Wednesday, January 16, 2019

A Letter from CMA President, Luther F. Cobb, M.D.

Dear Colleagues:

Although 2014 will long be remembered as the year that all modes of practice and specialties of the House of Medicine came together in a group effort to defeat Proposition 46, it is imperative that we maintain the momentum we have gained as we confront the issues of the coming year and beyond.


Following such a historic year, I would like to take a moment to reflect on what we have accomplished and what we can look forward to over the next 12 months.

I have, for over three decades, been a firm believer in the institution of organized medicine and the good that we can accomplish with unified action. As the President of the Humboldt-Del Norte Medical Society and Chair of the Council on Legislation, and in my time as Vice Speaker and Speaker of the House of Delegates, I have seen you all accomplish remarkable feats together. Whether it has been determining our stance on the sweeping changes of health system reform; combating unwarranted extensions of allied health professionals’ scope of practice; fighting for access to care; working to ensure the practice of medicine is dedicated to patient welfare rather than the insurance bottom line; redefining Medicare geographic payments, and on and on; we have been able to get all this done because we work together for the benefit of all.


Our political power was evidenced this November when we handed the trial attorneysProposition 46 an unprecedented two for one electoral defeat, in conjunction with an unparalleled coalition across all party and advocacy lines. We distributed over three million lab coat cards, hundreds of thousands of patient brochures, posters and yard signs all over the state, mostly because of the ground game we mobilized.


Such a victory would never have been possible if not for the dedication we all had to one another and to the future of the practice of medicine.


It is indeed a great honor to follow in the footsteps of Richard Thorp, M.D., who as last years president led an incomparable team effort to victory, not only with Proposition 46, but also the other battles and challenges we faced.


So what does that mean for the year ahead?


Already, the California Medical Association (CMA) has been involved in a public launch to increase the tobacco tax in California. We currently stand 47th in the nation in that regard. A broad coalition of public health advocates will be working all across the state. This action may end up being a legislative effort, or perhaps a ballot initiative, but we will be pressing forward this year.

We know that as millions of citizens are signing up for health insurance coverage, it is more important than ever to ensure that they have real access to quality medical care, not just a card promising care without the infrastructure to deliver. To that end, CMA has been working with partners to educate physicians and patients about their choices.


Many other issues are sure to arrive in the coming year; they always do. As a group, united, we can accomplish great things, as we have already proven.


I look forward to working with you all in the exciting new year.

Luther F. Cobb, M.D. CMA President

The Ultimate Measure - CMA's 2014 Legislative Wrap Up

By Janus L. Norman, CMA Senior Vice President

For more than 150 years, the California Medical Association has upheld the banner for practicing physicians. Year after year, the state medical society has partnered with the local medical societies to diligently strive to ensure the care and well-being of patients and to protect public health by working for the betterment of the profession. In years of prosperity, the challenge of carrying out this duty is restrained. In years of controversy, the same duty is laborious. This year was full of controversies.

The fight to defend the Medical Injury Compensation Reform Act (MICRA) may have ended with a ballot box victory in November, but the threat of a statewide ballot measure loomed heavily from the onset of the 2014 Legislative Session. The leader of Senate, President Pro Tempore Darrell Steinberg, introduced Senate Bill 1429 as vehicle to execute the strong-arm strategy of the plaintiffs bar attorneys to eliminate MICRA’s cap on non-economic damages. Tremendous political pressure and immature bullying tactics were employed in an attempt to force CMA to the bargaining table, but the association held fast to its principle of working to create an economic environment that allows physicians in all specialties the ability to practice throughout California. Rejecting the false choices presented by opponents of MICRA and choosing to make our case before the people of California, CMA united its political allies to ensure Senate Bill 1429 never received a hearing, leaving the trial attorneys' Proposition 46 ballot measure the only available avenue for overturning MICRA.

Senator Mark DeSaulnier’s Senate Bill 1258 contained another component of Proposition 46: the requirement for Schedule V controlled substance prescriptions to be reported to the Controlled Substance Utilization, Review and Evaluation (CURES) database. The bill also would have required the electronic prescribing of controlled substances, expanded government access to CURES and dictated the quantity of controlled substances allowed to be prescribed. Like the mandatory checking of CURES inserted into Prop. 46, SB 1258 was touted as a bill to address prescription drug abuse. However, the impact would have been to legislate the practice of medicine, undermine the patient/physician relationship and reduce patient access to care. CMA was instrumental in killing the bill, which was held in the Senate Appropriations Committee. The committee's action prevented passage of bad policy and also extinguished Bob Pack’s ability to use the bill as a platform from which to campaign against CMA in the months leading up to the November vote on Prop. 46.

Senate Bill 492, authored by Senator Ed Hernandez, sought to expand to scope of practice of optometrists to include surgical procedures and primary care services. Senator Hernandez, a practicing optometrist and Chair of the powerful Senate Health Committee, worked feverously toward the passage of Senate Bill 492, which passed out of the Senate in 2013 and was resting in the Assembly. Utilizing his great influence and charm, Senator Hernandez, along with the Optometric Association, battled with CMA, the California Academy of Eye Physicians and Surgeons, the California Academy of Family Physicians and the California Society of Plastic Surgeons to win the votes of the members of State Assembly. Hundreds of CMA members made phone calls and wrote emails and letters outlining the flaws within Senate Bill 492 and urging legislators to vote no on the measure. As the coordinated statewide effort moved forward, members of the Assembly began to acknowledge the harm that would have resulted from irresponsibly expanding the scope of optometrists to perform surgeries and provide primary care services by publicly committing to stand with the physician community in opposition to Senate Bill 492. With a majority of the members poised to oppose the measure, Senator Hernandez and the optometrists agreed to drop the bill and allow it die quietly on the Assembly Floor.

California’s physician shortage is consistently utilized as an argument for expansion the scope of allied health professionals. To combat this argument and the increase access to quality care, CMA has prioritized improving our state’s physician workforce by increasing the number of residency slots for medical school graduates. Studies have indicated that where a physician completes his or her residency is a primary indicator of where the physician will practice. CMA pushed the state to make an initial investment in its future medical workforce. The 2014-15 Budget Act signed by Governor Brown included $7 million to support primary care residency slots through the state’s Song-Brown program. Of that $7 million, $4 million will be prioritized to residency programs that wish to expand and train additional residents in internal medicine, pediatrics, obstetrics-gynecology and family medicine.

The 2014-15 state budget also provided significant resources to physicians. Specifically, the budget includes $3.7 million to draw down $37.5 million in federal funds for technical assistance to Medi-Cal providers on implementing and achieving meaningful use of electronic health records (EHRs). The 10 percent contribution from the state will allow an additional estimated 7,500 Medi-Cal providers to participate in the Medi-Cal meaningful use incentive program and receive the necessary training from the existing technical assistance infrastructure. In addition, CMA convinced the Governor to forgive the retroactive Medi-Cal cuts contained in AB 97 (Chapter 3, Statutes of 2011), which reduced Medi-Cal provider cuts by 10 percent.

For the last several years, CMA led the effort to seek an injunction to invalidate and stop the implementation of the 10 percent Medi-Cal cuts, arguing that this reduction would threaten the ability of physicians to continue to treat Medi-Cal beneficiaries and would create significant gaps in access to care for this population. The legal process ran its course when the U.S. Supreme Court declined to hear our appeal. CMA was, however, able to convince Governor Brown to not attempt to retroactively collect the portion of the cuts during the period of time the injunction was in place. As a result, physicians will be able to retain $218 million in Medi-Cal payments.

During the last months of the 2014 legislative session, CMA learned of the imminent closure of Doctors Medical Center in Contra Costa County. Doctors Medical Center (DMC) is the area’s main medical facility, serving over 250,000 patients in west Contra Costa County, including the city of Richmond and surrounding areas. Even though over 80 percent of its patient population is insured through Medi-Cal or Medicare, low reimbursement rates prevent DMC from creating a business model that would allow for sustained financial viability. CMA sponsored Senate Bill 833 (Hancock) to appropriate $3 million from the Major Risk Medical Insurance Fund to DMC to provide bridge funding to secure additional avenues of finance and create a new and viable business model for the facility going forward.

CMA sponsored and strongly supported additional legislation that addresses the daily challenges faced by physicians and raised public awareness surrounding critical health care issues. Assembly Bill 1755, authored by Assembly Member Jimmy Gomez and co-sponsored by CMA and Planned Parenthood Affiliates of California, was signed by Governor Jerry Brown. The bill will improve California’s notice requirement specific to breaches of medical information in order to reduce administrative burdens on providers and health facilities, while also ensuring accurate notification to patients, thereby allowing health care providers to put those resources back into patient care.

CMA, joined by various patient advocacy groups, worked with the Legislature and Governor to secure the enactment of Senate Bill 964 (Hernandez), which required Medi-Cal managed plans and insurers offering individual plans through Covered California to provide annual reports to the California Department of Managed Health Care (DMHC) about the adequacy of their provider networks and to make the reports available online.

Our successful advocacy did not come without sacrifices. As CMA battled in the Assembly to defeat Senate Bill 492, Senator Hernandez, Chair of Senate Health, held two CMA sponsored bills hostage in the Senate: Assembly Bill 2400 (Ridley-Thomas), which reintroduced an important discussion in the Legislature about the contracting relationship between physicians and health care plans and health care insurers, and Assembly Bill 1771 (Pérez), which would have ensured physician reimbursement for non-face-to-face patient management services to help increase patient access to care. Ultimately, CMA stood strong in the midst of controversy and held to its core principle of ensuring the safety of patients, and as a result both measures were held in the Senate. However, CMA was able to convincingly make the policy argument for both measures and to secure bipartisan support for the underling policy, for which we will be advocating again in the near future.

In its first year, the “My CMA Idea” contest produced one of the most hotly debated topics of the year: the negative impact of sugary drinks. CMA co-sponsored SB 1000 (Monning), which would have required warning labels on sugary drinks. A strategy to help educate consumers about the risks associated with consuming sugary drinks, the bill was the first of its kind in the country. It generated unprecedented media attention, including coverage by international media outlets. Twenty-four California papers editorialized in support of the bill. Scholastic News magazine, a teaching tool distributed throughout the country, included stories on the bill in a way that encouraged classroom debate on the issue. SB 1000 was even referenced in the nationally syndicated cartoon strip “Drabble.”

SB 1000 faced a tough political environment from the outset, with the soda industry pulling out all the stops to defeat it. Though the bill died in the Assembly Health Committee, the campaign supporting the bill showed CMA’s strong commitment to reducing obesity, our willingness to pursue innovative public health policy and – most importantly – helped educate people about the risks associated with consuming sugary drinks.

As Martin Luther King, Jr. famously said, “The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.” In 2014, I am proud to say, CMA measured up!

For more details on the major bills that CMA followed this year, visit

RCMA Member Honored

CMA President Tarek Mahdi, M.D., has been named November 2014 Member of the Month from among the 8,700 members of the California Academy of Family Physicians (CAFP). RCMA congratulates Dr. Mahdi on being recognized as a leader transforming primary care.

New Healthcare Laws for 2015

The California Legislature had an active year, passing many new laws affecting health care. In particular, there was a strong focus on scope of practice for allied health professionals, prescription drug abuse, public health issues and health care coverage.

The California Medical Association has published a summary of the most significant new health laws. For more details, see "Significant New California Laws of Interest to Physicians For 2015."

Voters resoundingly defeat Prop. 46

Voters resoundingly defeat Prop. 46

Dear Colleagues,

When I took office as President of the California Medical Association just over a year ago, I felt the weight of our future on my shoulders. As your leader, representing our 40,000 members, I vowed to do everything I could do to ensure the defeat of the trial attorneys and their deceptive work.

Shortly after I assumed my role, it became clear that the Consumer Attorneys of California and their front group, Consumer Watchdog, would indeed be moving forward with a three part ballot measure that would be put before voters. With my family and my colleagues, I was determined to commit to you and to fight for you.

It is with a humbled gratitude, a thankful heart and a smile that I can say, we did it. And I mean when I say that WE did it. Without your commitment, dedication and fortitude, we could not have come out victorious last night.

Yesterday, the voters of California spoke loudly and definitively, sending the trial lawyers' Proposition 46 to defeat by a vote of 67 to 33. The message is clear – Californians simply don’t want to increase health care costs and reduce health access so trial attorneys can file more lawsuits.

An increase in the Medical Injury Compensation Reform Act (MICRA) cap on non-economic damages has been rejected in California again and again: 10 times in court, 5 times in the Legislature and now overwhelmingly by voters. This idea now has its own dedicated spot in California’s political trash heap. 

But this time, we energized the membership of CMA as a whole to fight the fight together, as one unified voice of medicine, representing the patients we so deeply care about and the care that we have committed to provide them.

This has been a long haul. It was May of 2013, when I was called upon, as President Elect, to respond to a press conference that Consumer Watchdog held on the steps of the State Capitol. At that point, we didn't know exactly what the proposition would say, but we knew that it was going to be deceptive.

And, soon enough we would see that the trial attorney sponsors added provisions like random and mandatory drug testing of doctors to help “sweeten” the deal. The bottom line is that they knew voters wouldn't approve a measure that raises health care costs for everyone and decreases access – especially for those that need it most.

One of the secret weapons of this effort was the size and diversity of our coalition. We helped amass one of the largest and most diverse coalitions in California history. The breadth of the coalition — which includes labor, business, local government, health providers, community clinics, Planned Parenthood, ACLU, NAACP, taxpayers, teachers, firefighters and more – underscores just how important affordable, accessible health care is to every Californian.

I cannot express my thanks to each of you enough, members of this esteemed organization. It is with great honor that I hand over the torch to Luther Cobb, M.D., as he now takes the seat as your CMA President. It has been my honor to serve you during this pivotal year. I would like to offer my sincerest gratitude to the physicians of California who rallied their patients, families, friends and colleagues to defeat Prop. 46.

This has truly been an example of just how much stronger we are when we speak together with one voice to ensure that our patients continue to have access to quality patient care.

This was one of the most contentious and high-stakes ballot fights in California history and we rose to the occasion. We must use this unity moving forward and showcase to our colleagues the value the California Medical Association brings to our great profession and stay united for whatever comes our way next.

Thank you!

Richard Thorp, M.D., FACP
Immediate Past President, California Medical Association

Proposition 46 Update From the President of RCMA

October 23, 2014

Dear Colleague:

As Election Day nears, we are now just 12 days from the polls closing on Tuesday evening, November 4.

On November 5, I want to be able to report to you that Proposition 46 was soundly, decisively, and overwhelmingly defeated.

We continue to gain momentum and move in the right direction. Public polling shows voters reject Proposition 46 when they know what it's really about and who is behind it. If you haven't seen the news recently, editorial boards across the state are urging voters to say No in November. Our own Press Enterprise called out the proponents for their deceitful tactics and trickery.

The endorsements are streaming in from every corner of the state and here in our own communities as well. Everyone from doctors and hospitals to Chambers of Commerce to local governments, civil liberty groups, and community clinics - the coalition opposed to Proposition 46 grows daily.

We cannot afford complacency. We need the proactive help of every doctor in Riverside County, and we need to get out the vote.

As president of Riverside County Medical Association, I am asking every doctor in Riverside County to take the following actions:
  1. Wear your "No on Prop 46" button. We need everyone to publicly demonstrate their opposition. If you need more buttons, you can order them a  - they will be shipped to you ASAP. You can also pick buttons up in person at RCMA, 3993 Jurupa Ave., Riverside
  2. Commit to handing out "lab coat cards," and let your patients and neighbors know what the measure is really about. Cards can also be ordered at or at the RCMA office.
  3. Energize your physician peers to defeat Prop 46. Speak up at your hospital, your clinic, your office. Get the message out: If Prop 46 passes, it means real harm to patients and doctors. Brochures and posters for your waiting rooms are available at and at the RCMA office.
  4. Speak to family and friends - every voter counts!
  5. Put up yard signs - Please call RCMA at (951) 686-3342 if you want some. Yard signs matter - this is how elections are won, i.e., with relentless pressure.
  6. But be very, very careful about public communications. We have trained speakers at the ready and have off-the-shelf printed materials. Contact RCMA if you need something or need something looked at; we cannot afford a media malfunction, this includes internal newsletters, communication to local media, and blast emails and bulletins that could be made public.
  7. Pay your dues or become a member. We are spending a ton of money to defeat Prop 46 - we must have your financial support!
Thank you so much. Keep up the pressure!

Tarek Mahdi, M.D.
President, Riverside County Medical Association

Ebola Resource Center

In response to the recent Ebola Virus Disease(EVD) outbreak, RCMA is constantly updating a list of resources for your practice.

Riverside County Department of Public Health Disease Control:
  • During  Regular Office Hours Call: (951) 358-5107
  • After Hours (24x7) Call: (951) 782 2974, ask for second call
  • Ebola Information Page

Please visit the Centers for Disease Control and Prevention Ebola Website for additional resources.

Proposition 46 isn't the CURE(S)

On November 4, voters will be asked to weigh in on Proposition 46, a costly and deceptive measure funded and sponsored almost exclusively by trial lawyers. In addition to raising health care costs and reducing access to quality medical care, Prop. 46 could put patient prescription drug history at risk of being hacked and would force physicians and pharmacist to use an unworkable database.

The Controlled Utilization Review and Evaluation System, or CURES, is a statewide, government-run database that allows physicians to know which medications patients are taking. In concept, it could be a helpful tool in ensuring that patients don’t “doctor shop” – or visit several doctors to get multiple prescriptions for controlled substances.

Though the database already exists, it is underfunded, understaffed and technologically incapable of handling the massively increased demands this ballot measure will place on it. In its current form, the CURES database is plagued with system errors and major deficiencies. The state staffer in charge of CURES recently testified that the database is “not sufficient enough to carry out the mission that we need.” To see excerpts of his testimony, click here.

In fact, in evaluating Prop. 46 the independent, non partisan Legislative Analyst noted, “Currently CURES does not have sufficient capacity to handle the higher level of use that is expected to occur when providers are required to register beginning in 2016.”

While a potentially useful database, CURES simply isn’t able to handle what’s being asked of it. The health care community helped to pass SB 809, which will increase funding for the database and update the technology along with adding funds for more staff; unfortunately upgrades won’t be ready until the middle of 2015, at the earliest.

Despite all of this, Prop. 46 includes a provision that would mandate physicians and pharmacists check the CURES database before prescribing Schedule II or III drugs – a list of medications that is far too long for this newsletter. This “CURES mandate flaw” puts physicians in the untenable position of either breaking their professional oath to give patients the best possible care or breaking the law.

What’s more, the CURES mandate comes without any increased security to ensure that the database is up and running efficiently, effectively and safely before legally making health care professionals check it.

That’s a risky gamble in these days of massive data breaches.

Many of you reading this know firsthand the difficulties of the CURES database and have yourselves tried to use it to improve and advance patient safety. You then also know how unlikely it is that the CURES mandate will work. 

In the few weeks left between now and Election Day, RCMA cannot stress enough how important it is to spread the word about the dangers of Prop. 46.

No on 46 - get engaged

By now, many of you are familiar with the Medical Injury Compensation Reform Act (MICRA) lawsuit initiative that will appear on the November 4, 2014, ballot. Proposition 46 is being opposed by a coalition of doctors, community health clinics, Planned Parenthood Affiliates of California, local governments, working men and women, business groups, taxpayer groups, hospitals and educators, all of whom know that the measure will lead to more lawsuits and higher health care costs. What’s more, it will threaten personal privacy and jeopardize people’s access to their trusted doctors or clinics. Practices are encouraged to get engaged now!

What you can do

Sign up formally (as an organization, practice or individual) in opposition to the campaign. Visit the campaign website at to add your name to the growing list of groups and organizations opposing Prop. 46.

Request a CMA staff member to speak to your group, hospital or specialty society. Let your local county medical society or CMA know and we can ensure you’re hearing from the right people about the most recent campaign updates.

Participate in message/media training. The campaign is looking for physicians interested in taking on a more public role speaking to community groups about why this ballot measure should be defeated. Contact Molly Weedn at for more information.

Speak to your colleagues, patients and community. Use the resources at to talk to your colleagues, patients, friends and family. Don’t forget to speak to community members as well – groups such as Rotary, Kiwanis, Soroptimist and more provide great venues for presentations.

Order campaign collateral. Download the Order Form to receive office posters, English- and Spanish-language patient brochures, campaign buttons, message cards and more. You can also order directly online by visiting

Spread the message on social media. If you’re active on social media, start by following the California Medical Association and No on Prop 46. Retweet and repost the information that is being put out to help spread the word about how dangerous and costly Prop. 46 will be for everyone. For questions about how to start a Twitter or Facebook account or how to engage with CMA, please contact Brooke Byrd at

CMA: @cmaphysicians
No on 46: @NoOn46

No on 46:

CPT® Modifier 22 – reporting and reimbursement

Tip comes from G. John Verhovshek, managing editor for AAPC, a training and credentialing association for the business side of health care.

CPT® modifier 22 increased procedural services allows a provider to gain additional reimbursement for an unusually difficult or time-consuming procedure. To realize that extra payment, your billing staff will have to make a special effort, as well.

Per CPT® Appendix A, modifier 22 may be appended to a CPT® code to indicate that the work performed was “substantially greater than typically required…. ” CPT® does not define a “substantially greater” effort, although some payors do offer guidelines (e.g., the effort and/or time to perform the procedure should be “at least 25 percent greater than usual”). Regardless of payor, you should append modifier 22 infrequently, and for only the most unusual procedures.

Specific circumstances that may call for modifier 22 include:

  • Intra-operative hemorrhage resulting in a significant amount of increased operative time.
  • Emergency situations that require significant effort beyond the normal service. This does not include minor intra-operative complications that sometimes occur.
  • Abnormal pathology, anatomy, tumors and/or malformations that directly and significantly interfere with the normal progression of a procedure.

Also, keep in mind these caveats:

  • Additional time, by itself, does not justify the use of modifier 22.
  • Do not use modifier 22 when the existing CPT® code describes the service.
  • Do not use modifier 22 to indicate that a specialist (no matter how specialized) performed the service.
  • Do not use modifier 22 if the complication is due to the surgeon’s choice of surgical approach.

CPT® guidelines require that provider documentation support “the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of the procedure, severity of patient’s condition, physical and mental effort required).” The provider should explain and identify additional diagnoses, pre-existing conditions, or unexpected findings or complicating factors that contributed to the extra time and effort.

Use comparisons to clarify how the procedure differed, using quantifiable criteria. For example: The patient lost 800 cc’s of blood, rather than the usual 100-200 cc’s lost during a procedure of the same type. Time is also quantifiable (e.g., “the surgery took four hours instead of the usual 1½-2 hours”).

Payors may request a full operative report to verify the unusual nature of the coded procedure. Because most claims are now sent electronically, you should include comments in the narrative field, using everyday language, to explain precisely why (and how much) additional effort and/or time were required to complete the procedure, along with the statement, “Request documentation if needed.” If the payer requests the additional details, be prepared to send the full operative note, along with a cover letter (with provider signature) detailing the unusual nature of the procedure.

The Centers for Medicare & Medicaid Services and other payers scrutinize modifier 22 claims, and primary payor claims submitted with a 22 modifier are often subject to a full medical review. If your claim is correctly coded and well supported by documentation, be persistent in pursuing payment.

Lastly, when submitting your claim with modifier 22, you have to ask for additional payment. Payors won’t automatically increase reimbursement. Instead, you should recommend an appropriate fee. For instance, if a surgical procedure takes twice as long due to unusual clinical circumstances, you could ask the payor to increase the intra-operative portion of the payment by 50 percent. 

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