2011 March/April

MARCH / APRIL 2011 | Volume 17 | Number 2

It’s Not Too Late:

One Dozen Important Topics You Might Not Have Learned Enough About in Medical School ALSO INSIDE: Why Are ACOs Important in the Future of Medicine?

MARCH / APRIL 2011 | THE BULLETIN | 1

While incremental changes are made along the way, you’ll still need to continue to make important decisions about health insurance for you and your employees, especially when it comes to managing premium costs.

So what can you do until then?

• Enroll in a qualified High Deductible Health Plan and open a Health Savings Account.

This provides significant premium savings that can fund your HSA account.

With individual only coverage you are eligible to contribute up to $3,050 to your account, or $6,150 with family coverage, on a tax deductible* basis (members age 55 – 64 are eligible to contribute another $1,000).

• Investigate RAF Sales Health plans offer incentives through discounts off their risk adjustment factors (RAFs) for you to change health plans. Instead of

your medical rates increasing this year, we might be able to help you offset some of that increase.

• Mercer Select HRKnowHow If you play a role in your medical group’s healthcare and benefit plan decisions, staying current on the challenging issues. Access is included at no charge for all members who purchase group health insurance through Marsh.

Includes: • News and analysis of important benefit issues • Compliance Link tool to assist with healthcare and group benefit plan administration and samples of notices and forms

* Marsh and the Association do not provide tax, investment or legal advice. Please consult with your professional advisors for guidance on these issues.

Please call Marsh at 800-842-3761.

We serve members who want assistance in evaluating the medical insurance choices before them. We can assist you with the information you need to make the critical choices on the road ahead.

Sponsored by:

Administered by:

51715 (3/11) ©Seabury & Smith Insurance Program Management 2011 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

CA Ins. Lic. #0633005 • AR Ins. Lic. #245544 2 | THE BULLETIN | MARCH / APRIL 2011

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org

MEMBER BENEFITS

From the MCMS President 5

John T. Jameson, MD

Legal Services/On-Call Library

From the Editor’s Desk 6

Joseph Andresen, MD

Reimbursement Advocacy/ Coding Services Billing/Collections Discounted Insurance Referral Services With Membership Directory/Website Membership Directory iAPP for

Tips for Lowering Ambulatory-Care Risks 8

Karen D. Davis, MA, CPHRM

11 2011 MCMS/SCCMA Ticket Program It’s Not Too Late 12

Philip R. Lee, MD, and Steve Heilig, MPH 16 What Are Accountable Care Organizations

and Why Are They Important in the Future of Medicine?

the iPhone Legislative Advocacy/MICRA

House of Delegates

Coding Q’s 18

Sandie Becker, CMC

Representation Practice Management Resources and Education Financial Services

Joseph Andresen, MD

Medical Times From the Past: Bloodletting 19

Leon P. Fox Medical History Committee

Resources

20 SCCMA Alliance News 21 Save These Dates 22 Bisphenol A in Cash Register Receipts: It’s

Publications

CME Tracking

I Believe 28 This, Richard Mahrer, MD

Professional Development Health Information Technology

Physicians’ Confidential Line Verizon Discount Human Resources Services

Not Just for Dinner Anymore Cindy Russell, MD

30 MEDICO News 36 Classified Ads MARCH / APRIL 2011 | THE BULLETIN | 3

The Santa Clara County Medical Association Officers

AMA Trustee - SCCMA

Councilors

President Thomas Dailey, MD President-Elect William Lewis, MD Past President Howard Sutkin, MD VP-Community Health Cindy Russell, MD VP-External Affairs Rives Chalmers, MD VP-Member Services Scott Benninghoven, MD VP-Professional Conduct Eleanor Martinez, MD Secretary Sameer Awsare, MD Treasurer James Crotty, MD

James G. Hinsdale, MD

El Camino Hospital of Los Gatos: Art Basham, MD El Camino Hospital: Lynn Gretkowski, MD Good Samaritan Hospital: Jeff Kaplan, MD Kaiser Foundation Hospital - San Jose: Efren Rosas, MD Kaiser Permanente Hospital: Allison Schwanda, MD O’Connor Hospital: Jay Raju, MD Regional Med. Center of San Jose: Emiro Burbano, MD Saint Louise Regional Hospital: John Huang, MD Stanford Hospital & Clinics: Peter Cassini, MD Santa Clara Valley Medical Center: John Siegel, MD

Tanya W. Spirtos, MD (Alternate)

SCCMA/CMA Delegation Chair James Crotty, MD (District VII)

CMA Trustees - SCCMA Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (President) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)

Chief Executive Officer William C. Parrish, Jr.

Debbi Ricks (Alliance)

BULLETIN

THE MONTEREY COUNTY MEDICAL SOCIETY

Editor

OFFICERS

THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Printed in U.S.A.

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin or the Santa Clara County Medical Association and the Monterey County Medical Society. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by the Santa Clara County Medical Association or the Monterey County Medical Society of products or services advertised.

Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2011 by the Santa Clara County Medical Association.

4 | THE BULLETIN | MARCH / APRIL 2011

President John Jameson, MD President-Elect James Ramseur, MD Past President William Khieu, MD, MBA Secretary Eliot Light, MD Treasurer John Clark, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD

R. Kurt Lofgren, MD

Valerie Barnes, MD

Patricia Ruckle, MD

Ronald Fuerstner, MD

Scott Schneiderman, DO

David Holley, MD

Steven Vetter, MD

MESSAGE FROM THE MCMS PRESIDENT

John T. Jameson, MD President, Monterey County Medical Society

All Good Things...

The passing of the gavel in Monterey

By John T. Jameson, MD 2010-2011 MCMS President By the time you read these words, the other shoe (or shoes) may have finally dropped in Washington and/or Sacramento; but in a democracy, swift action frequently requires a crisis (real or manufactured), public hysteria, and a stampede of politicians eager to at least be perceived to be doing the right thing, so I’m not inclined to hold my breath over the evolution of the process. It’s no wonder that dictatorships are sometimes looked upon with envy; it seems they can actually get things done, and, of course, are especially popular among those who get to be the dictators, like Moammar Gadhafi. So, perhaps as Churchill said, democracy is the worst form of government – except for everything else!

The end of my term as “dictator” is fast approaching and I will no longer have to chair board meetings or write these letters. But, I am pleased to see the energy, imagination, and enthusiasm which our current membership and staff devote to serving the needs, aspirations, and goals of our profession, particularly the residents from Natividad who take time out of their brief freedom from toil to listen to their elders windbag at board meetings about the issues confronting (semi) organized medicine.

It gives me hope that at least some of us are thinking, paying attention, and taking action, as necessary, to make a better world for all of us.

I used to think that if I could only go to Mars, I could look back at Earth and laugh as the idiots, lunatics, greed-heads, and megalomaniacs propelled humanity to self-destruction. The Martian option seems increasingly unlikely for me, although I’m willing to open an embassy for wannabe asylum seekers. As a founding member of the Mars Society, I have title to an as yet unassigned acre of Martian soil, which I am willing to share with suitably motivated individuals. All we need is transportation and self-sustaining life support systems

for when we arrive. Hydroponic gardening, anyone?

In the meantime, we’re stuck on this planet and, if we have any interest in the perpetuation of our so-called intelligent species, we’ve got our hands full; and it may take some strong medicine to make it happen. It isn’t just the splitting of the atom that portends unparalleled catastrophe; it’s the swelling human population that fuels the depletion of resources, pollution of the air, land, and water, climate alteration, and the sometimes violent scramble to get at least a fair share of the remaining pie (or, all too often, more than one’s fair share). The Chinese may have had the right idea: one-child families. Three generations of those would cut

the population to 1/8 of what it is now, which is historically sustainable. The task would require a suitable combination of carrots and sticks, including the end of tax write-offs for children, maybe large cash payments for voluntary sterilization. But, those are just my ideas; do any of you have better ones?

John T. Jameson, MD, is the 2010-2011 President of the Monterey County Medical Society. He is board certified in pathology and is currently practicing at Natividad Medical Center.

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FROM THE EDITOR’S DESK

Joseph Andresen, MD Editor, The Bulletin

Trials and Tribulations Experiencing the strength, energy & resilience of the human spirit

By Joseph Andresen, MD Since my last editorial column, Mother Nature has thrown her worst at us with the tragic earthquake and tsunami in Japan that has claimed tens of thousands of lives, destroyed entire cities, and displaced so many.

If that wasn’t enough, the nuclear accident and leakage of radiation into the environment is a catastrophic event still unresolved. Our hearts and prayers go out to the people of Japan. If you haven’t already, consider making a donation to the Red Cross: https://american.redcross.org/site/ Donation2?idb=0&5052.donation=form1&df_id=5052.

The cry for greater freedom throughout the Middle East sparked by social media, the new information age, and decades of suppression highlights our daily news. We are witnessing a time of new hope and possibilities, accompanied by war, strife, and loss of life. Doctors Without Borders, winner of the 1999 Nobel Peace Prize, is on the front line in these areas of conflict. Their mission is to bring quality medical care to people caught in crises regardless of race, religion, or political affiliation. They are a nonprofit organization and depend on private donations to carry on their work. Please consider making a donation to aid their efforts in Japan, the Middle East, and around the globe: http://www.doctorswithoutborders.org/donate/overview.cfm.

Closer to home, March 23, 2011, marks the one-year anniversary of the Patient Protection and Affordable Care Act (PPACA) being signed into law. Much publicity has been given to the political conflict surrounding attempts to de-fund the health reform law in Congress. A number of state attorney generals have issued challenges to the constitutionality of the individual mandate that is proceeding through the courts. Not surprisingly, a recent poll of Americans revealed that 22% thought the law had been repealed and another 26% weren’t sure. The public remains evenly divided on support of the new law. Again, not surprising with the amount of misinformation and confusion that currently exists.

So will the law be repealed? No, probably not. With a Democratically-controlled Senate and Democratic president, the law will remain in effect for the foreseeable future. How have you been affected? Depends on whether you’ve had Joseph Andresen, MD is the editor of access to medical inThe Bulletin. He is board certified in surance, or used seranesthesiology and is currently practicing vices recently, or run a in the Santa Clara valley area.

small business. There has been a ban on preexisting condition exclusions for kids; preventative care now covered without a co-pay; restrictions on annual benefit limits, and removal of lifetime caps, in addition to new tax credits for small businesses providing insurance to their employees, and reinsurance to retirees not yet eligible for Medicare.

So why have insurance premiums continued to rise? We have seen recent announcements of large rate increases of greater than 30% by both Anthem Blue Cross and Blue Shield in California. However, both were forced to back down after investigation by the State Insurance Commissioner. Annual increases of this magnitude in the individual insurance market have been a common occurrence for a number of years. The PPACA has not yet dampened this trend. It may be the case that insurance carriers are raising their rates while they can, to further enrich their cash reserves. The hope is that when health insurance exchanges are introduced in 2014, a true competitive marketplace will finally be made available to consumers. In the meantime, new legislation to give the California State Insurance Commissioner the power to regulate health insurance premium rate increase requests, as 20 other states currently do, would be a big step in the right direction.

Full implementation of the PPACA comes into effect in 2014. With the most robust benefits, including the health insurance exchanges yet to come, public support is very likely to grow in the future. Linda Bergthold gives a very succinct summary in her recent article entitled, “What Health Care Reform Has and Has Not Accomplished One Year Later.” (http://www.huffingtonpost.com/linda-bergthold/q-and-a-on-healthreforms_b_838243.html.)

After tackling such weighty and serious topics above, I would like to end my column sharing a more joyous occasion. Surrounded by 19,596 fans this past Tuesday evening, I found myself immersed in the crowd and the music.

For two brief hours, we all felt the freedom, joy, and passion of being lost in the moment.

6 | THE BULLETIN | MARCH / APRIL 2011

“Just dance, gonna be okay, da da doo-doo-mmm.

Just dance, spin that record babe, da da doo-doo-mmm” The words were sung loudly and rhythmically. The reverberating bass and drumbeats shook the concert hall as everyone rose to their feet to cheer the performer’s entrance.

Followed by a melodic ballad:

“I’m beautiful in my way, “Cause God makes no mistakes I’m on the right track, baby I was born this way Don’t hide yourself in regret Just love yourself and you’re set I’m on the right track, baby I was born this way.”

For two brief hours, we all felt the freedom, joy, and passion of being lost in the moment.

For a brief time, the world’s trials and tribulations seemed far away. For two brief hours, music was the common language reaffirming the strength, energy, and resilience of the human spirit. Basking in youthful exuberance, the entire stadium shook as we rose to our feet cheering the last encore, as Lady Gaga and her ensemble exited the stage.

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MARCH / APRIL 2011 | THE BULLETIN | 7

Managing Professional Risk Tips for Lowering Ambulatory-Care Risks

By Karen D. Davis, MA, CPHRM Effectiveness of Risk Management, PMSLIC Insurance Company and the NORCAL Group Among the factors that influence the safety of ambulatory care and the liability risk levels of office-based physicians, three of the main ones are: • the level of communication with other health care providers about patients’ care; • the effectiveness of office follow-up processes; and • the attention given to documentation of telephone calls.

The following tips may help physicians and office staff members increase patient safety and lower liability exposure related to these factors.

Communication With Other Health Care Providers

• When you refer a patient to another physician, have some mechanism in place to determine whether your referral recommendation has been carried out and the patient has been seen by the recommended consultant (or another physician of the patient’s choice).

• Communicate in writing with the consultant about the requested consultation. An effective way to convey significant details to another physician is to prepare a “fact sheet” with the patient’s clinical information and your impression.

• After your patient is seen by a consultant, you and the consultant should establish who is responsible for which aspects of the patient’s care and who will order further testing and consultations if necessary. If there is a question about what you or the consultant will do, you should take the time to communicate physicianto-physician and to document the understanding you reach in your discussion.

8 | THE BULLETIN | MARCH / APRIL 2011

Follow-up Processes

• Systematically monitor compliance with appointments. Establish a process whereby a designated staff member reviews all noshow appointments to determine which patients must be called and rescheduled. Document no-shows, along with the steps taken to contact the patient and reschedule the visit.

• When a patient is advised to undergo a test, three areas of concern require

follow-up: Has the patient complied with the recommendation? Have test results been received and reviewed by the ordering physician? Has the patient been notified about the results? An appropriate follow-up system provides answers to these questions.

• Patients should not be solely responsible for making appointments for tests, to see consultants, or for calling the office to obtain results.

You should assist patients in making

appointments in order to be assured that the appointment has been made.

It is also prudent to notify all patients of all test results (rather than just reporting abnormal results). Such a policy helps close each testing loop and reduces the possibility of patient information “falling through the cracks.”

• Your follow-up system for tests should not only confirm receipt of test results, but also ensure that you review the results. The review should be timely. A test result should never be filed until you (as the ordering physician) have personally reviewed, dated, and initialed it. Without such a method, a positive result can be accidentally misplaced or filed away before you review it or the patient is notified. If the patient later alleges that harm occurred as a result of a delay in diagnosis and treatment, the mishandled test result may well be viewed as concrete evidence of negligence.

Documentation of Telephone Calls

• Generally, the types of telephone

calls from patients that should be documented include: clinical questions and what advice was given, calls for prescriptions or renewals, after-hours calls, and calls to an oncall physician. Calls to patients that should be documented include: calls to share test results, calls to contact no-show patients, calls to give patients instructions or to advise about further access to care, and unsuccessful attempts to contact patients.

• Telephone contacts should be documented in the appropriate medical record. If your office simply keeps a call log, information about a specific call can be difficult to retrieve.

The facts surrounding a call are not readily available if they are recorded in a call log; thus, using a log can be detrimental if a malpractice claim is filed and your office must produce information about the patient’s interactions with the practice.

• You should have a system for documenting all after-hours phone calls. You can use telephone call forms or a tape recorder or dictation machine to record patient name, time of and reason for the call, and your

advice or action. When the call is from a patient, the information should be added to the patient’s chart as soon as possible.

• Giving clinical or medical advice over the telephone without timely, face-to-face follow-up increases your liability exposure. Prescribing over the phone is also risky, as it requires you to assess the patient sight unseen.

You should not prescribe for a patient unknown to you without seeing the patient. It is also prudent to have established parameters as to when prescriptions will be renewed by phone.

Consider developing the preceding suggestions as policy and including them in a policy manual. Make sure all employees review your policy and consider asking them to sign off yearly that they have been advised of the policy and understand it.

Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL Mutual insureds. To learn more, visit www.norcalmutual.com/cme.

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San Jose | San Francisco | Hayward | Sacramento MARCH / APRIL 2011 | THE BULLETIN | 9

The practice of medicine is about to undergo revolutionary change. Are you prepared?

The Next Step: Successfully Negotiating Health Reform 14th Annual California Health Care Leadership Academy June 3-5, 2011 Renaissance Esmeralda Resort and Spa Indian Wells, California

• Restructuring of Medical Practice and Payment • Physician-Hospital Alignment: Definitions, Elements, How to Assess Integration Offers • The (Ongoing) Politics of Reform • Health Reform and Health Care Quality: Burden or Opportunity?

• HIT: Interoperability, Meaningful Use, Quality Measurement and Reporting • Health System Reform and the Physician Workforce • Practice Management: Reengineering Your Practice for Survival • Managing Change Effectively • Physician Leadership in the Era of Reform

Featured Workshops: • Strategies for Independent Physicians to Compete • Learning from Disney: Cultivating and Sustaining Patient Loyalty • It’s Official: ICD-10

Multiple Registration & Early-Bird Discounts Save up to $200 per person Register by May 6th

To Register: 800.795.2262 caleadershipacademy.com

The California Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The California Medical Association designates this educational activity for a maximum of 18.75 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. The credit may also be applied to the CMA Certification in Continuing Medical Education.

10 | THE BULLETIN | MARCH / APRIL 2011

2011MCMS/SCCMA Ticket Program CALIFORNIA’S GREAT AMERICA

Regular Price

Discounted Price

Adult Admission $54.99 $30.00 JR/SR (under 48” or 62+) $34.99 $30.00 Season Pass (includes Parking Pass and Gilroy Garden admission) $70.00 $79.99

Gilroy Gardens Adult Admission Child/Senior Admission (3-6 years or over 64)

$44.99 $34.99

$22.00 $22.00

DISNEY Theme Park (contact the Membership office) Corporate Discount Ticket Program Order Tickets online – Information on the MCMS/SCCMA website Save $40, $50, $60 per ticket (based on various ticket packages) Monterey Bay Aquarium ONLINE ONLY; HTTP://AFFILIATE.MONTEREYBAYAQUARIUM.ORG Adult (18-64 years) Child (3-12 years) Student (13-17 years) Senior (65+ years)

Raging Waters

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$49.99 $179.99 $12.00

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$15.00 $16.40 $10.00

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Raging Waters Discount Code: 1164 Monterey Bay Aquarium Store Code: SCCMA1001 Six Flags Discovery Kingdom Discount Code: SixFlags7 Santa Clara County: If you purchase 4 or more tickets, SCCMA will deliver to your office for $5.00. To order, call Membership at 408/998-8850 before Wednesday for Thursday delivery.

MARCH / APRIL 2011 | THE BULLETIN | 11

BEYOND MEDICAL SCHOOL

It’s Not Too Late One Dozen Important Topics You Might Not Have Learned Enough About in Medical School

By Philip R. Lee, MD, and Steve Heilig, MPH This article appeared in the September 2010 issue of San Francisco Medicine and is reprinted with their permission.

Medical training is intense by design. Starting with medical school, most of the formal curriculum is filled with numerous essential topics, and as scientific and medical knowledge increase, it is further difficult to “triage” what must be learned. Efforts to insert new topics are often fraught with obstacles and resistance. Thus, it may seem ridiculous to suggest that even more be taught in those finite years of formal medical education. It is not ridiculous to suggest that practicing physicians put these topics on your to-learn list now.

The following is a somewhat subjective list, but it is based on research, reports, and experience. The discussion of each area is short, with resources listed for those who want to learn more. Again, improvement in these (and other) topics is taking place across the nation. Consider this is an “alert” list conveyed with the hope that future physicians will be aware of these issues on their way to becoming good physicians.

Addiction

The American Medical Association has recognized that drug abuse is one of our nation’s prime public health problems. It’s a clinical problem too, and the biggest culprits are not stereotypical street junkies; they are often everyday patients using legal drugs. For example, despite much progress in reducing smoking, more than 20% of adults still use tobacco.

Alcohol overuse is rampant at almost all ages. Abuse of prescription drugs is also rising. As for illegal drugs, the epidemic of methamphetamine addiction has spread everywhere. Yet many MDs are not aware of addiction issues; alcoholism and other problems often go undiagnosed and, even if recognized, untreated. It is known that having MD counsel about smoking, for example, is an important step toward quitting, yet many MDs are uncomfortable even talking about these problems.

More doctors need to know more about and apply addiction medicine principles.

Resources American Society of Addiction Medicine. www.asam-csam.org “Addiction and Recovery: From Neurons to National Policy.” www. sfms.org/source/members/magazine_archive_list.cfm?theme=June%20 2010%20Addiction%20and%20Recovery&section=Article_Archives

Nutrition and complementary therapies

The dean of the UCLA School of Public Health has stated that, due to obesity, “For the first time in two centuries, the current generation of children in the United States could have shorter life expectancies than their parents.” In a society obsessed with weight, but also increasingly obese (or shockingly bulimic), nutrition becomes a critical matter for patient guidance. Information about extreme nutritional deficiencies, like 12 | THE BULLETIN | MARCH / APRIL 2011

scurvy or pellagra, may be interesting, but is usually irrelevant. More common problems related to physiological development; drug interactions; and use of supplements, herbs, and other “alternative” or “complementary” approaches are far more important.

Unfortunately, patients often do not look for nutritional counseling from their MDs. Physicians should inquire about and become better able to counsel their patients regarding diet and nutrition.

Resources Nutrition in Medicine. CD-ROM series. Chapel Hill: University of North Carolina. www.med.unc.edu/nutr/nim/ Nutrition Guide for Physicians. Wilson, Bray, Temple, Struble (eds.), www.springer.com/new+%26+forthcoming+titles+(default)/book/9781-60327-430-2

Sexuality

Human sexuality has long been taught in a biomedical fashion that often does not reflect real lives. How comfortable is the average MD in talking about sexual practices and health? Homosexuality? Sexual dysfunction? Sexually-transmitted infections? Cultural issues? Teen sexuality? With epidemics of sexually-related disease a part of modern life, and unwanted pregnancy a perennial problem, education and training to elicit such key aspects of patients’ daily lives are vital. This includes contraception. Taking the time to delve into the “uncomfortable” realms of sexuality will not only strengthen rapport, but will allow a physician to address specific health needs that tend to go unrecognized.

In Europe, an accepted sexual medicine accreditation and curriculum now exist (see resource below); perhaps the AMA should recognize this subspecialty as well.

Resources Sexual Health in MedlinePlus: www.nlm.nih.gov/medlineplus/ sexualhealth.html European Society for Sexual Medicine: www.essm.org/easm/sexual_med_curriculum.asp

Pain

Research shows that pain, particularly chronic pain, is vastly undertreated. Fortunately, the presence of pain is being considered another vital sign. Concerns about pain at the end of life, as well as the overuse of medications, are being addressed, and the issue of “assisted dying” at the end of life is not now overshadowing the imperative of pain relief. Medical schools are incorporating pain issues into the curriculum; MDs in California who have been required, often against their will, to complete a CME requirement have often expressed reluctant surprise and gratitude at how much they learned. Progress is being made and needs to continue.

Resources American Academy of Pain Medicine: www.painmed.org

org

American Pain Foundation: www.painfoundation.

End-of-life care

Medicine is not only about cure, but also about caring for patients when cure is no longer an option. Traditionally, however, death scares many physicians as much as anyone else. Now, however, palliative care is a growing discipline with great rewards. Pain, as noted above, is only part of the picture. Physicians need to know how to help ease patients (and their loved ones) into a palliative mode, to use therapies and medications in optimal ways as death approaches, and to work with skilled hospice and other similar professionals.

Resources American Academy of Hospice and Palliative Medicine: www.aahpm.org/ Education for Physicians on End-of-Life Care: www. epec.net

Physical fitness

We all know exercise is good, and often the single most important variable in overall good health. Numerous studies have categorized physical exercise as a positive predictor of good health, disease prevention, and longevity. Our bodies are built to be used vigorously. Yet how many MDs effectively address and motivate patients toward sustainable cardiovascular fitness and weight loss?

Although many schools hammer the “stages of change” model into students so they can motivate patients to change their lives, further work needs to be done with practicing physicians to enhance their knowledge of these life-saving techniques.

Resource American Academy of Family Physicians: http:// familydoctor.org/059.xml

Medical ethics

Ethical questions are common in clinical practice.

Medical ethics committees are now required in hospitals. However, formal education of medical ethics varies widely. This variability is evident later in practice, as many physicians see “ethics” as superfluous and may even resist any involvement with an ethics committee. This is no longer acceptable because ethical standards, processes, and practice are complicated and call for continued reminders and training. The important ethical dilemmas that physicians face remind us of the responsibility of

Continued on page 14

MARCH / APRIL 2011 | THE BULLETIN | 13

It’s Not Too Late, from page 13 MDs to stay informed and updated on appropriate standards, be they about life-or-death choices, financial conflicts of interest, or other issues.

Resources AMA Council on Ethical and Judicial Affairs: www.ama-asn.org/ go/ceja “Clinical Bioethics: A Practical Approach to Ethical Decisions in Clinical Medicine,” by Albert Jonsen, Mark Siegler, and William Winslade. w w w. m hprofe s siona l .c om /pro duc t .php?s e a rc h _ crawl=true&isbn=0071491538

Violence

The media confirm that we live in a violent world. Anyone who has spent time in an emergency department knows that, but much (or arguably most) violence is concealed. “Domestic” (partner, elder, child) violence is endemic. Like addiction, it often goes unrecognized, untreated, and unreported, although it impacts a patient’s health as much or more than any other factor in life. Physicians need to learn methods of identifying and treating or referring issues revolving around domestic abuse, including hospital protocols, patient counseling, and resources available to patients. (Gun control and community violence are unfortunately beyond our scope here.)

Resources “Domestic Violence: A Practical Approach for Clinicians.” San Francisco Medical Society: www.sfms.org/domviol.htm “Simplifying Physicians’ Response to Domestic Violence.” www. ncbi.nlm.nih.gov/pmc/articles/PMC1070885/

Environmental health

No man or woman is an island. Our environment affects our health in more ways than we usually imagine. So where and how a patient lives and what they eat, drink, and breathe are all factors physicians need to know something about.

Knowledge is rapidly growing about the impact of chemicals, infectious agents, irradiation, maybe even global warming on our environment, bodies, and health. An “environmental history” is part of good clinical assessment—particularly for children, who are often most severely affected. Physicians have the unique opportunity to link personal and environmental status, which can be important for prevention and for acute and chronic care.

Resources The Collaborative on Health and the Environment: www.healthandenvironment.org Medicine and the Environment: Practice, Prevention, and Policy: www.sfms.org/AM/Template.cfm?Section=San_Francisco_ Medicine&Template=/CM/HTMLDisplay.cfm&ContentID=2978

more when a respected clinician speaks and acts on behalf of policy issues and public health. This voice becomes ever more important as modern “health reform” evolves.

Resources “Understanding Health Policy: A Clinical Approach,” by Thomas S. Bodenheimer and Kevin Grumbach. www.accessmedicine.com/resourceTOC.aspx?resourceID=56 UCSF Institute of Health Policy Studies: www.ihps.medschool.ucsf. edu/

The business and organization of medicine

Physicians have rarely been taught much about how to run a medical practice or manage finances. Thus, the old stereotype about physicians being brilliant at medicine, but ignorant about money, is often not too far from the truth. Depending on what type of practice environment a doctor works in, this is more or less important. But everyone should know, for example, about health insurance, managed care, electronic health records, and other information technology, down to negotiating rent and personnel issues. How to work effectively as a care team is crucial as well. This arena, too, is ever more important with evolving “health reform.” And knowing about how pharmaceutical industry money has intruded on medical practice (and education) is important, too.

Resources Contact your local medical society for educational opportunities on practice management, electronic health records, and so on.

Marketing of Medicines: An online CME course from UCSF: w w w.cme.ucsf.edu/cme/CourseDetail. aspx?coursenumber=MED11006

Your own well-being

Anyone who has read this far might have a sense of being overwhelmed by all there is to know and do. It’s a common feeling among physicians (and medical students); it may be one reason for the tragic fact that physicians are at elevated risk for depression, substance abuse, and suicide. Frustration in meeting expectations both external and internal, stress from all sources, and the challenge of leading a balanced life are common problems. Many physicians may also struggle with feeling they have an unrewarding life and career. Physicians need to be aware of resources available to address their needs, able to define and maintain priorities, and recognize the numerous daily rewards that are unique to the medical profession. Doing so can help one retain the idealism that so often motivates the career choice of medicine in the first place.

Resources RENEW: www.renewnow.org “The Heart of Medicine”: www.theheartofmedicine.org/

Health policy

Many clinicians may believe, or wish, that their practices exist in social vacuums, but that is untrue. Priorities and decisions made—or not made—in legislative arenas affect what kinds of clinical problems come in your door and what you can do about them. Public health— epidemiology, prevention, and so on—have long been neglected factors in medical education and practice. Yet physicians have high credibility among the public and legislators, and that prestige is heightened even 14 | THE BULLETIN | MARCH / APRIL 2011

Dr. Philip Lee is chancellor emeritus of UCSF, former United States assistant secretary of health, and professor emeritus at Stanford University’s program in Human Biology and in the Department of Medicine at UCSF. Steve Heilig is director of public health and education for the San Francisco Medical Society and the Collaborative on Health and the Environment and coeditor of the Cambridge Quarterly of Healthcare Ethics.

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HEALTH CARE REFORM

What Are Accountable Care Organizations?

Why Are They Important in the Future of Medicine?

By Joseph Andresen, MD The political and legal battles regarding funding and implementation of the Patient Protection and Affordable Care Act (PPACA) continue after the legislation was signed into law one year ago. However, one provision in the law is prompting both public and private sector preparations, behind the scenes, despite the lack of front-page news publicity. It is es-

16 | THE BULLETIN | MARCH / APRIL 2011

timated that the ACO (Accountable Care Organization) provision will remain intact no matter what the final outcome of current health reform law challenges.

Described in Section 3022 of the ACA, an ACO is an organization designed to “promote accountability for a patient population and coordinates items and services under Medicare Part A and B, and encourages investment in infrastructure and redesigned processes for high quality and efficient service delivery.�

This is not a new concept, but one that was first introduced and built on the Medicare Physician Group Practice Demonstration in 2003. The goal is to improve quality, while reducing costs in health care.

Despite having the most sophisticated medical care and technologies in the world, our health care system has been roundly criticized for being fragmented, costly, inequitable, and spotty in terms of quality and delivery. Recognition of these shortcomings, and with unsustainable rising costs, ACOs will become a broad part of the Medicare program after demonstrating success in pilot projects.

So what are Accountable Care Organizations?

ACOs may consist of a variety of providers ranging from integrated delivery systems, primary care medical groups, and hospital-based systems, to virtual networks of physicians such as independent practice associations.

The fundamental responsibility of any organized group will be the joint accountability for achieving measured quality improvements and reductions in the rate of spending growth. A strong primary care base will be an essential building block.

How will payment be made?

A variety of payment models can be implemented. One possibility is the opportunity to share in demonstrated savings within a fee-forservice environment where the providers take on no new financial risk. Another arrangement would include limited or substantial capitation arrangements. Here, payments would be unrelated to the volume, intensity, or frequency of service and providers would share in some financial risk for poor quality results or inability to control costs. As one can see, success of such an organization will require strong, well organized leadership of physicians with a strong primary care base who are held accountable for the quality of care provided and the costs of service. A second fundamental will be the linkage of payments to quality improvements that reduce overall costs. Thirdly, progressively sophisticated data will be essential for monitoring quality indicators and demonstrating savings that are accomplished through improvements in care.

This may look good in theory, but how will it work in the real world?

As mentioned earlier, ACO models are based on the Physician Group Practice Demonstration. In 2005, ten provider organizations and physician networks, which range from free-standing physician group practices to integrated delivery systems, began in a “share savings� pilot program with continued payment with fee-for-service fees, but bonus payments for improved care and reduced costs. By year three, most groups had met the majority of quality measures and five of the groups received more than $25 million in bonus shared savings bonus payments with a total of more than $32 million in Medicare savings. So with the proper organization and strategy, it appears

that there can be an upside for both physicians and patients.

The overall effectiveness of ACOs will require additional funding afforded by the ACA. This includes increased support for primary care services such as medical homes. This would involve additional payments to primary care physicians for leading prevention, disease management, and care coordination services reflecting best practices in primary care. Medical homes may involve a team of primary care physicians caring for a specific patient population with shared accountability.

How are ACOs different than HMOs of the 1990s?

HMOs were promoted as the best means to reduce overall health costs in the 1990s. The public and providers quickly learned that in many cases, HMOs controlled costs by reducing access and/or treatment. These shortcomings were quickly recognized and a public outcry, backlash, and government action resulted in punishment of the worst offenders where appropriate care was denied. ACOs approach cost containment of medical expenditures from a different direction. Quality measures are used as a means and measure to reward providers and organizations, rather than through a reduction in overall services.

Examples of the range of performance measures in Accountable Care Organizations from beginning, intermediate, and advanced accountability may include the following: Beginning, claims-based measures: Hospital readmissions; depression follow-up and management.

Intermediate, limited clinical, and survey measures: Timely outpatient follow-up (clinic, home care) for patients (heart failure, AMI, mental health).

Advanced, comprehensive patient-focused measures: Reconciled medication list and discharge plan received by providers and patient; patients report high level of understanding of medications and plan.

There will be many complexities in organizing and implementing a successful ACO. Sufficient information available to providers, experience of both providers and payers, and the handling of legal and regulatory issues are all important considerations. Successful implementation will require support of providers to achieve meaningful improvement in patient care. Ongoing learning will be essential to respond to the new challenges required.

It is clear that many of the major stakeholders in the health care sector are already preparing for the arrival of ACOs. Careful co-

ordination and negotiation between Medicare, Medicaid, and most importantly, providers and private payers will be essential to test these new alternatives. This new paradigm may threaten many of us who have become accustomed and secure in the long established fee-for-service and production based reimbursement system.

Yet for those physician groups and organizations that are able to adapt and meet the many challenges of forming successful ACOs, the goals are clear: Higher quality medical care at lower cost is a win-win for both physicians and patients. This is what true health care reform is all about.

STOP THE PRESS!

ACO regulations released March 31 by HHS with a 60-day comment period. Affordable care organizations will be required to accept responsibility for at least 5,000 beneficiaries for at least three years, and must lay out how it will improve care and lower costs when applying for the program. The program is expected to save $510 million to $960 million over three years, according to CMS. More details and discussion, including an analysis by the California Medical Association, to follow in our next issue of The Bulletin!

References: 1. McClellan, Mark, et al: A National Strategy to Put Accountable Care Into Practice http://tdi.dartmouth.edu/documents/ publications/A%20National%20 Strategy%20by%20McClellan.pdf.

2. An Engelberg Center for Health Care: Achieving Better Care at Lower Costs through Accountable Care Organizations http://www.brookings. edu/events/2011/0201_accountable_ care.aspx.

3. Ward, MD: ACOs must steer clear of anti-trust issues http://rewardhealth. com/archives/581.

4. Kaiser Family Foundation: The ScanAccountable Care Organizations http://healthreform.kff.org/Scan.asp x?tag=Accountable+Care+Organiza tions.

Joseph Andresen, MD is the editor of The Bulletin. He is board certified in anesthesiology and is currently practicing in the Santa Clara valley area.

MARCH / APRIL 2011 | THE BULLETIN | 17

REIMBURSEMENT ADVOCACY

SANDIE BECKER Certified Medical Coder

Coding Q’s Answers to those tough coding questions...

by Sandie Becker Certified Medical Coder

Question: What CPT codes should be used for a tonsillectomy, palatal implants, and uvular radiofrequency reduction performed at the same surgical session?

Answer: The tonsillectomy is reported with code 42836, Tonsillectomy, primary or secondary; age 12 or over. The palatal implants and radiofrequency uvular coagulation are not reported with any specific CPT code; therefore, code 42299, Unlisted procedure, palate, uvula, should be reported once to describe both of these procedures.

When performing two or more procedures that require the use of the same unlisted code, the unlisted code should be reported only once to identify the services provided. This is due to the fact that the unlisted code does not identify a specific unit value or service. Unit values are not assigned to unlisted codes because the codes do not identify usual procedural components or the effort/skill required for the service.

When performing two or more procedures that require the use of more than one unlisted code for different anatomic locations,

18 | THE BULLETIN | MARCH / APRIL 2011

the unlisted code may be reported for each different anatomic location.

Question:

Is CPT code 68815, Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent, reported per duct or per eye?

Question:

I billed a claim with CPT 63075 and 22554. The insurance denied the 22554, saying that it was inclusive with the 63075. This has never happened before. What’s up?

When performing the procedure described by code 43770, Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components), would laparoscopic repair of a hiatal hernia be separately reported or would this be considered an inclusive service of code 43770?

Answer: Per the CCI edits, 63075, Discectomy, anterior, with decompression of spinal cord and/or nerve root(s) including osteophytectomy, cervical, single interspace, is considered column 1 to 22554, Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2. Additionally, as of this year, CPT instructions state “Do not report 22554 in conjunction with 63075 even if performed by separate providers. To report anterior cervical discectomy and interbody fusion at the same level during the same session, use 22551,” Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2.

Answer: Because laparoscopic repair of a hiatal hernia is not integral to the laparoscopic placement of an adjustable gastric restrictive device, it is appropriate to report the hernia repair separately. Modifier 51, multiple procedures, should be appended to the additional procedure code.

For coding questions and reimbursement issues, contact Sandie @ 408/998-8850 or MCMS 831/455-1008 or email sandie@ sccma.org.

Answer: Code 68815 is billed per eye. If the procedure is performed bilaterally, report code 68815 with modifier 50 appended.

Question:

MEDICAL TIMES FROM THE PAST

Bloodletting Submitted by the Leon P. Fox Medical History Committee The practice of bloodletting dates back several thousand years. It was extremely popular in America in the nineteenth century. Two theories for the etiology of disease were responsible for its use: (1) There was an imbalance in one of the four humors (blood, phlegm, black bile, and yellow bile); (2) The circulatory system was in a state of excitability and needed to be relaxed.

Benjamin Rush, MD, was the most influential proponent of bloodletting in the United States. He recommended it for treatment of convulsions, concussion, labor pain, hernia, smallpox, croup, pneumonia, and any other disease that produced a fever.

The method used in bloodletting was straightforward. With the patient sitting upright, a tourniquet was applied to the upper arm. A single blade lancet or a multiple blade lancet (scarificator) was used to cut the vein in the arm. A cup,

usually made of glass, was heated and applied to the bleeding site. This added a small amount of suction to the procedure. The blood was collected in a volume marked bleeding bowl until the desired amount was obtained or the patient fainted.

The process was often repeated several times over several days until the patient started to recover or died. It is thought that George Washington’s death was more directly related to bloodletting than to his respiratory infection.

The following is a vivid firsthand account of bloodletting in the nineteenth century: The patient is the first wife of Salmon P. Chase, the future secretary of the treasury under Abraham Lincoln. The diagnosis was puerperal fever two weeks after delivery. The year was 1837. “ The next morning (she had already been bled three times the previous day), such was her condition, there was a fair prospect of her recovery. All the symptoms boded well. But Drs. Drake and Richards were of the opinion that she had not been bled sufficiently, and that the disease had not been subdued. They, accordingly, recommended

further bleeding; Dr. Colby opposed it, saying that all her symptoms were improved, and they ought to watch the result. The other physicians insisted, however. It was anticipated that the effect would be to reduce the frequency of the pulse and augment its volume. Kitty was told that the doctors thought of bleeding her again, and was asked if she was willing. She said “Yes, anything.”

She was then raised up in bed and twenty ounces of blood were taken from her. The physicians seemed to entertain some hopes of her recovery, and agreed upon a course of treatment to be adopted. The (patient’s) father came into her room exclaiming, ‘Thank God, my child, the doctors say there is hope.’ She said nothing. All hope had vanished. Dr. Drake felt her pulse, and said she was dead.”

Bloodletting retained its popularity until the latter half of the nineteenth century. Bacteriology, the germ theory, and the growing realization that bloodletting was detrimental to the patient, finally put its use to rest.

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MARCH / APRIL 2011 | THE BULLETIN | 19

alliance news

SCCMA Alliance News The philanthropic and volunteer arm of SCCMA Alliance members have been busy these past winter months and are planning events for spring. Past, present, and future activities include the following: • Membership: There are currently 133 Alliance members. The membership drive for the 2011-2012 year begins in May. Join now by going to www. sccmaa.org.

• Attendance at CMA Alliance events: Past CMAA and SCCMAA President Debbi Ricks attended the Western States Conference in San Diego, February 3–5. Conference proceedings included information regarding how the AMAA can help local Alliances, how to keep children safe online, information on bullying programs in schools, tips on leadership/ communication skills, and how to get the Alliance message out to potential members in the medical community.

Debbi also attended the Anti-Bullying Conference sponsored in part by the Los Angeles County Medical Association Alliance.

March 14, 2011 Santa Clara County Medical Association Alliance Board Meeting using Skype to include Treasurer/Membership Chair Debbi Ricks in the meeting.

Board Members: Front: Suzanne Jackson, Carolyn Miller, Siggie Stillman Back: Jean Cassetta, Mary Hayashi (president), Sally Normington, Heather Goodman, Kathleen Miller On the Monitor: Debbi Ricks

• SCCMA Alliance Volunteers in Food Basket Program: Volunteers from the SCCMA Alliance are spending one morning per month helping with the Food Basket Program in Santa Clara County. This program provides groceries for the HIV/AIDS population in the county.

Volunteers include Mary Hayashi, Carolyn Miller, and Suzanne Jackson.

• May 2011 marks the return of the Alliance health project, “Not Even for a Minute.” The campaign reminds community members of the dangers of leaving children unattended in vehicles. The health project manager is Alliance member Sally Normington. Information packets including bookmarks, static surface decals, and posters will be sent to hospitals to distribute to over 2,500 families of newborns.

Upcoming CMAA Annual Session to be held in Los Gatos, May 5–7

The 2011 CMAA Annual Session is scheduled for Friday and Saturday, May 5–7 at the Toll House Hotel, located in the heart of Los Gatos.

This is the annual business meeting of the CMAA, as well as a luncheon 20 | THE BULLETIN | MARCH / APRIL 2011

honoring the SCCMAA’s “Dedicated County Alliance Member of the Year.” The meeting also will be hosting AMAA leader Pat Hyer and honoring CMAA past presidents. All Alliance members are invited to attend this spring event.

Meeting registration forms can be obtained by contacting Suzanne Jackson at email: suepurr@gmail.com. Hotel reservations must be made

by April 11, 2011 in order to get the group discount. Please contact Suzanne for additional hotel and conference information.

Upcoming Events:

May 2011: Spring Campaign, “Not Even for a Minute.”

May 5–7, 2011: CMAA Annual Session, Toll House Hotel, Los Gatos

The Santa Clara County Medical Association Alliance is the philanthropic and volunteer arm of SCCMA that consists of physicians, physician spouses, students in training, and friends of medicine. To join, please visit the website at http://www.sccmaa. org. You will also find the most current updates and contact information on that site.

SCCMA Annual Awards Banquet and Installation Tuesday, June 7, 2011 • 6:15 pm Social 7:00 pm Dinner & Program • The Fairmont Hotel, San Jose Installation: William S. Lewis, MD, SCCMA President 2011-12 Honoring: Thomas Dailey, MD, SCCMA President 2010-11 Award Honorees Philipp M. Lippe, MD – Robert D. Burnett, MD Legacy Award Robert Armstrong, MD – Outstanding Achievement in Medicine Dennis Siegler, MD – Contribution in Medical Education Tanya Spirtos, MD – Contribution to the Medical Association Gary Silver, MD – Contribution to the Community Kathleen King – Citizen’s Award Senator Elaine Alquist – Special Recognition Award William B. Ricks, MD – Dedicated County Alliance Member Award Formal invitations will be mailed in April

MCMS Annual lnstallation Dinner Tuesday, June 28, 2011 • 6:00 pm Social 7:00 pm Dinner & Program • Monterey Beach Hotel

Installation: James Ramseur, MD, MCMS President 2011-12 Honoring: John Jameson, MD, MCMS President 2010-11 Formal invitations will be mailed in May

SCCMA: Town Hall Meeting

Tuesday, May 3, 2011 • 6:00 pm-8:30 pm SCCMA – 700 Empey Way, San Jose 95128 James Hay, MD, CMA President-Elect, will be the Guest Speaker

MARCH / APRIL 2011 | THE BULLETIN | 21

COMMUNITY HEALTH

Bisphenol A in Register Receipts It’s Not Just for Dinner Anymore

By Cindy Russell, MD VP of Community Health, SCCMA When we heat up a can of soup, we are getting more than we bargained for. Along with the vegetables and meat, we are getting a tagalong endocrine disruptor called bisphenol A (BPA) which leaches from the lining of the can. It has been known for many years that bisphenol A is found in baby bottles, food, aluminum cans, and dental sealants, but it is also in many other products we commonly are in contact with as well. The most surprising recent discovery is cash register receipts, where it is found, in some cases, at levels 250-1,000 times higher than in cans.

Why is it of concern? It is found not only in many consumer products, but also in amniotic fluid, breast milk, and our bodies. Decades of exhaustive research have linked this particular chemical in low doses with breast cancer, miscarriages, low sperm counts, prostate abnormalities, thyroid abnormalities, neurologic developmental abnormalities, and insulin resistance. There is special concern for pregnant women and the developing fetus.

Bisphenol A has a DES sister

Bisphenol A and its sister Diethylstilbestrol were studied to see if they could prevent miscarriages. BPA was synthesized in 1891 and was found to be estrogenic in 1930. At that time, a lot of interest was given to making synthetic estrogens. DES was found to be strongly estrogenic and was used to prevent miscarriages. As we know, it became associated with an increased risk of a rare vaginal cancer in the offspring of pregnant women who took it. Bisphenol A was found to be weakly estrogenic, thus was passed over for medical use. However, it later was found to prevent cracking of plastics, thus found many uses in consumer products. Despite the knowledge that BPA was estrogenic, it has been used to line food cans since the 1950s.

It is a high production volume chemical (over 1 million pounds per year),1 which is used in a variety of consumer products including Nalgene bottles, clear plastic bottles, 22 | THE BULLETIN | MARCH / APRIL 2011

PVC pipe, CDs, eyeglasses, enamel lining of cans, canned soda,26 epoxy resins, toys, and in plastic #7. BPA is also known as polycarbonate and has been found to leach out of plastic and into water or foods, which until now has been thought to be the predominant source of human exposure.2 Recently, it has been found in even higher levels in cash register receipts and other paper products. In some cases, the levels are 250 to 1,000 times higher than in food containers. Paper receipts are now of great concern as a significant consumer source of BPA.

What is an endocrine disruptor?

The EPA defines an endocrine disruptor as an exogenous agent that interferes with the synthesis, secretion, transport, binding, action, or elimination of natural hormones in the body that are responsible for the maintenance of homeostasis, reproduction, development, and/or behavior.23

Widespread human exposure to BPA

The Centers for Disease Control and Prevention (CDC) has found that 93% of Americans over six years of age have detectable urine levels of BPA, based on the National Health and Nutrition Examination Survey (NHANES).2 BPA is found in breast milk at about 1.1 ng/ml.12 BPA is found in amniotic fluid.16 The halflife of BPA is about two days, thus humans are exposed to BPA regularly on a daily basis via consumer products. About fiveto-six billion pounds of bisphenol A are produced annually, worldwide, according to the CDC.11

Tolerable daily intake and levels of concern

Scientific risk assessments from the European Food Safety Authority and the FDA propose a Tolerable Daily Intake(TDI) limit of 50 micrograms per kilogram body weight or 0.5mg/kg body weight per day. 27 Adverse effects on animals, however, have been found in much lower levels in about 120 studies. These levels are what we may consume on a daily basis and are called clinically relevant doses.

Abundant research on BPA

Some 1,000 studies have been done on BPA. It has been researched for decades and it has been associated with a wide range of adverse effects on endocrine systems including breast cancer, prostate cancer, diabetes, obesity, heart disease, diminished sperm production, early puberty, disruption of sexual differentiation in the brain, and developmental neurotoxicity at clinically relevant levels in the parts per trillion. It has endocrine disruption effects similar to DDT and PCB.37 Bisphenol A is now listed as a chemical of concern by the EPA.3 The widespread use and exposure of this chemical makes it a significant threat to public health.

Developing fetus and children most vulnerable

Recent research is finding that many adult diseases, such as infertility, have their origin during development. Irreversible “organizational” effects begin in the fetus and continue through puberty, resulting in adverse health effects, evident only in adulthood. As we know, growing infants and children are the second most vulnerable population as their brains, immune systems, reproductive systems, and breast tissue are immature at birth. Studies on rats and humans have demonstrated BPA can alter the course of normal neural development and can increase aggressive behavior.

Prenatal BPA exposure

Prenatal exposure to BPA causes permanent adverse effects on the female reproductive tract, breast cancer induction, as well as abnormal neural development. Dr. Reth Newbold found that rats exposed to clinically relevant doses of BPA on days 9 and 16 of gestation showed abnormalities in the reproductive tracts at 18 months, none of which were seen in the control animals.

Researchers at Yale University found that BPA exposure during pregnancy caused permanent abnormalities of the uterus of the offspring, including alternation of DNA. Dr. Taylor found that the mice exposed to BPA as

a fetus had an exaggerated response to estrogens as adults, long after the exposure to BPA. The genes were permanently programmed to respond excessively to estrogen.10 Kubo found that prenatal exposure to BPA at levels below Tolerable Daily Intake (TDI) altered sexual differentiation reversing sex differences in open field behavior and diminishing brain centers responsible for sexual differentiation.13

The brain and BPA

Adriani studied the perinatal effects of BPA on offspring of both sexes. He found the males to have a feminized profile.15 Xu et al found that perinatal exposure to BPA affects normal behavioral development in both spatial memory and avoidance memory, and also permanently influences the behavior of offspring in adulthood.19 Palanza looked at maternal oral exposure during the last part of gestation to a low, environmentally relevant dose of BPA (10 microg/kg bw/day) on behavioral responses of mouse offspring. They found that maternal exposure to BPA affected: (1) behavioral responses to novelty before puberty and, as adults; (2) exploration and activity in a free-exploratory open field; (3) exploration in the elevated plus maze; and (4) sensitivity to amphetamine-induced reward.

A consistent effect of exposure to BPA was the decrease or elimination of the sex difference in behavior. In addition, exposure of female mice to BPA in both adulthood or during fetal life altered subsequent maternal behavior.

“These findings, together with those from other laboratories, are evidence of long-term consequences of maternal exposure to low-dose BPA at the level of neurobehavioral development.”21 One mechanism of diminished brain development may be due to its antagonistic effect on thyroid hormone.17

BPA and aggressive behavior

Prenatal exposure to bisphenol A (BPA) is known to increase aggression in offspring and diminish differences in sexually specific behaviors in rodents. Braun et al examined the association between prenatal BPA exposure and behavior in two-year-old children in a prospective study. They found BPA concentrations collected around 16 weeks were more strongly associated with externalizing (aggression, delinquency, and hyperactivity), and scores among all children and this association were stronger in females than in males.23

Asthma and BPA

BPA has been shown to induce mast cell

degranulation and enhance IgE-mediated release of allergic mediators in the perinatal period. They found significantly increased eosinophilic inflammation in the airways of the mice whose pregnant mothers were exposed to BPA compared to unexposed mothers.5

Diabetes and BPA

Insulin resistance by BPA is thought to develop via its ability to mimic 17B-estradiol.

Insulin resistance is associated with type 2 diabetes and heart disease. M. Nathaniel Mead, a science writer who writes for Environmental Health Perspectives, writes of a study which exposed pregnant mice to BPA and evaluated glucose metabolism on the mother and subsequently on her offspring. They found the BPAtreated pregnant mice had aggravated insulin resistance and weighed more at four months postpartum. The male offspring had reduced glucose tolerance and increased insulin resistance than untreated mice.14

Obesity and BPA

Several studies have found that BPA produces obesity in mice. Recently, a new test was developed to discover the mechanism. Bisphenol A, as well as benzyl butyl phthalate, can modulate the signals controlling the number of fat cells produced and the uptake and storage of fats in those cells. More fat cells and fatter cells underlie weight gain in people.15

Breast Cancer, DCIS, and BPA

A substantial body of evidence indicates that exposure to bisphenol A (BPA) during early development may increase breast cancer risk later in life. A study by the Human Cancer Genetics Program at Ohio State University looked at epigenetic changes in breast epithelial cells and identified 170 genes with expression changes in response to BPA.22 Several studies

have shown BPA in utero to cause enhanced sensitivity to estradiol, decreased apoptosis, and increased the number of progesterone receptor-positive epithelial cells at puberty. In addition, research has demonstrated that prenatal BPA exposure in mice causes ductal hyperplasia and carcinoma in situ of the breasts.

The fetal exposure was 2.5, 25, 250, and 1,000 micrograms bisphenol A/kg body weight. The TDI is 50. This indicates that current clinically relevant BPA levels appear “sufficient to induce the development of preneoplastic and neoplastic lesions in the mammary gland.”18

BPA in medical products

Because of concerns about BPA’s effects on development, a study was carried out to see if BPA was found in newborns in neonatal intensive care units where there are no other outside influences. Levels of 30.3 micrograms per liter were found, which is a level of magnitude higher than the general population. A strong association was found with use of DEHP-containing products. DEHP is a phthalate chemical and known endocrine disruptor added to many commonly-used plastics to soften them.

It is used in medical products, including IV bags and tubing.31 In May 2008, Health Canada announced a new requirement for those applying for a license for Class II, III, and IV medical devices to disclose the amount of BPA if it contains more than 0.1% BPA in the medical device or if BPA was used as a raw material in the production of the device. 35

BPA in thermal paper products

New studies have found significant levels of BPA in thermal paper products. Dr. John Warner, professor of Community Health and Sustainability and Plastics Engineering at the

Continued on page 24 MARCH / APRIL 2011 | THE BULLETIN | 23

Bisphenol A, from page 23 University of Massachusetts-Lowell and one of the founding fathers of Green Chemistry, is a chemist who worked for Polaroid many years ago and learned of the thermal coating processes for paper. A powdery coating of BPA is laid down on the paper with a dye and a solvent.

When heat or pressure is applied, the coatings’ constituents merge to release the ink’s color.

After hearing about BPA in the news, he wondered if thermal paper still used BPA, and he had his university students run assays. The first study found levels of BPA from 0% – 1.7%.8 A 2010 University of Missouri study, looking at receipts from 36 different locations, found BPA in 40% of receipts and at levels averaging 1.9%. Safeway had the highest levels at 2.8% of the receipts’ weight, although Whole Foods also had substantial BPA on their receipts. BPA has been found to stick to skin and can be transferred from hand-to-mouth, being absorbed in the digestive tract and possibly through the skin. In the Environmental Working Group Study, a damp wipe of four receipts demonstrated that 0.7% – 3.8% of the BPA easily wiped off.9 Those with sweaty palms beware.

In a Swiss study published online July 11, 2010 in Analytical and Bioanalytical Chemistry, found that BPA transfers readily from receipts to skin and can penetrate skin to a level that it cannot be washed off.6

Alternatives to thermal paper

Appleton Paper Company, which makes more than 50% of the receipt paper in the country, knew there would be issues with BPA and, in 2006, switched to a non-BPA process. “After reviewing available science, we concluded that removing BPA from our thermal products was the responsible thing to do. In doing so, we gave retailers and restaurants a safe, easy, and cost-competitive choice. Our BPA-free thermal receipt paper is available globally.” (Appleton Papers August 9, 2010. www.appletonideas. com.)

Recycling bisphenol A: The water cycle, the food cycle, the pollution cycle

Synthetic chemicals we produce are not biodegraded in the same way as natural chemicals and, thus, become part of the pollution cycle in our air, soil, water, and food. Many of the man-made chemicals are built to last and not biodegrade easily—fragrances with phthalates, soaps with nonylphenol, pesticides, anti24 | THE BULLETIN | MARCH / APRIL 2011

cholesterol, and antidepressant medications (chemotherapy, anticholesterol, antidepressant)32,34, chloramine in water, antibacterials such as triclosan, and, of course, bisphenol A. When these chemicals do degrade, they may also produce even more toxic substances, i.e.

DDT to DDE. In grade school, we learned about the water cycle, the soil cycle, the food cycle, etc.

Natural substances are moved from one system to another. In our vital water cycle, the sun heats up water, which moves from lakes, rivers, oceans, and plants via evaporation and transpiration. Then, via condensation and precipitation, water comes back to the earth in the form of rain. The water returns to the lakes, rivers, oceans, and plants, and the cycle continues feeding new life on earth. We now know why cutting down the forest causes the rivers and streams to dry up. It ends the water cycle.

In the pollution cycle, many of the manmade chemicals we use everyday may not only bioaccumulate in us, they are also excreted from us to sewage sludge and also thrown away in the garbage. In this way, through different routes, they end up in the water and soil, continuing to pollute the entire food chain, from the basic aquatic life forms, to fish, to mammals, to us again.

What we pour down the sink, we eventually drink

We know municipal water contains many man-made substances that are now part of the water cycle, including personal care products and pharmaceuticals.33 It is the job of regional water quality control boards to monitor these human pollutants and try to remove them. It is an expensive proposition. Waste water contains all of these pollutants which we flush or pour down our drains including bisphenol A. We are now recycling waste water as well as discharging most of these synthetic chemicals into our bay. What effect is it having on the ecology of the Bay and us? Why not prevent the pollutants from going into the pipe in the first place?

In the human waste stream, scientists have found pollutants such as brominated flame retardants as well. They look at sewage sludge, which is considered an “organic” compost and soil amendment used daily on our large agricultural fields. It contains a multitude of pollutants which are monitored, and some limits are placed on some known contaminants.

Bisphenol A in recycled paper

Bisphenol A has a special role as a recycled pollutant in the waste stream as it is used in paper products and now is found in recycled toilet paper in significant amounts – up to 430 mg/kg dry mass. This is due to the fact that cash register receipts and ATM receipts, 40 % of which contain significant amounts of BPA, are recycled with regular paper. “Because of the distinct contamination with xenoestrogens, both paper waste and recycled paper products should not be mixed with biological waste.”1 BPA is also found in recycled cardboard and there also may be other paper products not yet recognized as a significant source of BPA.

Top sources of BPA to avoid

BPA is used in thousands of consumer products. Here are some common sources: 1. Polycarbonate clear plastic shatterproof containers—Nalgene water bottles, baby bottles.

2. Many Sassy baby products, including those that change color.

3. Aluminum water bottles lined with an enamel coating to prevent leaching of aluminum.

4. Soda cans.

5. Beer and wines fermented in metal vats, lined with BPA. 6. Credit card receipts.

7. Credit cards.

8. Pizza boxes with recycled cardboard.

9. Recycled toilet paper.

10. Canned goods — even canned organic tomatoes.

11. Many hard plastic dishes and cups — Plastic #7.

12. Blue-tinted five gallon drinking water bottles — plastic #7 or polycarbonate.

13. CDs.

Many states are banning BPA in children’s products

Because of the vast amount of data showing harm of this estrogen-mimicking chemical in very low doses, 20 states are in the process of banning BPA in baby products. Suffolk County, NY was the first county in the U.S. to ban BPA. Several states — Connecticut, Washington, Oregon, Minnesota, and New York — already have passed legislation to reduce BPA exposure. In June 2010, in a unanimous vote, both the Senate and Assembly of the New York State Legislature voted to ban the sale of paci-

fiers, baby bottles, sippy cups, and straws containing BPA. The statewide ban in Connecticut included not only baby food cans and jars, but also reusable food and beverage containers without an age limit. Washington became the fifth state to pass a ban which included not only drink cups and bottles used by kids under three years old, but also water bottles. Federal legislation has also been introduced to remove BPA from canned goods and food containers (HR 1523).1 In addition, there is legislation to ban BPA as a contaminant in foods via the proposed Federal Food Safety Bill (S 510). This would also expand the FDA’s authority over food processing and production.

California introduced Pavley SB 797, which bans BPA not only in baby bottles, but also in canned beverages and food containers for children three-and-under. This passed the Assembly and all committees in the Senate. It was ultimately killed in the Senate due to attacks by the chemical industry claiming there would be no more baby formula, as these cans are lined with BPA.

Canada and Australia have banned BPA in some consumer products

Canada has voluntarily banned BPA in all baby bottles, as of 2008. In June 2010, the Australian government announced the phaseout of polycarbonate plastic baby bottles with BPA.

Conclusion: Beyond BPA

It appears that science has produced overwhelming evidence that BPA is toxic and widespread at environmentally-relevant levels. As a potent endocrine disruptor, it alters normal endocrine function and is especially harmful to pregnant women and the developing fetus, as well as children. This dangerous chemical should be removed from most, if not all, consumer products in a phased fashion, beginning with any container or product used for food or water, medical devices, thermal paper, and then beyond.

CMA resolution passed

At the 2010 House of Delegates, the CMA passed a resolution to call for the reduction, towards elimination, of BPA in all consumer products. Hopefully, legislation to reduce harm from this chemical and others will get some traction in the new year.

Removal of bisphenol A from consumer paper products — 116-10 Resolved: that the CMA recognizes a public health concern for bisphenol A, a known

endocrine disruptor, and endorses efforts to reduce, towards elimination, BPA in consumer products including food containers, baby products, and thermal paper products.

References BPA

For a full report of all references, visit www.sccma-mcms.org and click on the “Going Green” tab.

1. http://www.scorecard.org/chemicalprofiles/def/hpv.html.

2. Bisphenol A data in NHANES suggest longer than expected HalfLife, substantial nonfood exposure, or both. Environmental Health Perspectives, January 2009, Stahlhut R. 3. EPA lists BPA as chemical of concern http://yosemite.epa.gov/opa/admpress. nsf/eeffe922a687433c85257359003f534 0/78110048d7f696d1852576f50054241 a!OpenDocument.

Researchers at Yale University found that BPA exposure during pregnancy caused permanent abnormalities of the uterus of the offspring, including alternation of DNA

4. BPA Legislation http://www. saferstates.com/2009/03/bpa-states. html.

5. Asthma. Maternal Bisphenol A Exposure Promotes the Development of Experimental Asthma in Mouse Pups. Environmental Health Perspectives. Vol. 118(2) Feb 2010.

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member CONTRIBUTION

Richard L. Mahrer, MD SCCMA Member Since 1956

This, I Believe The importance of giving

By Richard L. Mahrer, MD I am nearly 83 years old. I am still a practicing physician and have been in the sole practice of internal medicine for 54 years because I still believe in giving to my patients all that I can, from the profession I truly love. My wife (youthful and beautiful) is my office manager and is no doubt one of the reasons patients still come. Together, we make a good health team, but in a league which time has nearly forgotten.

I’ve always believed in the importance of giving both of myself and my skills to any patient who chooses me as their doctor.

When I had the good fortune to be admitted to medical school, it was with enormous relief, gratitude, and enthusiasm. I believed I had found my life’s work, despite the seem-

ingly endless hours of study, examinations, and training, which did, however, succeed in producing an embryo physician, enabling me to enjoy the coming years of practice with a significant measure of equanimity, which I feel is the sin equa non of medical practice.

Internship, residency, and temporary service in the Army Medical Corps encompassed a six-year interval after medical school graduation, helping to improve my confidence and experience, confirming the belief that the giving of myself and my skills to my patients was to become the mantra of my professional life. I believe that my work as a physician is neither a part-time job, nor should it lead to premature retirement as a result of financial reward. I believe that my life’s work should last a lifetime

and that I owe that much to my teachers, who had confidence in me, and to my patients, who I hope have felt the same.

I believe that in giving to patients my listening, understanding, and experience sprinkled with a generous helping of humor, and even a little skill, has rewards far in excess of monetary compensation. The simple act of giving has the emotional satisfaction and contentment that keeps me looking forward to my next day of practice—which is still 24/7!

I also believe in my patients, who are often engulfed in unwanted medical and emotional tragedies. I still make house calls, which is a practice not included today in most physician’s list of therapeutic endeavors. One involved a non-reimbursed, life-saving helicopter call and out of town (aerial call) to accompany a paraplegic patient on her dream balloon ride when her local physicians refused to go. I also take care of patients in convalescent homes (where many colleagues fear to tread), as well as seeing office patients, and those who tragically end up with hospice care.

I believe giving can create a positive affect so important to patients who return the favor to me, but I also believe in the advancing and exciting new innovations in diagnosis and treatment, which will benefit our entire global community.

My medical journey in solo practice is fast becoming an extinct entity and I’m afraid I can be considered a medical dinosaur.

Perhaps medicine is advancing at such a great speed, that the time honored doctor/patient relationship will become sadly challenged and jeopardized. I only hope the new wave of physicians will share the beliefs of giving that have made for me a practice filled with joy and satisfaction. It is a work still in progress and certainly not yet finished.

Richard L. Mahrer, MD, has been an SCCMA member since 1956. He has practiced internal medicine in San Jose for over 54 years.

28 | THE BULLETIN | MARCH / APRIL 2011

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When someone in your family gets sick, it feels like you are going walking by yourself. But when hospice comes, you feel like somebody is guiding you and you are not alone. Thank God there’s a program like this that picks you up and helps prepare you for the journey you and your loved ones are going to take. Hospice of the Valley helps everyone prepare for that.

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When patients and families are coping with serious, life-limiting illness,

they require expert care, compassion and personal attention. Whether it is spending time with loved ones, fulfilling dreams, or simply remaining comfortable and independent for as long as possible, Hospice of the Valley guides patients and their families to meet their goals.

• The hallmark of hospice care is that it serves patients wherever they live—be it in their home, nursing home, hospital or assisted-living facility • Hospice of the Valley team members consist of physicians, nurses, social workers, chaplains, hospice aides, volunteers, and grief counselors who are experts in palliative and hospice care and are available to assist in the management of your patient’s needs Margarita Vizcaya, hospice aide

Jeanne Fabricius, RN, case manager

• For those dealing with grief and loss, the Community Grief and Counseling Center at Hospice of the Valley provides families and individuals with one-on-one counseling and loss-specific support groups to adults, teens and children • Since 1979, Hospice of the Valley‘s legacy of compassionate palliative and hospice care, community education, advocacy and outreach has set the standard for quality hospice care state wide and nationally, and our organization is a locally-based, operated, and supported non-profit organization Monique Kuo, MD, medical director

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MARCH / APRIL 2011 | THE BULLETIN | 29

medico news

Governor Brown signs budget bills, including Medi-Cal and Healthy Families cuts Governor Jerry Brown signed budget bills on March 24 containing $14 billion in cuts, including reductions in Medi-Cal and Healthy Families programs, which the California Medical Association (CMA) strongly opposed.

However, the budget bills prohibit the state from implementing the Medi-Cal cuts unless they are approved by the Centers for Medicare and Medicaid Services (CMS). CMA’s advocacy team will be doing everything possible to stop those cuts before they are implemented. CMS denied the 2008 Medi-Cal reductions, and although that issue is still under appeal, the state has not presented any new evidence that would cause CMS to change its opinion.

The cuts in the bills the governor signed included: • A 10% reduction in Medi-Cal provider reimbursement rates.

• Mandatory Medi-Cal co-payments for physician office visits ($5), non-emergency use of the emergency room ($50), and inpatient hospital stays ($100 per night up to a $200 maximum). The $5 Medi-Cal copayment, never before required in California, also applies to dental and pharmacy visits and Medi-Cal prescriptions.

• A “soft cap” on physician office visits of seven per year. This is called a “soft cap” because physicians will be allowed to authorize more office visits if they feel they are medically necessary.

• Increases in premiums and co-payments for children enrolled in Healthy Families.

• Elimination of vision services in Healthy Families.

CMA succeeded last month in working with emergency physicians to remove from the budget a provision that would have taken $55 million from the Maddy Emergency Medical Services Fund, which reimburses emergency and on-call physicians and hospitals for treating the uninsured.

CMA is continuing negotiations on a compromise proposal to allow the state to obtain a federal match for a portion of the Maddy Fund, which would permit the fund to retain its core purpose of caring for the uninsured. A loss of the entire Maddy Fund would threaten access to emergency care throughout California.

All told, the Legislature has approved and the governor has signed budget cutbacks, closing roughly half of the state’s $26.6 billion deficit.

Approximately $1.7 billion of the reductions were in the Medi-Cal program. Spending also was slashed for child care, universities and colleges, libraries, transportation, state parks, and prisons.

Still unresolved are the governor’s proposal to eliminate more than 400 redevelopment agencies, and, the cornerstone of his budget, a measure that would ask voters to approve a five-year renewal of temporary vehicle, sales, and income taxes that are due to expire July 1, 2011.

Brown is in continuing negotiations with lawmakers to resolve the remaining issues.

(California Physician News, posted March 25, 2011)

Act now to avoid e-prescribing penalties in 2012 A change in Medicare law will penalize physicians beginning in 2012 if they don’t e-prescribe in the first six months of 2011. The new rules require physicians in individual practices to submit at least 10 Medicare Part B claims with the electronic measure code eRx G8443 and an eligible encounter code by June 30, 2011, or face a claims payment reduction of 1% in 2012. Physicians must also submit electronic prescriptions at least 25 times by the end of 2011 to avoid a penalty in 2013.

A group practice participating in eRx GPRO I or GPRO II must also submit a minimum number electronically, but the number required will vary by the size of the group.

Physicians can also avoid the reduction if they have fewer than 100 cases containing an encounter code in the measures denominator (outpatient E&M codes) for the period January 1 to June 30, 2011. Further exemptions are described by the Centers for Medicare & Medicaid Services (CMS) in the educational article “2011 Electronic Prescribing (eRx) 30 | THE BULLETIN | MARCH / APRIL 2011

Incentive Program Update—Future Payment Adjustments,” available at http://www.cms.gov.

It should be noted, however, that a February 17 report by the Government Accountability Office criticized CMS for failing to coordinate the e-prescribing program with the federal electronic health record (EHR) incentive program, which provides financial incentives to physicians who demonstrate “meaningful use” of an EHR system. Each program requires different technology and each has different reporting criteria.

The American Medical Association and other medical organizations wrote a letter to the U.S. Department of Health and Human Services in December 2010, urging changes in the e-prescribing program, but CMS has not yet responded.

(CMA Alert, March 21, 2011 issue)

California physicians among most efficient Medicare providers California physicians who provide care to Medicare patients are among the nation’s most efficient, spending just 90% of the national average per patient, once the rates are cost- and risk-adjusted, according to new data made public by the Institute of Medicine (IOM). Physicians in many California regions spend much less, the IOM data showed.

The analysis by IOM’s Committee on Geographic Variation in Medicare Spending and Value counters previous studies published in the Dartmouth Atlas that found wide variations in spending across the country, and alleged that California had some of the highest spending regions.

“The new IOM data set correctly shows that California physicians provide some of the highest-value care in the nation,” said California Medical Association (CMA) President James Hinsdale, MD. “The IOM validated the CMA message that policy makers must take into account risk and cost factors when designing Medicare payment systems to ensure seniors get the health care they need, no matter what their background or where they live.”

CMA has long argued that Medicare spending must be adjusted for geographic practice cost differences and the socioeco-

nomic and health status of patients. California has some of the highest rents and wages in the country. CMA believes that lowering payments in high-cost areas, without adjusting for practice costs, would undermine quality of care and drive more physicians out of these highcost areas.

IOM, an independent nonprofit organization tasked with studying geographic differences in Medicare spending and value of care, released the data for public comment before making its final recommendations to Congress on new Medicare payment methodologies.

California legislators were recently briefed on the IOM committee’s findings by CMA member Lawrence deGhetaldi, MD, president of the Santa Cruz division of the Palo Alto Medical Foundation and chair of CMA’s Medicare Technical Advisory Committee. Dr. deGhetaldi, a national expert on Medicare geographic payment issues, also told a joint hearing of the Senate and Assembly Health Committees that to further control costs, it is important to invest in primary and preventive care and chronic disease management.

During the earlier federal health care reform debate, some members of Congress proposed a Medicare payment “value modifier”

based on the Dartmouth Atlas studies that would have rewarded physicians spending less than the national average per Medicare beneficiary and cut payments to physicians spending more than the national average. This proposal would have reduced Medicare payments to California physicians by more than 15%, using the Dartmouth methodology.

CMA successfully argued against those payment cuts, and Congress ordered IOM to study the issue and make recommendations.

In his testimony to IOM, Dr. deGhetaldi said, “While Dartmouth Atlas studies show big variations in Medicare spending region to region, they do not adequately weight for other crucial factors that account for these differences, such as costs to practice medicine in different regions and differences in patients’ income levels, ethnicities, and health histories.

“Once you accurately assess risk and cost factors unique to each region,” deGhetaldi said, “Medicare spending does not differ as much region to region. For example, Los Angeles County has a high poverty rate and high rents and wages, which all push up the cost of providing health care there.”

(CMA Alert, March 21, 2011 issue)

CMA offers guide and model documents to help physicians comply with ATD standards The California Medical Association’s (CMA) “Guide to CMA Sample ATD Exposure Control Documents” is now available to help physicians comply with the Aerosol Transmissible Disease (ATD) standards adopted by the California Occupational Safety and Health Administration (OSHA) in 2009.

This guide, developed by Jeff Tanenbaum, chair of the Nixon Peabody LLP Occupational Safety and Health Group and one of the leading OSHA attorneys in the nation, will help physicians determine if they are covered by

the standard. It also helps physicians identify specific occupational exposure control policies and procedures that their practices need to develop and document, with prompts to customize the plan for various office settings.

The guide includes samples of CMA’s Model ATD Exposure Control Plan and Model Policies and Procedures for Referring or Exempt Employers.

For more information on the ATD standards, see CMA’s webinar, “Take a Deep Breath and Cough: Compliance with the ATD

Standard,” available for on-demand viewing to CMA members. Additional information is available in CMA On-Call document #1842, “Protecting Employees from ATDs in the Health Care Workplace.” CMA’s archived webinars and On-Call documents are free to members at the CMA members-only website, http://www.cmanet.org/member.

(CMA Alert, March 21, 2011 issue)

MARCH / APRIL 2011 | THE BULLETIN | 31

CMA delegation meets with CMS, members of Congress on health reform, Medi-Cal, Medicare Members of the California Medical Association (CMA) executive committee, county medical society leaders, and a contingent of California medical students recently traveled to the nation’s capital for the American Medical Association’s Lobby Day. The CMA delegation met with 30 members of Congress and their staffs and with Donald Berwick, MD, administrator of the Centers for Medicare & Medicaid Services (CMS).

Protect access to care, CMA urges CMS’s Berwick. In a lengthy meeting with Dr. Berwick and his staff, the CMA officers asked that CMS continue to protect access to care by rejecting the State of California’s request to reduce Medi-Cal physician reimbursement rates by 10%.

They reminded Dr. Berwick that MediCal rates in California rank 47th among the 50 states and are 40% below Medicare rates. Because half of California’s doctors cannot afford to accept Medi-Cal patients, 50% of Medi-Cal patients report difficulty in finding a doctor.

Recognizing that successful implementation of health care reform in California depends upon appropriate access to care in the state’s Medi-Cal program, the CMA officers informed Dr. Berwick that CMA is eager to work with CMS as it prepares a rule to clarify the federal “equal access” law, which requires

states to provide Medicaid (Medi-Cal in California) recipients access to medical care equal to the care of privately insured persons.

CMA leaders also discussed accountable care organizations (ACOs) and asked that CMS allow flexibility for different models that reflect local community needs. CMA emphasized that ACOs should be led by physicians. CMA leaders also told Dr. Berwick that CMS should focus on providing resources to help independent solo and small group physicians succeed in the era of health care reform.

Other topics of the daylong meeting included a long-overdue California geographic payment formula fix; how the value index should be cost and risk adjusted to account for California’s higher practice expenses and the socioeconomic health status of patients; and a new quality assessment proposal from CMA’s Institute for Medical Quality.

CMA’s Capitol Hill meetings press Congress on wide range of issues. CMA’s delegation to the nation’s capital also met with 30 members of Congress and pushed for changes in the new health care reform law, including increases in the Medi-Cal reimbursement rate, and elimination of the Independent Medicare Payment Advisory Board (IPAB).

CMA continued to advocate for a repeal of the Medicare Sustainable Growth Rate (SGR)

physician payment formula. CMA reminded lawmakers that physicians face a 27% Medicare SGR payment cut on January 1, 2012, unless Congress acts to stop the cuts and maintain access to physicians for California’s seniors and military families. CMA is working with other groups in organized medicine to develop an alternative to the flawed Medicare SGR payment formula to present to Congress before the end of the year.

The delegation also urged members of Congress to give seniors increased freedom to see the physician of their choice. To improve access to care, CMA is proposing legislation that would allow seniors to use their current Medicare coverage to see a physician who does not participate in Medicare through a private contract with the physician.

CMA also lobbied the lawmakers for protection of the Medical Injury Compensation Reform Act (MICRA), California’s landmark medical liability law, which has saved billions of dollars in health care costs for both physicians and patients across California. CMA is keeping a close watch on federal medical liability legislation to make sure that it does not undermine California’s successful law.

(CMA Alert, March 7, 2011 issue)

Use CMA’s online “return on investment” calculator to gauge physician savings from converting to electronic health records The California Medical Association (CMA) has launched a new resource to help physicians estimate savings and return on investment if they make the switch from traditional paper medical records to electronic health record (EHR) technology.

The resource is called the ROI Calculator and it is available at http://www.cmanet.org/ roi. To use the calculator, click on either “primary care practice” or “specialty practice” and 32 | THE BULLETIN | MARCH / APRIL 2011

begin by answering some basic questions about your practice, including average number of patients seen per year, average charge per office visit, and what percentage of patients’ visits are considered new patients.

When you have answered all the questions, you will be able to estimate your administrative savings, how much you qualify for in federal incentive payments, and what the overall return on investment would be from con-

verting to electronic health records.

Also coming soon is CMA’s model EHR contract. The model contract will provide CMA members with an example of a physician-friendly vendor agreement that can be used in negotiating vendor contracts. For the latest information on health information technology (HIT), go to CMA’s HIT Resource Center at http://www.cmanet.org/hit.

(CMA Alert, February 23, 2011 issue)

Federal appeals court exempts physicians from costly FTC “red flags” identity theft rule A federal appeals court has ruled that physicians who bill patients after providing services are not subject to the expensive and burdensome requirements of the Federal Trade Commission’s “red flags” rule. The rule, which took effect last year, requires financial institutions and “creditors” to implement identity theft detection and prevention programs.

Despite objections from the California Medical Association (CMA), the American Medical Association (AMA), and others in organized medicine, the FTC had insisted that physicians who regularly bill their patients for services (including co-payments and coinsurance) are considered “creditors” and thus are subject to the red flags rule.

CMA argued that the rule is unnecessary for most physicians because the Health Insurance Portability and Accountability Act (HIPAA) and California laws impose strict requirements to safeguard the confidentiality and security of patient information.

CMA and AMA also objected to the red flags rule requirement that physicians verify the identity of their patients before agreeing to treat them if the patients did not pay in-full at the time of the visit. The intention of the requirement was to prevent identity theft so that if a patient provides a false identity, the wrong person would not be billed for the physician’s care.

But physicians objected, arguing that requiring proof of identity is time-consuming, awkward, and might delay care if the patient failed to bring proper documents to their appointments.

AMA applauded the ruling by the U.S. District Court of Appeals in Washington, D.C. “The court’s decision reinforces the intent of a new law clarifying the scope of the red flags rule and helps eliminate any further confusion about the rule’s application to physicians,” said AMA President Cecil Wilson, MD. After the appeals court ruling, AMA dropped a lawsuit it brought against the FTC in May 2010.

In December 2010, President Obama signed the Red Flag Program Clarification Act of 2010, which states that small businesses, such as physician offices, are not classified as creditors because they do not provide or maintain accounts that are identity theft risks.

“The Clarification Act makes it plain that the granting of a right to ‘purchase property or services and defer payment therefore’ is no longer enough to make a person or firm subject to the FTC’s red flags rule— there must now be an explicit advancement of funds,” said the ruling by the three-judge appeals panel.

(CMA Alert, March 21, 2011 issue)

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A3208_Bulletin_SantaClara.indd 1

2/1/11 4:17 PM MARCH / APRIL 2011 | THE BULLETIN | 33

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CRAFT YOUR IMAGE TO MATCH YOUR PROFESSIONALISM Medical office build-outs take a specialized skill to get done right. With rents nearing $4.00/sq ft in spaces adjacent to the local hospitals many doctors are converting professional office space to medical use for almost half the cost. Married to a surgeon, I understand the business of medicine and can help you manage your facilities costs to help reduce your overall cost structure.

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We are Wealth Advisors and Financial Planners to high net worth individuals, families and institutions.

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The LWA team includes Michelle Hamilton, MBA as a specialist in financial planning and portfolio administration.

MARCH / APRIL 2011 | THE BULLETIN | 35

Classifieds office space for rent/lease PRIMARY CARE/LOS GATOS SPACE FOR LEASE Part- or full-time physician sought to join existing practice to share rent and staff. 3,400 sq. ft. recently remodeled space with onsite lab.

Currently, we have one full-time MD and one part-time MD. Concierge practice setting. Very light call schedule, approximately one weekend in 17. Hospital work by choice only, close to Good Samaritan Hospital.

If interested, or for further details, please call 408/829-3033.

MEDICAL SUITES • LOS GATOS – SARATOGA Two suites, ranging from 1,000 to 1,645 sq. ft., at gross lease cost. Excellent parking. Located next door to Los Gatos Community Hospital.

Both units currently available. Call 408/355-1519.

MEDICAL OFFICE FOR LEASE/SUBLEASE/SALE Office in close proximity to O’Connor Hospital for lease/sublease/ sale. Please call 408/923-8098 for more information.

OFFICE SUITE AVAILABLE Location is highway 85 at De Anza. One suite available. Currently configured with six Tx rooms/offices, entry, large master office with balcony. Street signage to 100,000 cars a day. Marble entry. Zoned medical/office. No variance required. Looking for established business/practice that values prime location in beautiful building. Please be qualified. No start ups. Contact Dr. Newman at 408/996-8717. Brokers welcome if you have a client. $2.00 per sq. ft. plus 3N. Located at 1196 South De Anza at Rainbow.

MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/2280454.

OFFICE/LAB SPACE FOR LEASE • MTN VIEW One room space. Office/lab – upstairs. Located at 2500 Hospital Dr, Bldg I, Mtn View. Call 831/375-6105.

MEDICAL/DENTAL OFFICE SPACE FOR LEASE • MTN VIEW Medical/dental office space located at 2500 Hospital Dr, Bldg I, Mountain View. Call 831/375-6105.

MEDICAL BUILDING FOR LEASE • FREMONT New Class A medical building for lease in Fremont with surgery center, imaging center, and abundant parking. Trask Leonard, Bayside Realty Partners, 650/282-4620, or tleonard@baysiderp.com.

MEDICAL OFFICE TO SHARE • SUNNYVALE One exam room plus one large office, shared waiting room and front office. Newly built, 1,280 sq. ft. Call 408/438-1593.

ELEGANT AND SPACIOUS LOS GATOS MEDICAL OFFICE Available to share with prominent aesthetic dermatologist. This upscale office has seven exam rooms, a lab, two large administrative offices, and a marble and granite waiting room with comfortable seating for eight patients. Call Irene at 408/358-5757 to schedule your private showing. Price is negotiable.

MEDICAL SUITES • GILROY First class medical suites available next to Saint Louise Hospital in Gilroy, CA. Sizes available from 1,000 to 2,500+ sq. ft. Time-share also available. Call Betty at 408/848-2525.

36 | THE BULLETIN | MARCH / APRIL 2011

DOWNTOWN MONTEREY OFFICE FOR SUBLEASE Spacious, recently remodeled, excellent parking, flexible terms. Call Molly at 831/644-9800.

MEDICAL OFFICE TO SHARE • SAN JOSE Conveniently located off The Alameda near Hwy 87 and 880, with quick access to both O’Connor Hospital and Regional Medical Center of San Jose. Excellent parking, recently remodeled suite with two dedicated exam rooms and private office, shared reception, and waiting area. Please email: nsl1958@yahoo.com.

MEDICAL OFFICE TO SHARE IN MEDICAL BUILDING OF O’CONNOR HOSPITAL One large exam room and one office, shared waiting room, and receptionist area. Email at minasehhat@yahoo.com.

MEDICAL/PROFESSIONAL OFFICE FOR LEASE Medical/Professional office 2,600 sq. ft, ground floor near Santana Row. $2.00 sq. ft. Available now. Email at sksiddiqui@yahoo.com.

OFFICE SPACE FOR LEASE OR PURCHASE • SAN JOSE For lease or purchase. 900 sq. ft. space in a medical/dental office building opposite Regional Medical Center. Please call 408/926-2182.

AGRESSIVELY PRICED MEDICAL/DENTAL OFFICES FOR LEASE • CAMPBELL, CA 3,000 sq. ft. and 1,600 sq. ft. office spaces conveniently located on Bascom Avenue between O’Connor and Good Sam Hospital. Larger suite has two separate entrances and break area. Space is ideally suited for separate office/procedure area configuration. Covered parking, monument signage, and elevator included. Vascular surgeon currently occupies second floor. 50 K TI package offered for 5+ year lease. Owner will build to suit. $2.25/sq. ft. NNN. Call 408/858-3586.

SAN JOSE DENTAL/MEDICAL/PROFESSIONAL OFFICE FOR LEASE Two suites, 1,532 sq. ft. and 2,518 sq. ft. Plumbing ready for dental offices, can be used as medical, lab, or professional offices. Located across the street from Regional Medical Center of San Jose, 2380 Montpelier Dr.; easy freeway access to 680/101/880. Call Thuy Le at 408/272-3706.

PRIME MEDICAL OFFICE FOR LEASE • SAN JOSE Excellent location. Westgate area. 1,584 sq. ft. West Valley Professional Center, 5150 Graves Ave. Suite 2/stand-alone unit. Private office, reception area, exam rooms with sinks. Available 2/1/11. Call owner at 408/867-1815 or 408/221-7821.

SANTA CLARA OFFICE • HOMESTEAD AND JACKSON Plumbed for Dental/Medical, or other use. 1,200 sq. ft. Downtown across from post office and weekly farmers market. Excellent location! Dentist on site, please do not disturb. Don’t miss! Come see! Call 408/838-8191 or 408/741-1956.

MEDICAL/PROFESSIONAL OFFICE SPACE • SAN JOSE Located off The Alameda near Race Street, conveniently accessible to both O’Connor Hospital and Regional Medical Center of San Jose.

1,100 sq. ft. suite with excellent parking. Asking $1.25 per sq. ft. with no triple net. Please email: tgallo@svmsmg.com or call 408/410-7533.

MEDICAL OFFICE FOR LEASE • REGIONAL MED CENTER AREA Suite at new medical office building next to hospital. Three exam rooms. Ready to move in. Call 408/393-2883 or 408/206-2237.

PRIVATE PRACTICE/OFFICE for sale PRIVATE PRACTICE FOR SALE IM/FP/GP. Primary care practice for sale, including inventory and equipment. Close to O’Connor Hospital. If interested, please call Stacy at 408/297-2910.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Dan R. Azar MD, MPH at 408/790-2907 or e-mail dazar@allianceoccmed.com for additional information.

NURSE PRACTITIONER/PHYSICIAN ASSISTANT Part-time Nurse Practioner/Physician Assistant to provide care under MD supervision.

Includes H&P and occasional detoxification from drugs/alcohol. Knowledge in CD is desirable, but not necessary. Physician training is provided. Call Robert Daigle, MD at 408/568-7004.

have superb communication, clinical, and warm interpersonal skills. Offering a competitive salary. Located in Sunnyvale. Send CV to lbeem@eyelink.com.

PHYSICIAN OPPORTUNITY Established group has opportunity for Internal Medicine physician to join. The practice is located in Los Gatos; has reasonable call schedule. Please send letter of interest and CV to fax 408/358-0261 or email to Cristine at: lrpg@yahoo.com.

• • • • • •

BETWEEN SAN FRANCISCO & CARMEL Tri-level condo right on ocean. Bedroom/bath on every level. Master bedroom offers sitting area, stereo, sauna, and hot tub overlooking ocean. Living room has wood burning stove, TV, spiral staircase to third level bedroom with access to ocean front deck. 468 Ocean View, La Selva Beach, CA. Kendall & Potter Property Management, 800/386-6826 or www.montereycoast.com.

FOR SALE BEAUTIFUL PALMILLA TOWNHOME • CABO 2 Bedroom/2.5 bath/1,600 sq. ft.; golf, beach.

Villa Diamonte D403. Call 408/309-8457. http://bit.ly/caboforsale.

Full Service Billing 25 years in business Book Keeping ClinixMIS web based software Training and Consulting Client References

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com

condo/COTTAGE rentals

Visit our Website www.metromedicalbilling.com

CHANGE THE WAY PATIENTS SEE YOU

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All medical practices are unique in services and the part of the community they serve

WANTED

Call for a complimentary consultation for a “check up” on your practice

PEDIATRIC PRACTICE Will buy Pediatric practice in South Bay. Call 408/455-2959.

Integrated Physician Services 831-324-0441 Ipsmonterey.com

TURN KEY OPERATION • MEDICAL WEIGHT LOSS FOR PHYSICIANS California Medical Weight Management offers a turnkey opportunity for physicians to participate in a profitable medical weight loss industry. We provide a comprehensive threestep program, procedures and protocols, collaterals, software to run the entire medical weight loss, marketing and advertising assistance. Physicians on the average can expect to add $1,500 – $1,800 per day in additional revenue. Please get in touch with us, if you are interested in becoming involved in this high-growth sector and bringing substantial health benefits to your patients while adding significant revenue to your practice. Email: partnership@calmwm.com. (www.calmwm. com).

OPHTHALMOLOGIST WANTED Part-time, board certified General Ophthalmologist to compliment dynamic MD/OD group. Oculoplastic specialist a plus. Must

METRO MEDICAL BILLING, INC.

Pajaro Dunes Beachfront Condo Shorebirds #58 2 Bedroom -- 2 Bath Top Level -- Great Ocean View Great for Families Owners Bill & Debbi Ricks 408-354-5613

Rental Agent Pajaro Dunes Company 1-800-564-1771 MARCH / APRIL 2011 | THE BULLETIN | 37

Our Policyholders Own the Company

James O. Gemmer, MD Chairman of the Board

What does this mean?

It means they receive the profits, $24,000,000 in dividends in 2011!

“

We return operating profits after expenses back to our policyholders as dividends in the form of premium credits.

”

In California this is an average savings on premiums of 40.4%* for 2011.

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KEEPING TRUE TO OUR MISSION For more information or to apply contact: n

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MIEC 6250 Claremont Avenue, Oakland, California 94618 • 800-227-4527 • www.miec.com SCCMA_ad_03.17.11

38SCCMA_Ad_03.17.11.indd | THE BULLETIN 1 | MARCH / APRIL 2011

MIEC Owned by the policyholders we protect.

3/17/11 12:12 PM

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MARCH / APRIL 2011 | THE BULLETIN | 39

BULLETIN THE

Address service requested

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way, San Jose, CA 95128-4705

We provide superior protection.

Some insurers cap their defense costs or take them from your coverage limits.

NORCAL Mutual does not.* We are committed to protecting you regardless of the cost. There is no cap on the value of the reputation you’ve earned.

To learn more about NORCAL Mutual’s products and services, please contact: > Ken Stacey, Senior Account Executive License #: 0A00400

Phone: 800-652-1051, ext. 2054 Fax: 415-735-2353 E-mail: kstacey@norcalmutual.com

Our passion protects your practice

NORCAL Mutual is proud to be endorsed by the Santa Clara County Medical Association as the preferred medical professional liability insurer for its members.

* Except for DataShield™, our coverage enhancement for risks associated with

information and network security. DataShield coverage limits include defense costs.

You provide superior care.

PRSRT STD U.S. Postage PAID San Jose, CA Permit No. 503