<html xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office" xmlns:w="urn:schemas-microsoft-com:office:word" xmlns:dt="uuid:C2F41010-65B3-11d1-A29F-00AA00C14882" xmlns:m="http://schemas.microsoft.com/office/2004/12/omml" xmlns="http://www.w3.org/TR/REC-html40"><head><meta name="Microsoft Theme 2.00" content="CALAAEM NS template 6.18.15v2.htm 011"><meta http-equiv=Content-Type content="text/html; charset=us-ascii"><meta name=Generator content="Microsoft Word 15 (filtered medium)"><!--[if !mso]><style>v\:* {behavior:url(#default#VML);}
o\:* {behavior:url(#default#VML);}
w\:* {behavior:url(#default#VML);}
.shape {behavior:url(#default#VML);}
</style><![endif]--><style><!--
/* Font Definitions */
@font-face
{font-family:"Cambria Math";
panose-1:2 4 5 3 5 4 6 3 2 4;}
@font-face
{font-family:Calibri;
panose-1:2 15 5 2 2 2 4 3 2 4;}
@font-face
{font-family:Verdana;
panose-1:2 11 6 4 3 5 4 4 2 4;}
/* Style Definitions */
p.MsoNormal, li.MsoNormal, div.MsoNormal
{margin:0in;
margin-bottom:.0001pt;
font-size:12.0pt;
font-family:"Times New Roman",serif;}
a:link, span.MsoHyperlink
{mso-style-priority:99;
color:#0563C1;
text-decoration:underline;}
a:visited, span.MsoHyperlinkFollowed
{mso-style-priority:99;
color:#954F72;
text-decoration:underline;}
span.EmailStyle17
{mso-style-type:personal-compose;
color:black;}
.MsoChpDefault
{mso-style-type:export-only;
font-family:"Calibri",sans-serif;}
@page WordSection1
{size:8.5in 11.0in;
margin:1.0in 1.0in 1.0in 1.0in;}
div.WordSection1
{page:WordSection1;}
--></style><!--[if gte mso 9]><xml>
<o:shapedefaults v:ext="edit" spidmax="1026" />
</xml><![endif]--><!--[if gte mso 9]><xml>
<o:shapelayout v:ext="edit">
<o:idmap v:ext="edit" data="1" />
</o:shapelayout></xml><![endif]--></head><body lang=EN-US link="#0563C1" vlink="#954F72"><div class=WordSection1><p class=MsoNormal><span style='font-size:9.0pt;font-family:"Arial",sans-serif'> <img width=623 height=151 id="Picture_x0020_1" src="cid:image009.jpg@01D2F2AD.3808F1E0" alt="Description: Description: Description: Description: CAL/AAEM: California Chapter of the American Academy of Emergency Medicine"><o:p></o:p></span></p><p class=MsoNormal><span style='font-size:9.0pt;font-family:"Arial",sans-serif'><o:p> </o:p></span></p><div style='margin-left:15.0pt;margin-top:7.5pt;margin-right:15.0pt;margin-bottom:7.5pt' id=content><div style='border-top:solid #7F7F7F 1.0pt;border-left:none;border-bottom:solid #7F7F7F 1.0pt;border-right:none;padding:4.0pt 0in 4.0pt 0in'><p class=MsoNormal><b><span style='font-size:11.0pt;font-family:"Arial",sans-serif;color:#7F7F7F'>June 12, 2017<o:p></o:p></span></b></p></div><div style='margin-top:11.25pt;margin-bottom:11.25pt'><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'><o:p> </o:p></span></b></p><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'>Medi-Cal Patients Flocking To ERs More Than Before ACA <o:p></o:p></span></b></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0000CC'><a href="http://californiahealthline.org/news/medi-cal-patients-flocking-to-ers-more-than-before-aca/?utm_campaign=CHL%3A%20Daily%20Edition&utm_source=hs_email&utm_medium=email&utm_content=52995346&_hsenc=p2ANqtz-8Y40BYfeTyrRNON3VtQVHawfLApKMpnoaQGwJia6YMOpsyeSse-eD_C-k2Pf-iBleW7ADLczFoJLnCL3Z36dnYtkpZUA&_hsmi=52995346"><span style='color:#0000CC'>California Healthline</span><span style='font-family:"Times New Roman",serif;color:#0000CC'><o:p></o:p></span></a></span></p><p class=MsoNormal style='margin-right:15.7pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:15.7pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>By Kellen Browning<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Medi-Cal patients are swamping California emergency rooms in greater numbers than they did before the Affordable Care Act took effect, despite predictions that the health law would ease the burden on ERs.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Emergency room visits by people on Medi-Cal rose 75 percent over five years, from 800,000 in the first quarter of 2012 to 1.4 million in the last quarter of 2016, according to data recently released by the state’s Office of Statewide Health Planning and Development.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The most dramatic increase began roughly around the time the ACA expanded health care benefits in January 2014. More than 5 million Californians have gained coverage under the ACA, either through the expansion of Medi-Cal, California’s version of the Medicaid program for low-income people, or by purchasing health plans from Covered California, the state’s Obamacare insurance exchange.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The architects and proponents of Obamacare had argued that once people got health coverage they would stop going to the ER so much, because they could visit primary care doctors instead. But in reality, people who were uninsured before the ACA were actually reluctant to go to the ER unless they were “about to die,” because they would be saddled with big bills, said state Sen. Richard Pan (D-Sacramento), a pediatrician. Under Medi-Cal, though, patients aren’t worried about those expenses.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>And old habits die hard: A newly-insured patient accustomed to visiting the ER for treatment might not immediately switch to a primary care doctor who is, “just a name — not somebody you know,” Pan added.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Still, experts believe fewer Medi-Cal patients would be visiting the ER if there were more doctors willing to treat them.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Though “we have seen a very strong increase in the number of Medi-Cal patients … the number of doctors willing to see Medi-Cal patients has not increased accordingly,” said Jan Emerson-Shea, vice president of external affairs for the California Hospital Association.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Dr. Marc Futernick, the immediate past president of the California American College of Emergency Physicians, agreed that “there aren’t adequate providers for the demands.” He said he believes Medi-Cal’s low payment rates for physicians play a role.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Historically, doctors across the country have been reimbursed less for treating Medicaid patients than those on private insurance or Medicare — especially in California, which ranks 47th in the country in fee-for-service reimbursement rates.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>This means the state’s doctors are less likely to accept Medi-Cal patients, who will then seek treatment wherever they can get it, Futernick said. The ER is always open and cannot legally turn people away, even though many of the Medi-Cal patients’ ills could be treated by primary care providers, Emerson-Shea said.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>California doctors have long lobbied to increase Medi-Cal reimbursements. They are pushing hard to use some revenue from California’s recently passed tobacco tax to increase Medi-Cal rates. But Gov. Jerry Brown wants to use it more broadly for overall Medi-Cal spending.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Pan, the state senator, noted other factors that could explain the surge in ER use.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Health clinics, which see many Medi-Cal patients, generally cannot provide specialty care on site, he said. “What’s the quickest way to see a specialist? Send them to the emergency room.”<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Moreover, many Medi-Cal patients work jobs without flexible hours or sick leave, which means they are not able to make appointments or visit health care providers during regular hours, Pan said.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>“When I worked in the emergency room,” he recalled, “people would show up early in the morning with their kids who had an ear infection or cold or something and the parents would tell me, ‘Well, I have to go to work today or I’ll get fired.’”<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>California is not the only state where the ACA has failed to produce a drop in ER use. A study published in 2014 found that Oregon residents who won Medicaid coverage in a 2008 lottery made 40 percent more trips to the ER in the first 18 months they were covered than those who entered the lottery but were not selected.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:30.95pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:30.95pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p></div><div style='border-top:solid #7F7F7F 1.0pt;border-left:none;border-bottom:solid #7F7F7F 1.0pt;border-right:none;padding:4.0pt 0in 4.0pt 0in'><p class=MsoNormal><b><span style='font-size:11.0pt;font-family:"Arial",sans-serif;color:#7F7F7F'>June 16, 2017<o:p></o:p></span></b></p></div><div style='margin-top:11.25pt;margin-bottom:11.25pt'><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'><o:p> </o:p></span></b></p></div><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'>California ER use jumps despite Medicaid expansion <o:p></o:p></span></b></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0000CC'><a href="http://www.modernhealthcare.com/article/20170616/NEWS/170619908?utm_source=modernhealthcare&utm_medium=email&utm_content=20170616-NEWS-170619908&utm_campaign=financedaily"><span style='color:#0000CC'>Modern Healthcare</span><span style='font-family:"Times New Roman",serif;color:#0000CC'><o:p></o:p></span></a></span></p><p class=MsoNormal style='margin-right:15.7pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>By Virgil Dickson<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>California is the latest state to report that emergency room usage is up despite expanding Medicaid eligibility.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Emergency room visits by people on Medi-Cal, the state's Medicaid program, rose 75% over five years from 800,000 in the first quarter of 2012 to 1.4 million in the last quarter of 2016, according to California's Office of Statewide Health Planning and Development.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Similar findings have also been noted in studies on Illinois, Massachusetts and Oregon. The trend contradicts what policy experts thought would happen if people gained more insurance coverage. They could also give Republican lawmakers the ammunition they need to dramatically overhaul Medicaid, as they propose in the American Health Care Act that passed the U.S. House of Representatives.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>From 2013 to 2016, enrollment in Medi-Cal grew by 57%; 5 million new members were added, bringing current enrollment to 13.5 million. Medi-Cal now covers more than one-third of all Californians, leading some to claim that it's the closest to universal coverage of any state.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>California health officials couldn't explain the rise, but providers think they have an answer.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>"There has not been an increase in physicians willing to see Medi-Cal patients, mostly because the payment rates are so low," said Jan Emerson-Shea a spokeswoman for the California Hospital Association. Therefore, newly enrolled Medi-Cal patients continue to seek care in hospital ERs because they cannot access primary care in physician offices and clinics.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>California ranks 47th in the nation for payment rates for providers, according to the CMS.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Republicans have already used reports of increased ER usage in expansion states and rising spending in the program as reasons to convert Medicaid into a per capita cap system.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Medicaid spending jumped 4.3% to $575.9 billion in 2016 with the federal share growing 4.5% to $363.4 billion, according to the CMS.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>"Despite these significant investments, one-third of doctors in America do not accept new Medicaid patients," HHS Secretary Tom Price told the Senate Appropriations Committee on Thursday. "We need structural reforms that equip states with the resources and flexibility they need to serve their unique Medicaid populations in a way that is as compassionate and as cost-effective as possible."<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Price supports President Donald Trump's budget proposal that includes a $600 billion cut to Medicaid over the next decade.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The trend in rising ER visits could also support Republican's rationale for imposing co-pays on those services, according to Josh Archambault, senior fellow at the Foundation for Government Accountability, a conservative think tank. Wisconsin recently submitted a waiver for such a requirement.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>"Hopefully these kinds of reports grant urgency to change Medicaid and the health system it operates in," Archambault said.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>High ER use in expansion states also gives Republicans some political cover as they seek to roll back Medicaid expansion.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>"The argument that expanding coverage would reduce ER use was always a bit of a canard used to sell the ACA," said Charles Blahous a senior research fellow for the Mercatus Center, a conservative research organization, adding that while the information would have been useful when crafting the ACA, the findings could still be useful to discount the notion that any decrease in Medicaid coverage would lead to more ER visits.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Dr. Larry Stock, president of the California chapter of the American College of Emergency Physicians, worries how Medicaid cuts and ER visit co-pays could affect patients.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>"We don't want to scare people from coming into the emergency department if they need to," he said.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>In California, provider groups have lobbied for new taxes that could increase reimbursement for providers and boost the number of residency slots in the state.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Insurers say in order to affect the number of ER visits, patients need to be better informed about their options in healthcare especially since many who enrolled under expansion had never before had coverage.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Mary Ellen Grant, a spokeswoman for the California Association of Health Plans, said plans will continue to work with providers to lower ER overuse.<o:p></o:p></span></p><p class=MsoNormal style='margin-right:15.75pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:15.75pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:15.75pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><strong><span style='font-family:"Arial",sans-serif'>Jeff Wells</span></strong><span style='font-family:"Arial",sans-serif'><br>Deputy Editor, CAL/AAEM News Service<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><strong><span style='font-family:"Arial",sans-serif'>Brian Potts</span></strong><b><span style='font-family:"Arial",sans-serif'> MD, MBA</span></b><span style='font-family:"Arial",sans-serif'><br>Managing Editor, CAL/AAEM News Service<br><br></span><o:p></o:p></p></div><p class=MsoNormal style='background:#D9D9D9'><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>Contact us at: <span style='color:#0000CC'><a href="mailto:calaaem.news.service1@gmail.com"><span style='color:#0000CC'>calaaem.news.service1@gmail.com</span></a></span><br><br>For more articles, visit our <span style='color:blue'><a href="http://www.calaaem.org/news_archives.php"><span style='color:blue'>archives</span></a></span>. <br><br></span><span style='font-size:9.0pt;font-family:"Arial",sans-serif'><a href="mailto:somcaaem@uci.edu"><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:black;text-decoration:none'>To</span></a></span><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:#0070C0'><a href="https://maillists.uci.edu/mailman/listinfo/calaaem"><span style='color:#0070C0;text-decoration:none'> </span><span style='color:blue'>unsubscribe</span></a></span><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'> from this list, visit our mail server.<br><br>Copyright (C) 2015. The California Chapter of the American Academy of Emergency Medicine (CAL/AAEM).</span> <span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:#0000CC'><a href="http://www.calaaem.org"><span style='color:#0000CC'>http://www.calaaem.org</span></a></span><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>. All rights reserved.<br><br>CAL/AAEM, a nonprofit professional organization for emergency physicians, operates the CAL/AAEM News Service solely as an educational resource for physicians. Dissemination of an article by CAL/AAEM News Service does not imply endorsement, agreement, or recommendation by CAL/AAEM News Service, CAL/AAEM, or AAEM.<br><br><o:p></o:p></span></p><p class=MsoNormal style='background:#D9D9D9'><b><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>Follow CAL/AAEM on Facebook and Twitter:<o:p></o:p></span></b></p><p class=MsoNormal style='background:#D9D9D9'><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='background:#D9D9D9'><a href="http://www.facebook.com/pages/CalAAEM/172577489479442?sk=wall&filter=12" target="_blank"><span style='color:black;text-decoration:none'><img border=0 width=28 height=28 id="Picture_x0020_6" src="cid:image010.jpg@01D2F2AD.3808F1E0"></span></a> <a href="https://twitter.com/#!/CALAAEM"><span style='color:windowtext;text-decoration:none'><img border=0 width=30 height=30 id="Picture_x0020_7" src="cid:image011.jpg@01D2F2AD.3808F1E0"></span></a> <a href="http://escholarship.org/uc/uciem_westjem"><span style='color:windowtext;text-decoration:none'><img border=0 width=112 height=30 id="Picture_x0020_4" src="cid:image012.jpg@01D2F2AD.3808F1E0"></span></a><o:p></o:p></p><p class=MsoNormal style='background:#D9D9D9'><span style='color:black'><o:p> </o:p></span></p></div><div id="DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2"><br />
<table style="border-top: 1px solid #D3D4DE;">
<tr>
<td style="width: 55px; padding-top: 13px;"><a href="https://www.avast.com/sig-email?utm_medium=email&utm_source=link&utm_campaign=sig-email&utm_content=emailclient&utm_term=icon" target="_blank"><img src="https://ipmcdn.avast.com/images/icons/icon-envelope-tick-round-orange-animated-no-repeat-v1.gif" alt="" width="46" height="29" style="width: 46px; height: 29px;" /></a></td>
<td style="width: 470px; padding-top: 12px; color: #41424e; font-size: 13px; font-family: Arial, Helvetica, sans-serif; line-height: 18px;">Virus-free. <a href="https://www.avast.com/sig-email?utm_medium=email&utm_source=link&utm_campaign=sig-email&utm_content=emailclient&utm_term=link" target="_blank" style="color: #4453ea;">www.avast.com</a>
</td>
</tr>
</table><a href="#DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2" width="1" height="1"> </a></div></body></html>