By Dr. John Lam, MD, MBA – CUA Rep to HOD
California Medical Association (CMA) HOUSE OF DELEGATES SUMMARY – October 20-22, 2017
By John Lam, MD, MBA
SPECIALTY DELEGATION TO CMA CAUCUS
Dr. Michele Raney (Chair) was interested on strategies for increasing membership to CMA within each of the specialty organizations and feedback on the year-round resolutions that allow for the submission of resolutions for debate and discussion throughout the year, rather than just once a year as was previously the case. This was to allow CMA to be more nimble and effective in making decisions on critical issues that are important to physicians.
President of the American Medical Association, David O. Barbe, MD, MHA, met with the Specialty delegation and gave a brief speech on physician leadership, staying engaged, and the need to shape the future of healthcare, including quality and value-based measurements and payment systems. Also discussed the importance of specialty societies, such that the AMA delegation changed so that specialty society representation was equal to geographical society representation. Discussed the 3 areas of interest of the AMA: health outcomes, improving medical education to include health system sciences, physician satisfaction and practice sustainability.
Urologists use Modifier 25 up to 32% of time. Some Blue Cross plans (mostly on East Coast) have reduced payment by 50% for all E/M services with modifier 25 appended that are reported on the same day as a minor procedure, defined as those CPT codes with a 0-day or 10-day post-operative period raising concern that other payers may follow suit. On January 1, 2018, Anthem Blue Cross in California will cut reimbursement for E/M using Modifier 25. CMA is actively pursuing this matter and there was debate whether to bring this matter as an emergency resolution for this year’s HOD meeting, but final decision of the delegation was not to move forward.
- Reduction brings reimbursement below cost of physician expense
- Disincentives physicians to provide unscheduled services
- Patients could incur higher out of pocket costs and increased inconvenience due to return encounter
- Patients could encounter longer wait times with impacted specialties
- RUC and CMS are now already making reductions in value when E/M is reported over 50% of the time with a procedure
Dr. Barbara Weissman (Board of Trustees) gave a report to the Specialty Delegation. The CMA is financially healthy with the reserves increasing a bit and the loans decreasing substantially. The executive committee also authorized sending $10,000 to Florida and Texas to help support doctors with losses due to the hurricanes; and also authorized $10,000 for Puerto Rico and $20,000 to help support doctors here in California who have losses due to the recent fires. There was an extensive presentation from the Diversity TAC about data collected comparing CMA membership to active state medical board licensees, however, in the medical board data 40% of doctors declined to state their ethnicity. The Institute for Medical Quality reported on its ongoing expansion including into the jail setting to ensure adequate medical care there and they are looking for additional doctors to work as surveyors. CMA has been very involved in federal healthcare reform, and the executive committee has met with ABMS about MOC issues. AB 72 continues to have a dedicated staffer and a focus of attention for CMA from both providing support to individual physicians and groups and also advocating around issues like average contracted rate, network adequacy, etc. CMA continues to work to ensure the Proposition 56 monies go to physicians. CMA plan legislation on limiting recouping by MediCal to 365 days in 2018. CMA is also focused on the upcoming gubernatorial election, as having a governor who is focused on healthcare will be important. The CMA Foundation Board agreed to change the name of the foundation to Physicians for a Healthy California – to emphasize that it is not a foundation that wants to dispense grants to others, but instead are looking to get grants to improve care in California.
On July 1, 2017, a new law (AB 72) took effect that changes the billing practices of non-participating physicians providing non-emergent care at in-network facilities including hospitals, ambulatory surgery centers and laboratories. The law, signed in 2016, was designed to reduce unexpected medical bills when patients go to an in-network facility but receive care from an out-of-network doctor. CMA is aware of the potential adverse impacts of the new law on our physician members and have dedicated significant resources in order to achieve the best possible outcomes for physicians in light of the new billing restrictions.
CMA HOUSE OF DELEGATES GENERAL SESSION
Dr. David O. Barbe, President of the American Medical Association, spoke to the power of the AMA and how well California was represented in the AMA. He discussed AMA’s work to prevent insurance mega-mergers, reform prior authorizations, scope of practice advocacy, address issues around chronic disease care (diabetes prevention, blood pressure, and opioids in particular), and shaping medical education to be more relevant (health systems sciences). AMA has provided $425,000 in support of CMA’s position of the medical staff in the Tulare Regional Medical Center case. Dr. Barbe discussed the success the AMA has had in shaping 2017 MACRA/QPP regulations as well as the planned 2018 proposals.
AMA objectives for improving the ACA
- Ensure that individuals currently covered do not become uninsured and take steps toward coverage and access for all Americans.
- Ensure that low/moderate income patients are able to secure affordable and meaningful coverage.
- Ensure that Medicaid, CHIP and other safety net programs are adequately funded.
- Maintain key insurance market reforms, such as pre-existing conditions, guaranteed issue and parental coverage for young adults.
- Stabilize and strengthen the individual insurance market.
- Reduce regulatory burdens that detract from patient care and increase costs.
- Provide greater cost transparency throughout the health care system.
- Incorporate common sense medical liability reforms.
- Continue the advancement of delivery reforms and new physician-led payment models to achieve better outcomes, higher quality and lower spending trends
Dustin Corcoran (CMA CEO) gave his remarks and spoke about Assembly Bill 2121 that was signed into law that would make Department of Alcoholic Beverage Control (ABC) responsible beverage training mandatory statewide for anyone serving alcoholic beverages. This law was the result of a tragic drunk-driving accident that occurred in May 2015 when two UC San Diego medical students were killed in a collision by a drunk driver going the wrong way. He also talked about how CMA was able to recoup money for a single practice from the Medi-Cal system as well as the supporting the medical staff independence of the Tulare Regional Medical Center case.
Andrew B. Bindman MD, UCSF; Sandra R. Hernández, MD, President and CEO, California Health Care Foundation; and Congressman Raul Ruiz, MD participated in a panel discussion on Federal Health Care Reform.
Rick Kronick, PhD, UCSD gave a talk on “Options for Achieving Universal Coverage in California”. Universal coverage could be achieved either through public financing or through mixed public-private financing. A system with public financing can either be ‘single payer’, in which the government pays hospitals and physicians directly, or ‘multi-payer’, in which the government pays health insurers, which then pay hospitals and physicians. Achieving universal coverage through mixed public‐private financing is less disruptive than through public financing. Public financing has the potential to mitigate many systemic problems, but actual results would depend on governance structures, politics, and mechanisms of accountability.
Micah Weinberg, PhD, President of the Bay Area Council Economic Institute, gave a talk on “The Case Against Medi-Cal Fee for Service for All”. The case for Medi-Cal Fee for Service for all is that it would be vastly simpler, would ensure coverage and basic access for all, would likely prioritize public health measures over specialty access and may cost somewhat less. However, there are tradeoffs. At least 50% of California would have less coverage because of fewer benefits than almost all employer-based insurance and more limited benefits than Medicare. If Medi-Cal Fee for Service for all reduces costs, it will primarily hit providers The Medi-Cal Fee for Service Proposal would destroy our managed care system. He also discussed the “Bismarck” multi-payer model in Germany.
Peter S. Arno, PhD, Political Economy Research Institute, gave a talk, “Single Payer for California & the Nation: Universal Coverage, Billions Saved, And How We Pay For It”. Universal coverage in California is estimated to cost $331B.
Four (4) Major Issues Debated in 2017
- Health Care Reform: Federal
- Health Care Reform: Single-Payer & Public Option
- Mental Health
The CMA House of Delegates discussed recommendations and regulations that will assist with federal health care reform, as well as discussed how single payer or public health care options might work.
The recommendations related to improving the ACA include, an improvement in the Medicaid physician payment rates to ensure access to care, Covered California and Medicaid network adequacy enforcement, stable funding for the cost-sharing subsidies that help low-income families afford copayments and deductibles, more reinsurance funding to cover high-cost, catastrophic cases which would stabilize the individual market and bring down premiums for everyone, and either higher penalties on the individual mandate or a continuous coverage penalty to encourage healthy people to purchase insurance. There was also a recommendation to address the high cost of prescription drugs as part of federal reform.
Any single-payer legislation will face political challenges in passage mainly due to the financial hurdle and strong opposition from various interest groups; operational challenges in implementation due to the complete change in health care financing and delivery; and uncertain impacts on cost and health outcomes. However, single-payer proposals are gaining traction. Existing CMA policy addresses some of the components of a single-payer system that are of concern to physicians, however these policies are outdated and do not address the other components of single-payer proposals, such as funding of the single-payer system.
A public option could be viewed as a compromise between a single-payer system and the current system. A public option preserves the present system, but provides a lower cost plan for patients, and has the potential to spark necessary improvements to the current system such as lowering costs and improving quality. Hence, a public plan may be a more likely health care reform option. CMA policy supports a wide variety of health plan options and increased competition. However, existing CMA policy specific to a public option is limited and does not address most of the components of public option proposals that are of concern to physicians.
Despite raised awareness, mental illness continues to go unrecognized and underfunded in California. Many people with mental illnesses do not receive the help they need. The delegates discussed significant factors affecting the mental health system including access and infrastructure, and considered policies to support and improve the mental health system.
Maintaining a physician workforce that ensures all patients have sufficient and timely access to quality medical care continues to be a challenge for California.
There are proposed strategies for leveraging and growing California’s physician workforce. The Council identified several additional areas for inclusion in a comprehensive statement of principles, which would replace existing CMA policy related to physician workforce.
Two candidates are running for election for 2018 CMA President-Elect position: Dr. Peter N. Bretan (Urology) and Dr. James J. Strebig (Internal Medicine).
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