By Ann F. Haas, MD
On April 28, a broad coalition of physicians, patients, and other stakeholders joined together to defeat Senate Bill (SB) 1215 — legislation introduced by California Sen. Ed Hernandez. The bill would have eliminated California's in-office exception to the self-referral prohibition for anatomic pathology services, among other services. CalDerm and the American Academy of Dermatology Association (AADA) teamed up to swiftly defeat the bill, including by offering expert testimony from dermatologists — including myself.
SB 1215 was introduced as a way to lower health care costs in California, although it became clear that the bill would not have this effect. Limiting patient access to in-office services provided under the physician self-referral exception would have interfered with the physician-patient relationship and run counter to the U.S health care system’s goal of improving coordinated and integrated care. If the bill had passed, dermatologists would have been required to refer their pathology slides to an outside laboratory, potentially outside the state, thereby hindering their ability to provide high-quality, affordable care to patients in California.
Most significantly for the specialty, the bill, as written, had no protection for Mohs surgeons. One point that I noted in my testimony is that a quarter of residency training and the board examination is dedicated to dermatopathology. We don’t read slides to make more money — we read them because we are uniquely trained to practice this way.
SB 1215 was soundly defeated in the California Senate Business, Professions, and Economic Development Committee, where it received only a single vote of support from the bill’s author. Listed below are some of the components that were critical in quelling the bill.
Grassroots efforts: Grassroots advocacy was easily the most effective factor in the defeat of the bill. The Academy was a huge help in this effort. The AADA was instrumental in providing resources that a smaller organization like CalDerm could not, such as sending out mass emails and letters to reach a wider audience and providing much needed guidance. CalDerm and the AADA sent out many communications about SB1215 — each one sounding more urgent than the last. These efforts to reach out and spread word worked! People wrote, telephoned, emailed, and scheduled meetings to ensure their voices were heard. It was the actions of many that made the difference.
Lobbying: Devoting time to educate legislators and staff was critical. Because of the complexity of the issue, legislators and staff needed to hear our message and the bill’s implications multiple times and through various channels. Having a lobbyist is important to getting your society and coalition’s voice heard not only on a state level, but also on the national level. Our lobbyist made important contacts and coordinated the major players that worked to defeat the bill. Without the help of a lobbyist, the process would not have gone nearly as smoothly as it did. The California Medical Association (CMA) included the bill in its legislative Lobby Day, which further increased awareness of how the bill would negatively impact dermatology as well as other specialties.
Patient voice: The patient perspective is powerful and needs to be communicated to policymakers. During the bill’s hearing, a skin cancer patient being treated by Mohs surgery testified how the bill would negatively impact his access to treatment. Unlike CalDerm’s work on tanning legislation, the topic of anatomic pathology doesn’t cause the non-medical community to feel warm and fuzzy. However, our patient came through with an effective point: He acknowledged that physicians who abuse the system should be sanctioned. But those who provide excellent patient care well within ethical and legal boundaries should not be penalized.
In addition to CalDerm, CMA, and the AADA, nearly 30 groups across the medical community rallied against SB 1215, including the American Society for Dermatologic Surgery Association, American College of Mohs Surgery, American College of Surgeons, the Ambulatory Surgery Center Association, and numerous other medical specialties, such as cardiology, neurology, neuroimaging, gastroenterology, ophthalmology, orthopedic surgery, and anesthesiology. There were plenty of organizations in support of the bill — nearly 20 — including the California Radiological Society, California Society of Pathologists, Quest Diagnostics, California Labor Federation, California Physical Therapy Association, and the California Professional Firefighters. Despite the strong division over the bill, its defeat highlights how integral the above factors were to leading a successful advocacy effort.
It is vital that coalitions remain vigilant and united. It is likely that SB 1215 will be reintroduced next session; however, a strong groundwork has been laid to defeat future attempts to eliminate the self-referral exemption.
Dr. Haas is a member of the AAD State Society Committee. She has been active on the Board of Directors of CalDerm and is a past president of that society. Practicing in Sacramento, she has frequently given testimony at the California Legislature on behalf of dermatology.