November 2014 | Physician Magazine

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A PUBLICATION OF PNNwww.PhysiciansNewsNetwork.com

R E P O R T I N G O N T H E E C O N O M I C S O F H E A L T H C A R E D E L I V E R Y

NAT I O NA L D I A B E T E S M O N T H : T H E I M PAC T O F D I A B E T E S O N CA L I F O R N I A H E A LT H CA R E

DEFININGVALUE IN HEALTHCARE

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Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 04 Copyright ©2012 by LACMA Services Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. POSTMASTER: Send address changes to Physician Magazine, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Advertising rates and information sent upon request.

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10 DEFINING VALUE IN HEALTHCARE

Healthcare delivery reform and the shift from vol-ume-based to value-based healthcare is creating both challenges and opportunities for physicians. With the federal government, commercial health plans and other organizations increasingly using measures of healthcare spending to reward or penalize providers and healthcare systems, it is key that providers know how value-based care is being defined and how it will affect them. We will take a look at some of the new delivery models and what the implementation of these models can mean for your practice.

NATIONAL DIABETES MONTH

6 The Impact of Diabetes on California Healthcare

15 Communication Is Key to Improving Diabetic Patient Outcomes and Reducing Liability

DEPARTMENTS FRONT OFFICE | PRACTICE MANAGEMENT

8 California’s Anti-Markup Laws on Labs and Imaging

FROM YOUR ASSOCIATION

4 President’s Letter | Pedram Salimpour, MD

16 CEO’s Letter | Rocky Delgadillo

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NORCAL Mutual is owned and directed by its

physician-policyholders, therefore we promise

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can expect caring and personal service, as you

are our first priority. Visit norcalmutual.com, call

877-453-4486, or contact your broker.

SUBSCRIPTIONSMembers of the Los Angeles County Medical Association: Physician Magazine is a benefit of your membership. Additional copies and back issues: $3 each. Nonmember subscriptions: $39 per year. Single copies: $5. To order or renew a subscription, make your check payable to Physician Magazine, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. To inform us of a delivery problem, call 213-683-9900. Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

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4 P H YS I C I A N M AG A Z I N E | NOVEMBER 2014

Dear Colleagues:

Ebola is a crisis, not just for people someplace far away this time, but for us right here in Los Angeles. While we do not have any direct flights from LAX to the affected areas in West Africa from LAX, we are still at risk. And the risk can be real or it can be just panic, based on the population’s perception of it. Still, this has the potential to test the limits of our clinical systems, our communication platforms and our emergency re-sponse practices. Because of the threat, real or perceived, and because this can happen again with something else, as it did with SARS and many other threats over the past

decade, we ought to use this crisis to exercise our capabilities in the management of infectious diseases in hospitals and within other healthcare setting. Most importantly, we have to exercise our duty as physicians to understand the science and to make sure cool heads prevail. It is our responsibility to be the voice of medicine and science and to have that voice guide political and public health policies.

The Los Angeles County Medical Association (LACMA) has re-ceived calls from the Los Angeles Times and Los Angeles Daily News, as well as other outlets, doctors and patients, about the Ebola threat we face. We have used this opportunity to educate ourselves and the public about where we stand today and in what direction the disease spread can go.

We have also used the opportunity to educate the public about threats much more real to them in the immediate future -- threats such as the simple flu and the importance of receiving a vaccine. While Ebola is far more unforgiving than the flu, it is likely that the flu will take many more lives in Los Angeles this year than Ebola ever will. We have recognized the severity of the crisis but also seize the moment to remind the public that we are going

into flu season, and the way the public can help is by getting their flu vaccine. This simple act will at the very least minimize the number of worried well people who come to doc-tors and hospitals with the same symptoms.

Once again we are reminded of the great power that united physicians at the Los Angeles County Medical Association possess to influence the daily lives of every man, woman and child in our region.

United, we can conquer the most significant healthcare and public health challenges, and the political ones, too!

I look forward to seeing all of you at this month’s LA Healthcare Awards event as we honor the outstanding achievements our City’s most prominent leaders.

Your President, Pedram Salimpour, MD

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A RECENT STUDY by the UCLA Center for

Health Policy Research found that since 1980,

diabetes cases have more than tripled nation-

wide to 20.9 million. In California, diabetes

cases have risen by 35% in the last 10 years,

with one in three hospitalized patients (aged

35 and older) having diabetes. Hospital stays

for patients with diabetes cost nearly $2,200

more than stays for non-diabetic patients. The

result is an added $1.6 billion to annual hospi-

talization costs in our state alone.

In Los Angeles County, additional hospital costs for diabetics run $491 million a year, the highest in the state.

The study’s lead author, Athena Philis-Tsimikas, MD, of the Scripps Whittier Diabetes Institute, said, according to news reports, that the rising rates of dia-betes are devastating to not only patients, but to the whole healthcare system.

The study looked at discharge records of hospital-ized California patients aged 35 and older — a group that accounts for the most hospitalizations — and found that 31% of the patients had diabetes.

Although diabetes may not have been the initial reason for hospitalization, the disproportionate share

of patients with the disease has an impact on Califor-nia’s healthcare spending, the study found.

According to UCLA, diabetes is a skyrocketing problem, adding $1.6 billion to annual hospitaliza-tion costs in California. Hospital stays for patients with diabetes cost nearly $2,200 more than stays for non-diabetic patients.

Three-quarters of that care is paid through Medi-care and Medi-Cal, the authors found, including $254 million in costs paid by Medi-Cal alone.

Treating diabetics in the hospital costs more be-cause diabetics tend to heal slower and require ad-ditional medication, noted Dr. Philis-Tsimikas.

A 30% prevalence of diabetes in hospital patients aged 35 and older is higher than in the general popu-lation, which is about 11% for that age group in Cali-fornia, the researchers noted.

Ethnicity plays a role: 42% of hospitalized Latino patients have diabetes and 40% of African-American, Native American and Asian-American patients have diabetes vs. 27% of white patients.

The study authors noted that Latinos and African-Americans, who are “at a higher risk for developing diabetes in the first place,” also had higher hospital-ization rates than whites.

“They may also in some cases not have access to care that is as good as for white patients,” said Sue Babey, co-author and senior research scientist at the UCLA Center for Health Policy Research according to news reports.

The researchers said that while a lifestyle change — regular physical activity, eating a healthy diet and maintaining a normal body weight — can reverse or stabilize diabetes, public policy changes are also needed.

Among the authors’ recommendations are provid-ing reimbursement for early screening for diabetes, funds to educate the public about the importance of eating a healthy diet and regular exercise, greater ac-cess to healthier foods and creating walking trails and other public places to encourage physical activity.

Babey noted that having a healthcare team of nurses, dietitians and peer educators, such as the one at the Scripps Whittier Diabetes Institute, can help improve diabetic care for patients.

“Physicians can sometimes be busy,” she said. “If you can work with the entire team, they have more time to spend with the patient, letting them know for the in-dividual patient what they need to do,” Babey said.

The Impact of Diabetes on California Healthcare

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In an era of declining reimbursement and rising costs, ancillary services, and especially laboratories, present an attractive opportunity for physicians to re-alize revenues from patient services. Many physicians have established in-office labs for CLIA-waived or high-complexity test. Others have looked for oppor-tunities not only in shared labs (as we addressed last month) but also in outside lab testing. The challenge is that many of these opportunities are barred by legal restrictions. In our experience, many physicians are unaware of these prohibitions until an insurance com-pany or government agency raises them as an issue in an effort to recoup payments.

One issue that warrants attention is the disclosure requirements for mark-ups on outside laboratory test-ing. Since 1991, Section 655.5 of the California Busi-ness and Professions Code has limited the ability of California physicians to mark up lab tests. (In addi-tion to lab tests, other California laws limit physicians from marking up certain anatomic pathology (Section

655.7) and diagnostic imaging (Section 655.8) servic-es, and federal law also limits mark-ups of diagnostic imaging services.)

With respect to lab tests, Section 655.5 prohibits providers from charging for a laboratory test that they did not perform (in an in-office lab) unless the pro-vider (a) notifies the patient of the name, address and charges of the laboratory performing the test, and (b) charges no more than what he or she was charged by the clinical laboratory that performed the test. Viola-tion of this provision is punishable by imprisonment and/or a $10,000 fine.

Section 655.5 does not prohibit the billing of all provider services associated with a laboratory test that is “purchased” from an outside lab. For example, a physician may charge a reasonable fee for the drawing and processing of the patient’s blood, or interpreting the test results, because these are examples of services performed by the physician for the patient that are sep-arate from the performance of the test itself. However,

IN LAST MONTH’S COLUMN, we ad-

dressed common misconceptions regard-

ing whether physician-owned laboratories

qualify for the in-office ancillary services

and shared practice “exceptions” to both

the federal Stark laws and California laws.

This month, we tackle another common

source of confusion: When are California

physicians permitted to mark up lab tests

and imaging studies? (“Marking up” oc-

curs when a physician purchases a test

from an outside lab or imaging center,

and then charges the payor more than

the lab or imaging center would have had

that entity billed the payor directly.)

California’s Anti-Markup Laws on Labs and ImagingBY HARRY NELSON AND LAURA PODOLSKY

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an ordering physician may not add any “additional” charge to a clinical laboratory service unless the ser-vice is “actually rendered” by the physician and item-ized in the bill.

While this provision does not limit charges for tests rendered by physicians in their own in-office labs, it raises a potential problem as to purchased or out-sourced tests. Providers must be careful about billing for services associated with purchased tests because any errors could be viewed by the government or in-surance companies as tacking on an additional charge to the purchased test in violation of Section 655.5.

Although this law has been on the books for over two decades, insurance companies and law enforce-ment rarely if ever invoked Section 655.5 in disputing physician lab fees. Over the past several years, howev-er, Section 655.5 has become a central issue in health plan-physician disputes over a popular test known as “ALCAT.” ALCAT, which stands for the Antigen Leu-kocyte Cellular Antibody Test for Chemical and Food Allergies, claims to measure adverse re-actions to dietary substances. This being the era of “Gluten Free,” patients loved ALCAT. Meanwhile, insurance compa-nies reimbursed ALCAT tests at a notably higher rate than the ordering physicians actually paid to purchase the test from the lab. Many physicians saw a “win-win”: Patients got information that they be-lieved would improve their health, while the physician got an opportunity to profit on the difference between the purchase price and the insurance reimbursement. Inundated with ALCAT claims, the private insurers were less enamored of the test, questioning its reliability and medically necessity and also objecting that doctors had violated Section 655.5 by marking up an outside lab test.

Since then, some payors have initiated recoupment actions for ALCAT testing, seeking to force physicians to repay reim-bursement and leaving many physicians uncertain of their rights. In a recent San Diego case, the district attorney indicted a physician who billed for ALCAT for viola-tion of Section 655.5 and other criminal charges. While criminal prosecution is an extreme example, physicians should not underestimate the risks of running afoul of anti-markup requirements.

These enforcement activities highlight

the need for physicians to be attentive to the anti-markup provisions with respect to outside laboratories. Physicians, for example, need to distinguish between their right to charge a reasonable drawing and pro-cessing fee for lab specimen and the marking up of the lab test itself. Physicians also should review their billers’ practices with respect to the place of testing of the CMS-1500 billing form to ensure accurate comple-tion of the form, distinguishing between in-office and outside billing. Physicians also should verify that pro-cesses are in place to ensure that their billers make necessary disclosures. Finally, physicians who already face threats, demands or enforcement actions from in-surance companies may wish to seek legal counsel to explore the legal and equitable defenses to such ac-tions.

Harry Nelson is the managing partner of Nelson Hardiman, LLP, and can be con-tacted at [email protected].

Laura Podolsky is an associate at Nelson Hardiman, LLP, and can be contacted at [email protected].

1 0 P H YS I C I A N M AG A Z I N E | NOVEMBER 2014

In the National Scorecard on Payment Reform re-leased last March, Catalyst for Payment Reform (CPR) found that the vast majority of payments, 89%, are still being tied up in fee-for-service and other methods that are agnostic about quality of care, according to CPR’s executive director Suzanne Delbanco.

That, however, is going to change soon given that in 2015, providers will be subjected to Medi-care penalties if they do not meet up to 26 measures of value-based purchasing.

These include 12 clinical process-of-care mea-sures, eight patient-experience dimensions, five outcome measures and one efficiency measure on spending per beneficiary.

Many physicians and healthcare experts are con-cerned that the methodology that the Centers for Medicare and Medicaid Services (CMS) adopted may lead to distorted comparisons and perverse in-centives and may not achieve desired goals.

In a recent report published by the Center for Healthcare Quality and Payment Reform, a Pitts-

burg-based not-for-profit focused on the quality and affordability of U.S. healthcare services, the au-thor identified six areas of concern with the current value-based purchasing methodology.

Harold Miller, president and CEO of the Center, wrote that patients who lack a primary-care physician can cause distortion in comparisons of spending.

Physicians can easily be made accountable for services a patient received from another provider and may also be assigned spending on a prevent-able condition, such as a hospital-acquired infec-tion, when treating the condition rather than the person who caused the condition.

Miller noted that poorly designed measure-ments, attribution and accountability systems fail to provide providers with the information they need and can discourage them from making feasible changes by demanding they control services and spending beyond their range of influence.

CMS responded to the report by saying that it only holds providers accountable for the patients

Healthcare delivery reform and the shift from volume-based to value-based healthcare is creat-

ing both challenges and opportunities for physicians. With the federal government, commercial

health plans and other organizations increasingly using measures of healthcare spending to

reward or penalize providers and healthcare systems, it is key that providers know how value-

based care is being defined and how it will affect them. In this article, we take examine some of

the new delivery models—Accountable Care Organizations (ACOs), patient-centered medical

homes, bundled payments and population-based models that aim to improve the health of en-

tire communities—and what the implementation of these models can mean for your practice.

DEFINING VALUE IN HEALTHCARE

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they have the greatest ability to direct and influence. Others questioned whether the measures accu-

rately reflect quality. A report from the Rand Corp. this year also re-

portedly found mixed results from a broad array of value-based purchasing arrangements with govern-ment programs and private insurers.

“Even those with strong methodological designs did not lead to significant improvements,” the or-ganization wrote, concluding that more research is needed to determine the program’s impact.

Either way, “the movement to value is here to stay,” Richard Umbdenstock, who served as presi-dent and CEO of the American Hospital Association since 2007, told Modern Healthcare.

“It’s going to take Medicare a while to move off fee-for-service, and that’s a bellwether. But there’s a whole lot more in Medicaid and Medicare managed care. The nongovernmental payers are all moving in this direction.”

Delbanco agreed with Umbdenstock’s assess-ment and expects that the 2014 scorecard, which is expected to be released next fall, will reflect pay-ment models moving from volume-based to value-based care.

Both Delbanco and Umbdenstock predicted that several variables will affect the success or failure of various payment reform programs and strategies.

Delbanco predicted that payers and purchas-ers will offer consumers incentives to seek care from “high-value” providers. This, in turn, could incentivize providers to accept new forms of payment to receive a greater market share.

Secondly, she wrote in an article, government policies can also hinder or en-hance the success of pay reforms, such as state laws mandating price transparency to complement a pay-for-performance program.

Umbdenstock told Modern Healthcare that states are trying to limit their exposure as well, noting that in Maryland alone, 10 rural institutions have adopted the value ap-proach of less utiliza-tion, more communi-ty-based services and less reliance on in-patient care because they only get a fixed

amount of money. Instead, they are in the community and collabo-

rating with social service providers.“The future will be in serving acute care for when

it’s absolutely necessary but trying to reach commu-nity through less intensive, less expensive forms of intervention,” he said. The question of how to make it work financially remains.

Finally, local market forces will also impact the success or failure of pay reform.

Umbdenstock said that large national employers can be real influences in their respective market-places.

Umbdenstock predicted that in the future, phy-sicians will probably play either more of a consul-tative role within a larger team or their services will be reserved for issues of clinical ambiguity that no other team member is as qualified to address. Doc-tors may be seeing fewer patients, and their practice models will likely change.

Traditionally, many hospitals have competed based on services and level of technology, and now they are competing more on cost, patient satisfac-tion and quality outcomes, Umbdenstock told news sources.

ACCOUNTABLE CARE ORGANIZATIONS In a re-cent article in Forbes magazine, business guru and best-selling author Clayton Christensen offered his views on some of the obstacles facing ACOs today and how physicians may overcome some of these hurdles.

To date, ACOs have ac-counted for measurable quality improvements and a reported $380 million in savings, but progress re-mains slow and inconsis-tent.

There are an estimated 500 to 600 ACOs in the U.S., providing care for 15% to 17% of the population within three models: Medi-care Shared Savings Pro-grams, Pioneer ACO Mod-els and commercial ACOs.

Each model is slightly different, but all share com-mon goals of coordinating care, reducing redundan-cies, focusing on preven-tion, improving clinical outcomes and making healthcare more affordable.

None have demon-strated consistent success,

IN 2015, PROVIDERS WILL BE SUBJECTED TO MEDICARE PEN-ALTIES IF THEY DO NOT MEET UP TO 26 MEASURES OF VALUE-BASED PURCHASING.

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because moving from a fragmented, fee-for-service, paper-based healthcare system to a team-oriented, value-driven care and electronic health record system is difficult.

However, National ACO LLC, a Los Angeles-based phy-sician-owned and -operated healthcare company that was awarded participation in the Center for Medicare and Med-icaid Services Shared Savings Program and Advanced Pay-ment option in January 2013, may be the exception.

In 2013, the ACO’s 20 participating physicians achieved $6.1 million in savings to the Medicare program and had shared savings of $3.05 million by improving quality of care for some 20,000 patients, said Alex Foxman, MD, who co-founded National ACO with Andre Berger in 2013.

Foxman agreed with Christensen that there are major obstacles that need to be addressed, but he also pointed to opportunities, especially for private physicians, to get in-volved.

Here are the four major obstacles that both agreed need to be addressed:

1. Perverse Payment Models For many providers who are used to increasing revenue and covering expenses by driving volume, the idea of moving toward an evidence-based reimbursement system is scary. But it comes down to what’s best for the patient is best for the bottom line, Christensen said. Doctors who convert their practices and revenue stream from fee-for-service to a prepaid model as rapidly and aggressively as possible can avoid being trapped between the past and the future. “Physi-cians have to start thinking differently,” Foxman agreed. “The traditional thinking is the more we bill patients, the more money we make. In the new system it’s not about how many times you see the patient, but about how well you manage the patient.”

2. Wrong-sized Medical Staff Christensen said that the typical community hospital should consider reassigning care and excluding unnecessary specialists. The solution requires improvements in care delivery and a willingness to reassess pricing based on projected increases in vol-ume.

3. Technology Platform Incompatibility Today, different groups of physicians use electronic health records (EHRs) in their offices that are incompatible with the hospital’s EHR system, which makes redundancy of care inevitable. The solution is for ACO providers to invest in connecting their information technologies early on, according to Chris-tensen. Foxman agreed that ACOs are very data-driven and that the lack of interoperability of systems remains a huge issue, because doctors need information in real-time. “Information technology interoperability is not possible to-day,” Foxman said. “In the future, if it happens, it will be a tremendous asset to the American healthcare system.”

4. Lack of Physician Leadership and Management Structure A strong physician leadership and self-gov-

MEASURING VALUE IN HEALTHCARE While current hospital rankings by U.S. News &

World Report, Leapfrog and others measure quality and popularity, there has never been a means of mea-suring the VALUE hospitals deliver to their patients – until now.

Medical Value Partners (MVP) has developed the Medical Value Index (MVI), based on the work of vet-eran orthopedic surgeon William Mohlenbrock, MD. MVP uses a patented algorithm to process data pro-vided by hospitals themselves to create a value-based index. The MVI is based on six widely recognized healthcare metrics scoring a hospital on a scale of 0-800 points. The higher the number, the greater the value delivered to healthcare consumers by the hospital.

Based on MVP’s analysis, the top five hospitals in the Los Angeles area are (150+ beds):

• Pacifica Hospital of the Valley in Sun Valley • Citrus Valley Medical Center in Corvina• Centinela Hospital Medical Center in Inglewood• Community Hospital of Long Beach • Los Angeles Metropolitan Medical Center..

Dr. Mohlenbrock said that knowing which Los An-geles area hospitals deliver the greatest value empow-ers consumers to entrust their care to those providers.

“Value is what we pay for in every area of our lives,” Dr. Mohlenbrock told Physician Magazine. “It should be the same in medicine. The challenge has always been to determine how to measure value in health-care. With the methodology used in the Medical Value Index, we have identified the essential features for measuring healthcare value.”

For more information visit www.MedicalValuePartners.com


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ernance is key to success in implementing clear reporting relationships and achieving individual accountability, which means that hospital admin-istrators need to embrace physician leadership and invest in its development. Foxman agreed by saying it takes many strong physician leaders to drive success.

PATIENT-CENTERED MEDICAL HOMES Primary care is the foundation of healthcare reform and pa-tient-centered medical homes.

Introduced in 2007, the patient-centered medi-cal home is a model of healthcare that stresses per-sonal relationships, team-based care and coordina-tion across specialties and care settings. The model ranks among the delivery systems encouraged by the Patient Protection and Affordable Care Act to improve quality and reduce costs.

Yet, to date, several studies suggest that the value of creating medical homes remains to be elusive with telehealth care possibly offering viable alternatives.

A CMS-funded study by RTI International re-searchers compared cost and quality measures, col-lected between July 2008 and June 2010, for 308 medical homes recognized by the National Commit-tee for Quality Assurance and 1,906 non-recognized practices.

The study found that total Medicare payments, acute care payments and emer-gency department visits declined com-pared with the non-recognized practices.

Declines were sharper among sicker patients and solo practices, according to an article in Modern Healthcare.

Another study by researchers at New York’s Weill Cornell Medical College found one- to two-doctor practices had 33% fewer ambulatory care-sensitive hospital admis-sions than practices with 10 to 19 doctors.

The study also found that physician-owned practices had fewer preventable admissions than hospital-owned practices.

The researchers suggested that public policymakers and health insurance com-pany executives consider policies that sup-port groups that help small practices share resources.

They said that these groups might “pro-vide a viable alternative for physicians who do not want to become employed by hos-pitals” or don’t want to join a large medical group.

Another study, by Milbank Reports, that looked at medical home programs in 17 states concluded that payer alignment is needed to foster medical home success and the corresponding payment reforms

needed for that success. “This is often because no single payer can invest

enough to make transforming the entire practice cost-effective,” the Milbank researchers wrote.

Proponents of telehealth believe that expand-ing and integrating telehealth services into medical homes would be an effective way to control costs and improve outcomes.

To date, however, roadblocks such as reimburse-ment issues, Medicare restrictions and interopera-bility and compatibility issues in technology remain.

The American Medical Association (AMA) also proposes integrating telemedicine into a new value-and-team-based accountable care model.

“Promoting patient care coordination through medical home and accountable care models will become achievable where data portability and in-teroperability are promoted in the context of tele-medicine,” the AMA said in a written statement.

BUNDLED PAYMENTS The verdict on the value of bundled payments, when doctors, hospitals and healthcare providers share a fixed payment for a health episode under one “bundle” of services in an effort to keep costs down and improve care, is also


still out.Proponents say

that bundled pay-ments give healthcare organizations more autonomy over how they spend money and deliver care while increasing transpar-ency to the healthcare systems, as patients would know the costs upfront.

But because bun-dles aren’t replac-ing all fee-for-service claims, critics predict their overall effect will be small.

In a recent RAND Corp. study, funded by a $2.9 million federal grant, for the care of insured ortho-pedic patients under 65 by a handful of California hospitals and insurers, the few healthcare groups that embraced bundled pay chose to process bills manu-ally because the custom-made software needed to process bundled claims cost more than $1 million, according to an article in Kaiser Health News.

The prospective model also raised concerns for regulators in California, such as whether providers would assume a higher insurance risk and how to apply copays and coinsurance.

The study evaluated a three-year effort coordinat-ed by the Integrated Healthcare Association, which conducted the three-year study who said in news reports that the results of the study should not be in-terpreted as a death sentence to bundled payments.

Rather it should be looked at as a “hard-fought battle offering important lessons.”

POPULATION HEALTH A recent report from Chil-mark Research said while population health is a key trend and long-term goal for healthcare organiza-tions and vendors, the results from a recent study show that reimbursement creates a huge barrier.

The report by Chilmark Research, a Cambridge, Mass.-based group, found that more than 100 ven-dors claimed to address analytics for population health management, but few actually delivered.

The potential for vendors in the EHR space is particularly significant, given the ubiquity of EHRs in large health systems and how they impacts physi-cians’ work.

“To leapfrog competitors, EHR vendors will ac-quire best-of-breed vendors that have the solutions best suited for their target markets,” according to an article in MedCity News.

The eHealth Initiative’s 2014 survey, which in-cluded 135 respondents, also found that the financial burden of health information exchange and chal-

lenges in interoper-ability among vendors are among the top challenges facing the national health IT infra-structure and the shift toward population health management, according to a recent article in HealthIT Ana-lytics.

When asked about the biggest obstacles for building a data ex-change infrastructure with their hospital, lab,

ambulatory and community health provider partners, most respondents named cost as the biggest issue.

Forty-seven percent also indicated that getting consistent and timely responses from EHR and HIE (Health Information Exchange) product vendors was a chief concern, while technical issues of building an interface, implementing data standards and meet-ing end-user expectations also ranked high on the list.

At the same time, population health and the ris-ing retail and consumer-minded approach are real and will be around for a long time, according to a blog by healthcare consultancy firm Advisory Board.

With more consumers looking for convenient ac-cess to care, demanding transparency in pricing and turning to the Internet and social media networks to find doctors as well as read and write reviews on providers and healthcare systems, the trend is here to stay.

The Advisory Board believes that with all the consolidation that has occurred, smart partnerships will be vital for a hospital’s survival.

“No matter the form it takes (and it’s not always M&A), a smart partnership can strengthen any orga-nization’s appeal to retail consumers,” according to an Advisory blog post.

ConclusionThe immediate past president of the American

Medical Association, Ardis Dee Hoven, MD, recog-nizes the importance of healthcare value. She was quoted in a recent article in the Wall Street Journal reporting on healthcare cost data as saying, “What we need in this country is data that shows value”

Whether dealing with ACOs, medical homes, bundled payments or population health manage-ment, defining, measuring, understanding and ad-dressing current challenges with value-based mod-els will be key for services and products to grow in the changing health environment and have the de-sired positive effect on outcomes and costs.

“WHAT WE NEED IN THIS COUNTRY IS DATA THAT SHOWS VALUE ”

PAST PRESIDENT OF THE AMA , ARDIS DEE HOVEN, MD, IN A RECENT ARTICLE

IN THE WALL STREET JOURNAL

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In a study of claims closed from 2007 to 2013, The Doctors Company identified four common al-legations made by patients with diabetes: improper management of treatment (37%), failure or delay in diagnosis (31%), failure to treat (9%), and improper management of medication regimens (6%).

Diabetic patients’ treatment is often managed by a multidisciplinary care team, which may include a primary care physician, endocrinologist, dieti-cian, ophthalmologist, podiatrist, and dentist. When patients file claims, it’s not uncommon for them to name the entire care team in the complaint, alleging failure to properly diagnose, supervise, monitor, and/or treat their disease.

To promote patient safety, the healthcare team should engage the patient in collaborative care planning and problem solving to produce an indi-vidualized care plan as well as team support when problems are encountered. Other ways to promote patient safety and mitigate the risk of malpractice claims related to diabetes care are: • Communicate. Talking openly with diabetic pa-

tients about their condition and encouraging them to take an active role in decision making enhances patient safety.

o Overcome patients’ fears about their disease by taking time to answer questions.

o Discuss all associated risk factors, including weight gain. The American Medical Associa-tion and American Diabetes Association have resources available to help physicians talk to their patients about weight and diabetes.

o Provide written instructions and information

about adverse effects for prescription drugs and complex prescription drug regimens.

o Communicate with the patient and prepare written information in the language and at the literacy level that the patient understands.

o Ask patients to repeat the information shared, not just whether they understand what they have been told.

• Educate. Educate patients about the importance of self-management to help increase their com-pliance and to reduce the risk of patients attrib-uting their injuries to substandard care. Diabetic patients should be able to articulate the impor-tance of lab tests, medication management, diet, and exercise. Barriers to self-management such as financial issues or lack of social support, health-care literacy, and patient-caregiver relationships should be assessed.

• Document. Document any and all patient inter-actions and discussions regarding the patient’s condition, including diagnosis, specialist refer-rals, and treatment options.

• Manage care. Implement a program that ensures timely follow-up when a patient fails to sched-ule an appointment, misses an appointment, or cancels an appointment and does not reschedule. Failure to follow up and provide intensive patient management can lead to missed or delayed diag-noses, accelerated disease symptoms, morbidity, and/or mortality.

Contributed by The Doctors Company. For more patient safety articles and prac-tice tips, visit www.thedoctors.com/patientsafety.

Communication Is Key to Improving Diabetic Patient Outcomes and Reducing Liability

RISK TIP

BECAUSE DIABETES HAS the

potential for serious com-

plications and requires im-

mense involvement by pa-

tients and physicians for

successful outcomes, health-

care professionals who treat

diabetic patients may be at

risk for malpractice lawsuits.


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CEO’s LETTER

WITH THE EBOLA cases capturing national attention, Los Angeles County physicians are rightfully concerned about our health system’s preparedness to protect their pa-tients and healthcare workers.

Los Angeles County doctors are continually learning and practicing preparedness. To remind the public that physicians are the primary line of defense

against this potentially deadly disease, LACMA’s president, Pedram Salim-pour, MD, took the opportunity in recent media interviews to highlight the critical role doctors play in our public safety infrastructure.

Dr. Salimpour has been quoted repeatedly in media outlets, discussing the preparedness of our LA healthcare system to handle the possibility of an Ebola outbreak.

In addition, Dr. Salimpour urged the public to help the hospital system by getting flu shots. The key to prevention, Dr. Salimpour told the Los An-geles Daily News, is honesty between patients and their doctors.

This serves as a reminder to all physicians, who put their lives at risk every day, of the critical role they play to serve the public good.

As an organization, LACMA is proud to once again demonstrate its critical leadership in LA County and the nation overall. We are looking forward to our continued growth and strength in numbers.

During this time of celebration and reflection, we want to thank our phy-sicians for giving so much of themselves to their profession.

We are excited to celebrate our outstanding physician leaders during the annual LA Healthcare Awards on Nov. 13 at the California Club.

This year, we are thrilled to honor former LA mayor, Richard Riordan, as our “Healthcare Champion of the Year.” Riordan, a longtime healthcare champion, has never wavered in his public policy statements.

In Riordan’s words, “Every child that comes into this world has a God-given right to a quality education and quality healthcare.” Let us hope that future generations of lead-ers will heed those words.

While the verdict of Proposition 46 may have already been decided by the time you read this letter, LACMA remains hopeful during this time that voters will do the right thing and side with our physicians to vote “No” on Prop. 46.

Happy Thanksgiving!

Rocky DelgadilloChief Executive Officer


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For a copy of your renewal invoice please email Carolina Velazquez, [email protected]

How to renew:

Call: Carolina Velazquez, 213-226-0361

Renew online at www.lacmanet.org/Renew Your Medical License number will act as your login

Mail your invoice and payment to:

707 Wilshire Blvd, Suite 3800; Los Angeles, CA 90017

By renewing your dues, you will continue to receive:

Legislative Advocacy—Continuous fight to protect the medical profession from current challenges such as Proposition 46, narrow networks in California, and CalMediConnect.

Access to documentation to help you navigate through today’s changing healthcare landscape.

Free Reimbursement Assistance—CMA has recovered nearly $8 million recovered since 2010 in unpaid claims for its members!

Free Jury Duty Assistance—Your time is valuable! Maximize your flexibility and increase your chances for reporting for the minimum period when scheduling jury duty service.

15-27% average annual savings through LACMA’s exclusive partnership with Medline, the medical supplies company.

Free and low cost access to events including CME events, mixers, training workshops, and webinars for you and your staff.

Renew your dues today!

Los Angeles County Medica l Assoc ia t ion

For our Valued Members

FREE DUES! Renew your 2015 membership by

December 31st, 2014 and be entered in a drawing to win FREE dues for 2015!

LACMA Lauds DHS Efforts to Increase Primary Care

in Underserved AreasLACMA is commending the Los Angeles Coun-

ty Department of Health Services (DHS) for its ag-gressive approach to secure federal funding to bring more doctors to our most challenged communities. Millions of Americans have trouble accessing basic care because of the lack of primary care physicians available in their area. In Los Angeles County, 1.2 million individuals reside in areas without access to primary care. In the last two years, DHS applied to have these areas designated as a Health Profes-sional Shortage Area (HPSA) for primary care and increased the number of areas eligible for such funding from 24 to 34 county-wide, with another thre under evaluation.

“With Los Angeles County facing a growing physician shortage, LACMA recognizes the exem-plary efforts by DHS to provide quality healthcare for all patients and calls on other stakeholder groups to convene and define a cohesive strategy to increase the number of physicians serving the neediest communities in the county,” said LAC-MA President Dr. Pedram Salimpour.

HPSA is a designation that recognizes a par-ticular geographical area, population or institu-tional facility that is experiencing a shortage of primary care services. Once a HPSA designation is achieved, the government infuses aid through various programs and incentives, including physi-cian recruitment assistance and financial incen-tives, which may include student loan forgiveness and Medicare bonuses to providers practicing in an HPSA area. These incentives make these areas more attractive to physicians. As these profession-als establish their practices within an HPSA, the shortage of primary caregivers is alleviated, gov-ernment assistance is eventually withdrawn, and the physicians frequently establish permanent roots within their service area to the benefit of their careers, families and the community.

“The County Health Department’s efforts gen-erate a win-win for patients and their doctors; physicians fulfill their personal goal of serving the neediest communities while receiving a reduction in their medical school debt,” added Dr. Salimpour. “Utilizing loan repayment programs as a recruit-ment and retention strategy enables DHS to attract physicians to its Ambulatory Care Network and hospital-based clinics that serve our most vulnera-ble patients. And it helps doctors to stay connected with their patients throughout their careers.”

All physicians providing services in an HPSA are eligible to receive Medicare bonus payments. Eligible providers include primary care physi-cians, specialists, surgeons, doctors of podiatric medicine, licensed chiropractors and optome-trists. In addition, psychiatrists furnishing services in a geographic mental health HPSA are also eli-gible to receive bonus payments.

1 8 P H YS I C I A N M AG A Z I N E | NOVEMBER 2014

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TOP10REASONSFOR JOINING LACMA AND CMA

Working together, the Los Angeles County Medical Association and the California Medical Association are strong advocates for all physicians and for the profession of medicine. Of the many reasons for joining LACMA and CMA, 10 stand out.

LACMA/CMA IS THE VOICE OF PHYSICIANS

1Legislative AdvocacyLACMA and CMA are distinguished by their successes. Dual membership provides for unparalleled legislative advocacy to end abusive practices. In addition, LACMA has sued health care plans on behalf of members to stop intimidation tactics.

two FREE Reimbursement Assistance

Tired of fighting with payors? CMA’s Economic Services experts have recovered nearly $8 million for members since 2010!

3 FREE Jury Duty AssistanceLACMA can help you: • Reschedule your date • Relocate for your convenience • Reduce number of call-in days from 5 to 1!

27% in AVERAGE SAVINGSThrough an exclusive partnershipwith Medline, LACMA saves members a guaranteed minimum of 10% on their medical supplies and equipment. Find out how one member saved $31,000 for his practice!

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Benefits & DiscountsAimed at meeting both your professional and personal needs, LACMA offers you additional discounts and savings on Auto & Home Insurance, UPS services, Staples office supplies, Financial Planning, HIPAA Compliance Kits, and more!

five

FREE CME & Educational ResourcesCMA develops toolkits, guides, webinars, and resources on all things related to today’s changing healthcare landscape—all FREE with membership. In addition, LACMA provides access to important and local CME-accredited events.

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8FREE Networking & Referral Events• Socialize and network with members of the medical community• Find or create opportunities for your practice• Engage with legislators and policymakers

Unlimited Access to Legal ExpertsSave time and money by consulting with a CMA legal expert before hiring a lawyer. Services include HIPAA Compliance, ACOs, Buying and selling a practice, Upkeep of medical records, and much more!

9 State-of-the-Art CommunicationInformation is power. LACMA and CMA produce several publications full of valuable information including the award-winning Physician Magazine, Physicians’ News Network, and CMA Practice Resources, full of tips and tools for your practice.

tenAccess to your Physician AdvocatesWhen you join LACMA and CMA, you hire a professional staff that serves as an extension of your practice. We are here to help you reach your goals and connect to the resources you need most. Whatever you need—be it help with a problematic payor, or details about your member discounts—just call the member helpline at (800) 786-4262 or visit www.lacmanet.org

LOS ANGELES COUNTY MEDICAL ASSOCIATION707 WILSHIRE BLVD, SUITE 3800

LOS ANGELES, CA 90017

PHONE: (213) 683-9900FAX: (213) 226-0353

For more information on member benefits and resources, visit www.lacmanet.org/Membership

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November 2014 | Physician Magazine