"Welcome to the Presidency, Dr. Hay."

“Your year starts at the close of the House of Delegates, Mr. President, and, oh, by the way, we have eight reporters who want to talk to you about your marijuana policy …”

CMA’s board of trustees had three days earlier unanimously approved a new approach to the controversial substance, and I assumed that day that that was what my whole year was going to be about. Fortunately — or unfortunately — there are many other issues CMA is grappling with.

2012 will be the year the Supreme Court rules on the Affordable Care Act and on CMA’s lawsuit to stop the state from further reducing the already abysmal physician reimbursement for serving Medi-Cal patients. It will be the year the State Health Insurance Exchange, or the Administration, or the Legislature — at this point it isn’t clear which body will have this authority — determines what the basic benefit package will be for insurance plans that wish to participate in the market through the Exchange. And, because it is an election year, 2012 will be another year Congress fails to kill the SGR and create a realistic and equitable way to reimburse physicians for Medicare services.

To successfully address these and all the other issues on our plate, CMA must grow to be the organization of all California physicians, and, to do that, we need to rethink all of organized medicine’s business model. Other than that, it should be an easy year.

The Exchange

Since we expect this Congress to avoid any real Medicare reform and any substantial change to the current healthcare reform, we are now focused on the Exchange, which we know will have a tremendous impact on how we all practice. California’s AB 1602 (Perez) and SB 900 (Alquist) created an “active purchaser” model (as opposed to an open-market model now being adopted by many other states) with a small and powerful governing board that will decide what must be provided by plans that wish to sell to individuals and small-group employers through the Exchange. Health and Human Services Secretary Kathleen Sebelius enabled that power when she recently deferred the benefits determination to the states rather than setting a national standard. With a rich benefit package like those required now in California for Knox-Keene plans, and by the 49 legislatively mandated service requirements for all plans, and with the constraints on premium that will be set by the Exchange and already by the federal law, the likelihood of Medi-Cal-like per-service reimbursement creates another terrible incentive for little or no physician participation and subsequently very limited access for the anticipated 12.8 million patients to be insured by the participating plans. Early feedback also suggests that many plans currently in the market may not participate in the first place.

CMA is developing a coalition of stakeholders to address these concerns and to work to influence how the Exchange will affect our practices and our patients. The Exchange is sure to be one of the most historic changes in our industry that very likely, in its current configuration, will lead inexorably to a single-payer or all-payer system in California.

Medicare and Palmetto

Many physicians have received letters and are experiencing audits of their billing by our Medicare intermediary, Palmetto. CMA is very concerned that the government’s attempt to find and eliminate fraud and abuse, which we wholeheartedly support, has spread a net far too wide and assumes guilt before innocence. By the time of this publication, CMA will have surveyed its members to assess the extent by which this audit practice has increased the hassle factor of caring for Medicare patients, analyzed what response we will make, and will have begun dialogue with Palmetto about our concerns.

Clearly, physicians want their purposefully overbilling and illegally behaving peers to be found and stopped. We also want to be paid fairly and according to the rules already established by which we currently act, not downcoded arbitrarily by the government like we were by the plans we sued in the RICO lawsuits years ago. We also want to be presumed innocent and want any auditing that is done to be targeted to the ones more likely to be outliers. Failure in this effort will only further induce physicians to decrease or stop their participation in the Medicare program, especially as drastic SGR reductions continue to loom year after year.

The Business Model of Organized Medicine

Physicians in recent years feel attacked from all sides by those who would control what we do and for how much. We are not victims, however, as we so often complain we are. We merely suffer the consequences of systems we designed ourselves. With so many geographic, specialty, generational, ethnic, and mode of practice differences, and with each of those having its own organization to argue for its members, and with so few physicians belonging to any of them in the first place, is it any surprise that large and coordinated efforts by others succeed at times we don’t?

It is time we look at how CMA and the counties and the specialty societies and the medical groups and the ethnic and other special-interest groups of physicians are related. It is time we find what we have in common and more tightly align with each other, forgetting turf issues and remembering that every one of these organizations exists for the benefit of its physician members, not for the organization itself. It is time we get together for the good of the profession, which of course means for the good of our patients.

Conclusion

There are many other important issues, like public health initiatives, responding to the development of ACOs, protecting physicians and patients with fair peer review, developing a new state-supported Physician Health Program for those with potentially impairing illnesses, and so many more. I invite your ideas and opinions on any of them. I dealt only with a few here. Feel free to contact me at jthay@ ncfmg.com anytime.

CMA is rolling out an entirely new and much expanded communication process to engage all California physicians in determining the future of our organization, our CMA business, but also of our very existence as Organized Medicine. We must grow and we will continue to succeed in the legislature and in the courts and in the public health because we are physicians and because it is our profession.