Last week, the Governor and State Legislature enacted a budget package they hope will bridge California's $26.3 billion budget gap. The budget contained no tax increases and $16 billion in program cuts, including deep cuts to health care programs. Complicating the final budget was the Assembly's rejection of the proposed provision that would have taken $1 billion in gasoline tax money from local governments, and its rejection of oil drilling off the Santa Barbara coast (projected to bring in $100 million). In the absence of these two measures, the Governor believed he needed to balance the budget by cutting another $500 million - and did so using his line-item veto authority to cut several health programs by dramatic amounts. This included further reductions to the Healthy Families Program which, in combination with the original cut, will cause the loss of health insurance for 900,000 children.

Overall Budget Cuts:

The largest of the cuts ($9 billion of the $16 billion) would come from Education. $2.7 billion would be cut from Health and Human Services. One of the largest concerns for CAFP going into the budget negotiations was the Governor's call for the elimination of the Healthy Families program. The budget agreement gives him half of what he wanted - a $582 million dollar cut ($174 million in state funds plus the existing $20 million shortfall in the program, plus $388 million in lost $2 to $1 federal matching funds) which officials estimate would eliminate coverage for half of the nearly one million children currently enrolled, and cause thousands more to be put on a waiting list. Democratic leaders are hoping private foundations and possibly First 5 (Proposition 10) dollars will back fill some of the funding reductions.

  
Health Care Cuts Contained in the Original Budget:

• Expand long-term care fees for an additional $18 million in revenue and reduced long-term care rates for a savings of $75.7 million General Fund.

• Reduce funding for community clinic programs by approximately 30 percent, including: Rural Health Services ($2.2 million); Seasonal Migratory Worker Program ($1.9 million); Indian Health Program ($1.5 million); and Expanded Access to Primary Care Program ($4.5 million General Fund and $3.9 million Prop. 99 funds).

• Eliminate Prop. 99 funds for County Health Services. This would be a $25.6 million cut, including: $438,000 from the Asthma Program, $3.1 million from the Alzheimer's Research Centers of California, $4.9 million for the Access for Infants and Mothers (AIM) program, and $6.6 million for the MRMIP program.

• Eliminate next years funding ($18 million) for the Immunization Program.

• Cut $226 million from the In-Home Supportive Services program including eliminating care for clients who are able to do their own cooking and cleaning. The budget also enacts efforts to prevent and combat fraud in the program, including requirements of unannounced visits, fingerprinting clients, background checks of providers, making timecard changes, additional provider training, and providing additional resources to bolster fraud investigation and quality assurance efforts. 

• Suspend the Children's Dental Disease Prevention Program ($2.9 million)

• Reduce funding for domestic violence shelter programs by 20 percent - from $20.4 million to $16.3 million.

• Reduce funding for the AIDS Drug Assistance Program and other Office of AIDS Programs by $35 million.

• Reduce funding for Maternal, Child and Adolescent Health (MCAH) programs, including: the Black Infant Health Program ($900,000), the Adolescent Family Life Program ($1.75 million), and Local County Maternal and Child Health Grants ($2.1 million).

• Reduce funding for the California Poison Control System by 50 percent, from $5.9 million to $2.95 million.

• Eliminate the state's portion of funding ($90 million) for the Substance Abuse and Crime Prevention Act.

• Completely eliminate the Rural Health Care Equity Program cutting $17.2 million for this year and 2010, with ongoing savings of approximately $15 million.

Line-item Vetoes Made After the Budget Passed:

• Nearly $7 million from Prop. 99 funds for the Tobacco Control Program for anti-tobacco media campaigns and competitive grants to local entities
• $25 million from community clinics in the Primary and Rural Health program
• More than $80 million from Public Health Local Assistance programs including:
  • $52 million from various programs administered by the Office of AIDS: Education and Prevention, Therapeutic Monitoring, Counseling and Testing, Early Intervention, Home and Community-Based Care, and Housing
  • $16 million from the Domestic Violence Program
  • $9 million from the Adolescent Family Life Program
  • $3 million from the Black Infant Health Program.

Worst May Be Yet To Come

Critics believe that several billion dollars in the budget may not materialize, which could leave another large budget gap at the end of the calendar year, even if the economy stabilizes. These assumed savings come from an unspecified $1.3 billion cut to the Medi-Cal program, an unspecified $1.2 billion dollar cut to the prison system, $90 million from increased fraud detection in the In Home Support Services (IHSS) program, and $1 billion if the state is able to sell the State Compensation Insurance Fund, the Orange County Fair Grounds, and 10 state-owned office buildings (none of which are guaranteed to sell before the next fiscal year).  

Governor's Line-Item Vetoes May Have Been Made Unconstitutionally

Democratic legislative leaders and many health advocacy groups are seeking legal counsel to determine whether the additional cuts the Governor made through his line-item veto authority were constitutional. The issue is whether the Governor can use his line-item veto authority to further reduce funding cuts, or if he can only reduce budget bills that increase or designate specific spending.  The California Constitution states, "The Governor may reduce or eliminate one or more items of appropriation while approving other portions of a bill." The recent budget action was an addendum to the budget passed in February, and it did not include any new spending (or "appropriation"). Anticipating that the Governor would attempt to make further cuts, legislative leaders inserted "control language" in the last pages of the budget bill that said the February budget amounts were being reduced (as opposed to being appropriated). CAFP will continue to keep you updated on the legality of these cuts. We ask ALL CAFP members to inform us of the specific consequences these cuts will have on your patients so that we may communicate this to state lawmakers.

Last week, the House Energy and Commerce Committee continued its debate on the health reform bill (HR 3200) as Committee Chair Rep. Henry Waxman (D-CA) and House Speaker Rep. Nancy Pelosi (D-CA) tried to bridge the divide between fiscally conservative Blue Dog Democrats and the liberal Progressive Caucus. After a number of false alarms, Chairman Waxman announced that these groups had come to an agreement. The proposal will assuage Blue Dog concerns about the bill's cost, while also addressing concerns about the affordability of premiums. One major change requested by AAFP was to separate the public plan option from the Medicare payment schedule and permit the Centers for Medicare and Medicaid Services (CMS) to negotiate rates from the inception of the public plan, if a public plan is enacted.  This will assure additional bargaining leverage for providers, since they will not be locked into Medicare rates for three years, as originally proposed.

With a vote on HR 3200 by the full House of Representatives likely to occur in September, CAFP and AAFP are encouraging all members to meet with their congressional representative while they are in their home districts this month.

Materials to help you set up and prepare for your meeting (click on any of the following):

1. Find your Representative's contact information here
2. Template Meeting Request Letter
3. CAFP's HR 3200 Endorsement Letter
4. CAFP's Latest Policy Document on Health Care Reform in California: Fractured

Patricia Samuelson, MD, and CAFP Executive Vice President Susan Hogeland, CAE participated in a July 28 conference call convened by the California Department of Public Health to discuss upcoming availability of the H1N1 flu vaccine.  The department may be calling on CAFP and other physician membership organizations to recruit members willing to be "vaccinators" when more information is known about when and in what quantity the new vaccine will be available.  If supply is limited initially, target populations will be identified to receive the vaccine first. 

The vaccine will be paid for by the federal government; physicians should be paid for administration in ways similar to how they are paid now.  America's Health Insurance Plans, the trade association for health plans, issued a statement saying:  "Just as health plans have provided extensive coverage for the administration of seasonal flu vaccines in the past, public health planners can make the assumption that health plans will provide reimbursement for the administration of a novel (A) H1N1 vaccine to their members by private sector providers in both traditional settings e.g., doctor's office, ambulatory clinics, health care facilities, and non-traditional settings, where contracts with insurers have been established."

The seasonal flu vaccine should be available beginning in August or September.  CAFP will launch an influenza and H1N1 resource page on August 19.  The page will include immunization recommendations, patient education materials, pod and video casts, a chat forum with an infectious disease expert, and links to vital sites such as CDC, AAFP and AMA.  Check http://www.familydocs.org/ for your flu updates!

It is CRUCIAL that physicians and their staff members be vaccinated for both H1N1 and seasonal flu.  CAFP hopes family physicians will lead the way in preventing illness and deaths caused by either flu type by ensuring they and their staffs are vaccinated in a timely manner.

After reviewing a "crosswalk" analysis of the provisions of the bill compared to CAFP principles for health care reform, the CAFP Board of Directors approved sending a letter to the entire California Congressional Delegation endorsing HR 3200, America's Affordable Health Choices Act of 2009, the main vehicle for health care reform in the House of Representatives.

Acknowledging that the bill is not perfect, CAFP wrote "we feel that it provides our best opportunity to expand coverage, offer every American the opportunity to have a medical home, reform the payment system, and ensure that the primary care workforce is adequate."   The Academy stressed the need for a coverage expansion plan with universal access and coverage as defined goals, inclusion of cost management strategies that are realistic and emphasize a coherent strategy to improve our nation's health, and the need for steps to build and maintain the medical workforce needed for the 21st Century.

The CAFP Board of Directors met in an abbreviated, two-hour session on July 11 in Oakland prior to the start of the Academy's Strategic Planning meeting.  Among actions taken were adoption of a new reserves policy, approval of a resolution authorizing a statement condemning the murder of George Tiller, MD, a family physician, retention of a new audit firm, review of the IRS Form 990, and approval of Academy positions on a number of bills pending before the Senate and Assembly.  CAFP Director of Health Policy Sandra Newman, MPH, gave presentations on health information technology and federal health care reform efforts.

Click here to view the full minutes of the Board meeting.

Members interested in representing the issues facing California family physicians and shaping the AAFP's agenda are encouraged to contact CAFP to apply for nomination to AAFP Commissions on Continuing Professional Development*, Education*, Finance and Insurance, Governmental Advocacy*, Health of the Public and Science*, Membership and Member Services and Quality and Practice. 

For more details regarding these Commissions, please visit the AAFP's Web site.

*CAFP has members serving on these commissions.  The likelihood of securing an additional seat for a Californian is not known.

If you are interested, please submit the following items by October 1 to, Mariah Brooks by email or at, 1520 Pacific Avenue, San Francisco, CA 94109.

1. Typed Commission Appointment Fact Sheet (electronic version preferred)
2. Current photo
3. Conflict of Interest form

You may complete the Conflict of Interest form by completing the following steps:

1. Go to http://www.aafp.org/conflict
2. Key in AAFP ID numbers and last name or password.
3. Press "submit."
4. Select Option 2.
5. If there is anything to disclose, type the conflict in the box entitled "Disclosure of Actual" or "Potential Conflict of Interest."  If there are no conflicts, please type "none."
6. When the "I agree" button is pressed, the Conflict of Interest form is submitted at the central database.

Physicians interested in developing and implementing CAFP programs and projects are encouraged to apply for appointment to the following CAFP committees:

• Communications
• Continuing Professional Development
• Legislative Affairs
• Medical Practice Affairs
• Medical Student and Resident Affairs

For information on the scope of activities and accomplishments of these committees, please visit CAFP's committee page.  

The Federal Trade Commission (FTC) has, yet again, moved the "red flags" rule deadline from August to November 1. This rule, which affects many medical practices, requires physicians to adopt a written policy to track and respond to identity theft in their practices. The "red flag" is the indicator of a possible risk of identity theft. For more information and additional resources, click here to view a presentation provided by AAFP to assist you and your staff in learning about and complying with the "red flags" rule, or read CAFP's Practice Management News article on the same topic.

8/9: San Diego Chapter Picnic at the Races
8/11: San Luis Obispo Chapter Meeting
8/15: Orange County Chapter Picnic
8/27: Family Medicine Advocacy in These Uncertain Health Care Times, Fresno

For more information on upcoming events, click here.

Hosted by the California Diabetes Program, California Department of Public Health, and University of California San Francisco, the California Diabetes Summit will be held September 2-3 at the Radisson Hotel in Sacramento.

Don't miss out on this opportunity to:

• Interact with colleagues from throughout California
• Discuss the social determinants of health
• Gain the national perspective
• Learn best practices and new approaches for diabetes prevention and control in California
• Find out the winner of the 2009 DIRC Award of Excellence

9/2: Evening reception
9/3: Summit

View the full agenda and to register, click here; space is limited.

The CAFP Board of Directors has just approved establishing CAFP as a center of excellence for adoption of the Patient Centered Medical Home, so the timing of a new arrangement beneficial for CAFP members couldn't be timelier.  CAFP and TransforMED have agreed to provide consulting and services to California family physicians at a discounted rate.  Some TransforMED services are low or no cost, including an extensive Web site that provides valuable information on transforming the medical office into a Patient Centered Medical Home, which is available at http://www.transformed.com/ and through the CAFP Web site.

As health care is debated on the national stage, one thing is certain to emerge ... family physicians will play a major role in the new national health care system, but they must be ready to provide care in new ways. There is broad-based support for the Patient Centered Medical Home, which is emerging as a potential catalyst for multiple health care reform efforts. According to a recent Harvard study, TransforMED is involved in one way or another in nearly all of these projects. No other entity has figured out how to create a sustainable transformation around the PCMH. Based on the results of the National Demonstration Project, TransforMED has created an array of products and services for primary care physicians who want to transform their practices into medical homes. 

TransforMED can design an effective transformation program for any sized budget. Custom proposals can be created within 24 hours to clearly define project objectives, time lines and costs. Please email Dan McKean or call him at 913-906-6323.

To following is a brief summary of the products and services available to CAFP members:

1.  Medical Home Implementation Quotient - A free online assessment that gauges how well a practice meets the components of the PCMH model. This nine-part series details the components required to become a PCMH and offers free resources to help a practice meet these requirements. Included are a summary score and an indication of the level a practice meets in the NCQA PCMH recognition process.

2.  Delta Exchange - For just $30 a month per user, TransforMED's Delta-Exchange brings together a community of healthcare professionals and provides tools and resources designed to help primary care practices transform to PCMH. An easy-to-use, private, collaborative Web site, the Delta Exchange provides a place for practices to collaborate on projects, ask questions of the group or TransforMED facilitator, and to share practical knowledge and experiences.

3.  Baseline Practice Assessment - The Baseline Practice Assessment is a combination of proprietary assessments and commercial evaluation tools administered by certified facilitators delivered either virtually or onsite. The facilitators capture critical data and conduct extensive interviews to identify a baseline for the practice as it relates to the PCMH model. The facilitators will create a practice transformation plan to help guide the process. Costs vary by practice size and engagement type, but range from as little as $300 per month up to several thousand dollars.

4.  Leadership and Teamwork - An in-depth look at the practice regarding leadership identification and development, and an assessment of how well a team functions as a cohesive unit. Defining, creating, assessing, and optimizing leadership and teamwork are fundamental elements of the change process. Costs vary by practice size and engagement type, but range from $300 per month to several thousand dollars.

5.  Practice Management - The PM Assessment reviews workflows, revenue cycle management, and technology infrastructure to determine gaps that exists within the practice. New workflows are suggested, ways to enhance revenue are defined, and technology gaps to support PCMH are identified. This option is great for practices that seek to not only enhance the workflow, but optimize the revenue cycle and create additional revenue. Costs vary by practice, but start as low as $500 per month.

6.  Full Transformation - With the guidance of a Practice Enhancement Facilitator, your practice will engage every area of the TransforMED patient-entered Model. Your PEF will visit your practice and perform a Baseline Practice Assessment to guage your practice's performance in each of the modules. Based on the assessment, your PEF will work closely with you to custom design a program of evaluations, education, training and metrics that address your practice's specific needs. Over the next 1 to 2 years, your PEF will keep your project moving and on track to meet the objectives and timelines of your transformation plan. Options include both on-site and virtual alternatives designed to control costs yet deliver the desired outcomes. Prices vary by practice but can be as low as $500 per month.

CAFP is pleased to announce Mario San Bartolomé, MD, MBA as our August Member of the Month.  Dr. San Bartolomé completed his residency training at the Long Beach Memorial Family Medicine Residency Program where he served as chief resident and later joined the faculty as assistant director of community medicine.  After leaving Long Beach Memorial, Dr. San Bartolomé moved to the California Central Coast to work in a small group practice where there is a critical need for family physicians.  In addition to his clinical activities, Dr. San Bartolomé is organizing a meeting to revitalize CAFP's San Luis Obispo County Chapter.  He is also the CEO of PreZone, Inc., a nonprofit organization aimed at fostering the development of more civically and socially responsible pre-health professional students.  Click here to learn more about Dr. San Bartolomé.

For more information about the upcoming San Luis Obispo Chapter meeting on August 11, please visit CAFP's chapter events page.     

If you would like to become or nominate a future Member of the Month, please contact CAFP Membership Manager Jessica Kuo.

Join family physicians, residents, and medical students at the second annual OCCAFP Membership Picnic on Saturday, August 15, at the Irvine Regional Park from 10 am to 2 pm!  Bring your family and friends to enjoy a day in the sun in the company of your fellow family medicine colleagues.

The picnic will be catered, but you can bring your own food.  Please contact Debra Innis for more information or to RSVP. 

After several year of inactivity the San Luis Obispo Chapter is hosting an inaugural meeting on Tuesday, August 11 from 6-7 pm.  Join CAFP member Mario San Bartolomé, MD, MBA at his home in Arroyo Grande for an informal soiree of the family medicine community to determine the chapter's direction.  Appetizers and refreshments will be provided. 

This is a great opportunity to network with your fellow FP colleagues.  Your input is vital to the chapter's growth.  For event details or to RSVP, please email Dr. San Bartolomé or call the CAFP office at 415-345-8667.