SDCMS "News You Can Use" (2009.10.01)

SDCMS "News You Can Use"
— October 1, 2009

H1N1 Video Presentations by and for San Diego County Physicians
Below is a series of four "quick and easy" videos for physicians and office staff on H1N1:

• "H1N1 Epidemiology" [1] by Michele M. Ginsberg, MD, San Diego County, HHSA, Community Epidemiology Branch (2009.09.11)
• "Laboratory Diagnosis of Influenza During the H1N1 Pandemic" [2] by Patricia McVay, MD, San Diego County, HHSA, Public Health Laboratory (2009.09.11)
• "Use of the Pandemic H1N1 Vaccine for Fall 2009" [3] by Mark H. Sawyer, MD, and Robert Peters, PhD, MD, Representing SDCMS' GERM Commission (2009.09.11)

Executive Director Observations on Healthcare Reform
Following is a Healthcare Reform (HCR) update based on my observations in DC last week, including meeting with four out of five of our congressional representatives:

1. Perhaps most unsettling, no one can describe HCR in detail — in general, HCR covers as many of the uninsured as possible while lowering costs as much as possible while providing more "security" to people — but when it comes to specifics, it is all things to all people because there are so many variations. Until the House-Senate conference committee reports out, any attempt to characterize HCR will be challenging.
2. There is a real possibility that the country may see no HCR at all, or only a façade of HCR — a statement I would not have made six weeks ago. The policy and political divisions are very, very deep.
3. In DC, there is a palpable sense of the distrust of the American public in their government's spending habits. Everyone in DC was worried that HCR would appear as "just another government bailout" that "exploded the deficit" (see item 7b).
4. There is agreement on much that does not cost the government money, insurance reform, for one.
5. There is little appetite for a piecemeal solution, i.e., carving the bill(s) up into little pieces, passing one bit a time, because only the easy (read: low-impact) stuff would get passed.
6. If HCR passes, the devil will be in the implementation, and that implementation will take a long time to sort out and a long time to start ... years. Not coincidentally, the longer the interval between signature and implementation, the lower the 10-year costs, which is what is scored by the Congressional Budget Office (see item 3).
7. There is much, as physicians, to be afraid of:
   • A) Because of fiscal constraints in the Senate, there is questionable appetite for a long-term fix to the Sustainable Growth Rate (SGR) travesty, which has kept physician Medicare Part B reimbursements flat for almost a decade — BEFORE adjusting for inflation. There is NO SGR champion in the Senate on either side of the aisle.
   • B) Solving the fiscal problem for doctors by stealing from specialists to pay for (well-deserved) increases for primary care doctors.
   • C) More under-resourced and over-promised mandates.
   • D) A significant reduction in Medicare monies to California due to flawed studies of urban vs. non-urban Medicare utilization (Dartmouth Atlas study).
   • E) Adding a significant, unfunded requirement on states by expanding Medicaid (read Medi-Cal) without paying for it. See the bi-annual California budget dance.
   • F) In the "adding insult to injury" category, the idea of charging physicians to participate in Medicare/Medicaid truly exemplifies the disconnect between policy and reality.
8. There is a huge backlog of legislation — major legislation — that is waiting for HCR to get done, which is creating an impetus for not dawdling.
9. Having said all that, speaking as an individual, I sincerely hope we can address the moral imperative of covering the uninsured and the fiscal imperative of not going broke, as patients, as physicians, as hospitals, and as a country.

"Preparing to Practice" Workshop Saturday, November 14, 2009
Young physicians, residents, and physicians just starting your practices, on Saturday, November 14, 2009, we will hold our bi-annual free workshop: "Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice." Contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org [4] for further information or click here [5].

Executive Director Comment: This Letter From CMA's President to All Physicians Is Well Worth Reading in Its Entirety!

September 30, 2009

Federal health reform discussions took a turn for the worse last week with the introduction of the "America's Healthy Futures Act of 2009" by Senator Max Baucus (D-MT), chairman of the influential Senate Finance Committee. Together with the Texas Medical Association, the California Medical Association sent a letter to Senator Baucus to express our serious concerns and to urge him and his committee to work towards universal access to care for the uninsured and healthcare delivery reform based on proven models from around the country that work for patients and physicians in all modes of practice. You can see our joint letter to Senator Baucus here [6]. While the Baucus proposal has some positives, such as a 10% Medicare bonus payment to expand access to primary care and the authorization of non-profit community co-ops in lieu of a public insurance option, CMA strongly opposes many other provisions that will undermine the profession of medicine and threaten patient access to their doctors. Initial analysis by CMA projects that the net effect of various provisions relating to Medicare payments could result in a 33% cut in Medicare payments for California primary care physicians and a 48% cut in Medicare payments for California specialist physicians depending on the region and mode of practice. Other notable shortcomings in the bill include:

• Expands the unreliable "Physician Feedback" program
• Imposes 5% penalties on physician outliers
• Fails to eliminate the Medicare Sustainable Growth Rate (SGR)
• Creates independent and unaccountable Medicare Commission to set Medicare policies
• Includes an enrollment fee for Medicare and Medicaid providers
• Fails to protect physicians from expanded liability from new clinical guidelines
• Fails to update Medicaid physician payments

The Baucus bill is still undergoing "mark-up" in committee, so the exact nature of the final proposal remains very fluid. The mark-up process to date has not improved the bill. However, Chairman Baucus has committed to propose an amendment on the Senate floor to eliminate and rebase the current SGR. CMA and AMA are also exploring a floor strategy to include additional medical liability protections for physicians. As things stand now, the Baucus proposal is a tremendous step backwards for Medicare/Medicaid payment reform efforts, particularly compared to the health reform legislation moving through the House, which includes an SGR fix and Medicaid payment updates, and does not include many of the punitive measures against physicians contained in the Baucus proposal. CMA believes that we must reform our healthcare system by building upon what works and fixing what is broken. Unfortunately, the version of health reform advancing in the Senate promises to undermine what is working and is based on unproven, unsuccessful models of care, while failing to address aspects of healthcare that need to be fixed. CMA and organized medicine will continue to advocate on behalf of patients and physicians of all modes of practice.

Dev GnanaDev, MD
CMA President

For more information from CMA on health reform, click here [7].

CONTENTS

• SDCMS H1N1/Influenza Updates and Resources
• NIH Recommends N95 Respirators for H1N1 Protection
• CDC Encourages Swift Use of Antivirals in High-risk H1N1 Patients
• Four H1N1 Vaccines Approved by FDA
• HHS and AMA Actions on H1N1 Vaccine Administration Coding and Payment
• CMA's 10% Medi-Cal Rate Cut Injunction Upheld!
• Alfred Gilchrist Named New CMA CEO
• Hospital Outpatient Clinics: Legal Considerations for Physicians
• Blue Cross Physicians: Don't Forget to Review New Fees Before November 11, 2009
• CMA-sponsored Bills Awaiting Governor's Signature
• Governor Signs Legislation to Keep Kids Enrolled in Healthy Families
• Message from CMA President Dev GnanaDev, MD, on Health Reform
• SDCMS Healthcare Reform 2009 Resource Center
• Medical Liability Reform Demonstration Projects
• Stricter Self-referral Rules May End Some Physician Contracts With Hospitals
• Average Family Health Plan Premiums Top $13,000
• New Specialty Approved for Treating Child Abuse
• Mark Your Calendars to Attend the Following Upcoming SDCMS Seminars and Webinars!
• Free Smoke Alarms for Seniors
• UCSD Pre-medical, Co-ed Fraternity Launching New Academic Enrichment Program
• Events

MEDICAL

Executive Director Comment: On our website, we've gathered as many resources from as many authoritative HIN1 sources as possible. If you see something useful, let us know and we'll add it.

SDCMS H1N1/Influenza Updates and Resources
Click here [8] to access the latest H1N1 and influenza updates and resources from the County of San Diego, the Centers for Disease Control and Prevention, the California Department of Public Health, and others at SDCMS' website.

NIH Recommends N95 Respirators for H1N1 Protection
A Sept. 3, 2009, Institute of Medicine report advised physicians and other healthcare professionals to use well-fitted N95 respirators rather than looser-fitting medical masks to guard against contracting the H1N1 virus while treating patients. During an H1N1 news briefing an hour after the IOM report was released, CDC Director Thomas Frieden, MD, said his agency would be "looking carefully at [the report] in the coming days to weeks" and that the IOM committee that wrote the report was instructed not to consider economic or logistical concerns when evaluating personal protective equipment designed to guard against respiratory infection. Click here [9] to read the complete article.

CDC Encourages Swift Use of Antivirals in High-risk H1N1 Patients
The CDC is advising physicians not to wait for lab tests to confirm the presence of the H1N1 virus before prescribing antivirals for high-risk patients with flu symptoms. The drugs work best when started within 48 hours of the onset of symptoms. The CDC is also discouraging physicians from prescribing antivirals to low-risk individuals. To keep physicians up-to-date, both the CDC [10] and the California Department of Health [11] have released updated H1N1 guidance for physicians.

Four H1N1 Vaccines Approved by FDA
The FDA has approved four H1N1 vaccines, with California expected to receive 5.5 million doses by mid-October and 9 million doses by early November — slightly more than previously expected. Preservative-free formulations, for children three years old and younger are expected to arrive later in the season. If you have not yet preregistered for the vaccine, you can do so here [12]. Unlike the seasonal flu vaccine, the H1N1 vaccine will not be distributed through regular suppliers. Due to the uncertainty of the supply and capacity, the California Department of Public Health is serving as a central distribution point so that the vaccine is available to those who need it most.

HHS and AMA Actions on H1N1 Vaccine Administration Coding and Payment
The Centers for Medicare and Medicaid Services (CMS) has developed two new H1N1 codes for the Medicare Program:

• G9141 - Influenza A (H1N1) immunization administration (includes physician counseling the patient/family)
• G9142 - Influenza A (H1N1) vaccine, any route of administration

CMS indicated that the H1N1 vaccine will be provided free of charge to immunizers. For H1N1 vaccine administration, Medicare will pay the same rate as it does for administering seasonal flu vaccine, about $21. In addition, for both seasonal flu and H1N1 vaccine administration, Medicare will pay 100% and patients will not be charged any co-pays or deductibles. HHS has also asked private insurers to provide first-dollar coverage of H1N1 vaccine administration. Click here [13] for further information.

STATE

Executive Director Comment: Medi-Cal rates are the worst in the nation, but CMA kept them from being cut even further.

CMA's 10% Medi-Cal Rate Cut Injunction Upheld!
On September 23, 2009, the Ninth Circuit denied the State of California's request for rehearing of the Court's July 9, 2009, decision upholding the injunction against the 10% Medi-Cal rate cut. This means that the State's last option is to ask the U.S. Supreme Court to review the decision of the Ninth Circuit.

Alfred Gilchrist Named New CMA CEO
Alfred D. Gilchrist, the CEO of the Colorado Medical Society (CMS) and former longtime director of state and federal governmental advocacy for the Texas Medical Association (TMA), has been named the new chief executive officer of CMA following the resignation of Joe Dunn. Gilchrist brings to CMA 30 years of forward-thinking advocacy and strategic innovations, including groundbreaking achievements in patient rights, medical liability, and tobacco control measures. He will attend the 2009 CMA House of Delegates in Anaheim, where he will briefly address the attendees, and he will take over as CEO on November 16, 2009.

Hospital Outpatient Clinics: Legal Considerations for Physicians
Because the outpatient clinic model is a relatively recent development, neither the Legislature nor the courts have addressed this new healthcare delivery model - as a result, some hospitals have structured their outpatient clinics in ways that could run afoul of several federal and state laws, including antitrust, anti-kickback, and the corporate practice of medicine prohibitions. To help physicians understand the pros and cons of the outpatient clinic model, CMA has published a new ON-CALL document, #0214, "Hospital Outpatient Clinics: Legal Considerations Impacting Physicians," available free of charge to members at CMA's website [14]. For assistance in logging onto CMA's website, contact Marisol Gonzalez, your SDCMS physician advocate, at (858) 300-2783 or at MGonzalez@SDCMS.org [15].

Blue Cross Physicians: Don't Forget to Review New Fees Before November 11, 2009
Anthem Blue Cross has notified physicians of changes to its Prudent Buyer physician fee schedule that will take effect January 1, 2010. In a letter to physicians on September 2, 2009, Blue Cross informed physicians that it would be modifying payment levels for many CPT codes. The new fee schedule also incorporates a site of service rate differential. If you have questions about the new contract terms, contact Blue Cross Provider Relations at (800) 933-6633. Physicians are urged to calculate the financial impact the fee schedule changes will have on their practices (use CMA's financial impact worksheet, available at the members-only website [14]. The new rates are available at the Blue Cross website [16]. (Log in to ProviderAccess and select the "Prudent Buyer Fee Schedule Update Effective 1/1/2010" link under the "What's New" section.) You can also request the new rates via fax (click here [17] for form). Be aware that you have the right to terminate an agreement if any "material change" to the contract terms is not acceptable to your practice. If you choose to terminate, you must do so before November 11, 2009 (for a termination date of January 1, 2010). Termination letters can be mailed to: Anthem Blue Cross, Prudent Buyer Plan Contract Processing, Mail Station 8A, P.O. Box 4330, Woodland Hills, California 91365-4330. Click here [18] for more details.

CMA-sponsored Bills Awaiting Governor's Signature
Three of CMA's sponsored bills have passed the Legislature and now await the governor's signature. CMA also successfully averted a number of physician-unfriendly bills, including legislative attempts to erode the ban on the corporate practice of medicine and to expand the scope of practice of allied health professionals. All of these bills were defeated or were tabled until next year. The CMA-sponsored bills on the governor's desk are:

• AB 2 (De La Torre): This CMA-sponsored bill would prevent the practice of health plans and insurers wrongfully rescinding coverage for patients after they become seriously ill. It would do so by requiring insurers to obtain approval from an independent review organization before rescinding a patient's health insurance.
• AB 120 (Hayashi): This CMA-sponsored bill would increase fairness and transparency in the peer review system. The bill would improve an already robust peer review system to make it even more effective in ensuring high quality care in California hospitals.
• SB 606 (Ducheny): This bill would make osteopathic physicians eligible for the Steven M. Thomson Loan Repayment Program. The program, currently only open to MDs, provides medical school loan repayment grants of up to $105,000 in exchange for a three-year service commitment in a medically underserved area of the state.

Governor Signs Legislation to Keep Kids Enrolled in Healthy Families
On Sept. 22, 2009, the governor signed AB 1422, the California Children and Families Act of 1998, which will keep some 700,000 children in the Healthy Families Program (HFP) and will reopen the program to new admissions.

FEDERAL

Message to Physicians From CMA President Dev GnanaDev, MD, on Health Reform
Click here [19] to read Dr. GnanaDev''s September 30, 2009, letter.

SDCMS Healthcare Reform 2009 Resource Center
Click here [19] to access healthcare reform resources at SDCMS' website, including a Sept. 21, 2009, letter from CMA and the Texas Medical Association to Senator Baucus, a Sept. 21, 2009, AMA letter to Senator Baucus, and a Sept. 21, 2009, CMA, Massachusetts Medical Society, and Texas Medical Association letter to Senator Cantwell.

Medical Liability Reform Demonstration Projects
The Agency for Healthcare Research and Quality (AHRQ) will announce the details of the demonstration project by mid-October. The demonstrations will likely provide financial incentives to states and health systems to test models that meet four goals: 1) Put patient safety first and work to reduce preventable injuries; 2) Foster better communication between doctors and patients; 3) Ensure that patients are compensated in a fair and timely manner for medical injuries, while also reducing the incidence of frivolous lawsuits; and 4) Reduce liability premiums.

Stricter Self-referral Rules May End Some Physician Contracts With Hospitals
Sweeping changes to the federal anti-self-referral rules, approved more than a year ago, will take effect Oct. 1, 2009, potentially causing many physician-hospital arrangements to fall out of compliance if doctors are not prepared. Being unaware of the Stark law revisions or the structure of a particular deal will not excuse physicians from liability, legal experts say. The Stark law generally prohibits physicians from referring patients to entities in which they have a financial stake, with certain exceptions. CMS in an August 2008 final rule instituted broad revisions to the Medicare hospital inpatient prospective payment system that will restrict:

• so-called "under arrangements," in which hospitals contract with physician-owned entities to provide a wide range of ancillary services, such as clinical labs or imaging services
• per-use or "per-click" payments for equipment and space leases
• compensation deals based on a percentage of revenue generated by space or equipment use

Attorneys representing physicians and hospitals said many of these arrangements would have to be restructured to avoid federal penalties. Some deals may have to be unwound completely. Click here [20] to read the complete article.

Average Family Health Plan Premiums Top $13,000
Family health insurance premiums in 2009 increased by a relatively moderate 5% for the third consecutive year, while premiums for single coverage remained virtually unchanged. But many workers felt a greater impact this year due to the recession and steadily growing out-of-pocket costs. Click here [21] to read the complete article.

New Specialty Approved for Treating Child Abuse
A new medical specialty in treating child abuse is becoming a reality after years of work by many pediatricians. The first exam in the specialty will be offered at sites around the country on Nov. 16, 2009. An estimated 225 physicians are expected to take the test, which will be given on alternate years. Click here [22] to read the complete article.

LOCAL

Mark Your Calendars to Attend the Following Upcoming SDCMS Seminars and Webinars!

• Financial Issues Seminar/Webinar: "Ten Strategies for Economic Survival" Oct. 15
• Certified Medical Coder Course Oct. 23, 30, Nov. 6, 13, 20
• Resident and New Physician Workshop: "Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice" Nov. 14
• Risk Management Webinar: "Electronic Health Records: Are You Ready?" Nov. 18
• Risk Management Webinar: "Electronic Health Records: Are You Ready?" Nov. 19

For further information about these or any of our other seminars and webinars, click here [23].

Free Smoke Alarms for Seniors
From September through December 2009, the Burn Institute will join a team of community volunteers to install free smoke alarms in the homes of seniors residing within San Diego County who are 55 years or older, own their own homes, and do not have a working smoke alarm. Call Gwen Lammers at (858) 541-2277, ext. 15, to make an appointment.

UCSD Pre-medical, Co-ed Fraternity Launching New Academic Enrichment Program
Phi Delta Epsilon, UCSD's pre-medical, co-educational fraternity, is launching a new academic enrichment program that would serve to further its members' future careers as medical professionals. The program includes mentoring and speaking opportunities for physicians who are interested. For further details, contact Angela Sohn at angsohn@gmail.com [24] or at (818) 534-6242.

EVENTS

• OCT 1-4 Fall Meeting of the American Academy of Facial Plastic and Reconstructive Surgery Hilton San Diego Bayfront Hotel http://aafprs.org/upload/brochure/Fall%202009%20Onsite.pdf [25]
• OCT 2-3 Healthy Babies, Healthy Planet: An International Breastfeeding Conference Courtyard by Marriott-San Diego Airport/Liberty Station http://www.breastfeeding.org/pdf/ConferenceBrochureFullsize.pdf [26]
• OCT 3 Free Arthritis Expo (National University, 9388 Lightwave Ave., San Diego 92123) (858) 492-1090, ext. 124
• OCT 3 The Society of Physician Entrepreneurs (SOPE) Physician Bioscience Commercialization Workshop San Diego Marriott Hotel and Marina http://www.sopenet.org [27]
• OCT 6 The State of Lawsuit Abuse (sponsored by Citizens Against Lawsuit Abuse (CALA) http://www.cala.com [28]
• OCT 15 Free SDCMS Financial Issues Seminar/Webinar Contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org [4]
• OCT 17-18 4th Annual Clinical Update on Heart Failures and Arrhythmias: From Prevent to Cure http://www.scripps.org/health-education__continuing-medical-education__a... [29]
• OCT 18-23 9th Annual Destination Health: Renewing Mind, Body, and Soul http://www.scripps.org/health-education__continuing-medical-education__a... [29]
• OCT 21 Collaborative Care: Treating the whole person (Mental Health America) http://www.mhasd.org/programs.htm [30]
• OCT 22 Invitation to North County Physicians to Attend CDI-Head Start Health Services Advisory Committee Contact Jessica Dorn at (760) 704-0550, ext. 114, or at jdorn@sdchs.org [31].
• OCT 23, 30, Nov. 6, 13, 20 Discounted SDCMS Certified Medical Coder Course Contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org [4]
• OCT 24 The 12th Annual School Health Leadership Conference: "Back to School" http://www.aapca3.org [32] or email Meredith Kennedy at mkennedy@aapca3.org [33]
• OCT 24 & 25 Treating the Difficult Patient: Using Attachment-based Intensive Dynamic Psychotherapy to Overcome Resistance http://www.istdp.com [34]
• OCT 26 - Nov 1 The Faces of Chronic Fatigue Syndrome at the Westfield County Fair, Escondido http://www.cfids.org/sparkcfs/health-professionals.asp [35]
• OCT 28-30 20th Annual Coronary Interventions http://www.scripps.org/events/coronary-interventions [36]
• OCT 29 Southern California Healthcare Summit Ontario Convention Center http://www.socalhealthsummit.com [37]
• OCT 30 2009 San Diego Day of Trauma http://www.scripps.org/health-education__continuing-medical-education__a... [29]
• NOV 4-8 XVII World Congress of Psychiatric Genetics Contact (858) 534-3940 or ocme@ucsd.edu [38]
• NOV 14 New Developments and Best Practices in Colorectal Cancer Screening Admiral Baker Clubhouse (Presidio Room) sbazzo@sandiegoafp.org [39] or (858) 458-9439
• NOV 14 Free SDCMS Resident and New Physician Workshop: "Preparing to Practice: What You Need to Know Before You Begin Your Practice" Contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org [4]
• NOV 18, 19 Free SDCMS Risk Management Webinars Contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org [4]
• JAN 16-17 Melanoma 2010: 20th Annual Cutaneous Malignancy Update http://www.scripps.org/health-education__continuing-medical-education__a... [29]
• JAN 21-24 7th Annual Natural Supplements: An Evidence-based Update http://www.scripps.org/health-education__continuing-medical-education__a... [29]
• FEB 13-16 Scripps Cancer Center's 30th Annual Conference: Clinical Hematology and Oncology http://www.scripps.org/health-education__continuing-medical-education__a... [29]

"Government is not reason, it is not eloquence, it is force; like fire, a troublesome servant and a fearful master. Never for a moment should it be left to irresponsible action."
— George Washington (1732-1799)