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Washoe County Medical Society

Highlights of the 2018 Mid-term Election: NSMA prepares for the 2019 Legislative Session

By Catherine M. O’Mara, JD

Call it a blue wave, call it a pink wave, there is no question that the November 6 mid-term election shifted the nature of policy-making in Nevada. Citing healthcare as a primary concern, Nevada voters elected record numbers of Democrats and women in races for both federal and state office. Expect to see healthcare a key topic in Carson City come February.

For the first time in state history, Nevada will send a Congressional delegation to Washington D.C. that includes more women than men. Democratic Congresswoman Jacky Rosen defeated Republican Incumbent Dean Heller joining Senator Catherine Cortez-Masto as Nevada’s second-ever female Senator. Nevada retained Dina Tinus in CD1, elected Susie Lee to CD3, and re-elected (after a defeat in 2014) Steven Horsford to CD4, all Democrats. Nevada elected only one Republican to the Congressional delegation, Mark Amodei representing CD2.

Statewide, Steve Sisolak won the race for Governor, becoming the first Democrat to take the highest state office for the first time since 1999. Democrats also won every constitutional office except Secretary of State, held by Barbara Cegavske. Democrats earned a super-majority in the Assembly winning 29 seats to the Republicans’ 13 and picked up 2 seats in the Senate, just narrowly, by 28 votes, failing to turn a third Senate seat necessary to achieve a super-majority in the Senate and a veto-proof Legislature.1 In the Senate, Democrats hold a 13-8 advantage over Republicans.

Nevada sends a female majority (22 of 42) to the Assembly. In the non-partisan races for Nevada Supreme Court, voters retained Lidia Stiglich and elected two additional women, Elissa Cadish and Abbi Silver, creating a female majority on the state’s highest court for the first time in state history.
Three vacancies will need to be filled by county commissions. In Assembly District 36, notorious Republican Dennis Hof, who died during the pendency of his campaign defeated Democrat Lesia Romanov. The county commissions of Nye, Clark, and Lincoln will soon appoint a Republican to that seat. But look to Democrats to fill two Senate seats vacated by Tick Segerblom and Aaron Ford. Segerblom won his race to the Clark County Commission and Ford was elected Attorney General.2

Preparation for 2019 Session

We expect 2019 to a healthcare legislative session. Since the close of last session and with the guidance of our contract lobbying team, the Perkins Company, NSMA’s Government Affairs Commission (“GAC”) has been preparing our policy agenda. In February, the GAC will reform into our Legislative Core Group and will meet most Mondays through the session.

NSMA’s key policy objectives for the next session include refining the opioid law and improving public health through the establishment of a Maternal Mortality review. During the interim NSMA participated in working groups on Medicaid buy-in proposal and legislation that seeks to ban the practice of balance billing. Governor-elect Sisolak has stated that he will sign legislation that bans balance-billing, and NSMA will continue to fight for a fair resolution for patients and physicians that encourages contracting and protects access to care. We are prepared to engage in legislation challenging tort reform, pertaining to scope of practice, mandatory electronic prescribing, drug prices, funding for GME and Medicaid, and insurance issues including covered benefits, step therapy and prior authorizations, among many others.

We expect several tough fights and we encourage you to join us in our efforts by providing input on matters impacting your practice and please challenge your colleagues to join as members of WCMS/NSMA. Plan to join us in Carson City for Nevada Physician’s Day at the Legislature, Monday, February 25, 2018 in Carson City. Keep reading the WMCS Newsletter and watch for NSMA electronic updates on policy proposals impacting physicians. To get more involved and ensure you are receiving our updates, please contact NSMA today.

With healthcare playing a huge role in the outcome of the 2018 mid-term election, we expect insurance affordability and access to care to be at the forefront of debate both nationally and in Nevada. Whether we are working to advance patient and physician-friendly legislation or playing defense against policy proposals that seek to undermine patient care, NSMA will continue to advocate for you, our physician member!

1Republican Keith Pickard narrowly won Senate District 20 by 28 votes. At the time of writing, Julie Pazina has officially requested a recount.
2Notably, Ford’s victory makes him the first African American to win a statewide race in Nevada.

Governor-Elect Steve Sisolak (D)

Governor-Elect Steve Sisolak (D)

 

Senator Kelvin Atkinson (D)Majority Leader

Senator Kelvin Atkinson (D)Majority Leader

 

Assemblyman Jason Frierson (D)Speaker

Assemblyman Jason Frierson (D)Speaker

A Heartfelt Thank You

As I write this brief article, Thanksgiving is just a few days away and the chaos of the holidays is right around the corner. This time of year always gives rise to reflection about the past year and I ask your indulgence to take off my attorney hat for a moment and diverge from offering words of legal insight in this article and instead offer words of thanks.

I have the privilege in my professional life to represent an array of individuals who have dedicated their careers to health care. This has allowed me the opportunity to observe the amazing commitment and devotion of these wonderful people to the patients that they care for.

In this era of ever-changing legal regulations, reduced reimbursements and a seemly never-ending array of new challenges to the practice of medicine, the physicians and other healthcare providers I encounter in both my professional and personal life continue to provide the best patient care possible. At the same time the medical profession often seems to bear the brunt of any frustration with healthcare harbored by the public or governmental entities. While these challenges appear daunting, I am increasingly amazed by the tenacity and passion of my health care clients to their chosen profession and the patients they serve.

As we come to the close of a year in which family and friends, myself included, have experienced the highs and ultimate lows that can be experienced in arena of healthcare, I would like to offer a heartfelt thank you for all that you do and continue to do, day in and day out, for your patients; the care you provide is appreciated far more than you may know.

I wish you all a very happy holiday season.

Ms. Beggs, principal of the Law Offices of Lyn E. Beggs, PLLC, focuses her practice primarily on assisting clients with administrative and professional licensing board matters in addition to representing healthcare providers on a variety of issues. Ms. Beggs may be reached at 775-432-1918 or at lyn@lbeggslaw.com. This article does not constitute legal advice and should not be considered a substitute for retaining counsel for advisement in legal matter.

One Student’s Journey

It was very cold up on Mt. Rose. As the cold seeped through my boots I quickly realized I needed more socks, but it was a welcome feeling—sometimes we medical students forget what the outside world feels like! While we don’t get out much, some of medical school’s most valuable lessons are learned outside the classroom and immersed in the community.

Volunteering allows us to have balance in our curriculum, helping ground us and reminding us of what we are working so hard for.

Throughout medical school, I have been fortunate to volunteer with the Nevada Cancer Coalition’s Sun Smart Nevada program. Sun Smart Nevada is now in its fourth year of outreach to schools and the community. This year I have been fortunate to represent the program at the American Cancer Society’s Relay for Life, at local elementary schools, up at the slopes on Mt. Rose, and at the Dragon Boat Races. And those are just a handful of the events at which Sun Smart Nevada has educated Nevadans on sun safety and skin cancer prevention.

One of the most inspiring parts of Sun Smart Nevada is the outreach at K-12 schools. The program has a fun and interactive presentation that highlights the 5 S’s of Sun Safety: Slip, Slop, Slap, Seek, and Slide. And the students actually remember the presentation! At a recent community event two middle school students came to our booth to get a few UV activated bracelets and they were proud to tell me the 5 S’s they learned months before in an assembly.

I am so excited to volunteer with a program that is educating the community. Here’s hoping the work the Sun Smart Nevada program does now keeps people healthy and out of my office years down the road.

Physician Well-Being and the Regenerative Power of Caring

In 1948, Life magazine published what has become an iconic and, for many, nostalgic photographic essay depicting the life and work of Dr. Ernest Ceriani, a Colorado general practitioner.

Among the 38 photographs is one of Dr. Ceriani attempting to save the eye of a 2-year-old girl who was kicked by a horse, another of him carrying an 85-year-old man to the operating room to amputate a gangrenous leg and another showing him holding a newly delivered infant.

His expressive face shows anguish, anxiety, uncertainty, exhaustion—and triumph. Nowhere in the article does the word “burnout” appear.

The photographs of Dr. Ceriani document the seemingly unimaginable stress and loneliness of his job, but there is no evidence of the depersonalization, loss of job satisfaction or inability to care that characterizes the current reports of physician burnout.

On the contrary, Dr. Ceriani’s face shows the compassion, dedication and engagement that physicians have traditionally associated with the practice of medicine. He appears to be certain about both the obligations and rewards of his covenant with his community and patients.

Physicians could do little for patients in 1948 compared to modern day, but what they could do provided a deep sense of professional obligation and satisfaction.

Seventy years later, that obligation and satisfaction appear to be in peril, based on a crescendo of reports of the high level of burnout, discouragement and career dissatisfaction experienced by today’s physicians. The rates of medical student and resident depression have increased to epidemic levels. A high level of stigma precludes appropriate access to mental health care, and the high risk of suicide among students, residents and physicians casts a pall over the entire profession.

How have the well-being, the morale, the very core of physician professionalism deteriorated to such a low point among so many physicians? While one of the defining features of burnout is the loss of the ability to care, it might be better to examine the opposite logic: Are the barriers to the ability to care a fundamental cause of physician burnout?

Tired doctor sitting alone in hospital floor near windowIn earlier days, perhaps in 1948, physicians better understood their caring role and coped with the stresses of that role through a deeply personal, reciprocal relationship with their patients. That caring relationship has been lost for many physicians in the current system of fragmented, rushed, dysfunctional, digitized, corporatized and costly medical care—a system that prizes efficiency over relationships, profits over common good and volume over value.

The practice of medicine has always been demanding and exhausting, and it always will be. It is the loss of the ability to care and the buffering of stress and exhaustion that comes from caring deeply for and improving the quality of life of patients that have led to the current crisis of dissatisfaction and lack of well-being among many physicians. It is the ability to engage in reciprocal relationships, in which the fundamental act of caring is regenerative, affirming, and deeply soul satisfying, that was present in 1948 and is increasingly missing in 2018.

The U.S. health care system is often said to be the best in the world. Health care professionals in the United States do indeed provide some of the most extraordinary medical care, bordering on miraculous at times, but they also function in one of the poorest-performing systems compared with other developed countries. The U.S. system is characterized by highly variable quality and access, wasteful and expensive tests and treatments, poor communication and coordination, dissatisfied patients and high cost. Such a system also causes a deep level of dissatisfaction and misery in one of the main sectors of its workforce—physicians—because it markedly inhibits and impairs their ability to care.

Why? The biotechnological explosion of the last few decades is at one and the same time the source of health care miracles and the cause of the inability of physicians to care. It is not the extraordinary technology that is the cause of this loss, but its commercialization and monetization that have wreaked havoc on the health care system’s fundamental values.

The current system is the consequence of the mistaken belief that health care is most appropriately managed like other parts of the U.S. economy—as a market-driven, competitive enterprise. A major consequence of a market-driven system is the loss of the system’s ability to provide coordinated, comprehensive, patient-centered care, with declining opportunities for physicians to engage in reciprocal, caring relationships with patients.

The literature on physician burnout lists many potential causes, all of which detract from the ability to care.

The list is long, including risk- and productivity-based reimbursement strategies, the frustrations and time demands of electronic medical records, nonclinical clerical duties, patient requests that are influenced by direct-to-consumer advertising, work-hour restrictions that are not accompanied by new approaches to teamwork, and a lack of mentoring and support for trainees.

What all these features of the current health care system have in common—and the list could be much longer—is their detraction from and disruption of nurturing, satisfying, supportive and caring relationships with patients.

Physicians have a deep professional obligation to contribute to the resolution of these fundamental flaws that detract from clinical quality and patient satisfaction. We have an obligation to contribute to the restoration of a system that is based on fundamental values of quality and caring, in return for which physician well-being will be restored.

Physicians in 2018 are the proverbial “canary in the coal mine.” While the canary may be sick, it is the mine that is toxic. Caring for the sick canary is compassionate, but likely futile until there is fresh air in the mine. The current system has made it nearly impossible for most physicians to care as deeply and to give of themselves as they wish. Only by restoring their ability to care will physicians restore their health and their professional souls.

Riding the Blue Wave

Healthcare on the Legislative Docket We need to rally as one strong voice

The elections are over and now the real work begins, the collective work of the WCMS Government Affairs Commission (GAC), CCMS GAC, and NSMA GAC in conjunction with local and state PACs accurately assessed the outcomes of the elections with contributions and endorsements in all but one race throughout the state. For the first time in twenty years we have a Democrat Governor, Senate and House with Keith Pickard’s seat being contested possibly yielding a supermajority, although doubtfully needed.

We wholly expect this year to be another major healthcare session, as they all are now. Last session a bill passed, but ultimately vetoed by Governor Sandoval, that would have been very unfavorable to physicians seeking payment for services rendered provided to patients out of network (balance billing). This exact bill, virtually verbatim, has already been submitted as a bill draft request (BDR) for this session.

The leadership of WCMS and CCMS who are actively involved in the executive leadership of the NSMA have been meeting monthly with executive leaders of the Nevada Hospital Association (NHA) for over a year as part of a joint NSMA/NHA Balance Billing Task Force defining collaborative principles, attending legislative working groups and educating legislators about the linkage to network adequacy and contractual implications, reviewing model bill drafts and creating our own draft language, and strengthening ties for other important future collaborations.

Speaking of which, another serious threat facing healthcare providers in Nevada is tort reform. While most of us view this as a constant nagging concern, please be warned. The threat is now real. It might not come up until next session, but this will be part of the blue wave agenda. It is public record that the Nevada trial lawyer PAC gave large contributions to Governor-elect Sisolak’s campaign, among many other prominent government leaders. So, my friends, Keep Our Doctors In Nevada (KODIN) will almost certainly be challenged.

Sorry for the doom and gloom, but fear drives action and I am pleading with you to act. If you have read this far, then you are interested in the future of the practice of medicine in Nevada. Here is my plea. Make it your goal to recruit just one new member this year, maybe someone new to your practice, new to the hospital lounge, new referrer you discuss cases with, someone you think would like the stimulation and engagement. If not for political purposes, then for social gatherings and friendship, and if that doesn’t work use guilt. How could they not want to support their colleagues, people they depend upon every day, people they take themselves and their loved ones to see when they are sick? We need numbers. Sure, we need money, but more importantly we need to show unity. We need to be able to sit at the table and say we are here representing over three quarters of the physicians and this will not work. For anyone who nay-says the organization, please let them know that AB474, the Governor’s opioid law, was slated to be much more restrictive and that through the very hard work of our leaders was made workable. Furthermore, it has been sculpted in regulations and is set for revisions to be made more reasonable to physician practice patterns and workflow. This unfortunate, but necessary societal checkpoint, has been developed with input from our leadership. If we were not at the table, it would have been much, much worse. Just look to some of the other states in our Union (Kentucky limits opioids to a three-day supply) If we do not grow in number, demonstrate collective unity in public healthcare policy, then medicine and our patients in Nevada will suffer.

Sierra Neurosurgery Group’s Delegate Scholarship

Sierra Neurosurgery Group has established a special scholarship fund to support WCMS’ student and resident delegates to the NSMA annual meeting. The scholarships are awarded to University of Nevada Reno Scholl of Medicine student and resident to cover their registration and travel costs.

This sponsorship is aimed at enriching mentorship and the need for medicine and public health advocacy. The first recipients attended the NSMA Annual Meeting held Sept. 28-30 in Henderson. The recipients are: Neha Agrawal, student delegate, Class of 2021; Alex Cabrera, student alternate delegate, Class of 2021, and Chris Clifford, resident delegate, Class of 2018.

Sierra Neurosurgery Group embraces the mission of WCMS that quality care is essential for all Nevadans.

Contractual Relationships

Contractual relationships impact almost every aspect of a physician’s practice and merit a reminder of a few factors to keep in mind while considering entering such a relationship.

Who are the Parties to the Contract?

A simple question but a very necessary one. Are contracting in your individual capacity or through your professional entity? Is it more appropriate for the contract to be with your professional corporation for legal or tax purposes? Some contracts, such as an employment agreement, will typically be with an individual, but in many other cases a professional entity may be the better option.
As to the other party, who are you contracting with? Are you really entering into a contract with a local entity or their corporate parent entity? This could have an impact on issues such as how willing the entity is to negotiate modifications to the contract or what governing law applies.

Speaking of Governing Law….

Clause such as “governing law” are typically buried those clauses often referenced as the “boiler plate” of a contract. While it may be tempting to skip over these provisions when reviewing a contract, these clauses can have significant implications. Clauses such as governing law (what state’s law governs the provisions/interpretation of the contract) or jurisdiction can be problematic for the unsuspecting. Do you really want to have to file suit in New Jersey if you need to take legal action to enforce a contract or seek damages? Pay attention to these small details when reviewing a contract.

Know When to Walk Away

Does the contract you are considering open you up to unknown liabilities? What are your rights under the contract? How can you terminate it if need be and what potential penalties might you incur by doing so? Is the contract legally accurate? If you are reviewing a template document that was last revised in the prior decade, you should ensure that the terms all comply with current laws.

Know what your potential deal breakers are. Always keep in mind that unless your legal representative drafted the agreement, there may (and probably are) provisions that are more favorable to the other party. While some parties may be willing to negotiate terms, if the other party is resolutely set against any modifications, give serious thought as to whether you can live with the contract as is or if it’s best to leave it and walk away.

Ms. Beggs, principal of the Law Offices of Lyn E. Beggs, PLLC, focuses her practice primarily on assisting clients with administrative and professional licensing board matters in addition to representing healthcare providers on a variety of issues. Ms. Beggs may be reached at 775-432-1918 or at lyn@lbeggslaw.com. This article does not constitute legal advice and should not be considered a substitute for retaining counsel for advisement in legal matter.

One Students Journey

Can you guess what two words strike fear into the hearts of second year medical students? Prostate exam? Nope. Brainstem nuclei? No, already learned them. Cumulative final? Please, we are old pros at this point.

Step One? Bingo.

Our first of three licensing exams, passing the United States Medical Licensing Examination Step 1 is essential to progressing in our education. Scores range between 300 and 0, with most students scoring between 260 and 155, where 194 is considered passing. Thankfully, UNR Med prepares us well and the vast majority of students pass on their first try. While I know that my classmates and I will all be grateful to pass, excelling on Step 1 is essential to matching at a desired residency. And once you have passed Step 1, you can never take it again to try for a higher score. One test, one day, one time only defines us. Thus, it is not too surprising that we second year medical students compulsively reach for our study guides when we hear “Step 1” echo through our classroom.

One test one day will indeed define us, just as one patient interaction one day may define us, or define that patient’s life, for better or for worse. The high stakes will not end with this exam. People usually approach this test with fear, but I think it is time to change that.

Training in Aikido, a Japanese martial art, I used to have exams in front of a live audience of my peers. My teacher would call out the technique in Japanese and I would have to perform it on a grown man who was hurling a punch at me. I was nervous during my first exam. I got flustered and started to get sloppy in my techniques—which is pretty obvious when you are girl in her early teens trying to throw a grown man.
My sensei saw my nerves and paused my exam. He told me, “Do not think of this as a test. You know this material. Think of it as a demonstration.” That simple perspective shift increased my confidence and I have tried to use that frame on exams since.

So here is my call to action. Let’s not fear exams, but instead embrace the opportunity to demonstrate the wealth of knowledge we worked so hard to learn in the first two years of medical school.

WCMS 2nd Annual End of Summer Celebration

University of Nevada School of Medicine
Dr. Curry-Winchell & Girls

Thank You Sponsors!

Wells Fargo Home Mortgage
Sierra Neurosurgery Group

Recruiting Volunteer Community Physicians

Student Outreach Clinic Recruiting Volunteer Community Physicians

The UNR Reno School of Medicine’s Student Outreach Clinic is looking for eager community physicians who have a passion for teaching! Our student-run clinic relies on the guidance of volunteer physicians with expertise in dermatology, geriatrics, obstetrics and gynecology, internal or family medicine, and pediatrics to serve Reno’s medically uninsured. Clinics are held 3-4 times each month on Tuesday evenings and Saturday mornings. If you’re interested in instructing Nevada’s future doctors while also advocating for a healthier Nevada, please contact J. Riana Cerceo, physician relations officer, at jcerceo@med.unr.edu or
(775) 901- 6042 and visit our website for more details! www.med.unr.edu/soc.