Wednesday, January 16, 2019

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 http://cal.md/leg-wrap-2014.

Health Care Reform 2014 Marks a New Era

Starting in 2014, Americans must have minimum essential coverage or pay a tax penalty.  Options for coverage include insurance purchased through the individual market, a public exchange, a government program or an employer-sponsored program.   Minimum essential coverage includes ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health/substance abuse treatments, prescription drugs, rehabilitative services, laboratory services, preventive/wellness services and pediatric services.

 Changes Coming in 2014

•    Individual Mandate — Everyone (with few exceptions) will be required to have health insurance or pay a penalty.  Penalties start   at $95 per individual, $285 per family, or 1% of income (whichever is greater), and increase in subsequent years


•    Employer Mandate — Employers with 50 or more full-time equivalent employees must offer minimum essential coverage that is affordable (where employee only contributions do not exceed 9.5% of household income)  for at least 95% of its full-time employees or pay a penalty (i.e. play or pay) if one full-time employee goes to an Exchange and receives a premium tax credit.

      If coverage is not offered, penalty is $2,000 multiplied by the number of full-time employees (minus the first 30 employees).

      If coverage is offered but not affordable or does not cover at least 60% of essential benefits, the employer will be assessed $3,000 for each employee receiving a tax credit or $2,000 per full-time employee (the lesser will apply) (excluding the first 30 employees).

•    All states must have a health insurance exchange available for individuals and small business owners to view, compare, and purchase health plans offering minimum essential coverage.

 •    Subsidies — Through the exchange, individuals may qualify for a subsidy in the form of a tax credit if household income is between 100-400% of the federal poverty level.

•    Guaranteed issue — Health insurers must sell coverage to everyone, regardless of pre-existing conditions, and can't charge more based on health or gender.

•    No annual or lifetime limits — Individual and group health plans may not impose annual or lifetime limits.

•    Free preventive care — Plans offering minimum essential coverage must provide several preventive services and screenings at no charge.

 Options for Employers with Less Than 50 Employees

•    Purchase coverage via the SHOP exchange (Small Business Health Option Program) or traditional market.
•    Stop offering coverage and let employees buy an individual plan from the exchange  
•    Provide a defined contribution to assist employees with purchasing coverage.
•    Apply for tax credits to help cover the cost of premiums if the employer:
     Employs 25 or fewer employees.
     Pays annual wages averaging less than $50,000 per full-time equivalent employee.

     Provides at least 50% of the cost of health care coverage for their employees.

 Impact on Individuals and Employers

Individuals, their families, and their employees will have access to health insurance on a broad basis. Employers must assess their options carefully to determine the pros and cons of continuing to provide coverage or allowing employees to access the exchanges.

Although long-term implications are unknown, a number of experts agree reform regulations (i.e., guaranteed issue and mandated level of benefits) may result in increased premiums that will ultimately be passed to employees.

 Learn More

Stay tuned for more health care reform communications, including information on Marsh/Seabury & Smith Insurance Program Management's private health care exchange for members. In the meantime, please call Marsh at 800-842-3761 for more information.
*Marsh and the Association/Society do not provide tax or legal advice.  Please consult with your own advisors to determine how the law’s changes and your decisions impact your personal situation.  

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