Monday, December 18, 2017

OCMA Blog

Health Reform Heats Up

By James Noonan, CMA Staff Writer

More than three years have passed since the Affordable Care Act (ACA) was into law, setting into motion some of the most dynamic and volatile years the nation’s health care industry has ever seen.

Since its inception, the law has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation. For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy.

Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional and active steps are being taken to move forward at the federal and state level.

Despite being signed into law more than three years ago, the vast majority of activity has yet to come. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes.

The road has already been a somewhat rocky one.

Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse.

Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide. As of early February, only 19 states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form state-federal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas.

Despite these problems, the march toward reform continues on.

The Next Major Milestone

The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment. In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California.

Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA.

In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens – many of whom have never had the benefit of “open enrollment” or a similar purchasing period – understand how and where they can sign up for coverage under the reform law.

The task is daunting on its own, but with a deadline looming only months out, skeptics would be forgiven for questioning whether such a task is even possible.

California Leads the Way

Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines.

In the days following the ACA’s passage, California was the first state to establish a health benefit exchange (Utah and Massachusetts were operating their own versions of an exchange before the ACA was signed into law) and has been working toward implementation ever since. That exchange, recently named Covered California, has already launched its online consumer marketplace, www.coveredca.com, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level.

Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 19 geographical rating regions.

While the selection process is still far from over, it looks as though the Covered California board will not be short on options when it comes time to award the QHP designation. In October, more than 30 distinct insurance providers issued a “notice of intent to bid” to the board, and most of the state’s major insurance providers have since gone public with their intent to participate in California’s exchange.

The fact that insurance companies appear more than willing to play ball with the exchange, and that Covered California was established as an independent government entity operating outside the control of the Legislature and governor, means that the exchange’s Board of Directors has a considerable amount of power when it comes to shaping California’s post reform heath care landscape.

Protecting Physician Interests

Unfortunately several recent decisions by the exchange board have placed California’s physician community on its heels. The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several of issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required to meet in order to have their products considered for the QHP designation. One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs.

Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

CMA has repeatedly asked Covered California’s board to reconcile the state and federal policies, but to date an adequate fix has not been presented.

Given the exchange’s accelerated timeline, as well as the exchange board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014.

Action Under the Dome

With all of the moving pieces present between the federal government and California’s exchange board, it’s sometimes easy to forget that the state Legislature is also playing a large role in ACA implementation, so large, in fact, that Gov. Jerry Brown saw fit to call for a special session dedicated to health care reform in California.

A total of six bills (three identical proposals being heard in both houses of the Legislature) were introduced during the special session, seeking to address individual market reforms (ABX1-1 and SBX1-1), Medi-Cal expansion (ABX1-2 and SBX1-3) and a proposal to establish a “bridge plan” (ABX1-2 and SBX1-3) that would allow for a seamless transition between Medi-Cal and exchange plans for those individuals whose income may fluctuate past the income thresholds called for in the ACA.

Special sessions usually are reserved for a dire situation in need of immediate legislative action, which makes it somewhat surprising that members of the Legislature allowed the spring recess – their “soft deadline” for special session legislation – to come and go without any major action on these bills. As of early April, the individual market reform and Medi-Cal expansion bills had cleared their houses of origin and were set to be heard in committees within the second house, while the bridge plan proposal had yet to be heard on the floor of either house.

There’s also a considerable amount of activity related to health reform taking place outside of the special session, specifically regarding scope of practice expansions as a way of addressing the access to care issues that will inevitably take place when millions of currently uninsured Californians gain coverage beginning in 2014. Three bills, all authored by Sen. Ed Hernandez (D-West Covina), seek to expand the respective scope of practice for pharmacists, optometrists and nurse practitioners, while a fourth, authored by Sen. Fran Pavley (D-Agoura Hills) would call for a similar expansion for physicians assistants.

The ACA had two major goals: First, to expand access to health coverage to all, and second, to ensure efficient, high quality care. Those who are now invoking the ACA as the sole justification for allowing non-physicians to diagnose and treat California patients and perform complex medical procedures are attempting to achieve the first goal by undermining the second. Allowing non-physicians to practice beyond their training can only lead to inferior outcomes, higher costs and greater fragmentation of care.

CMA will be closely following and fighting these scope bills, working to ensure that California meets the ACA's objectives without eroding quality or jeopardizing patient safety.

To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts.


2014 Physicians of Excellence Nominations

Orange Coast magazine, in conjunction with the Orange County Medical Association (OCMA), will publish its annual list of Orange County Physicians of Excellence in the January 2014 issue and is currently seeking nominations. The Physicians of Excellence program was designed to honor outstanding physicians practicing in Orange County. The selection criteria that will be used to determine physician excellence were developed by a multi-specialty collaboration of the OCMA. 

Anyone can nominate a physician to be considered for the Physicians of Excellence program. Physicians need to be nominated only once to be eligible to apply for selection as a Physician of Excellence. Multiple nominations for the same physician are discouraged. Self-nominations will not be accepted. Once nominated, an application packet will be mailed to the nominee with the details of the application process. Membership in the OCMA is not a requirement for selection. Minimum criteria for Physicians of Excellence include:


- Hold board certification within specialty of nomination
- Maintain a primary practice location in Orange County, California for the last 5 years
- Be in good standing with the Medical Board of California
- Have been in practice within his/her specialty field for the last 5 years consecutively


Nominators are not required to certify that the physician they are nominating meets these criteria.


You may also download the form by simply clicking here.

Submit your nomination form to the Orange County Medical Association by 
June 14, 2013.
 
 
Send to: OCMA, 17322 Murphy Avenue, Irvine, CA 92614 or fax to (949) 398-8120. 

For questions call (949) 398-8100 ext 106 

OCMA Women Physician Leadership Conference Proves to be Huge Success

Women Physicians Share Insights at Local Conference

Article written by Physicians News Network,
 
www.physiciansnewsnetwork.com/orange_county

Presentations from Women's Conference speakers available at the end of the article

A women’s conference last week offered local female doctors an unprecedented opportunity to learn from each other, and gain critical insight from top women leaders on how to achieve work-life balance, while taking on leadership roles.

The conference, entitled Retreat, Relate, Reform: Women Physicians Leading Change, took place on March 15 at the Promenade Gardens in Costa Mesa. It was organized by the Orange County Medical Association.

Dr. Lisa Thomsen, a Glendora-based family practitioner in private practice and a board member of the Cooperative of American Physicians Inc. (CAP), said the conference exceeded her expectations.

“It was great to see examples of women doing it all,” Thomsen said. “They are very strong leaders.”

Dr. Kelly Traver, an internal medicine physician, medical director for Crossover Health, delivered the keynote address. She focused on the importance of physicians dealing with increasing levels of stress. The goal is to to adapt, in order to successfully continue practicing, and deliver the best care.

There is a constant pressure on physicians to deliver better care at a lower cost, but according to studies, physicians who are simply in a better mood can come up with correct diagnosis three times faster.

While physicians address the harmful effects of stress when treating their patients, they often ignore to take care of themselves, said Traver.

When speaking about new reimbursement models and payment systems, she said “the more complex compensation systems become, the less effective they become”.

Dr. Sharon Levine, president of the California Medical Board, talked about lessons in physician leadership and the importance of cultivating leaders inside the organizations themselves. She discussed creating a culture that motivates people, fosters new ideas and recognizes those who contribute to the organization.

While the older generation of women physicians felt privileged to have a chance to become doctors, to take on leadership roles, and were eager to take on extra work load at the expense of their personal lives, we cannot expect the current generation to do the same, she said.

Dr. Tanya Spirtos, CMA trustee, gave updates on the current state of the ACA implementation and the issues that directly affect physicians, such as the problem with a three-month grace period for people who will be subsidized on the exchange, which can result in physicians not getting reimbursed by the insurance companies when patients default on their monthly payments.

Spirtos said physicians need positive incentives, not penalties, and they have an unprecedented opportunity now to affect how incentives will work as the ACA gets implemented.

Thomsen said she was impressed with the speakers and their take-away messages. She pointed to Levine’s “quiet strength” as exemplary female physician leadership.

As Levine noted, for many women, their appointment to leadership roles is often accidental, but they take on those roles and rise to the challenge.

Thomsen welcomed the views of a presenter who noted that women can become physician leaders by taking small steps and engaging in different organizations throughout their lives. The gained confidence often catapults women to the next stage, and ultimately, into leadership roles.

She said there was one thing in particular that the keynote speaker said that struck a note with her. “Life is really long,” Traver said. “You don’t need to do everything at once.”

Presentations:

"The Healthiest You" - by Kelly Traver, MD

"Lessons in Leadership: The Challenges of Change" - by Sharon, Levine, MD

"Gender Equity, Ensuring a Positive Work Environment & Executive Contracts"                          -By Shannon Jenkins, Esq.

"Health Care Reform Impact on Physicians" - by Tanya Spirtos, MD - For a copy of this presentation, please contact Ashley Buchwald at abuchwald@ocma.org


Sequestration FAQ: How will the cuts affect California physicians?

Across-the-board federal budget cuts were triggered on Friday, March 1, because Congress failed to come to an agreement on how to reduce the federal deficit. Although it is still possible that Congress will reach some sort of a compromise before most of the cuts take effect on April 1, physicians should prepare for a 2 percent reduction in reimbursement from the Medicare program beginning in April.

 

The 2 percent Medicare "sequestration" cuts are part of the $1.2 trillion in cuts required by the Sequestration Transparency Act, part of a deal worked out to end last year's debt-ceiling crisis. The cuts are evenly split between defense spending and discretionary domestic spending. The mandatory Medicare cuts will result in a savings of $11 billion in 2013. Medicaid is exempt from the cuts.

 

The California Medical Association (CMA) continues to fight these Medicare cuts.While CMA understands the need to address our nation's budget deficit, CMA is urging Congress to take a more targeted approach than arbitrary across-the-board cuts that will harm public health and negatively impact access to care for children, seniors and military families.

 

For more information, see "Sequestration FAQ: How will the cuts affect California physicians?" This FAQ answers the most commonly asked questions about the sequestration cuts as they relate to health care. This document will be regularly updated as additional details become available.


Orange County Doctors give Testimonials in Honor of Outstanding Service Provided by Preferred Business Partner, The Doctors Company


“We have used The Doctors Company for our insurance needs for the past 10 years. We began with their medical malpractice coverage, which they did a tremendous job maintaining and always fighting for us to get the best possible rate. We later utilized their services in providing us with our business personal property, workers compensation, employment practices liability and professional liability for our facility. Their customer service is outstanding and I know if I ever need anything I only need to call. They are a vital part of our organization and we look forward to working with them for many years to come.” 

Kimberly Massoudi
Chief Operating Officer

Outpatient Healthcare, Inc.


“Our practice has been a client of The Doctors Company for several years.  They have always met our needs and had our best interests at heart.  They have been devoted to our practice and our physicians.  The Doctors Company’s representatives are supportive and always there to assist our practice in any way they can.  We are pleased to have The Doctors Company as a vital part of our practice.” 


Michael Muhonen, M.D.
WCP Neurosurgical Associates


“Over the past 10 years, we have experienced tremendous growth in our two long-term groups that contract with our ministry, with the addition of over 100 physicians in 13 new specialties.  Additionally we have added five distinct new medical groups to our organizational model across the state.  In every case and step of our journey, The Doctors Company’s leadership has been supportive and insightful and demonstrated a true partnership approach in meeting our needs.  Account management has been flawless, and the whole team at The Doctors Company is sincerely viewed as partners by our physicians and senior management team.”

C. R. Burke 
President and CEO
St. Joseph Heritage Healthcare


“Whether it be for a major problem, or merely for some sage advice, The Doctors Company is always there when you need them. In our experience, one telephone call results in an expeditious and appropriate response. The staff and management are outstanding, friendly and caring. I recommend The Doctors Company to any physician or medical care organization."

Arthur Goldstein, MD
President & CEO
Women’s Healthcare Physicians


How are Business Partners Selected?

After a potential Business Partner has been identified, either by an OCMA staff member's research or via referral, the vetting process begins. The vetting process is rigorous, thorough, and all final decisions regarding approval or denial are made by the OCMA Services Committee.

The OCMA Services Committee only approves those relationships that benefit you while refusing those of questionable value. In order to add value to your membership with OCMA, you can count on us to provide only business partnerships which offer unique and exclusive discounts on products and services, or preferential status in service delivery. 

OCMA's Business Partners help you accomplish your goals of being a successful physician, and running/maintaining an effective practice.  


Best Practices for Creating an Accountable Care Organization

The U.S. health care system is moving toward Accountable Care Organizations (ACOs), groups of health care providers who agree to be accountable for the quality, cost, and overall care of Medicare patients. According to the Future of Health Care Survey conducted by The Doctors Company, the nation’s largest medical malpractice insurer, 57 percent of doctors are either undecided or need more information regarding ACO participation.


In a video series at www.youtube.com/doctorscompany, health care industry thought leaders recommend the following best practices when forming ACOs:

1.    Create a readiness checklist.

“A readiness checklist ...involves things like patient-centered medical homes and the attributes that primary care physicians have,” said Robert J. Jackson, MD, MMM, president and medical director, Accountable Healthcare Alliance in Michigan. “It talks about, ‘How well do we deal with data? Do we have patient registries? Do we have patient care plans? Do we have transition of care issues developed?’”

2.    Meet patients’ specific needs.

“The key is designing the care management tools, resources, people, and interventions to manage the specific needs of that patient,” said Laura P. Jacobs, MPH, executive vice president, The Camden Group in California.

3.    Develop clinical integration.

“Make sure all the providers are engaged in real-time information sharing so a care plan can be developed within a very quick period of time and all the providers know their roles and the timelines in which they have to perform their services,” said Michael H. James, JD, president and CEO of Genesys PHO, a pioneer ACO, and Genesys Integrated Group Practice in Michigan.

4.    Engage the community.

“The community has to…support programs that improve health and improve the way patients live because health care goes beyond just acute care,” James said. “It involves the patients’ safety, whether they have enough to eat, their transportation, education, business opportunities or employment opportunities.”

5.    Select the right board members.

“A pioneer ACO requirement is to expand the board with a patient and a community advocate,” James said. “Genesys…selected the leader of their volunteer group. He is 72 years old and is very engaged and involved in community studies on how to improve access to care. The community advocate is the executive director of a group of nursing homes.”

Contributed by The Doctors Company. For more risk tips, patient safety tips, and physician practice tips, visit www.thedoctors.com.


2013 Physician of the Year Nominations

Now Accepting Nominations: 2013 OCMA Physician of the Year

DEADLINE: February 22, 2013


The Orange County Medical Association is now accepting nominations for the 2013 OCMA Physician of the Year. This award, which was established in 1983, recognizes a physician who, throughout his/her career, has exemplified what it means to be an accomplished physician. All OCMA members are encouraged to participate by nominating a fellow physician for his/her hard work and dedication, exceptional professional competence, and good rapport with patients. The award also acknowledges the physician for being a motivator, educator and community leader. If you would like to nominate a fellow physician colleague, please send your recommendation letter including:

  • Name and title of nominee 
  • Description of the nominee's accomplishments and contributions. Supporting documents such as a CV, newspaper clippings, etc. are encouraged 
  • Name, title and signature of nominator
Nominees are not required to be OCMA members.

The winner will be announced at the OCMA General Membership Dinner in May, details to come.


Nomination submission:

Attention Holly Appelbaum 2013 OCMA Physician of the Year
Orange County Medical Association
17322 Murphy Avenue, Irvine, CA 92614
(949) 398-8100 ext 106
Fax: (949) 398-8120
Email: happelbaum@ocma.org
DEADLINE: February 22, 2013




2013 Physicians of Excellence Reception Pictures

Pictures from the January 23, 2013 Physicians of Excellence Reception are up on the OCMA Facebook page.

Visit https://www.facebook.com/media/set/?set=a.10152478454530721.955051.250822655720&type=1&l=60016902fd to view them. Feel free to tag yourself, your friends and your colleagues.

Photos by www.lisareneephotography.com

Don't forget to "like" the OCMA Facebook page!


OCMA Needs Your Help with an Important Survey Regarding Dual Eligibles

Your participation is needed! Please consider taking a short, 10 question survey regarding the dual eligibles demonstration project.

Those who participate in this survey may enter to win one of three $100 Visa gift cards. By leaving your name at the end of the survey, you will be entered in the drawing! OCMA staff will contact the winners on or before February 7, 2013. 

The CalOptima board of directors is scheduled to make a critical decision regarding dual eligible patients (eligible for both Medicare and Medi-Cal) in Orange County at their February 7 board meeting. The decision could impact many physicians and their dual eligible patients. Your immediate input is necessary.

 

The OCMA has been working with CalOptima to advocate that the board adopt a very open health care delivery model for the duals patients; a delivery model that includes contracted health plans and individual physicians, via individual contracts. The broad health care delivery model will allow for patients to continue seeing their individual physician even if that physician is not affiliated with a CalOptima health plan for the purposes of Medicare managed care.

 

In order to effectively advocate for the physicians providing Medicare services, we need accurate and current information to share with the CalOptima staff and board members. This survey will enable us to provide a substantial portion of the important information that we need. The CalOptima board is uncertain, at this time, on the type of health care delivery model they will utilize for the duals patients in Orange County, so your immediate response is requested and will be of great value. Thank you for your time and participation.


For a more detailed update on the duals demonstration in Orange County, please go to the OCMA web site under the Local Advocacy section.

 

To continue to the survey, click the link below.


Survey Link: 

https://www.surveymonkey.com/s/CB9QHJR


UPDATE: Congress stops Medicare cuts for one year as part of fiscal cliff legislation

This morning (Jan. 3) CMS released instructions to contractors for implementation of the revised fee schedule.  In order to allow sufficient time to develop, test, and implement the revised 2013 Medicare physician fee schedule, Medicare contractors have been instructed that they can hold claims with January 2013 dates of service for up to 10 business days. CMS expects these claims to be released into processing no later than January 16, 2013.  The claim hold should have minimal impact on physician cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt. Based on prior history of similar fee schedule updates, CMA believes that physicians may expect to see claims paid in approximately 21 days, rather than the usual 14 days. Medicare contractors will be posting the new payment rates on their websites no later than January 23, 2013. 

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