright 2014 Mercer LLC. All rights reserved.

Member Benefit News:


KEY DATESCALENDAR

Practice Managers NetworkA monthly meeting for practice man-agement staff to network, exchange ideas and share resources.• Meets the 3rd Wednesday each month, 8:00—9:00am at the SCCMS Office.

Health Care Leadership ForumA local event organzied by SCCMS and supported by various health care partners in the SC area. Keynote speaker is Wendell Potter.• Location TBD.• February 2015 (Date TBA)

Legislative Leadership DayCMA members have the unique op-portunity to join hundreds physicians, medical students and CMA Alliance members who come to Sacramento every spring for Legislative Leader-ship Day to lobby their elected repre-sentatives as champions for medicine and their patients.• April 14, 2015 (Sacramento)

SCCMS Award/Membership DinnerOne of two dinners held annually; this is the Excellence In Health Care Award Dinner. • Location TBA• April 23, 2015 6:00—9:00pm

Western Health Care LeadershipAcademyThe Leadership Academy is the West Coast’s premier opportunity for phy-sicians, practice managers and other

health care leaders to learn about leading-edge trends and develop-ments in the rapidly changing health care marketplace, to access informa-tion and tools to help ensure the viability of medical practice, and to acquire the leadership skills needed to successfully manage change. For more information, visit www.calead-ershipacademy.com• May 28—31, 2015

House of Delegates (HOD)The delegates meet once a year to establish CMA policies on key issues that affect the practice of medicine, from medical ethics to critical mat-ters of public health. Each year the HOD debates and takes action on more than 100 resolutions, each of them authored by members like you. For more details, visit www.cmanet.org/about/cma-governance/house-of-delegates.• 2015 HOD – October 16-18, 2015 (Anaheim)

Volunteer OpportunityUncorked on the PacificDo you like wine? Do you like to party? Then come and help us plan our wine party! Uncorked on the Pacific is the first fundraiser for the CruzMed Foundation. Volunteers are needed for planning this exciting event. Interested? Contact Donna Odryna at [email protected] or call 831-479-7226.• April 2015

We appreciate the support of our publication advertisers!

Dignity Health Medical Group

Mercer

NORCAL Mutual

Office SpaceNear Dominican Hospital, this second floor space is above Wells Fargo Bank, next door to the Medi-cal Society. There is a sink and space for a refrigerator. Open floor plan with 1 enclosed office. 1200 sq ft. No elevator. Rent based on terms of occupancy.

Contact Donna Odryna [email protected]

For Rent

Advertising

Starting in January 2015 Coastal Medicine magazine will publish 6 issues per year. New pricing and ad publication choices are avail-able. Payment in full is required at time of order. For full details email [email protected] or call 831-479-7226 to have a Media Kit sent to you.

Santa Cruz CountyMedical Society

Excellence in

Health Care Award

Nominations are now open for the recipient of the 2014 award. How to submit a nomination ▸Email a nomination to [email protected]. Remember your reason paragraph. ▸Download a nomination form from the homepage of www.cruzmed.org and follow the directions

Deadline: January 15, 2015

Description: The Santa Cruz County Medical Society annually honors one of its members with an award for Ex-cellence in Health Care. A large plaque award trophy honoring successive recipients with a small name and date plaque is kept in the SCCMS offices and an individual plaque reflective of the recipient’s accomplish-ments is given to the recipient without monetary stipend.

Procedure: Nominations in writing are received from any active members, stating the reasons for suggesting the award. The SCCMS BOG members also nominate candidates. The SCCMS BOG, acting as a commit-tee of the whole, vote for the award recipients at the February BOG meeting. The award will be announced in the March Coastal Medicine magazine and presented at the membership dinner meeting in April.

Criteria: Qualities that exemplify the highest standards of the medical profession will be used to judge the possible recipients. Excellence of clinical knowledge, compassion in rendering care, commitment to com-munity service, and continuous leadership achievements in the improvement of the health care delivery sys-tem will be key factors in choosing the award recipient. If in the judgment of the BOG, no nominees meet the selection criteria there will be no award that year.

Call for 2014

Nominations


1975 Soquel Dr #215Santa Cruz CA 95065-1821

coastal medicine: winter 2014

Documents