MARCH/APRIL 2015 | VOLUME 21 | NUMBER 2
BILLING, CASH FLOW & ICD-10 Also Inside: Understanding Revenue Recovery Wi-Fi in Schools Telemedicine and Physician Liability Issues
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70078 (3/15) Copyright 2015 Mercer LLC. All rights reserved.
Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 777 S. Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.insurance.service@mercer.com • www.CountyCMAMemberInsurance.com * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days’ advance written notice. The County Medical Associations & Societies receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.
2 | THE BULLETIN | MARCH / APRIL 2015
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 Billing/Collections CME Tracking Discounted Insurance Financial Services Health Information Technology Resources House of Delegates Representation Human Resources Services
Feature Articles 8 Billing, Cash Flow & ICD-10 12 Understanding Revenue Recovery 16 Wi-Fi in Schools: Are We Playing It Safe With Our Kids? 26 Telemedicine and Physician Liability Issues 28 Primary Care Physicians: The Front Lines of Mental Health Care and the Fight Against Stigma 30 Do You Know How to Make Insulin Work Backward?
Legal Services/On-Call Library
Departments
Legislative Advocacy/MICRA
5 From the Editor’s Desk
Membership Directory iAPP for
6 Message From the SCCMA President
the iPhone Physicians’ Confidential Line
7 Save These Dates: Annual Awards Banquets and Installations
Practice Management
34 Medical Times From the Past
Resources and Education Professional Development Publications
36 MEDICO News 42 Energy Bars, From Sports to Snacks 44 Classified Ads
Referral Services With Membership Directory/Website Reimbursement Advocacy/ Coding Services Verizon Discount MARCH / APRIL 2015 | THE BULLETIN | 3
THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President James Crotty, MD President-Elect Eleanor Martinez, MD Past President Sameer Awsare, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Peter Cassini, MD VP-Professional Conduct Seema Sidhu, MD Secretary Seham El-Diwany, MD Treasurer Scott Benninghoven, MD
CHIEF EXECUTIVE OFFICER
COUNCILORS
William C. Parrish, Jr.
El Camino Hospital of Los Gatos: Ryan Basham, MD El Camino Hospital: Laura Cook, MD Good Samaritan Hospital: David Feldman, MD Kaiser Foundation Hospital - San Jose: Hemali Sudhalkar, MD Kaiser Permanente Hospital: Anh Nguyen, MD O’Connor Hospital: Michael Charney, MD Regional Med. Center of San Jose: Erica McEnery, MD Saint Louise Regional Hospital: Diane Sanchez, MD Stanford Hospital & Clinics: Vanila Singh, MD Santa Clara Valley Medical Center: Richard Kramer, MD
CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Randal Pham, MD (Ethnic Member Organization Societies) Tanya Spirtos, MD (District VII)
BULLETIN
THE MONTEREY COUNTY MEDICAL SOCIETY
Printed in U.S.A.
OFFICERS
Editor
President Jeffrey Keating, MD President-Elect James Hlavacek, MD Secretary Patricia Ruckle, MD Treasurer Steven Vetter, MD
THE
Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
Joseph S. Andresen, MD
Managing Editor Pam Jensen
Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising. 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 2015 by the Santa Clara County Medical Association.
4 | THE BULLETIN | MARCH / APRIL 2015
CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.
DIRECTORS Paul Anderson, MD Valerie Barnes, MD Ronald Fuerstner, MD Gary Gray, DO Steven Harrison, MD David Holley, MD John Jameson, MD
William Khieu, MD Eliot Light, MD Edward Moreno, MD Marc Tunzi, MD Craig Walls, MD Cary Yeh, MD
Have you sprung forward? By Joseph Andresen, MD
Editor, The Bulletin
JOSEPH S. ANDRESEN, MD
FROM THE
Have you sprung forward? Hopefully by now, we have adjusted to the time change and are enjoying the longer days and seasonal changes. Spring is here in Northern California! Certainly there is an ongoing concern of our continued drought and the realization that global climate change is upon us. Hopefully, there will be a continued and concerted effort to address this challenge with the same urgency that has been a call to action with recent public health crises such as Ebola, Alzheimer’s, and gun violence. Our March-April issue of the Bulletin highlights some timely and important topics. Are you getting proper payment from insurance companies for the care you render to patients? Are you getting your maximum in accounts receivable? These important issues are discussed in “Understanding Revenue Recovery” by Mark Christainsen. SCCMA members who are primary care providers don’t need to be told that they are on the front lines of mental health triaging and treatment. Over 50% of the population will have a mental health issue during one’s lifetime. Yet there is still a great stigma attached to mental illness that sets it apart from physical ailments. The importance of patient access, diagnosis, and proper treatment cannot be over emphasized. Read on to learn about “Each Mind Matters;” valuable tools and resources available to all physicians. Did you know that the deadline for implementing ICD-10 is this coming October, 2015? This will add over 68,000 diagnostic codes vs. the current ICD-9 listing of 13,000 codes. There are important strategies to prepare for these changes. This involves a proactive approach to meet compliance and facilitate proper reimbursement.
EDITOR'S DESK
Physician Editor, The Bulletin
Joseph S. 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 2015 | THE BULLETIN | 5
CMA Sponsored Legislation By James R. Crotty, MD, MBA President, Santa Clara County Medical Association
JAMES R. CROTTY, MD, MBA
MESSAGE FROM THE
SCCMA PRESIDENT
President, Santa Clara County Medical Association
James R. Crotty, MD, MBA, is the 2014-2015 president of the Santa Clara County Medical Association. He is a urologist and is currently practicing with The Permanente Medical Group/Kaiser in San Jose.
It is Spring and time to turn our attention to baseball and the newly elected and current representatives to the California Legislature. They have been busy introducing bills that they hope will become laws of the land. CMA has also been busy supporting some bills and tracking many others. The Bulletin is another way to get the word out. Here are some of the bills that CMA is currently sponsoring: Assembly Bill 366, introduced by Rob Bonta, JD, currently representing the 18th district (East Bay/Oakland), and Senate Bill 243 introduced by Ed Hernandez (Optometrist), currently representing the 22nd district (San Gabriel Valley) would increase Medi-Cal reimbursements. Medi-Cal is one of the lowest paying Medicaid programs in the country, ranking the 47th state. Also, there was a temporary increase in primary care to match Medicare that expired last December. The bill would restore a 10% cut to Medi-Cal reimbursement rates, and also place reimbursement on par with Medicare, increasing payment rates for inpatient hospital services and most outpatient services. The proposals would also require the Department of Health Care Services to pay Medi-Cal managed care plans at the upper end of the rate range. In 2011, Medi-Cal payment rates to doctors, hospitals, dentists, and other providers were cut by 10% as a way to balance the state’s budget. California now has one of the lowest payment rates in the country. The Medi-Cal program now covers more than 12 million patients, one in three Californians, and one in two children as a result of expanded eligibility under the ACA. The Department of Health Care Services has evolved from a direct payer of care to a contractor with health plans to provide health care services and holding them accountable for performance, quality, and access measures. Senate Bill 277, introduced by Richard Pan, MD and Ben Allen, JD, currently representing the 26th district (Santa Monica), would remove the
6 | THE BULLETIN | MARCH / APRIL 2015
personal belief exemption that is currently allowed to the immunization requirements for enrollment in schools in California. It would also require that schools notify parents/guardians of students about the immunization rates of the school. Senate Bill 591, introduced by Richard Pan, MD would increase the tobacco tax by $2 per pack and would allocate those funds to tobacco education, and related services provided by the Department of Health Care Services. Assembly Bill 1396, introduced by Rob Bonta, JD would provide oversight for the allocation of funds related to SB 591. This bill would also require an annual independent assessment of whether Medi-Cal provider rates are adequate. Senate Bill 563, introduced by Richard Pan, MD would require employers and insurers to disclose payment methodologies for the process of reviewing, approving, modifying, delaying, or denying requests by physicians related to providing medical services to injured workers. Assembly Bill 637, introduced by Nora Campos, currently representing the 27th district (San Jose), would allow nurse practitioners and physician assistants under physician supervision to sign Physician Orders for Life Sustaining Treatment (POLST) forms. The aim is to increase utilization and availability of the POLST forms. Assembly Bill 1086, introduced by Matt Dababneh, currently representing the 45th district (San Fernando Valley), would require health plans to honor assignment of benefit agreements, thereby sending any payment directly to the out-of-network provider when such an agreement is present. Assembly Bill 1434, introduced by Kevin McCarty, currently representing the 7th district (Sacramento), would close the “loophole” which allows Blue Cross and Blue Shield to choose the regulator with which to file their PPO products. This current loophole has been blamed on a loss of potential funds to the General Fund. The bill would also allocate these funds for the purpose of increasing provider rates under Medi-Cal. Assembly Bill 319, introduced by Freddie Ro-
! s e t a D e s Save The
SCCMA Annual Awards Banquet and Installation
Tuesday, June 9, 2015 | 6:15 pm Social | 7:00 pm Dinner & Program The Fairmont Hotel, San Jose Installation: Eleanor Martinez, MD, SCCMA President 2015-16 Honoring: James R. Crotty, MD, SCCMA President 2014-15 Award Honorees: John Sherck, MD – Benjamin J. Cory, MD Award Susan Kutner, MD – Contribution to the Community Stephen Wang, MD – Outstanding Achievement in Medicine Senator Jerry Hill – Citizen’s Award Arthur A. Basham, MD –Special Recognition Award James Wolfe, MD – Contribution in Medical Education (posthumous award) J. Ronald Tacker, MD – Contribution to the Medical Assoc.
Formal invitations will be mailed in May
•
MCMS Annual Physician of the Year Banquet & Installation Tuesday, June 2, 2015 | 6:30 pm Social | 7:00 pm Dinner & Program Bayonet Club/Black Horse Seaside Installation: James Hlavacek, MD, MCMS President 2015-16 Honoring: Jeffrey Keating, MD, MCMS President 2014-15 Physician of the Year: To Be Announced
Formal invitations will be mailed end of April
driquez, representing the 52nd district (Pamona) would require instruction on CPR and AED prior to graduation from high school. Support for this bill was recommended by the Council on Legislation. Another bill that is of importance to California physicians that CMA is currently tracking is Senate Bill 128, introduced by Bill Monning JD, currently representing the 17th district (Carmel), would allow citizens of California,
who have a terminal illness in certain circumstances, to choose to allow physicians to assist patients end their life. This bill is currently to be discussed by the CMA Board of Trustees. The best way to track these bills and others is the CMA website: cmanet.org. You can log in and write your opinion about these bills. CMA leadership is strongly encouraging members to use the website to get their opinions known and heard. It is easy to register. Please participate in
this democratic process. Your local Santa Clara County Medical Association Councilors spend time each meeting discussing the important California and federal legislative happenings. The CMA staff are knowledgeable and committed. A large share of our membership dues goes to the cost of the ongoing effort of advocacy for our members. Please encourage your friends to join CMA.
MARCH / APRIL 2015 | THE BULLETIN | 7
billing, cash flow, & icd-10 By Marion Webb This article is reprinted with the permission of Los Angeles County Medical Association’s Physician Magazine. With its October deadline approaching, ICD-10 implementation is at the top of the list of physician concerns for 2015. For many physicians, especially for those working out-of-network, knowing how to maximize recovery of pay will be a key consideration. In this article, we will address how you can prepare now to improve collections, and we will provide helpful tips and resources for getting on track to maximize your revenue.
LAYING THE GROUNDWORK FOR A SUCCESSFUL TRANSITION
Current ICD-9-CM diagnosis codes do not provide sufficient clinical specificity to describe the severity or complexity of various diseases, according to Physicians Practice. ICD-10 will add more than 68,000 codes, compared to ICD-9’s maximum of 13,000 codes. The new codes will be different in their organization, structure, detail, and composition and seek to improve operational capabilities of clinics and practices. Physicians will be able to better determine the severity of illnesses and therefore quantify the level of care more accurately. The codes will also create an electronic trail of documentation, which will 8 | THE BULLETIN | MARCH / APRIL 2015
help doctors receive proper payment and ensure that their reputation remains in good standing, wrote Mike Patel, CEO of Meditab Software, in an article published on the Advance Healthcare Network website. With the importance and significance of this transition, Patel said, it’s crucial that providers are amply prepared.
TIPS TO ENSURE ICD-10 READINESS AND MAXIMIZE INCOME
Here is a checklist of 14 tips from the experts to get on track with ICD-10 compliance and maximize revenue along the way. Experts include Patel as well as Robert Tennant, Health IT policy director for the Medical Group Management Association, and such online sources as Physicians Practice and Peoriamagazines.com. 1. CREATE AN IMPACT CHART: Practices should create an
impact assessment chart and capture key information in a spreadsheet including the area impacted, needed changes in workflow, how the new system will impact assigning of code, vendor information, and contingency plans. 2. TRAINING: To maintain their certifications, all medical coders must take a minimum number of ICD-10-specific CEUs before the compliance date. To ensure that your staff is adequately trained, the experts suggest conducting a gap analysis to determine your team’s knowledge of medical terminology, pharmacology, pathophysiology, anatomy, and physiology and review samples from different types of medical records to see whether the current level of documentation contains enough detail for ICD-10 coding. Physicians also have a learning curve, and those with specialty tools will be in the best position to make sure they aren’t negatively impacted financially. 3. TEST, TEST, TEST: Make sure your staff is up to speed and practices with active claims by coding them in the old system and the new to see if they are getting the right information. 4. CLEAR DOCUMENTATION: Ensure that your patient records are clear and complete in order to submit accurate claims and avoid delays in payment. 5. COST-EFFECTIVE RESOURCES: Visit the Centers for Medicare and Medicaid Services website as a resource. cms.gov/Medicare/Coding/ICD10/index. html?redirect=/icd10
Consultants advise doctors to keep three months of cash flow in reserve to prepare for any delays in pay as ICD-10 implementation gets closer.
6. SOFTWARE: In addition to impacting practice systems and electronic health record software, the move to ICD10 may require that practice software needs to be updated or replaced. To do this takes time and resources. 7. REGULATIONS: Know and identify all other regulations and changes so you won’t get behind as you approach ICD-10 implementation. 8. FILTERING: Filter out the codes you will be using the most for greater efficiency. 9. COMMUNICATE: Ensure clear communications with payers and clearinghouses to ensure that the system is ready to go, and ask if they are ready for the transition as well. 10. PAYERS: Find out if payers have adopted contractual changes regarding coding specificity that could affect how you process claims.
Continued on page 10
MARCH / APRIL 2015 | THE BULLETIN | 9
Billing, Cash Flow, & ICD-10, continued from page 9 11. EXTRA EXPENDITURES: Plan for unforeseen expenses in time and resources such as training of staff, IT upgrade costs, business process analysis of health plan contracts and documentation, and cash flow disruptions due to the ICD-10 transition. 12. OUTSOURCING VS. IN-HOUSE BILLING: If billing is handled in-house, the cost of keeping employees on staff may be higher than the cost of hiring a third-party biller. Here are some questions to consider in making the decision: What are some of the financial benefits in hiring a third-party biller that your practice currently does not get? How will your practice pay for the third-party biller and what hidden expenses will come up (postage or processing fees)? Also, ask yourself how will billing services be affected as your practice continues to grow, given that many revenue cycle management firms are paid a percentage of collections? 13. TURNOVER: Ask yourself if your billing department has a high turnover rate. If the answer is 20% or more, you may have inefficiencies that either need to be addressed in-house or may lead you to consider outsourcing. 14. HIRE COUNSEL: Because payment disputes are possible, providers should proactively address ICD-10 issues in their current negotiations. The attorneys at Epstein Becker & Green suggest that any provisions addressing group changes that address ICD-10, and those referencing “revenue neutral” requirements and provisions dealing with policy and manual compliance, should be carefully considered in contract reviews. Finally, the attorneys also recommend a clear, fair dispute resolution provision for ICD-10 conversion.
INCREASING YOUR CASH FLOW EARLY
While some organizations continue to wait to see if the compliance date of October 1 will truly stand, some experts caution that waiting for the final date could put your revenue at risk. Robert Wergin, MD, president of the American Academy of Family Physicians, expressed confidence that the October 1 deadline will stick. “This time, it looks like the real thing,” Dr. Wergin told Medscape. He agrees that doctors’ anxiety remains high over what it will take to implement the new coding system and what it will mean for doctors in terms of income. “There is concern that the technology won’t work when the systems start up,” he said. He also noted that providers might not get paid right away. The best way to prepare for any delays, the experts say, is to increase your cash flow early.
FIVE WAYS TO INCREASE CASH FLOW NOW:
1. CLEAR EXISTING BLOCKAGES: With the move by health plans to increase deductibles, more patients face higher outof-pocket costs. Rather than waiting to be reimbursed, by tapping into the payers’ systems, practices can assess the status of a patient’s deductible and accurately predict out-ofpocket expenses at the time of their visit. They then can obtain authorization right away to charge a patient’s credit card once the insurance claim is settled.
10 | THE BULLETIN | MARCH / APRIL 2015
2. USE NEW TECHNOLOGIES: Using new technologies such as lockbox services, remote deposit, electronic funds transfer, sweep accounts, and online bill payments for all expenses allows practices to get payments into their accounts faster. Combining claims into one outsourcing solution and a single electronic database rather than tracking them separately also helps improve cash flow. 3. COORDINATE CARE IN YOUR PRACTICE: In the old days, long wait times were seen as a sign of a physician’s popularity, but today any obstructions in a practice’s scheduling process will likely leave patients to seek care elsewhere. To keep your clients coming back and keep your reputation as an efficient and effective practice intact, you want to optimize care, which will ultimately translate into optimized cash flow. 4. IDENTIFY ERRORS EARLY: Post-service revenue cycle management opportunities abound, giving you tools to identify and correct errors before you submit a claim to your insurer. Also, training your staff to monitor claim denials to spot trends and fix problems at their source is key. Common preventable causes of claim denials include lack of insurance company-required referrals or prior authorization, inaccurate demographic or insurance information, claims that weren’t filed in a timely manner, and incorrect modifier, procedure, and diagnosis codes. 5. RULE OUT FRAUD: With large sums of cash coming in, it’s critical that you hire honest employees. It takes only one dishonest worker to disrupt your cash flow. Consider paying vendors with a business credit card instead of checks. Banks offer business credit cards to medical practices for internal use as well as credit card merchant processing for payments. Segregate banking duties among staff so no one person has access to all bank accounts. Ask your bank to send account statements directly to your accountant and limit online banking access. Put strong cash controls in place and log all funds collected on site and total them at the end of each work shift. Invest in periodic audits of internal controls performed by an accountant or an auditor who specializes in detecting fraud. Consultants advise doctors to keep three months of cash flow in reserve to prepare for any delays in pay as ICD-10 implementation gets closer. While some groups continue to push for additional delays, saying the mandate comes at a time when physicians are already dealing with several other technology requirements and risk penalties, several experts recommend that physicians who aren’t ready to comply put themselves at a financial risk.
Jun
2015 ICD-10-CM Code Set Boot Camp e3
0-
Jul
y1
• 20
15
Learn to code for ICD-10-Clinical Modification (ICD-10-CM) and prepare for the ICD-10 Proficiency Assessment. Training is led by a certified AAPC Instructor and is provided onsite in a classroom format. Conducted over two days, attendees will receive 16 hours of intensive general ICD-10 code set training along with hands-on coding exercises.
TRAINING FOCUSES ON:
WHAT’S INCLUDED:
• ICD-10 format and structure
• 16 CEUs
• Complete in-depth ICD-10 guidelines
• AAPC ICD-10-CM Code Set Course Manual
• Nuances found in the new coding system with coding tips
• AAPC ICD-10-CM Code Set Draft Book • AAPC Online ICD-10-CM Proficiency Assessment
PRICING:
(Required for current AAPC CPC’s to maintain their credential)
• $399 for CMA members & members’ staff • $499 for CA-MGMA members • $599 for non-members
• Access to AAPC’s Online ICD-10-CM Assessment Training Course Space through December 31, 2015
is Limite
d!
*Comparable AAPC ICD-10 Boot Camp Costs $799
SANTA CLARA/MONTEREY COUNTIES DATES & LOCATION: June 30 - July 1 Santa Clara County Medical Association • 700 Empey Way • San Jose, CA 95128 8 a.m. - 5 p.m. each day with an hour break from 12 - 1 p.m.
REGISTER: CALL (800) 786-4262 OR VISIT WWW.CMANET.ORG/AAPC-ICD10 INFORMATION: CALL JULI REAVIS AT (916) 551-2046 OR EMAIL JREAVIS@CMANET.ORG In partnership with: For more information about SCCMA and MCMS please visit: www.sccma-mcms.org MARCH / APRIL 2015 | THE BULLETIN | 11
UNDERSTANDING REVENUE RECOVERY First You Need to Determine Who Owes You Money and How Much Identify the Source of Payment: Insurer, Patient, or A Combination: Then the Next Step Is Billing Billers Are Not Collectors and Collectors Aren’t Billers
By Mark Christiansen Manager and Attorney for the Bureau of Medical Economics (BME) Many factors affect whether a physician is compensated for his/her professional services and the extent of that compensation. All physicians, at one time or another, have experienced the health insurer paying a check for remuneration for their services directly to the patient; sending a check for a reduced amount rather than what was billed; or a complete denial of the claim with no payment whatsoever. Most physicians are too busy healing patients to become actively involved in the remuneration stage of the process, so they 12 | THE BULLETIN | MARCH / APRIL 2015
don’t take the time to assess each aspect of their office’s revenue recovery procedures. This is a big mistake. Any time taken to evaluate your revenue recovery line of action is time well spent. Everyone is interested in decreasing the amount of write-offs; but there is something equally important in this day and age; personal accountability and its affect on the costs of health care. When an insurer does not pay the proper rates for services or a patient is not paying his/her patient responsibility there is no personal ac-
countability. When we accept the concept that a $25 co-pay is no big deal, the rest of us end up paying in increased costs. This article in no way can cover each and every aspect of medical revenue recovery. I will try to steer you in a direction that will assist you in accounts receivable as well as help the medical community by trying to hold those responsible for medical debt accountable. Did you know medical collection activities save each of us about $600-$800 per year in medical costs?
FIRST YOU NEED TO DETERMINE WHO OWES YOU MONEY AND HOW MUCH
INSURANCE CONTRACTS: Are there terms that govern what my recoveries will be? If you are contracted with an insurance carrier this answer is a simple, “yes.” I have handled many calls from physicians regarding whether a carrier can or can’t do something. I ask to see a copy of the contract and the response is they can’t find a copy. First, you need to know the identities of the health insurance carriers with whom you are contracted. All of your practice’s contracts with health insurers should be kept in a safe place and copies should be made available to the person(s) doing your billing. Addendums/changes should be attached to the originals and copies provided to update your biller. If you are “in network” with an insurer, you will be compensated based on the terms of that contract. If you have been doing business with certain health insurers and can’t find your contract, request a copy to update your records. If you run into problems, Sandie Becker, your physician advocate, for SCCMA-MCMS (408) 9988850 Ext. 3007 is a valuable resource and SCCMA-MCMS member benefit. Let’s face it, sometimes even when you have all of your contracts accounted for, and various product lines of insurance are understood by your staff/biller, there will still be issues raised about timely claims, improper coding, etc. That is why you need a strong advocate in your biller to appeal and question the insurers as to why claims were paid at less than contracted or not at all. OUT OF NETWORK/UNCONTRACTED SERVICES: The patient is usually responsible directly to the physician for services rendered where there is no contractual relationship between the insurer and doctor. It is possible for a doctor to verify benefits beforehand with a carrier and to accept the representation of payment of a certain amount. Caution: Always get authorizations and confirmations backed up in writing. The carrier will usually have provisions in their contract with their insured to pay a reduced amount or nothing at all for “going out of network.” What is my remuneration if I am not contracted with a particular insurer? If you have a written contract with the patient, the terms of the contract will dictate. If there isn’t a written contract, a doctor is entitled to “quantum meruit” which is the implied promise to pay the reasonable value for services rendered. This is determined by what is considered usual, customary, and
reasonable (UCR). This is determined by many elements including what other physicians in your geographical location are billing for this same service, your experience level and specialty, what you normally bill for this procedure or service, and as well as other factors. My experience in court is that if the procedure is one that you routinely perform, and you have a good idea what will be charged, you should advise the patient of same prior to rendering services. Otherwise, the doctor repairing knees on a 49er football player will likely get the same fee as other physicians in the area performing the same procedure for less. Most of our trauma surgeons are well aware of the problems emergent care poses with an insured patient. These emergency services should be paid on the basis of what is usual, reasonable, and customary (UCR); however, often times the carrier will only pay the lower rate they pay their contracted physicians. The doctor providing emergent care then has the ability to go after the insurance carrier for the balance. In this scenario, where no actual contract exists between the parties, case law has established an implied at law contractual relationship between physician and health insurer. You may legally pursue the patient for patient responsibility items such as co-pays, deductibles, etc. HOWEVER, USE CAUTION. In the case of HMOs and some PPOs, you may not “balance bill” the patient for the difference.
AFTER YOU HAVE IDENTIFIED THE SOURCE OF PAYMENT WHETHER IT IS INSURER, PATIENT, OR A COMBINATION OF BOTH: THE NEXT STEP IS BILLING Your office may employ persons in-house to handle your billing or you may employ an outside billing company. If you utilize a billing company, the average charge for services ranges from 5%-10% of the claims made or paid, depending on your agreement. As they are retained on a fairly low commission basis, their goal is to bill as many accounts as possible with the goal of getting it right the first time so additional time isn’t spent on appeals, etc., that are costly to a billing company. The physician should be certain his/her notes in the charts specifically match the CPT codes so claims are not rejected. Your biller should be comparing the claims with payments received to be certain the appropriate amount has been paid and, if not, why not. Your biller should be intimately familiar with your practice and the common CPT codes and modifiers you use daily. If you are presently having office staff conduct your billing and/or you are looking for a new billing company, to be certain you are maximizing your phase 1 (billing) of revenue recovery, we recommend you contact the newest sponsored partner of SCCMA and MCMS, ProMed Billing; they are located locally in Los Gatos. Their contact information: Adam Salinger at (408) 680-0000 or adam@promedbilling.net. A good biller knows when to move the account onto the next Continued on page 14 MARCH / APRIL 2015 | THE BULLETIN | 13
Understanding Revenue Recovery, continued from page 13 stage in revenue recovery – collections. An account that isn’t being appealed with an insurance carrier really shouldn’t stay in billing longer than 180 days. The longer the account sits prior to being assigned to collections, the greater the likelihood of nonpayment by the patient.
BILLERS ARE NOT COLLECTORS AND COLLECTORS AREN’T BILLERS COLLECTIONS: Though billers and collectors each have an important job in revenue recovery, they each have a different job and different incentives as to how they approach their job. A biller may take 5-10 minutes per claim to submit a claim on what is usually a fairly certain return (compensation from insurance) which is a fairly low risk factor; whereas collections may require several hours of repetitious contact with the patient after initial payment has already occurred by the insurance carrier. These second stage monies being pursued are now the monies that require discussion with and education of the patient as to why payment is due and the responsibility of the patient and not insurance. This all takes time. On top of all of this, the collector may receive less than complete recovery or no recovery whatsoever on a claim. Therefore, collection agencies usually charge 30%-50% in view of the extra time and money spent to collect (it costs about $2 for each notice sent out) in relation to the risk of recovery. Some even charge a $10-$15 per account loading fee in order to cover the costs of taking on the risk. Additionally, billers that are not employees of the physician, and are conducting collection activities for monies that are post insurance payment, are considered third party debt collectors and are subject to all of the same collection laws as a collection agency. If they are not following all state and federal collection laws they are subjecting themselves and your office to liability. A good collection agency is constantly keeping themselves up to date on changes in collection law; they are constantly training their staff as to proper protocol in order to protect themselves as well as you and your reputation in the medical community. Let’s face it, when it comes to selecting a collection agency for this last stage of the revenue recovery cycle, most physicians have left this important decision up to someone else in the office. In an attempt to do what is best for their employer or client, the staff or biller will usually be looking for the agency that charges the least amount and boasts the best recoveries. These are things to be taken into consideration, however, your criteria shouldn’t end there. Ever since the “great recession,” consumers/patients have gained a lot of rights that previously didn’t exist. These new found rights are being protected by agencies such as the FTC (Federal Trade Commission) and the CFPB (Consumer Finan14 | THE BULLETIN | MARCH / APRIL 2015
cial Protection Bureau) to name a few. Many of these rights don’t affect those already conducting themselves in a professional manner. It is important to have the appropriate associate agreements in place and to know that your associates are conducting themselves according to law. Does your collection agency credit report? If so, have they taken all of the appropriate steps according to the FCRA (Fair Credit Reporting Act)? They must restrict or encrypt all medical information including your identity so as to comply with HIPAA, etc. Medical credit reports are on their way out. FICO has already changed its criteria and the CFPB is still addressing further changes. However, that is the topic for another article. IN CONCLUSION, this portion of your business does deserve at least an assessment of your present revenue recovery procedures. Decisions need to be made to determine that you are utilizing people and associates that share your common goal of revenue recovery, while protecting your good name in the medical community and protecting you from liability. I often find it puzzling why some of our independent practices in the medical community sometimes make a decision to send their revenue recovery needs to large collection agencies, often owned by out of state interests, as they overlook the Bureau of Medical Economics (BME) which is unique for the following reasons: • A resource independently and locally owned by your own medical association, SCCMA; • A member benefit with a discount; • Not-for-profit – where all of the profits go back to the medical community; • Run by experts solely devoted to medical collections; • Endorsed by CMA, SCCMA, MCMS, and ACCMA; and • Lastly and probably most importantly, actively protecting physicians from liability. I am hopeful that when you take the time to investigate your revenue recovery cycle, you will allow BME the opportunity to show you why we are unique. This by no means encompasses each and every aspect of revenue recovery, you may wish to attend or have a staff member attend one of our upcoming Revenue Recovery Boot Camp Seminars. If you have questions or are interested in more information about BME, please contact our client relations director Karen Jorgenson at (408) 998-5811 Ext. 3034 or email karen@bmesc.org.
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“Current FCC standards do not account for the unique vulnerability and use patterns specific to pregnant women and children. It is essential that any new standard for cell phones or other wireless devices be based on protecting the youngest and most vulnerable populations to ensure they are safeguarded throughout their lifetimes.” American Academy of Pediatrics Letter to FCC August 29, 2013 (20)
By Cindy Russell, MD CHILDREN ARE MORE VULNERABLE THUS VP of Community Health, SCCMA Industry has been quite successful in creating magically useful wireless technologies such as cell phones, Ipads, Wi-Fi, and now wearable tech devices such as Google glasses, we all love. Many of these handy gadgets have now reached the typical classroom across the globe. It has become apparent, however, that there are substantial downsides to being too connected to technology and as safety concerns mount, governments such as France and Israel are backing away from the blind adoption of wireless technology in schools, especially for young children. These devices are cool and convenient, however there remains nagging questions of overuse and safety as the application of these devices has increased to the point we are literally exposed 24 hours a day to this radiation. Wireless microwaves come from many sources both at work and at home. An increasing number of physicians, scientists, and parents are concerned about long term health effects from Wi-Fi in schools. (42)(43)(44) (49) As any parent knows, computers now are as ubiquitous in schools as they are at work. From kindergarteners on up kids are required to learn computer skills in order to take core testing online. There is a push to enable students to be connected to the internet 24/7 to take photos, email documents, and research a topic. In schools, wired connections for computers have been rapidly being eliminated to install wireless systems that connect students both indoors and outdoors on campus. Europe and some schools in the U.S. are taking a different more precautionary approach and going back to the future with wired plug in computers. Studies have also cast doubt on some of the benefits of classroom computers and warned of the new age of “Digital Dementia” which has now crept into Korean youth due to the heavy use of electronic gadgets. (17)(48) Professors in college are banning computers during lectures and finding students learn more. (38) (39)
NEED MORE PROTECTION
Children have several organ systems that are immature at birth and are thus much more sensitive to toxic exposures. The human brain, one of the top vital organs, is far from being a finished product in youth. Longterm structural maturation of the nervous system is required for successful development of cognitive, motor, and sensory functions. Neuronal axons – long thin projections from the nerve cell – act as electronic transmission lines. Axons in major pathways of the brain continue to develop throughout childhood and adolescence. Myelin is the insulation surrounding individual nerves protecting it from outside electrical charges. The process of myelination is much faster the first two years but continues into adulthood. (16) Children have thinner skulls (29), their immune systems are undeveloped, their cells are dividing more rapidly, thus, they are more vulnerable to EMF radiation and other carcinogens. They also have a longer cumulative exposure to all toxins including EMF radiation.
CURRENT WIRELESS SAFETY STANDARDS AND MICROWAVING POTATOES
Wireless devices work on high frequency microwaves similar to the microwave you use to cook food with. It is with less power but substantial research (1)(2)(3)(4) demonstrates that even at low power within the current safety standards these microwaves can cause biologic harm to plants, animals, and cellular structures. Current Federal Communications Commission (FCC) standards are based only on heat generated by the device, not on adverse biological effects seen in hundreds of studies and at much lower levels. Our own CMA supports reassessment of EMF standards. The California Medical Association, in 2014, passed a resolution as follows: “Resolved 1:That CMA supports efforts to re-evaluate microwave safety exposure levels associated with wireless communication devices, including consideration
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Wi-Fi in Schools, continued from page 17 of adverse nonthermal biologic and health effects from non-ionizing electromagnetic radiation used in wireless communications and be it further Resolved 2: That CMA support efforts to implement new safety limits for wireless devices to levels that do not cause human or environmental harm based on scientific research.
ADVERSE EFFECTS DEMONSTRATED IN PEER REVIEWED PUBLISHED RESEARCH (2) • DNA with single and double stranded breaks • Leakage of the blood brain barrier ( two hours of cell phone exposure causes 7+ days of albumin leakage) • Stress protein production in the body indicating injury • Infertility/reproductive harm • Neurologic harm with direct damage to brain cells • Lowering of melatonin levels • Immune dysfunction • Inflammation/oxidation.
PLAUSIBLE MECHANISM FOUND FOR EMF MICROWAVE EFFECTS
HUMAN ELECTROSENSITIVITY: IS IT REAL?
There is varied opinion about those who state they are sensitive to EMF. Scientific research has not given a definitive answer, nevertheless, many seem to suffer from vague and often disabling symptoms they feel in the presence of EMF. Exposure to EMF radiation in some people reportedly causes headaches, memory problems, fatigue, sleep disorders, depression. This is so significant for some people that they have to live in a very low EMF environment to feel normal. (25) Sweden recognizes electro-sensitivity as a functional impairment and estimates that about 3% of the population suffers from this. (23)(24) Dr. Magda Havas found in replicated studies that some EMF sensitive individuals heart rates increased with wireless devices turned on in double blind study. (12)(26) Researchers at Louisiana State University, in 2011, studied a self reported EMF sensitive physician and found “In a double-blinded EMF provocation procedure specifically designed to minimize unintentional sensory cues, the subject developed temporal pain, headache, muscle twitching, and skipped heartbeats within 100 s after initiation of EMF exposure (p < .05).” They concluded that “EMF hypersensitivity can occur as a bona fide environmentally inducible neurological syndrome.” (27) Genius and Lipp reviewed the current literature on EHS, in 2011, and point to several explanations for this multisystem phenomenon, including toxicant induced loss of tolerance as many with EHS symptoms had high levels of PCB’s possibly causing immune dysfunction. Scientific research also identifies an inflammatory response with cytokine production. Another aspect of research points to catecholamine and adrenal gland dysfunction. In addition, heavy metal toxicity has also been proposed as contributing to EHS. (28) The Austrian Medical Association feels Electrohypersensitivity is a real phenomenon and in 2012 published Guidelines for EMF and Electro-hypersensitivity. They state the primary method of treatment should consist in the prevention or reduction of EMF exposure, taking care to reduce or eliminate all sources of EMF if possible. (32)
In May 2011, the International Agency for Research on Cancer (IARC) classified radiofrequency electromagnetic fields as possibly carcinogenic to humans (Group 2B).(30)
Dr. Martin Pall, Professor Emeritus of Biochemistry, Washington State University has studied how electromagnetic fields impact the cells of our bodies. His 2013 paper on this subject highlights a major biological mechanism of action of EMF microwave radiation on cell structure. His work, along with two dozen prior studies, demonstrated that EMF microwave radiation effects cellular calcium channels and this can be inhibited with calcium channel blockers. “A whole series of biological changes reportedly produced by microwave exposures can now be explained in terms of this new paradigm of EMF actions via Voltage Gated Calcium Channels (VGCC) activation.” (14)(15)
EMF AFFECTS ON WILDLIFE: BIRDS, BEES, AND TOMATO PLANTS
Bird researchers in Germany found that their migratory European Robins lost their sense of navigation when in the city. (5) This was found to be due to the EMF radiation interfering with the bird’s special internal magnetic compass. They replicated the experiment over seven years before publishing the results in the prestigious journal Nature. John Phillips and others have found that newts, sea turtles, and migratory birds use a magnetic compass to navigate long distances and this can be interrupted by low levels of EMF. (6)(7) A review of effects on cell towers and wireless devices showed that beehives can have rapid colony collapse with exposure to cell phone radiation. (8) Plants have been shown to have stress response to EMF from wireless devices. (9)(10) (22) In tomatoes exposed for short duration, the stress response seen by exposure to EMF was prevented by administration of calcium counteracting drugs. (11) Even simple high school science experiments document abnormal seed growth near Wi-Fi routers. (19) There appear to be adverse biological effects of this seemingly harmless radiation. 18 | THE BULLETIN | MARCH / APRIL 2015
GOVERNMENT ACTIONS ON WI-FI IN SCHOOLS
While much of the U.S. is marching forward with Wi-Fi in schools, Europe is changing direction, as indicated by the policies listed below. (45) Internationally there is wide disagreement in standards. The U.S. and Canadian limits are 1000 microwatts/cm2. China and Russia are 10 microwatts/cm2. Belgium is 2.4 microwatts/cm2, and Austria is 0.001 microwatts/cm2. The Bioinitiative Report 2012 recommendation for “No Observable Effect” is 0.0003 microwatts/cm2. Cosmic background EMF we evolved with is <0.00000000001 microwatts/cm2. (2)
COUNCIL OF EUROPE PARLIAMENT ASSEMBLY 2011 EMF MICROWAVE POLICY : “THE POTENTIAL DANGERS OF ELECTROMAGNETIC FIELDS AND THEIR EFFECT ON THE ENVIRONMENT”
The report notes “other non-ionizing frequencies, whether from ex-
tremely low frequencies, power lines or certain high frequency waves used in the fields of radar, telecommunications, and mobile telephony, appear to have more or less potentially harmful, non-thermal, biological effects on plants, insects, and animals, as well as the human body, even when exposed to levels that are below the official threshold values.” The Council calls for a number of measures to protect humans and the environment, especially from highfrequency electromagnetic fields. One of the recommendations is to “take all reasonable measures to reduce exposure to electromagnetic fields, especially to radio frequencies from mobile phones, and particularly the exposure to children and young people who seem to be most at risk from head tumors”. (37)
IN FRANCE: A NEW NATIONAL LAW BANS WI-FI IN NURSERY SCHOOLS
In January 2015, France passed a landmark law that calls for precaution with wireless devices for children and the general public. (34)(35) It calls for: 1. Wi-Fi banned in nursery schools. 2. Wi-Fi routers should be turned off in school when not in use. 3. Schools are informed when new tech equipment is installed. 4. Citizens will have access to environmental cell tower radiation measurements near homes. 5. There will be continued research conducted into health effects of wireless communications. 6. Information on reducing exposure to EMF radiation is mandatory in the contents of the cell phone package. 7. Wi-Fi hotspots are labeled.
ISRAELI MINISTRY OF EDUCATION ISSUE GUIDELINES TO LIMIT WI-FI IN SCHOOLS
On August 27, 2013, the Israeli Ministry of Education issued new guidelines regarding Wi-Fi use in schools. (33) The guidelines will: 1. Stop the installation of wireless networks in classrooms in kindergarten. 2. Limit the use of Wi-Fi between first and third grades. In the first grade, students will be limited to use Wi-Fi to study for one hour per day and no more than three days per week. Between the first and third grades, students will be limited to use Wi-Fi up to two hours per day for no more than four days per week. 3. To limit unnecessary exposure teachers will be required to turn off mobile phones and Wi-Fi routers when they are not in use for educational purposes. 4. All Wi-Fi equipment be tested for compliance with safety limits before and after installation in an Israeli school. 5. Desktop computers and power supplies be kept at least 20 cm from students.
2012 THE RUSSIAN COMMITTEE ON NON-IONIZING RADIATION PROTECTION
OFFICIALLY RECOMMENDED THAT WI-FI NOT BE USED IN SCHOOLS. 2011 THE RUSSIAN COMMITTEE ON NON-IONIZING RADIATION PROTECTION (RNCNIRP) RELEASED THEIR RESOLUTION ENTITLED “ELECTROMAGNETIC FIELDS FROM MOBILE PHONES: HEALTH EFFECTS ON CHILDREN AND TEENAGERS.” According to the opinion of the Russian National Committee on Non-Ionizing Radiation Protection, the following health hazards are likely to be faced by the children mobile phone users in the nearest future: disruption of memory, decline of attention, diminishing learning and cognitive abilities, increased irritability, sleep problems, increase in sensitivity to the stress, increased epileptic readiness. (36) Expected (possible) remote health risks: brain tumors, tumors of acoustical and vestibular nerves (in the age of 25-30 years), Alzheimer’s
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Wifi In Schools, continued from page 19 disease, “got dementia”, depressive syndrome, and the other types of degeneration of the nervous structures of the brain (in the age of 50 to 60).
PLAYING IT SAFE FOR OUR KIDS
A healthy and safe learning environment is a cornerstone of education. Current FCC standards are obsolete and inappropriate as they are based only on heat effects, not biological effects. They give us a false sense of security. There may be higher EMF levels at school than at home as routers are more powerful. Cumulative Effects on DNA or cell structures are not taken into consideration in any safety standard. Because of the longterm exposure to EMF microwave radiation this generation is experiencing, they will be at higher risk for potential health problems. We will not know what happens to our progeny’s DNA until our grandchildren are born. Considering there has been a more precautionary approach internationally to microwave radiation exposure and the trend is toward less exposure in schools, especially to vulnerable populations such as children, it makes sense to re-evaluate our wireless schools. We buckle our seat belts and wear a helmet when we ride bikes even though we don’t know if we will get in an accident. Although not all the issues of wireless microwaves are understood, there is enough science to understand it acts as a toxicant at even low levels that fall within current safety standards. We also know
3. Limit Wi-Fi use, especially in younger grades. 4. Cell phones stay off and in the backpacks during class and on the campus during school hours. 5. Have EMF and electrical measurements done by one or more qualified, experienced consultants before and after any installation. Understand you may need to increase your knowledge of low and high frequency electromagnetic fields and limits to accurately interpret the reports. The Bioinitiative Report is a very useful compendium that has recommendations for safer levels. 6. Support efforts by governments to provide independent standardized transparent research to define safe limits in all the different wireless frequencies used commercially. This could lead to less EMF emissions and safer wireless devices.
REFERENCES
“Overpowered” by Dr. Martin Blank, 2014 Bioinitiative Report. 2012 http://www.bioinitiative.org/ EMF Portal. http://www.emf-portal.de/ Why Fi? : Is Wireless Communication Hazardous to Your Health? http://www.sccma-mcms.org/Portals/19/assets/docs/ Why%20Fi.pdf 5. Electronics’ noise disorients migratory birds. Man-made 1. 2. 3. 4.
“Certain high frequency waves used in the fields of radar, telecommunications, and mobile telephony, appear to have more or less potentially harmful, non-thermal, biological effects on plants, insects, and animals, as well as the human body, even when exposed to levels that are below the official threshold values.” that decades of research precedes meaningful regulation in the area of toxins, thus the only reasonable approach is precautionary. In addition, we need to be thoughtful about how much our kids should use computers and what this is doing not only to them, but to our society as a whole. We get starry eyed with every new wireless gadget, however, in “Alone Together” Sherry Turkle expertly addresses the rise in isolation, loneliness, lack of privacy, and increasing pressure on students in this age of invasive technology. Her thorough and non-judgmental scientific investigation of the psychological effects of computers makes us aware that we need to take care that we do not replace real human connection with a “virtual reality” that will redirect us in an unhealthy direction. As physicians and parents, we understand that decisions we make today may have far reaching consequences in the future for our kids. Let’s play it safe for them right now.
RECOMMENDATIONS FOR SCHOOLS
1. Wired internet connections like we used to have are the safest and possibly cheapest option – all the benefits of the internet without the risk. 2. Wireless devices, but with an on/off switch in each room so teachers can use only when needed for educational purposes.
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electromagnetic radiation disrupts robins’ internal magnetic compasses. May 7, 2014 http://www.nature.com/news/electronicsnoise-disorients-migratory-birds-1.15176 6. True Navigation: Sensory Bases of Gradient Maps. Phillips, J. 2006 http://www.pigeon.psy.tufts.edu/asc/Phillips/ 7. A behavioral perspective on the biophysics of the lightdependent magnetic compass: a link between directional and spatial perception? Phillips, J. Journal of Experimental Biology. June 17, 2010. http://jeb.biologists.org/content/213/19/3247.full.pdf 8. Impacts of radio-frequency electromagnetic field (RF-EMF) from cell phone towers and wireless devices on biosystem and ecosystem – a review. Sivani, S. Biology and Medicine. Dec 3, 2012 http://www.emrpolicy.org/regulation/united_states/Exhibit_19_ EMRPI_Sivani_Bio_&_Med_2012.pdf 9. Effects of Microwaves on the Trees and Other Plants. Balmori, A. 2003. http://www.hese-project.org/de/emf/ WissenschaftForschung/Balmori_Dr._Alfonso/showDoc. php?lang=de&header=Dr.%20Balmori&file=THE%20 EFFECTS%20OF%20MICROWAVES%20ON%20THE%20 TREES%20AND%20OTHER%20PLANTS.html&back=../ showAuthor.php?target=Balmori_Dr._Alfonso 10. Effects of Electromagnetic Waves Emitted by Mobile Phones on
Germination, Root Growth, and Root Tip Cell Mitotic Division. Pol J of Envir Studies. Nov 2010. http://www.pjoes.com/pdf/21.1/ Pol.J.Environ.Stud.Vol.21.No.1.23-29.pdf 11. Intercellular Communication in Plants: Evidence for an EMF-Generated Signal that Evokes Local and Systemic Transcriptional Responses in Tomato. 2013. http://link.springer. com/chapter/10.1007/978-3-642-36470-9_16 12. Provocation Study using heart rate variability shows microwaves radiation from 2.4 Ghz cordless phones. European Journal of Oncology. January 16, 2011. http://www.bemri.org/ publications/dect/341-provocation-study-using-heart-ratevariability-shows-microwave-radiation-from-2-4ghz-cordlessphone.html?path= 13. Is newborn melatonin production influenced by magnetic fields produced by incubators? Early Hum Dev 2012; 88 (8): 707 – 710 http://www.emf-portal.de/viewer.php?aid=20376&l=e 14. Electromagnetic fields act via activation of voltage-gated calcium channels to produce beneficial or adverse effects. Pall, ML. J Cell Mol Med. 2013 Aug;17(8):958-65.http://www.ncbi.nlm. nih.gov/pubmed/23802593 15. Microwave Electromagnetic Fields Act by Activating VoltageGated Calcium Channels: Why the Current International Safety Standards Do Not Predict Biological Hazard. Professor Dr. Martin L. Pall http://apps.fcc.gov/ecfs/document/ view?id=7521102473 16. Communication Studies UCLA. http://cogweb.ucla.edu/CogSci/ Myelinate.html 17. “Digital Dementia” on the Rise. June 24, 2013 http:// koreajoongangdaily.joins.com/news/article/article. aspx?aid=2973527 18. International Precautionary Actions EMF. http://ehtrust.org/ international-policy-actions-on-wireless/ 19. Student Science Experiment Finds Plants won’t Grow near Wi-Fi Router http://www.globalresearch.ca/student-scienceexperiment-finds-plants-wont-grow-near-wi-fi-router/5336877 20. American Academy of Pediatrics Letter to FCC and FDA regarding EMF Exposure Policies and Standards. http://www. wirelesswatchblog.org/wp-content/uploads/2011/06/FCC-13-8409-03-2013-American-Academy-of-Pediatrics-7520941318-1.pdf 21. Transient DNA damage induced by high-frequency electromagnetic fields (GSM 1.8 GHz) in the human trophoblast HTR-8/SVneo cell line evaluated with the alkaline comet assay. Mutat Res. 2010 Jan 5. http://www.ncbi.nlm.nih.gov/ pubmed/19822160 22. High frequency (900 MHz) low amplitude (5 V m-1) electromagnetic field: a genuine environmental stimulus that affects transcription, translation, calcium and energy charge in tomato. Roux, D. Planta. 2008 Mar http://www.ncbi.nlm.nih.gov/ pubmed/18026987 23. Electrosensitivity in Sweden. http://www.emfacts. com/2009/02/1014-electrosensitivity-in-sweden-by-ollejohansson/ 24. Towards Better Health: Switzerland TV Program on Electrohypersensitivity. 2009. http://mieuxprevenir.blogspot. com/2013/03/swiss-tv-program-from-2009-on.html 25. ‘Wi-fi refugees’ shelter in West Virginia mountains. 2011. http:// www.bbc.com/news/world-us-canada-14887428 26. Replication of heart rate variability provocation study with 2.4-GHz cordless phone confirms original findings. Havas, M.
Electromagn Biol Med. 2013 Jun http://www.ncbi.nlm.nih.gov/ pubmed/23675629 27. Electromagnetic hypersensitivity: evidence for a novel neurological syndrome. Int J Neurosci. 2011 Dec;121(12):670-6. http://www.ncbi.nlm.nih.gov/pubmed/21793784 28. Review: Electromagnetic hypersensitivity: Fact or Fiction? Genius, S, Lipp, C. Science of Total Environment. Sept 2011. http://www.academia.edu/4125616/Genuis_EHS_paper 29. Electromagnetic absorption in the human head and neck for mobile telephones at 835 and 1900 MHz. Gandi, O. Microwave Theory and Techniques. Vol 44, Oct, 1996. http://ieeexplore.ieee. org/xpl/articleDetails.jsp?reload=true&arnumber=539947 30. International Agency for Research on Cancer. IARC Classifies Radiofrequency Electromagnetic Fields as Possibly Carcinogenic to Humans. http://www.iarc.fr/en/media-centre/ pr/2011/pdfs/pr208_E.pdf 31. Alone Together. Sherry Turkle. 2012. http://www.npr. org/2012/10/18/163098594/in-constant-digital-contact-we-feelalone-together 32. Austrian Medical Association Guidelines- EMF and Electrohypersensitivity. http://freiburger-appell-2012.info/media/ EMF%20Guideline%20OAK-AG%20%202012%2003%2003.pdf 33. Israeli Ministry of Education issue guidelines to limit Wi-Fi in schools. 2013 http://www.gsma.com/publicpolicy/israeliministry-of-education-issue-guidelines-to-limit-wi-fi-in-schools 34. France: New National Law Bans Wi-Fi in Nursery School! http:// ehtrust.org/france-new-national-law-bans-wifi-nursery-school/ 35. French government bans advertising of mobiles to children. 2009 http://www.independent.co.uk/life-style/gadgets-and-tech/ news/french-government-bans-advertising-of-mobiles-tochildren-1299673.html 36. Electromagnetic Fields From Mobile Phones: Health Effects on Children and Teenagers. April 2011. http://www.magdahavas. com/wordpress/wp-content/uploads/2011/06/Russia_20110514rncnirp_resolution.pdf 37. Parliament Assembly European Council EMF Microwave Policy. 2011. http://assembly.coe.int/Mainf.asp?link=/Documents/ AdoptedText/ta11/ERES1815.htm 38. Why A Leading Professor of New Media Just Banned Technology Use in Class. Sept 25, 2014. Washington Post. http:// www.washingtonpost.com/blogs/answer-sheet/wp/2014/09/25/ why-a-leading-professor-of-new-media-just-banned-technologyuse-in-class/ 39. Princeton/UCLA Study: Its Time to Ban Laptops in Law School Classrooms. Feb 5, 2015. http://taxprof.typepad.com/taxprof_ blog/2015/02/princetonucla-study-.html 40. Brain Cancer – Mobile phone and cordless phone use and the risk for glioma – Analysis of pooled case-control studies in Sweden, 1997-2003 and 2007-2009. Hardell. Pathophysiology. 2014 Oct 29. http://www.ncbi.nlm.nih.gov/pubmed/25466607 41. Brain Cancer – Mobile phone use and brain tumors in the CERENAT case-control study. Coureau G. Occup. Environ Med. 2014 Jul; http://www.ncbi.nlm.nih.gov/pubmed/24816517
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appointments & referrals: 408-377-3331 online spine encyclopedia at: SanJoseNeurospine.com
Physician Profile Adebukola Onibokun, MD Board-certified Neurological Surgeon
Announcing a new Silicon Valley spine center option for those wanting freedom from back and neck pain We’re pleased to announce a new option for back and neck pain patients: San Jose Neurospine, which began seeing patients in early September through its offices in Campbell and Atherton. The spine center includes the expertise of Adebukola Onibokun, MD, a board-certified neurological surgeon who specializes in minimally invasive spine surgery. Over his career, he has done more than 2,000 successful surgeries. Dr. Adebukola Onibokun emphasizes a conservative approach to the care of his patients and encourages non-surgical treatment first. Some of these non-surgical treatment options for back and neck pain can include pain relieving spinal injections that reduce inflammation around a nerve root and spine-specialized therapy which increases the flexibility of the back, strengthens muscles and ligaments and reduces likelihood of future strain. In this regard, he works very closely and collaboratively with outside pain management specialists and therapists to coordinate non-surgical treatment options. If non-surgical options fail, or when symptoms progress to weakness/numbness in an arm or leg, the center uses minimally invasive spine surgery techniques that enable most patients to be home later the same day.
Minimally invasive spine surgeries performed MIS Lumbar Discectomy & Posterior Cervical Discectomy This procedure is done by making a small 1-inch incision over the herniated disc and inserting a tubular retractor. Then the surgeon removes a small amount of the lamina bone that allows the surgeon to view the spinal nerve and disc. Once the surgeon can view the spinal nerve and disc, the surgeon will retract the nerve, remove the damaged disc, and replaces it with bone graft material. MIS Lumbar Fusion A minimally invasive lumbar fusion can be performed the same way as traditional open lumbar fusion, either from the back, through the abdomen, or from the side. Lateral interbody fusion (LIF) A lateral interbody fusion, often used to treat spondylolysis, degenerative disc disease and herniated discs, is performed by removing a disc and replacing it with a spacer that will fuse with the surrounding vertebra. The procedure is completed on the side of the body in order to reduce the effect on the nerves and muscles.
22 | THE BULLETIN | MARCH / APRIL 2015
Posterior cervical microforaminotomy (PCMF) A PCMF is performed to help relieve pressure and discomfort in the spine by making a small incision in the back of the neck and removing excess scar tissue and bone graft material. Anterior cervical discectomy An anterior cervical discectomy is used to reduce pressure or discomfort in the neck by removing a herniated disc through a small incision in the front of the neck. The space is then filled with bone graft material and plates or screws may be used to increase stability. Artificial Disc Replacement Artificial disc replacement is intended to be an alternative to spinal fusion surgery. Unlike a fusion that locks the two vertebrae in place, an artificial disc retains movement in the spine by simulating the natural rotational function of the disc.
San Jose Neurospine includes the expertise of Adebukola Onibokun, MD, a board-certified neurological surgeon who specializes in minimally invasive spine surgery. Dr. Onibokun (pronounced “Oh-kneebow-kun”) is Board Certified by the American Board of Neurological Surgery and is a fellow of the American Association of Neurological Surgeons. Dr. Onibokun received his medical degree from the prestigious Northwestern University Medical School, graduating with honors. He then completed 7 years of Neurosurgery Residency training at UCLA Medical Center, a program that consistently ranks as one of the top five neurosurgery programs in the country. Dr. Onibokun has previously served as Chief of Neurosurgery at Elmhurst Memorial Hospital in the Chicago area, where he established their Minimally Invasive Spine Surgery program. Prior to relocating to California, he was a Health System Clinician at the Northwestern Medicine Regional practice.
Home Remedy Book We provide a free 36-page Home Remedy Book that includes symptom charts that show when to see a doctor; home remedies; stretches that can relieve pain symptoms; and exercises that make the back stronger, more flexible and resistant to future strain. Call us, or email us at admin@ SanJoseNeurospine.com, and we’ll send 10 copies to your office for your patients. Our educational Internet presence at SanJoseNeurospine.com also has educational videos, medical illustrations, information on minimally invasive spine surgery options and a referral form.
View our video library to learn more about our practice online at: SanJoseNeurospine.com/videos
MARCH / APRIL 2015 | THE BULLETIN | 23
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MARCH / APRIL 2015 | THE BULLETIN | 25
Telemedicine & Physician Liability Issues By Steven Kmucha, MD, JD, FACS This article is reprinted with the permission of the San Mateo County Medical Association. Telemedicine—the provision of medical care using electronic communications, information technology or other means, between a licensee in one physical location and a patient in another—is growing especially rapidly. Telemedicine typically involves secure video-conferencing or store/forward technology to provide health care delivery by replicating the traditional in-person interaction between a patient and a physician. It generally excludes audio-only telephony, routine email, instant messaging, and fax. Telemedicine technologies can facilitate communication between patients and their health care providers, including scheduling appointments, monitoring chronic conditions, obtaining laboratory results, prescribing medication, and clarifying medical advice. However, state medical boards face complex challenges in adapting regulations historically intended for the in-person provision of medical care to this new delivery model. Last April, the Federation of State Medical Boards promulgated Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine to educate licensees about the appropriate use of telemedicine technologies in the practice of medicine. The following is a summary of those guidelines.
LICENSURE A physician must be licensed by, or under the jurisdiction, of the medical board in the state where the patient is located. Physicians who treat or prescribe through online services sites are practicing medicine and must possess appropriate licensure in all jurisdictions where patients receive care. A physician who lacks such licensure can be subject to prosecution for the unlicensed practice of medicine. Most professional liability insurance policies specifically exclude coverage for unlicensed activities; some states require 26 | THE BULLETIN | MARCH / APRIL 2015
professional liability underwriters to cover practice that extends beyond state borders and some do not; if coverage does not extend beyond state boundaries, there may be no protection. Even if an in-person activity is covered, this activity may not necessarily be covered if it is provided electronically at a distance, even if in the state of licensure.
ESTABLISHING THE PHYSICIANPATIENT RELATIONSHIP It may be difficult to define the beginning of a patient-physician relationship precisely, especially when the two parties are in different geographic locations, but it tends to begin when an individual with a health-related matter seeks assistance from a physician. The relationship is firmly established when the physician agrees to undertake treatment of the patient and the patient agrees to be treated, whether or not there has been an in-person encounter. The physician should disclose his or her identity and credentials, verify the location of the requesting patient, and obtain the appropriate consents from requesting patients after disclosures regarding the delivery models and treatment methods or limitations, including any special informed consents regarding the use of telemedicine technologies.
EVALUATION AND TREATMENT OF THE PATIENT Before providing treatment, the physician must obtain a documented medical evaluation and review relevant clinical history to establish diagnosis and identify underlying conditions and/or contra-indications to the treatment recommended.
INFORMED CONSENT
• The physician must obtain appropriate documentation regarding the patient’s informed consent for the use of telemedicine technologies, including the following: • Identification of the patient, the physician, and the physician’s credentials; • Types of transmissions permitted using telemedicine technologies
•
•
• •
(e.g., prescription refills, appointment scheduling, etc.); The patient agrees that the physician determines whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter; Details on security measures taken with the use of telemedicine technologies, such as encrypting data and password-protecting screen savers and data files, as well as potential risks to privacy notwithstanding such measures; Hold harmless clause for information lost due to technical failures; and Requirement for express patient consent to forward patient-identifiable information to a third party.
CONTINUITY OF CARE A patient should be able obtain follow-up care or information from the physician (or physician’s designee) with whom he or she had an encounter using telemedicine technologies. Physicians solely providing services via telemedicine technologies, with no pre-existing relationship prior to the encounter, must document the telemedicine encounter and make it easily available to the patient and, subject to the patient’s consent, any other health care provider identified by the patient.
REFERRALS FOR EMERGENCY SERVICES Should the patient have urgent or emergent health care needs associated with the condition for which care has been provided via telemedicine, an emergency plan is required and must be provided by the physician to the patient during the telemedicine encounter when the situation indicates that a referral to an acute care facility or emergency department is necessary for the safety of the patient. Such an emergency plan should include a formal, written protocol appropriate to the service being rendered via telemedicine.
MEDICAL RECORDS The medical record should include copies of any/all patient-related electronic communications, including patient-physician communications, consultations, evaluations, records of past care, prescriptions, laboratory and test results, and any instructions in connection with the utilization of telemedicine. Informed consent(s) should also be included. These records must be accessible for both the physician and the patient and consistent with all established laws governing patient health care records.
PRIVACY AND SECURITY OF PATIENT RECORDS AND EXCHANGE OF INFORMATION Physicians must meet or exceed federal and state legal requirements of medical/health information privacy, including compliance with HIPAA and relevant state privacy, confidentiality, security, and medical record retention result. A good source of information on these requirements is the “Standards for Privacy of Individually Identifiable Heath Information” issued by the U.S. Department of Health and Human Services (accessible at www.hhs.gov/ocr/hipaa). There is significant potential liability for failure to safeguard protected health information and to maintain safe transmission of this information. This potential risk of liability pertains to both the referring physician and the physician providing treatment by telemedicine. Written policies should be maintained at the same standard as traditional face-to-face encounters. Such policies should address a) privacy, b) health-care personnel who will process messages, c) hours of operation, d) types of transactions that will be permitted electronically, e) required patient information to be included in the communication, f) archival and retrieval, and g) quality oversight mechanisms. Privacy and security measures must be equivalent to those required for face-to-face encounters and documented to assure confidentiality and integrity of any patient-identifiable information. Transmissions, including patient emails, prescriptions and laboratory results, must be secure within existing technology.
DISCLOSURES AND FUNCTIONALITY ON ONLINE SERVICES MAKING AVAILABLE TELEMEDICINE TECHNOLOGIES Online services used by physicians in the provision of telemedicine should clearly disclose: • the services provided; • contact information for the physician; • licensure and qualifications of physicians and associated providers; • fees for services and means of payment; • financial interests (suggestive of potential conflict of interest) in any services, products or other information that is provided to a patient by a physician during a telemedicine interaction; • appropriate uses and limitations of the telemedicine site, including emergency health situations; • appropriate uses and anticipated response times for emails and other electronic communication transmitted by telemedicine;
• to whom a patient’s protected health information may be disclosed and for what purposes(s); • rights of patients with respect to protected health information; and • description of information collected and any passive tracking mechanisms utilized. Online services should provide patients with clear mechanisms to: 1) access and amend patient-provided personal health information, 2) provide feedback regarding the site and the information/services provided, and 3) register complaints. Online service must have accurate and transparent information about the website owner/operator, location, and contact information, including a domain name that accurately reflects this identity. Advertising of goods or products from which the physician receives direct remuneration, benefits, or incentive is prohibited.
PRESCRIBING When the prescription of medicines is involved, measures must be implemented to uphold patient safety in the absence of a traditional physical examination. Such measures should guarantee that the identity of the patient and the provider is clearly established, and that detailed documentation for the clinical evaluation and resulting prescription is completed. Measures to assure informed and accurate prescribing practices are encouraged. Further, telemedicine should limit medication formularies to those deemed safe by the applicable medical board. Prescribing medication is at the sole discretion of the treating physician. When professional standards are met and patient safety measures are upheld, and the clinical medication is adequately documented, the physician may exercise his or her judgment and prescribe medications as part of the telemedicine encounter. Using telemedicine technologies offers many benefits in the provision of medical care. However, it also carries significant liability pitfalls providers must understand before setting foot on this new “frontier.”
ABOUT THE AUTHOR Steven Kmucha, MD, JD, FACS, is board certified in otolaryngology-head and neck surgery and in the subspecialty of ear, nose and throat allergy. He also holds a law degree specializing in health and health care law. Source: “Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine,” Report of the Federation of State Medical Boards’ Appropriate Regulation of Telemedicine Workgroup – April 2014. MARCH / APRIL 2015 | THE BULLETIN | 27
EACH MIND MATTERS CAMPAIGN Primary Care Physicians: The Front Lines of Mental Health Care and the Fight Against Stigma
By Lisa Smusz
WHY PRIMARY CARE PHYSICIANS ARE THE FRONT-LINE OF MENTAL HEALTH CARE:
Kelechi Ubozoh and her mother
Over the course of a lifetime, nearly half the population will struggle with a mental health issue. Many of those will never seek support. For some, a lack of health care coverage is the determining barrier, but for many others fear of possible stigma associated with a diagnosis keeps them from reaching out. This barrier to treatment can have an impact not only to potential mental health outcomes, but physical health and mortality rates as well.1 As Ileana Arias, PhD, Principle Deputy Director, Centers for Disease Control and Prevention (CDC) notes: “We know that mental illness is an important public health problem in itself and is also associated with chronic medical diseases such as cardiovascular disease, diabetes, obesity, and cancer.”2 Of those that do seek support, 50% receive it solely from their general physician, meaning half of all the behavioral health care in the U.S. is provided by general medicine providers. In fact, 70% of all psychotropic medications are prescribed not by psychiatrists, but by general physicians, including 80% of all antidepressants.3 Clearly, general physicians are on the front lines of improving mental and physical health outcomes and reducing mortality rates for people with mental health issues. Yet significant challenges exist for the physicians themselves: the time pressure of having to understand and treat complex physical and behavioral health issues in a 15 minute visit, lack of adequate referral resources, or a lack of communication or care coordination with the patient’s behavioral health care provider, to name only a few examples often cited by general practitioners.
WHAT HELPS INSIDE THE TREATMENT ROOM:
Even when mental health issues are not the presenting problem for a patient visit, all interactions between a physician and patient have an emotional aspect to them. Small shifts in how those primary care visits are managed can have a significant impact on both mental health and behavioral health outcomes. One interview technique developed by Stuart Lieberman, known as BATHE (background, affect, trouble, handling, and empathy, see Table 1) can be easily implemented as part of a standard office visit and has been demonstrated to raise the quality of medical treatment and the level of patient satisfaction.4 Using simple empathic responses and questions framed from a posi28 | THE BULLETIN | MARCH / APRIL 2015
tive psychology orientation, the technique is used to help patients feel heard, and to gain a sense of self-efficacy over their own health behaviors and emotional states. The BATHE technique’s emphasis on deep listening is a way of formalizing what many effective primary care physicians and people with mental health issues have long known: Listen carefully, don’t discount what someone is telling you about their physical health just because they may have a mental health diagnosis. Open-minded listening with empathic understanding builds the relationship between practitioner and patient and ultimately, the relationship is the most critical tool at the doctor’s disposal. Kelechi Ubozoh, a young woman with a background in journalism who transitioned to the mental health research and activism field after her own experience recovering from mental health challenges, talks about the power of relationship: “When I was first diagnosed, I was too young to understand what it meant. I’ve had a label for longer than I haven’t. My mother, who is a primary care doctor, always looked at what I was going through as a health condition. She never shrugged off my problems. Sometimes, reaching someone with mental health challenges doesn’t require a bullet point list or years of training; it’s about connection and seeing the person first. I am not a diagnosis; I am a person.”
HOPE AND SUPPORT FOR PEOPLE WITH MENTAL HEALTH ISSUES AND THE HEALTH CARE PROFESSIONALS WHO TREAT THEM:
According to the National Alliance on Mental Illness (NAMI), with support and treatment, 70%-90% of people report reduced symptoms and improved quality of life from mental health conditions, even those considered “severe mental illness” such as bi-polar disorder and schizophrenia5, a statistic that often surprises many seasoned primary care and mental health care professionals. Changes in legislation, such as the Patient Protection and Affordable Care Act (PPACA), and the Mental Health Services Act (MHSA) are also supporting significant shifts in the way care is provided: promoting integrated approaches to behavioral and primary care, training and support for primary care physicians who are seeing more patients with behavioral health concerns in their practices, and tools to help lessen the impact of stigma as a barrier to treatment and support. Each Mind Matters, California’s Mental Health Movement, is one such project funded by the Mental Health Services Act. Created to unite all Californians who share a vision of improved mental health and equality, Each Mind Matters is starting conversations about what helps people feel safe to reach out, and connecting them to resources in the community. Example Question
Everyone experiencing a mental health challenge deserves the opportunity to live a healthy, happy, and meaningful life. People can and do get better, and by talking openly and honestly about mental health we take the first steps toward making that possible. To find out more about the Each Mind Matters campaign and the tools and resources available to primary care physicians, please visit www. eachmindmatters.org.
RESOURCES:
Below are some helpful, free resources and training materials for primary care physicians regarding suicide prevention, mental health screening tools, and integrated care. • http://resource-center.yourvoicecounts.org/content/trainingresource-guide-suicide-prevention-primary-care-settings • http://www.ibhp.org/uploads/file/IBHPIinteragency%20 Collaboration%20Tool%20Kit%202013%20.pdf • http://ibhp.org/uploads/file/IBHScreeningToolsRevFinal100313. pdf • http://www.namica.org/uploads/eng/pe_flier_jul2013.pdf
ABOUT THE AUTHOR
Lisa Smusz is a Licensed Professional Clinical Counselor with more than 15 years of experience operating large-scale mental health projects and has internationally published works on stigma reduction. Ms. Smusz currently serves as a consultant for the Each Mind Matters campaign.
REFERENCES
1. Care coordination for persons with complex mental health, substance use, and medical conditions: The case for providers. Available 3/10/15 online: http://www.ibhp.org/uploads/file/ BusinessCaseProvidersFinal.pdf 2. CDC Report: Mental Illness Surveillance Among Adults in the United States. Available 3/10/15 online: http://www.cdc.gov/ mentalhealthsurveillance/fact_sheet.html 3. California Primary Care Association, Integrated Behavioral Health Care: An Effective and Affordable Model. Available 3/10/15 online: http://www.cpca.org/cpca/assets/file/policy-andadvocacy/active-policy-issues/mhsa/integrationbrief.pdf 4. Effects of BATHE Interview Protocol on Patient Satisfaction. Available 3/10/15 online: http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3526719/ 5. National Alliance on Mental Illness (NAMI) Fact Sheet. Available 3/10/15 online: http://www2.nami.org/Content/ NavigationMenu/Inform_Yourself/About_Mental_Illness/ About_Mental_Illness.htm
Description
B
Background
“What is going on in your life?” This question helps elicit the context of the patient’s visit.
A
Affect
“How do you feel about that?” or “What is your mood?”
This question allows the patient to report on his/her current feeling state.
T
Trouble
“What about the situation troubles you the most?”
This question should be asked even when the patient’s affect is positive, as they may still be stressed about their current life circumstances.
H
Handling
“How are you handling that?” or “How could you handle that?”
This question is asked to evaluate what psychological stress the patient may be experiencing that may be contributing to their physical complaint or affective state.
E
Empathy
“That must be very difficult for you.”
Expressing empathy or sympathy conveys a sense of concern and of being understood, which affirms the patients and enhances positive feelings toward their health care provider. MARCH / APRIL 2015 | THE BULLETIN | 29
Do you know how to make Insulin 30 | THE BULLETIN | MARCH / APRIL 2015
BY BERNARD P. SHAGAN, M.D.,
Why Sliding-Scale Insulin Coverage Doesn’t Work This article has been reprinted on behalf of the San Joaquin County Hospitals Diabetes Special Interest Group (SJCH-DSIG) for the reading pleasure of SCCMA-MCMS members.
“It is easy to get a thousand prescriptions but hard to get one single remedy” - Chinese Proverb You are treating a patient admitted to the hospital for Streptococcus pneumoniae pneumonia. You write the following orders:
1. Check the patient’s
4. If it is between 102.1
temperature every four hours.
and 103 give penicillin 1,200,000 units.
2. If the temperature
5. If it is between 103.1
is below 101° F, give no antibiotic.
and 104 give penicillin 2,400,000 units.
3. If it is between 101
6. If it is above 104,
and 102 give penicillin 600,000 units IV.
call the doctor.
work backward? MARCH / APRIL 2015 | THE BULLETIN | 31
I am quite sure that any physician reading this article will recognize that the orders above are ridiculous. They do not address the basic problem aff licting the patient, pneumoccccal pneumonia, but merely one manifestation of that problem, the fever. They allow the patient’s infection to escape from control repeatedly. They do not ref lect our knowledge about the disease, the patient, or our ability to reverse the pathophysiology with proper treatment. Yet there are many physicians who see the inadequacy of these orders but who, when treating diabetic patients, will write insulin orders which similarly bear no relationship to the disease, the patient, normal physiology, and the pathophysiology of the disease. The system of orders to which I refer is called sliding-scale insulin coverage. It was developed when the normal physiology of insulin secretion and metabolic control was not understood and when the determination of blood sugar was laborious and time consuming. It was not physiological at the time and it remains non-physiological today.
In treating a diabetic patient , it should be our goal to restore and maintain metabolic normalcy. We should attempt to keep the patient’s blood sugar as stable and euglycemic as possible without causing problems in that attempt (avoiding hypoglycemia particularly). The objective is not to let the patient become repeatedly sick (hyperglycemic, hyperlipemic, hyperosmolar, polyuric) and then to try to treat the problem that we have allowed to occur. Yet, this is precisely what sliding-scale insulin coverage does, in whatever form it is used.
Giving insulin in response to a high blood sugar as a routine form of treatment is not physiologic, does not protect the patient, is not really a way of assessing the patient’s insulin sensitivity, and bears little if any relationship to the insulin needs of the patient under normal circumstances. Indeed, in terms of insulin secretion, infection, and osmotic regulation, this mode of therapy may be dangerous to the patient. It is always playing catch- up. If our goal is to maintain the patient in the best possible metabolic state, we cannot allow the patient’s glucose utilization and attendant blood sugar and lipid levels to seesaw throughout the day. If our goal is to approximate normal control as closely as possible, then we should do what we can to mimic normal insulin secretion.
SAN JOAQUIN PHYSICIAN 32 | THE16BULLETIN | MARCH / APRIL 2015
This entails giving insulin so that it can function prospectively and not attempting to make it work retrospectively.
Except when the patient is so dysmetabolic as to require insulin without food, insulin should always be prescribed with caloric intake and in relation to that intake. If the patient’s intake of calories is continuous, as when the patient is receiving continuous infusions of glucose-containing f luids or continuous enteral feeding by tube, then insulin administration should be as continuous as possible, given on a continuous, around-the-clock basis as long as the calories are given on that basis.
The Basal-Bolus Insulin order set is designed to provide a continuous, more normal physiologic state of glycemic control. It is available now for your use and should replace the sliding scale insulin regimen for most diabetic patients outside of the intensive care unit. For questions regarding the use of Basal-Bolus Control orderset, please contact Pharmacy.
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The History of O’Connor Hospital By Michael A. Shea, MD Leon P. Fox Medical History Committee
Judge Myles O'Connor 34 | THE BULLETIN | MARCH / APRIL 2015
Myles O’Connor was born on May 8, 1823 in Abbey Leix, Ireland. From this tiny hamlet, 50 miles from Dublin, his family migrated to London when he was two years old. In 1838, at the age of 14, they moved to America. They lived in St. Louis where Uncle Jeremiah O’Connor was well established. (He had given the city a large grant of land and donated property for the original site of St. Louis University.) Myles, a quiet studious boy, began work in a local lawyer’s office when he was 19. At age 23, he graduated with honors from St. Louis University Law School and immediately began practice. In April of 1849, the young attorney, lured by gold tales and the thought of practicing his craft in a new frontier, left St. Louis, bound for California. He was part of a wagon train, where his assignment was chef. One hundred twenty two days and 2,000 miles later, he arrived at Sutter’s Fort. He settled down in Grass Valley where he prac-
ticed law and gold mining. Romance entered Myles’ life in 1862, when he married a petite widow, Amanda Butler Young. This marriage was to last 47 years. Fortune smiled on the couple in 1863. O’Connor and two partners discovered the Idaho mine which was to produce a lifetime of wealth for the judge and his wife. Politics became his third occupation. He was elected to the California State Assembly in 1859 for one term. Later he served as justice of the peace in Grass Valley. He won re-election nine consecutive times. Following this, he won a seat in the state senate, which he held for six years. The next five years found the O’Connors traveling throughout Europe. When they returned to the states, they settled in San Jose. A long simmering idea to build a home for the aged and the needy, began to take shape in 1887. It would be known as the O’Connor Sanitarium. The construction was left to a long-time confidante, Edward McLaughlin. This sanitarium would be used for the care of the sick, a home for the aged, and a school for children. The Daughters of Charity of Saint Vincent de Paul were given control of the sanitarium. Theodore Lenzen, famous for his designs of city hall and many other civic buildings was chosen as the architect. The O’Connor Sanitarium opened its doors in 1889. It was located on a country site, chosen by Judge O’Connor, south of Stevens Creek Road, between Meridian and Race Streets. It encompassed 8.395 acres. Sister Severina Brandel of the Daughters of Charity was appointed the first superior. The building consisted of two stories, made of brick, with sandstone facings, giant white columns supported the portico over the main entrance. North and south wings stretched toward Meridian Road. The south wing lower floor was a woman’s ward and the upper story, the sister’s residence. The north wing housed the men’s ward, storeroom, and kitchen, with the second floor divided into apartments for families. In all, there were 44 rooms and five wards. The basement contained the engine room, furnace, and laundry.
At first, the hospital served more as a home for the aged and infirm. By the end of the century, medicine was advancing in great strides. Doctors were treating patients at the Sanatarium in growing numbers. Sister Raphael Jones, the second superior, began major changes that would convert the Sanatarium into a hospital. Carpets were replaced by sanitary flooring, high hospital beds went in, and electricity replaced the old acetylene lighting system. By 1902, an operating room was set up, north of the main entrance. Instruments were sterilized in boiling water on the kitchen range in the basement. In 1906, operations had increased to such a point, that a completely new surgical wing was constructed, north of the main unit. It was here that thousands of operations were performed for almost half a century. By 1910, an isolation building was added for contagious diseases. Departments now included x-ray, medical, obstetrical, electrotherapeutic, surgical, clinical laboratory, and pharmacy. The last renovation was the conversion of the 0’Connor House into a pediatric ward. (It had been added to the Hospital in the late 1800’s.) Feeling the need for more space, a building drive was started in 1947. The location of the new hospital was a 24 acre pear orchard, located off Forest Avenue. On January 23,1954, the new six million dollar O’Connor Hospital admitted the first patients.
ADDENDUM
Myles Poore O’Connor died on June 9, 1909, due to a series of strokes. He was 86. Amanda O’Connor passed away April 11, 1926 at the age of 90. They had no children.
MARCH / APRIL 2015 | THE BULLETIN | 35
(CMA Alert, April 6, 2015 issue)
CMA joins vaccine advocates to launch “I Heart Immunity” campaign in support of Senate Bill 277 The California Medical Association (CMA), American Academy of Pediatrics, California (AAPCA), California Immunization Coalition (CIC), Vaccinate California and Health Officers Association of California (HOAC) have joined forces to launch the “I Heart Immunity” campaign in an ongoing effort to promote the importance of vaccines and Senate Bill 277 (Pan/Allen). The bill would remove the personal belief exemption (PBE) option from the school and child care enrollment requirements. It would also require schools to publically provide information about their immunization rates. Removing the PBE will help protect the most vulnerable, including babies too young to be immunized, and people who are immunocompromised, from the risks associated with contracting these diseases. It will also protect the community at large from increased outbreaks of vaccinepreventable disease. “Immunizations have been a cornerstone of medical advancements in this century, eliminating the fear of death and permanent disability from diseases that once threatened communities across the world,” said Luther Cobb, MD, CMA president. “The ‘I Heart Immunity’ campaign brings awareness to the legislation and education around the effort to keep communities safe.” AB 2109 (Pan), which passed in 2012, sought to ensure that families were not using the PBE solely out of convenience or based on misinformation about vaccine efficacy or safety. Though that legislation resulted last year in the first decrease in PBE use in a decade, the measles outbreak earlier this year underscored the need to do more. “The recent measles outbreak has been a strong reminder that these diseases are still with us and can reemerge anytime, anywhere – especially in a community where vaccine rates are low,” said Catherine Flores-Martin, CIC executive director. “Parents should be able to send their children to day care and school without exposing them to vaccine-preventable diseases because of the decisions made by other parents.” In 2000, the Centers for Disease Control and Prevention (CDC) determined that measles had been eradicated in the United States. However, since December 2014, Califor36 | THE BULLETIN | MARCH / APRIL 2015
nia has had 133 confirmed cases of measles across 13 counties. Twenty percent of those cases have required hospitalization. Efforts to contain the outbreak have resulted in mandatory quarantines and the redirection of public health resources to investigations into exposure. “As a mother of young children and leading advocate for Vaccinate California, I am very concerned about the risk my son faces each day at school as outbreaks of preventable diseases continue to rise,” said Hannah Henry. “The safety and health of our children is essential,” said Kris Calvin, AAPCA CEO. “SB 277 will make sure that kids have the best chances to stave off preventable diseases.” Vaccines have undergone significant rigorous scientific review and continue to have ongoing safety tracking. That rigorous analysis indisputably shows that vaccines are effective and have very low risks. Recent endorsements of SB 277 include the Santa Cruz County Board of Supervisors, the Alameda County Board of Supervisors, the Marin County Board of Supervisors, the California State Parent Teacher Association, and the California School Nurses Association.
(CMA Alert, April 6, 2015 issue)
Senate delays vote on SGR until April, CMS to delay 21% cuts until midmonth The U.S. Senate failed to take a vote to permanently fix the Medicare sustainable growth rate (SGR) formula and extend the Children’s Health Insurance Program (CHIP) in March, and will take the measure up when it returns from a break on April 13. Majority Leader Mitch McConnell (RKY) said shortly after the budget debate at 3 a.m. on the Senate floor, “It’s encouraging this passed the House with such a large bipartisan majority, and I want to assure we’ll move to it very quickly when we get back…I think there is every reason to believe it’s going to pass the Senate by a very large majority.” The measure, a rare bipartisan achievement in a deeply divided Congress, was overwhelmingly approved on April 2 by the U.S. House of Representatives. The bill would create a new payment formula focused on the quality of care. To help pay for these higher rates, the bill would also impose higher premiums on wealthier Medicare beneficiaries and impose cuts on hospitals for post-acute care. The California Medical Association (CMA) is pleased that both Senators Barbara Boxer and Diane Feinstein were prepared to support the legislation and applauds the landslide vote of 392-37 in the House. This momentum should propel the Senate to act quickly when they return from recess. CMA will continue to stay in touch with our Senators over the recess and monitor the situation closely. We will keep fighting until we achieve passage, because we are too close now to let this opportunity slip away. Thanks to every California physician who called, emailed, and met with our Congressional Representatives to secure their votes. We had an overwhelming vote of support from the California Congressional delegation. Regarding payment for services between April 1-14: Physician services provided on or after April 1 will be subject to a cut of 21%. However, the Centers for Medicare and Medicaid Services (CMS) is instructing its carriers to “hold” for 10 business days any claims for services provided on April 1 and beyond, until legislation can be passed and signed into law that
reverses the 21% cut. The 10-day business hold means that April claims will be held through Tuesday, April 14. Since no claims by law can be paid sooner than 14 calendar days from their receipt, this hold should have little practical impact on Medicare remittance in the short-term, although billing for copayments and claims reconciliation will be more complicated. CMA and American Medical Association are advising against submitting claims with reduced amounts reflecting the 21% cut. Physicians have the option of holding claims and submitting them after the new fee schedule is released. If you choose to submit claims in the interim, CMA suggests that both participating and non-participating physicians bill their usual and customary fees-for-services to Medicare. Billing at your customary fee ensures that Medicare pays the highest amount possible when the claim is processed. In the unexpected event that Congress allows the 21% cut to take effect, Medicare would pay physicians at the reduced amount no matter what the physician billed and no further action would be necessary. However, non-participating physicians who have collected balance billing amounts for unassigned claims based on the currently-allowed amount could be required to make refunds to their patients based on new, lower balance billing amounts.
MARCH / APRIL 2015 | THE BULLETIN | 37
(CMA Alert, March 23, 2015 issue)
(CMA Alert, April 6, 2015 issue)
Match Day keeps some ACIP updates HPV new doctors in California, vaccine recommendations sends others out-of-state Friday, March 21, on National Match Day, California’s graduating medical students learned whether they can begin practicing medicine here – or if they must leave the state to begin their careers. The National Resident Matching Program matches graduating medical students with residency programs using a mathematical algorithm that pairs the rank-ordered preferences of applicants and program directors to produce a “best fit” for filling available training positions. However, this year, more than 41,000 medical school seniors and graduates applied for only 30,000 available residency positions. “Match Day is a pivotal point in a medical student’s career,” said California Medical Association (CMA) President, Luther Cobb, MD. “Many students graduating from California medical schools want to continue their education and training by attending residency programs here. Unfortunately, because of funding restraints, there aren’t enough openings to accept them all.” Beth Griffiths, fourth-year medical student at UC San Diego School of Medicine, is one of the lucky ones. Griffiths matched her first choice – UC San Francisco – for an internal medicine residency, primarily focused on training primary care physicians. She hopes to practice primary care for adults in Northern California, focusing on caring for Spanish-speaking patients. “Unfortunately,” she says,” there is a tremendous shortage of physicians who are fluent in Spanish.” Griffiths is thrilled to stay in California to practice medicine. “I like the commitment to serving the underserved that is part of so many of our training programs,” she says. “I also hope to stay active in issues of public policy, which are so relevant to the practice of medicine and improvement of public health.” But although Griffiths will remain in California, many medical students will not. The federal government, through the Medicare program, has been the major funding source for residency programs. Regrettably, this funding has been frozen since 1997, despite California’s population growing over 10% in the same time. In addition, many residency program leaders say that funding received from Medicare and Medicaid does not fully cover the cost of even the current residency training slots, so sponsoring institutions such as teaching hospitals must absorb residual costs. That’s why CMA is sponsoring SB 22, authored by California State Senator Richard Roth (D-Riverside). The bill would establish a Graduate Medical Education Trust Fund that can receive contributions from private sources in order to provide grants to residency programs in areas with the greatest need. 38 | THE BULLETIN | MARCH / APRIL 2015
During its February 2015 meeting, the Advisory Committee on Immunization Practices (ACIP) recommended the 9-valent human papillomavirus (HPV) vaccine (9vHPV; Gardasil 9, Merck) as one of three HPV vaccines that can be used for routine vaccination, according to a report published in the March 26 issue of Morbidity and Mortality Weekly Report. The U.S. Food and Drug Administration approved 9vHPV in December 2014. Based on a review of clinical trials, the committee determined the new vaccine was more cost-effective and had 97% efficacy compared with the current 4-valent HPV vaccine. With the addition of five strains, the new vaccine protects against 14% more HPV cancers for women and 5% more for men. The committee stressed that they did not express a preference of one vaccine over another. Nearly two-thirds (64%) of invasive HPV-associated cancers are caused by HPV types 16 or 18, and about 10% are caused by types 31, 33, 45, 52 and 58. HPV types 6 and 11 cause anogenital warts. Similar to quadrivalent HPV vaccine (4vHPV), 9vHPV protects against HPV 6, 11, 16 and 18; 9vHPV also protects against types 31, 33, 45, 52 and 58. Specific ACIP recommendations are as follows: • For routine vaccination of females, 9vHPV, 4vHPV, or bivalent HPV vaccine can be administered. • For routine vaccination of males, 9vHPV, or 4vHPV can be administered. • Routine HPV vaccination should begin at 11 or 12 years old, but the series may be started as early as 9 years old. • Females ages 13 through 26 and males ages 13 through 21 who have not been vaccinated previously or who have not completed the 3-dose series should also be vaccinated. • Males ages 22 through 26 may also be vaccinated. • Men who have sex with men and immunocompromised persons through age 26, including those with HIV infection, should also be vaccinated with either 9vHPV or 4vHPV if they were not previously vaccinated. The evidence underlying these recommendations included findings of a randomized trial enrolling approximately 14,000 females ages 16 through 26. This showed noninferior immunogenicity for the HPV types shared by 4vHPV and 9vHPV and high efficacy for the five additional types. Other trials in clinical development compared antibody responses across age groups and females and males.
(CMA Alert, April 6, 2015 issue)
Western Health Care Leadership Academy speakers include author of “Emperor of All Maladies,” subject of Ken Burns documentary The 2015 Western Health Care Leadership Academy, to be held May 29-31, will feature special guest speaker Siddhartha Mukherjee, MD, Pulitzer Prize winning author of The Emperor of All Maladies. The book is the focus of a recent three-part Ken Burns documentary that aired on PBS March 30 through April 1, 2015, which critics called “powerful and poignant.” Dr. Mukherjee is an oncologist, cancer researcher, and science writer who brought new insights into the causes and cures of cancer. In his book, Dr. Mukherjee gives readers a fascinating look into the origins and causes of cancer, its deadly effect on the human body, how it has virtually enveloped modern civilization and the epic battles that are taking place to control, cure, and conquer it. Dr. Mukherjee’s accomplishments as both a physician and author are powerful, illuminating, and inspiring. Attendees at this year’s Leadership Academy will have the chance to meet and speak with the author and other researchers about where the treatment of cancer may be going in the future. Joining the Academy’s discussions about cancer will be Patrick SoonShiong, MD. Recently featured on CBS’ 60 Minutes, Dr. Soon-Shiong is a visionary surgeon, medical researcher, businessman, philanthropist, and UCLA professor who invented the nation’s first FDA-approved nanoparticle delivery technology for the treatment of metastatic breast cancer. He is currently the chairman and CEO of both the Chan Soon-Shiong Institute of Molecular Medicine and NantWorks, a network of companies developing leading-edge infrastructure and digital technologies to create a future of personalized treatments to manage cancer. Following Dr. Mukherjee’s and Dr. Soon-Shiong’s talks will be a panel discussion with both physicians, looking toward the future and what all hope will be the final chapter of the cancer story. Register for the Academy today with the VIP upgrade and enjoy “up close and personal” experiences with Dr. Mukherjee and keynote speaker Malcolm Gladwell, as well as benefits including express conference check-in and preferred seating. The 18th Annual Western Health Care Leadership Academy continues its mission of providing information and tools needed to succeed in today’s rapidly changing health care environment. The conference will examine the most significant challenges facing health care today and present proven models and innovative approaches to transform your organization’s care delivery and business practices. This year’s event is set in the heart of Hollywood at the Loews Hollywood Hotel, just steps from the Dolby Theatre (home of the Oscars®) and the Hollywood Walk of Fame. For more information and to register, go to http://www.western-leadershipacademy.com.
(CMA Alert, April 6, 2015 issue)
April is National Donate Life Month; physicians encouraged to talk to patients about the importance of organ donation In honor of Donate Life Month, the California Medical Association (CMA) and the CMA Foundation are encouraging physicians to talk to their patients about the importance of organ and tissue donation, particularly in underserved ethnic communities. More than 123,000 people are currently waiting for an organ transplant in the United States, with more than 22,000 living in California. Each day, an average of 150 people are added to the national organ transplant waiting list. Unfortunately, an average of 21 patients on the waiting list die each day. What you can do: Visit the Donate Life California website, www.donatelifecalifornia. org and sign up to become a donor yourself, if you haven’t already done so. If you already registered via the Department of Motor Vehicles, you can also access/update your registry data. Educate patients about the benefits of becoming a donor. Talk to them about the lifesaving importance of organ and tissue donation and encourage them to register to become an organ donor at www.donatelifecalifornia.org. Donate Life California is the state authorized nonprofit organization responsible for managing California’s Organ and Tissue Donor Registry. The registry is a confidential database of donation wishes to be carried out at the time of death. Visit www.donatelifecalifornia.org for more information on how you can get involved. MARCH / APRIL 2015 | THE BULLETIN | 39
(CMA Alert, April 6, 2015 issue)
CDPH mounts television ad campaign highlighting the dangers of vaping Twenty-five years after launching the first anti-smoking advertisements in the state, the California Department of Public Health (CDPH) launched a new series this month of television, digital, and outdoor ads, all highlighting the dangers of e-cigarettes, a practice commonly known as “vaping.” With one of the lowest smoking rates in the nation, California has been a leader with its aggressive anti-smoking campaigns, but the aggressive marketing and escalating use of e-cigarettes threatens to erode this progress. CDPH recently released a report and a health advisory highlighting areas of concern regarding e-cigarettes, including the sharp rise in e-cigarette use among California teens and young adults, the highly addictive nature of nicotine in e-cigarettes, the surge in accidental nicotine poisonings occurring in young children and the many toxic chemicals found in secondhand e-cigarette emissions. Research shows that youth and young adults who use e-cigarettes are far more likely to also use traditional cigarettes and other tobacco products. The campaign includes two television ads that feature images portraying the health risks of e-cigarettes. One TV ad underscores the e-cigarette industry’s use of candy flavored “e-juice” and products that entice the next generation to become addicted to nicotine. The second TV spot emphasizes the dangers and addictiveness of e-cigarettes, while exposing the fact that big tobacco companies are in the e-cigarette business. E-cigarettes are largely unregulated at the federal level, while companies are not required to disclose what is in their products or how they are made. The ad campaign will run from March 23 through June 2015, with TV and digital ads on websites, online radio, and social media throughout the state. Outdoor ads, including billboards, at gas stations and in malls,
and ads in movie theaters will be phased in throughout the campaign. The California Medical Association’s headquarters in Sacramento also showcases the ads on its brick walls. This counter e-cigarette advertising campaign is part of CDPH’s ongoing anti-tobacco media efforts. In addition to advertising, CDPH’s educational campaign will include: • Partnering with local public health, medical, and child care organizations to increase awareness about the known toxicity of e-cigarettes and the high risk of poisonings, especially to children, while continuing to promote and support the use of proven effective cessation therapies. • Joining with the California Department of Education and school officials to assist in providing accurate information to parents, students, teachers, and school administrators on the dangers of e-cigarettes. The California Tobacco Control Program was established by the Tobacco Tax and Health Protection Act of 1988. The act, approved by California voters, instituted a 25-cent tax on each pack of cigarettes and earmarked five cents of that tax to fund California’s tobacco control efforts. California’s tobacco control efforts have reduced both adult and youth smoking rates by 50%, saved more than one million lives, and have resulted in $134 billion worth of savings in health care costs. Learn more at TobaccoFreeCA.com.
(CMA Alert, April 6, 2015 issue)
California has one of the lowest acceptance rates for new Medi-Cal patients A new report by the Centers for Disease Control and Prevention (CDC) reveals that, in 2013, only 54% of California physicians accepted new Medi-Cal patients, a rate that is significantly lower than the national average of 68.9%. California has the second-lowest physician acceptance rate of new Medi-Cal patients, with New Jersey coming in last with 2013 acceptance rates of 38.7%. The report compared physician acceptance of new patients across payors, mainly focusing on 40 | THE BULLETIN | MARCH / APRIL 2015
Medicare and private insurance. The CDC found that the national average of physicians who accepted new Medicare patients was 83.7%, with 84.7% for private insurance. California physicians accept new Medicare and private insurance patients at 77.2% and 76.6%, respectively. The California Medical Association continues to work with the We Care for California coalition to increase Medi-Cal provider reimbursement rates in an effort to ensure Californians have appropriate access to care. We Care
for California has recently worked with legislators to introduce AB 366 and SB 243, legislation that would not only restore a 10% cut to MediCal reimbursement rates, but would also place reimbursement on par with Medicare, increasing payment rates for inpatient hospital services and most outpatient services. The proposals would also require the Department of Health Care Services to pay Medi-Cal managed care plans at the upper end of the rate range, so as to ensure a more robust Medi-Cal provider network.
(CMA Alert, April 6, 2015 issue)
New study finds thousands may be eligible for health insurance in California under DACA Between 360,000 and 500,000 immigrants living in California could become eligible for Medi-Cal if they receive temporary protection from deportation through President Obama’s Deferred Action for Childhood Arrivals (DACA) program, according to a study by UC Berkeley’s Center for Labor Research and Education and the UCLA Center for Health Policy Research. Under the President’s executive actions on immigration, those people living in the U.S. without permission can’t enroll in Covered California, but the state does allow those granted temporary relief from deportation to sign up for Medi-Cal. That means up to half a million more people could apply for the state’s low-income health program. In November, Obama announced the expansion of DACA, which was established in
2012, and the creation of Deferred Action for Parents of U.S. Citizens and Lawful Permanent Residents (DAPA). Application processes for the new programs have been placed on hold under a court order, but immigration policy experts predict that the new programs will ultimately be implemented. The study also comes as the California Legislature considers the Health for All Act, or SB 4, proposed by state Senator Ricardo Lara. The bill would expand eligibility for comprehensive Medi-Cal to all low-income Californians, regardless of their immigration status, and broaden undocumented Californians’ options for purchasing private insurance. The study’s authors estimate that 66% of adults who would be eligible for Medi-Cal are working. The researchers also found that Califor-
(CMA Alert, March 23, 2015 issue)
nians eligible for the program are relatively young: 92% are under the age of 45, which would likely mean that their insurance premiums would be lower than the current statewide average. Providing comprehensive coverage would also build upon federal and state funds already spent. Previous research by the authors found that 60% of the cost per adult of comprehensive Medi-Cal coverage is already paid for by the federal and state government through restricted scope Medi-Cal, which covers emergency and pregnancy-related services. The health coverage and demographic estimates use data from the 2013 Current Population Survey, conducted by the U.S. Bureau of Labor Statistics and Census Bureau. The estimates are applied to the Pew Research Center’s estimate that 1.25 million Californians are potentially eligible for DACA and DAPA.
(CMA Alert, March 23, 2015 issue)
Raising the smoking age DWC implements annual to 21 could reduce tobacco changes to workers’ use among next generation compensation physician fee schedule
A report released March 12, 2015, by the Institute of Medicine (IOM) said that raising the smoking age to 21 could reduce smoking by as much as 12% in the next generation. In addition, smoking-related deaths could be cut by nearly 10%. Tobacco use remains the leading cause of preventable death in this country. The U.S. Surgeon General estimates that 5.6 million youth alive today will lose their lives prematurely if we don’t do more to reduce current smoking rates. Roughly 90% of daily smokers first tried a cigarette before age 19, a time when researchers say the brain is still developing in areas like decision-making and impulse control. That development continues until about age 25. In California, a bill to raise the minimum smoking age from 18 to 21 has been introduced in the state legislature. Senate Bill 151, introduced by Senator Ed Hernandez, would make California the first state in the country to raise the minimum smoking age as high as 21. Similar proposals have previously failed in New Jersey, Utah, Colorado, and Maryland. The California Medical Association supports the legislation. The IOM’s 335-page report, Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products, outlines the likely effects of setting the minimum age at 19, 21, and 25 years.
The California Division of Workers’ Compensation (DWC) has implemented its annual adjustments to the California workers’ compensation resource-based relative value scale (RBRVS) fee schedule effective for dates of service on or after March 1, 2015. Under the RBRVS Physician Fee Schedule regulations, located under “Physician services” on DWC’s Official Medical Fee Schedule (OMFS) webpage, the calculations to determine maximum allowable amounts for each code incorporate a number of factors, including the assigned relative value units for each code along with the yearly adjusted conversion factor determined by DWC. DWC updates these factors annually respective of changes in the Medicare payment system. DWC has reiterated that will not be publishing a composite fee schedule for physicians to access. Physicians seeking a streamlined method of determining correct reimbursement amounts for workers’ compensation medical services can contact DaisyBill, which offers an easy-to-use OMFS Calculator (http://www.daisybill.com/calculator-features).
MARCH / APRIL 2015 | THE BULLETIN | 41
ENERGY BARS, FROM SPORTS TO SNACKS By Claire Saxton and Dr. Randy Ligh
products. They are available in grocery stores, convenience stores, pharmacies, and many other places. Packaged Facts, a market research company, estimated the total U.S. retail sales in the food bars category to be $5.7 billion in 2011. (2) There is concern that consumers are not paying close attention to the ingredients and nutrition label. They may be falling prey to the marketing of a product, the taste of the product, or the hype created by celebrity endorsement. As with many other products, creative marketing is used to skirt food-labeling regulations. Energy bars can appeal to health-conscious consumers as a better choice than a candy bar, but it can be difficult for consumers to determine the right product and nutritional value when faced with so many options.
BACKGROUND
Once known as “performance food,” energy bars were originally developed for athletes to maintain their stamina during endurance events. Carbohydrate is needed for fuel as glycogen stores are depleted in order to avoid a drop in performance. However, the market has dramatically expanded, and products have been developed for before, during, and after athletic pursuits. Even more, people now gravitate towards these convenient foods for a quick and easy meal replacement or snack. The National Health and Nutrition Examination Survey (NHANES) found that snack consumption has risen in the last 30 years. In 1977, 41% of consumers reported eating no snacks daily while in 2007 only 10% of consumers did not snack at all. (1) The diversity and breadth of products available is astronomical. The traditional bars now come in a variety of sizes, texture, and nutritional compositions. Some popular categories are high protein or ones with natural ingredients. Since bars can be difficult to chew during running and other high impact events, gels and chews are commonly used during endurance events. However, their texture and taste generally make them less desirable as a snack food. Powders and tablets that dissolve into water, mainly with carbohydrate and electrolytes, are also useful for the running, hiking, and endurance athlete crowd. Again, these are less popular for the general population as their taste and availability is not as good as commercial sports drinks. Bars remain the most widely available and commonly eaten products. People of all ages and activity levels have become consumers of these Performance Bars Bear Valley Pemmican Bar Belly Timber Everyday Survival Bar Bonk Breaker Energy Bar Clif Bar Clif Mini Bars Clif Builder’s Bar Clif Luna Bar Hammer Nutrition Organic Energy Bar Hammer Nutrition Recovery Bar Honey Stinger Protein Bar Honey Stinger Stinger Energy Waffle PowerBar Energize Fruit Smoothie Bar PowerBar Performance Bar Probar Organic Whole Meal Bar
Calories per Calories from serving (1 bar) fat 400-440 110-120 310 130 250-255 72-81 230-250 20-50 100 15-25 270 70 170-190 25-50 220 80 330 126 190 90 160 63 210 30 230-250 15-35 350-390 150-180
42 | THE BULLETIN | MARCH / APRIL 2015
GUIDANCE
Consumers should be aware of their buying habits and be cognizant of what they are buying. READ the labels. Reflect on your age, gender, activity levels, overall diet, health concerns, limitations, and health goals. As general guidance, if the product is being used as a snack and not a meal replacement, the calories should not exceed 200-250. The product should also have no trans fats, and include fibers like inulin, chicory extract, and oligosaccharides, but these may not provide the same benefit as fiber from food. Ideally, bars with lots of added sugars would be avoided, but with current labeling it is not possible to tell whether “sugars” are from fruits or are added sugars. The ingredient list shows how many kinds of added sugars there are. There are numerous types of sugars that might be used, including fructose, glucose, honey, syrups, cane sugar, etc, and the earlier they appear in the ingredient list, the more of it there is (by weight). Natural
Total fat (g) 12 16 8-9 2.5-6 2-2.5 8 3-6 9 14 10 7 3.5 2-3.5 17-20
Sodium (mg) 80-90 50 170 100-250 60-95 230-310 120-200 18 80 27 55 100 200-210 30-90
Carbohydrate Dietary fiber (g) (g) 56-68 6-10 34 8 37 2 40-47 5 17-18 5 30 4 24-28 3-4 25-26 4-5 25 8 18 2 21 1 40 1 41-44 2-4 46-49 6-7
Sugar (g) 24-28 11 18 17-21 8-9 20 8-12 15-17 16 15 14 27 20-25 21-31
Protein (g) 16-17 11 8 8-12 4-5 20 10 9-10 20 10 0 6 9-10 8-9
sugars, sugar substitutes, non-nutritive artificial sweeteners, and natural sweeteners (Stevia) all have different nutritive values, cariogenicity, and sweetness factors. (3) Overweight patients should look for smaller bars that are lower in calories. If glucose control is an issue, bars that are higher in fiber are preferred. Patients with high blood pressure or heart failure will need to consider the sodium content of the foods. Bars that are truly designed for endurance events have significant added sodium, but a natural or organic type bar often has lower sodium. Patients with diabetes will need to consider the carbohydrate and fiber content of the bar to determine how it can fit within their guidelines for eating. Terms such as “impact carbs” or “net carbs” may be used by manufacturers to differentiate types of carbohydrates. Generally, the sugar alcohols and fiber are subtracted from the total carbohydrate, and that number is said to be the amount of carbohydrates in the product that affects blood sugars. However, these claims are not regulated or approved by the Food and Drug Administration. It may be helpful for an active type 1 diabetes patient to use an energy bar as a consistent snack before exercising. A consistent snack food can make glucose control more predictable and avoid hypoglycemia. For type 2 diabetes, smaller bars with higher fiber content and carbohydrate less than 25 grams are preferred. Underweight patients may find the bars as a convenient, nutrient dense snack that is easy to keep with them for between-meal eating. In this case, taste may be the key factor, and higher calorie bars are optimal. Patients with food allergies will need to find a trusted brand. Most companies use a wide variety of ingredients including many common allergens such as nuts and wheat, so the possibility for cross-contamination is high. A 2009 report by ConsumerLab.com, an independent lab that evaluates health and wellness products, concluded that there were occasional discrepancies between ingredients on the label and what was actually in the bar. (4) Endurance athletes have many factors to consider. Options for before the activity (within 1-2 hours) should be easily digestible and thus not too high in fat, fiber, or protein. Products for use during training or an event should have carbohydrate and electrolytes, and possibly some protein. Athletes who are running or doing other high impact sports may prefer gels and chews for their digestibility. Cyclists and hikers are less prone to stomach upset, so they may prefer the taste and texture of bars. Products for after activity published study, researchers discussed how triathletes, who have frequent intake of carbohydrates during training, are at increased risk for dental erosion. (5) A patient involved in weight training or cross-fit type exercise activities likely gets adequate protein from his or her diet, but may be attracted to a high protein type product nonetheless. Many of these bars would make an easy before or after exercise snack.
CONCLUSION
Energy bars can provide a convenient snack, especially for athletes. No matter how nutritious a bar is, whole fresh foods are essential as the mainstay of a healthy diet. Foods contain far more nutrition and synergistic components than basic calories, carbohydrates, and vitamins. Consumers should be encouraged to eat less processed foods whenever possible to improve the health of their diet. Please reference the chart of Performance Bars Product Information (REI Store).
REFERENCES
1. Sebastian RS, Wilkinson Enns C, Goldman JD. Snacking Patterns of U.S. Adults: What We Eat In America, NHANES 2007-2008. Food Surveys Research Group Dietary Data Brief No. 4. June 2011. Available from: http://ars.usda.gov/Services/docs.htm?docid=19476. 2. Packaged Facts. Not Just for Breakfast: A Boom in the Food Bars Markets. Press Release April 3, 2012. Available from: http://www.packagedfacts.com/about/release.asp?id=2681. 3. Ligh R and Saxton C. The Dental Effects and Associated Properties of Natural Sugars, Sugar Substitutes, and Artificial Sweeteners. The Bulletin. 2014;20(3):34-35. 4. ConsumerLab.com. Sixty percent of nutrition bars fail to meet claims in ConsumerLab. com tests. Press release Oct 30, 2001. Available from: http://www.consumerlab.com/news/ Nutrition_Bars_Tests/10_30_2001/ 5. Frese C, Frese F, et al. Effect of Endurance Training on Dental Erosion, Caries, and Saliva. Scandanavian Journal of Medicine & Science in Sports. Epub 11 Jun 2014.
ABOUT THE AUTHORS
Claire Saxton is a clinical dietitian at Kaiser Santa Clara Medical Center in Santa Clara – 408/569-1551. She is also an avid runner. Dr. Randy Ligh is a private practitioner for Pediatric Dentistry in San Jose – 408/2866308. He was previously a physical trainer. MARCH / APRIL 2015 | THE BULLETIN | 43
Classifieds OFFICE SPACE FOR RENT/ LEASE OFFICE FOR LEASE/SUBLEASE
O’Connor Hospital area with office lease/ sublease. Please contact Dr. Maggie Chau at 408/799-7842 for details.
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 408/228-0454.
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.
MEDICAL OFFICE SPACE TO SHARE • SUNNYVALE
Convenient location. One large private office plus one exam room, shared waiting room and front office. Newly built, total 1,280 sq. ft. Available now. Please call 408/438-1593.
MEDICAL OFFICE SPACE TO SUBLET • MTN VIEW
Mountain View medical office space to sublet. 1,100 sq. ft. Available three days a week. In large medical complex, behind El Camino Hospital. Basement storage, untilities included. Large treatment rooms, small lab space, BR, private office, etc. Call Dr. Klein at cell 650/2691030.
MEDICAL/DENTAL/PROFESSIONAL OFFICE SUITE • SALINAS
Second story of professional building across from Salinas Valley Memorial Hospital. Private balcony. Freshly painted and carpeted, ready for occupancy. 1,235 sq. ft. at $0.963/sq. ft. Rent is $1,190/month. Contact Steven Gordon at 831/757-5246.
PRIME MEDICAL OFFICE FOR LEASE • SANTA CLARA
Ideal for medical, dental, physical therapy, optometry, office use. Approximately 1,700 sq. ft., near Santana Row. Excellent parking. Call owner at 408/858-9687. 44 | THE BULLETIN | MARCH / APRIL 2015
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 Rick Flovin, CEO at 408/2280454 or e-mail riflovin@allianceoccmed.com for additional information.
FAMILY PRACTICE FOR SALE
Family Practice for Sale. East San Francisco Bay, CA. Multi-location, multi-discipline practice for the Asian community’s established residents and newcomers. Revenue over $1 million. The languages spoken by physicians and staff include Cantonese, Mandarin, Punjabi, and Spanish; buyer doctor must be fluent in at least one Chinese dialect. The office also performs sleep studies. EMR in place. High profit margin, and seller will stay to train buyer in proprietary systems. Independent appraisal available. Offered at only $682,000. Real estate also available. Contact Practice Consultants at info@PracticeConsultants.com or 800/5766935. www.PracticeConsultants.com.
INTERNAL MEDICINE PHYSICIAN NEEDED
We are looking for an internal medicine physician for our multi-specialty group. Please email your CV to kaajhealthcare@gmail.com.
FOR SALE PRACTICE FOR SALE • SANTA CLARA COUNTY
Family/General Practice for sale (will consider urgent care clinic or Internist). 35 years, well established. Very affordable sale price. Agents welcome. Call Sue at 408/666-4308 or email yoanlisu@yahoo.com.
OB PRACTICE FOR SALE
OB/GYN practice that stopped the OB side of the practice in 2011, leaving a great growth opportunity for a buyer. Even without OB, this practice has prospered; 2014 revenue was $587,000 while doctor took eight weeks of vacation. Practice Fusion EMR in place. This is a very good opportunity in a visually pleasing office on a hospital campus, upstairs from the Labor and Delivery area of the hospital. Photos available. Offered at only $341,000. Contact Practice Consultants at info@PracticeConsultants.com or 800/576-6935.
METRO MEDICAL BILLING, INC. • • • • • •
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 Visit our Website www.metromedicalbilling.com
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MARCH / APRIL 2015 | THE BULLETIN | 45
Ambulatory Care Review Program
CMA
The California Medical Association
Accredits a wide range of outpatient settings, including ambulatory surgery centers, occupational health centers, medical offices/medical groups and others. Recognized by MBC, insurance carriers, and many other states.
Hospital Surveys and Leadership Training
Hospitals can request that the Joint Commission include an IMQ physician surveyor on its hospital survey in lieu of a Joint Commission surveyor.
Peer Review & Medical Staff Service
IMQ
The Institute for Medical Quality A subsidiary of the California Medical Association
Provides on-site objective peer review of one or more physicians’ clinical practices. Consultations provide on-site educational programs for medical staff on a range of topics. Also offers panelists for judicial review panels.
Medical Staff Leadership Training
Funded by the Physicians Foundation, and offered in March by IMQ and PACE, this interactive skill-building course gives physicians practical knowledge and skills needed to successfully lead their medical staffs.
Corrections & Detentions Survey Program
Accredits medical programs in juvenile halls and jails. Also conducts Title 15 surveys and pre-surveys.
CME Certification Program
Assists physicians in providing documentation of AMA PRA Category 1 Credit(s)™ and tracking their CME credits for the Medical Board requirement of 50 hours every 2 years.
CME Program
Interested in a program or becoming a surveyor? Want more information about any program? Contact: www.imq.org (415) 882-5151 tdolan@imq.org
46 | THE BULLETIN | MARCH / APRIL 2015
Accredits hospitals and organization in California to offer AMA PRA Category 1 Credit(s)™ for continuing medical educational activities. Conducts workshops and seminars for CME providers.
Ethics Program
Addresses the legal and ethical dimensions of medical practice in California and introduces participants to many resources. Attendees referred by the Medical Board, medical staff, or attorneys.
On-line CME
Offers a wide range of CME courses available 24/7 on demand.
www.imq.org
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