2017 March/April

MARCH / APRIL 2017

VOLUME 23 | NUMBER 2

BULLETIN THE

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

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8 The Connected Physician

14 What Physicians Need to Know about Supervising Physician Assistants 16 Human Trafficking in California – What Role Can Physicians Play?

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20 Californians With Medi-Cal Face Hurdles to See Specialists Throughout the State

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22 CHPI Launches New Site Rating California Physicians

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26 Medical Plus Psychosocial Support: Providing Complete Cancer Care for Your Patients

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27 New Tools Developed to Increase Prediabetes Awareness

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28 Interesting Facts That May Affect Healthcare

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5 Save These Dates: SCCMA & MCMS Annual Awards Banquet/Installation

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18 Western Healthcare Leadership Academy 30 Hospital News 32 Medical Times From the Past 33 New Member Benefit: Intalere 34 CapAlt: A Private Insurance Company Covers Damage to Professional Reputation 35 In Memoriam 36 Welcome New Members 38 Classified Ads 39 Two Old Dogs 40 MEDICO News MARCH / APRIL 2017 | THE BULLETIN | 3

THE SANTA CLARA COUNTY MEDICAL ASSOCIATION OFFICERS President Scott Benninghoven, MD President-Elect Seham El-Diwany, MD Past President Eleanor Martinez, MD VP-Community Health Cindy Russell, MD VP-External Affairs Kenneth Blumenfeld, MD VP-Member Services Ryan Basham, MD VP-Professional Conduct Vanila Singh, MD Secretary Seema Sidhu, MD Treasurer Anh Nguyen, MD

CHIEF EXECUTIVE OFFICER

COUNCILORS

William C. Parrish, Jr.

El Camino Hospital of Los Gatos: Lewis Osofsky, MD El Camino Hospital: Vacant Good Samaritan Hospital: Vinit Madhvani, MD Kaiser Foundation Hospital - San Jose: Hemali Sudhalkar, MD Kaiser Permanente Hospital: Martin Wong, MD O’Connor Hospital: Michael Charney, MD Regional Medical Center: Erica McEnery, MD Saint Louise Regional Hospital: Faith Protsman, MD Stanford Health Care / Children's Hospital: John Brock-Utne, MD Santa Clara Valley Medical Center: Clifford Wang, MD

CMA TRUSTEES - SCCMA Thomas M. Dailey, MD (District VII) Kenneth Blumenfeld, MD (District VII)

BULLETIN THE

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

THE MONTEREY COUNTY MEDICAL SOCIETY

Printed in U.S.A.

OFFICERS

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 2017 by the Santa Clara County Medical Association.

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President Craig Walls, MD PhD President-Elect Maximiliano Cuevas, MD Past-President James Hlavacek, MD Secretary Alfred Sadler, MD Treasurer Steven Harrison, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Valerie Barnes, MD David Holley, MD William Khieu, MD Eliot Light, MD

Phillip Miller, MD David Ramos, MD James Ramseur, MD

! s e t a D e s e h T e v Sa

SCCMA Annual Awards Banquet and Installation Tuesday, June 6, 2017 6:15 pm Social | 7:00 pm Dinner & Program The Fairmont Hotel, San Jose Installation: Seham El-Diwany, MD, SCCMA President 2017-18 Honoring: Scott Benninghoven, MD, SCCMA President 2016-17 Award Honorees: James Hinsdale, MD – Robert D. Burnett, MD Legacy Award Susan Smarr, MD – Benjamin Cory, MD Award Tung Le, MD – Outstanding Achievement in Medicine Patrick Kearns, MD – Contribution in Medical Education Howard Sutkin, MD – Contribution to the Medical Association Kris Karlen, MD – Contribution to the Community Margaret McLean, PhD – Citizen’s Award Assemblymember Ash Kalra – Citizen’s Award

Formal invitations will be mailed by the end of April

•

MCMS Annual Physician of the Year Banquet & Installation

Thursday, June 1, 2017 6:30 pm Social | Dinner & Program to follow Bayonet and Black Horse, Seaside Installation: Maximiliano Cuevas, MD, MCMS President 2017-18 Honoring: Craig Walls, MD PhD, MCMS President 2016-17 Physician of the Year: To Be Announced

Formal invitations will be mailed end of April

Medical Mission A Life Changing Experience

President, Santa Clara County Medical Association

SCOTT BENNINGHOVEN, MD

MESSAGE FROM THE

SCCMA PRESIDENT

E

Scott Benninghoven, MD is the 2016-2017 president of the Santa Clara County Medical Association. He has a general surgery practice in the South County and practices at Saint Louise Regional Hospital, Regional Medical Center of San Jose, as well as O’Connor and Good Samaritan Hospitals.

ach and every one of us has had an event that changed the course of our lives and alters the way we view the world. Personal events such as marriage, the birth of a child, special trips with family or friends, and professional accomplishments such as joining a medical practice or the completion of a project or research, are such examples and usually come along infrequently.

This past January I experienced one such event.

As I look back, it was not the magnitude of the event nor what I did, but the interactions with my colleagues and patients. I am forever changed by the experience.

I had the honor to join a large group of medical professionals who gave of themselves and traveled to treat thousands of people without access to medical care, with the hope of changing their lives for the better. The Philippine Medical Society of Northern California was organized in 1972 and began Medical Missions 30 years ago. Their goal was to bring medical care to the extreme poor of the Philippines and this has continued every year since. This year, President Peter Bretan Jr., MD and Medical Mission Coordinator Marlene Cordero, MD lead the mission to Dumaguete.

I was one of about 150 members of the mission, only 30 of whom were physicians. Each volunteer travelled at his or her own expense to Dumaguete for eight days. This was my first year to join the group.

Most of the volunteers have been donating time and energy for over five years and some more than 25 years. Many of the volunteers came with a spouse, even if the spouse wasn’t in the medical field. I was fortunate to have my wife Pam travel on the Mission with me. Her critical care nursing and organizational skills complimented the team effort.

This brings me to the part that changed the way I view the world. The members of the mission acted and functioned as a team, creating an effect much greater than all of us could have achieved as individuals. EVERYONE contributed to the whole in the delivery of medical care to those who desperately needed it and had no other way to obtain it. Imagine seeing, evaluating and treating 6,187 new patients, performing 82 major surgeries (27 cataract and lens implants), 119 minor surgeries, 968 dental procedures and, 1,198 optometry treatments. I am so proud to be a part of an organization that selflessly delivers such compassionate care.

Physicians could never deliver the magnitude

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of what was accomplished in eight days alone. The pre-mission planning, the daily organization behind the scenes to maximize our workload was beyond my comprehension and truly amazing. Physicians, nurses, medical students and non-medical volunteers all came together to seamlessly provide care.

This is not to say that everything was planned – most of it wasn’t planned. In fact, the care that all of us were most proud of happened spontaneously.

In my opinion, the two most important members of the team, in the surgical area, were Dan and James, from “biomed,” who kept the whole process running. During a surgery when a piece of the anesthesia machine stopped working, such as the EKG monitor, no one panicked. Dan or James came to the rescue and had a new part harvested from another ventilator in minutes. When we had an unplanned orthopedic procedure that had not been done by the mission before, there was a flurry of activity and a new instrument tray was created from parts of other trays and magically the surgery went on to completion.

The other part I found so refreshing was that I could ask any physician for help and it was gladly given. All of us just wanted to provide great care and I, like everyone else, felt it an honor to be asked for our opinion or to assist.

Because this was usually the first time most of the patients had received a medical evaluation or treatment for their illness, most disease processes were far more advanced than what we see here at home. It quickly became apparent that we were the only chance they had to treat their illness and their gratitude was something to be humbled by. One of the ophthalmology patients was an eight-year-old boy who had been blind from birth due to congenital cataracts. The ophthalmologist removed the cataract and implanted a lens and that young man walked out of the OR seeing for the first time. Imagine how that one action will change his life. This is only one of hundreds of examples. Each and every patient I treated was grateful and that was an amazing feeling, one I rarely get treating patients at home.

I would recommend donating your time and skills for any Medical Mission if you ever get the opportunity. I am sure it will change your life as it did mine. Any one interested, I would be happy to show you pictures and tell you more about my experience.

President, Monterey County Medical Society

CRAIG A. WALLS, MD PhD

long international tradition of military doctors being armed. The idea is that the TEMS member can move independently in harm’s way and provide both self-defense as well as defense of the wounded patient and other team members.

The vast majority of preventable combat deaths occur from three major issues: hemorrhage, tension pneumothorax, and airway compromise. Tactical medicine shrinks the Golden Hour to the Golden Minute.

And so we get to the ethics of arming a highly qualified emergency physician or trauma surgeon and sending him or her into the “hot zone” of combat. Physicians take an oath of “Primum non nocere – First do no harm.” Is shooting a mass murderer in the act doing no harm? What if the guy’s name is Charles Whitman and he just arrived at the 28th floor of the University of Texas Tower in Austin with his Remington 700? What if the shooters are Eric Harris and Dylan Klebold and they just tossed out their first malfunctioning pipe-bomb and drew their pistols and shotguns at the start of the Columbine massacre? What about in San Bernardino and at the Pulse nightclub? What about Paris? What about when it happens in our neighborhood?

My residents and students struggled with this concept of tactical medicine. Can you argue that our heroic law enforcement officers, who are willing to rush toward the sound of gunfire in a shopping mall or a church, should not be accompanied by a practitioner who is uniquely qualified to save their life with hemorrhage control, tracheal intubation, cricothyroidotomy, and needle thoracostomy? Is it okay to say that these officers can wait a few minutes to get non-tactical medical care back at the “green zone” – outside the range of fire? No one argued that.

Can you argue that the tactical medic should be sent into the hot zone without a firearm to protect themselves or their teammate? Some thought about this, but whom would you ask and expect to accept that duty?

Do the ends justify the means? Is the greater good the greatest good for the greatest number?

Would you do it? Should someone else do it instead of you?

One of the patches I have seen on a tactical medicine practitioner’s uniform has words wrapping around the top and wrapping around the bottom: On the top, “Do no harm” and on the bottom “Do know harm.”

MESSAGE FROM THE

T

he agencies and organizations that survey and certify our medical centers are now asking if we are prepared for disasters and mass casualty. As leaders in the healthcare system, we are rightfully expected to be planning for the unthinkable, which is now entirely thinkable. A sniping massacre in 1966 Texas led to the creation of SWAT teams. A high school massacre in 1999 Colorado led to a new approach to countering active shooters. Similarly, the blur of modern atrocities and active shooters has led to the creation of tactical medicine. Tactical medicine was endorsed by the American College of Emergency Physicians in 2004, and I introduced the concept in a lecture at our hospital last month. The talk sparked an ethical discussion with our residents and medical students.

I first heard about tactical medicine when I was a resident myself. One of my attendings was medical director for the Secret Service, and he helped found the field of tactical medicine. I was aware of that and had a vague idea that it had something to do with caring for the operators who guard our leaders and VIPs. Tactical medicine is defined variously as “the services and emergency medical support needed to preserve the safety, health and overall well-being of SWAT officers” (Tactical Medicine Essentials American College of Emergency Physicians, 2012).

A more expansive definition is, “Emergency medical care that is provided during battlefield, terrorist or police operations.” (Taber’s Cyclopedic Medical Dictionary, Donald Venes, MD, 2013). More cheekily, “Docs with Glocks” (Michael Neeki, DO).

Tactical physicians are attached to SWAT and combat units and are intended to be in the field with the operators to save preventable deaths, to prevent additional casualties, and to complete the mission.

These are doctors with experience performing lifesaving procedures who attach to operational combat and law enforcement teams. They are geared-up, armed, and sent into harm’s way as an integral part of the team.

Arguably, tactical medicine began in 1989 in Los Angeles County with Dr. Rasumoff, retired Army physician. From there it has grown and Tactical Emergency Medical Support (TEMS) classes are taught throughout the Unites States and have the moniker “Care Under Fire.” The rationale to arming physicians who are deploying with SWAT teams is that these providers should not be placed into circumstances where they cannot defend themselves, and the precedent that they draw upon is a

MCMS PRESIDENT

Do Know Harm

Craig A. Walls, MD PhD, is the 2016-2017 president of the Monterey County Medical Society. He is an Emergency Medicine doctor with the California Emergency Physicians Medical Group and is currently practicing with Natividad Medical Center in Monterey.

MARCH / APRIL 2017 | THE BULLETIN | 7

THE CONNECTED PHYSICIAN 8 | THE BULLETIN | MARCH / APRIL 2017

THE CONNECTED PHYSICIAN

Stanford Study: Artificial Intelligence and Healthcare

By Sierra Hersek PNN Staff Writer Reprinted with Permission of Physicians News Network (www.physiciansnewsnetwork.com) Stanford University is leading the charge and inviting contributors from several institutions to begin a new project, “One Hundred Year Study on Artificial Intelligence (AI100).”

In the first report, “Artificial Intelligence and Life in 2030,” researchers pondered the useful application of artificial intelligence (AI) and found healthcare to be a likely fit.

“For AI technologies, healthcare has long been viewed as a promising domain. AI-based applications could improve health outcomes and quality of life for millions of people in the coming years — but only if they gain the trust of doctors, nurses, patients, and if policy, regulatory, and commercial obstacles are removed,” the panel of experts reported.

AI in healthcare promises a variety of lifeenhancing innovations, including clinical decision support, patient monitoring and coaching, automated devices to assist in surgery or patient care, and management of healthcare systems.

Data collection is a major part of these advancements. From personal monitoring devices and mobile apps to electronic health records (EHRs) in clinical settings, there is a wealth of information to be collected and applied. But restrictions around how this information can be used has slowed progress, according to the study.

“Using this data to enable more finely grained diagnostics and treatments for both individual patients and patient populations has proved difficult,” the panelists wrote. “Research and deployment have been slowed by outdated

AI in healthcare promises a variety of life-enhancing innovations, including clinical decision support, patient monitoring and coaching, automated devices to assist in surgery or patient care, and management of healthcare systems. regulations and incentive structures. Poor human-computer interaction methods and the inherent difficulties and risks of implementing technologies in such a large and complex system have slowed realization of AI’s promise in healthcare. The reduction or removal of these obstacles, combined with innovations still on the horizon, have the potential to significantly improve health outcomes and quality of life for

millions of people in the coming years.”

In a clinical setting the report points to the development of EHRs as a bumpy progression.

The panel says that a limited number of vendors control the EHR market, and user interfaces are widely considered substandard. The promise of new analytics using data from EHRs, including AI, remains largely unrealized due to these and other regulatory and structural barriers. In the next 15 years, AI advances, if coupled with sufficient data and well-targeted systems, promise to change the cognitive tasks assigned to human clinicians, according to HeathcareNewsIT. “The opportunity to exploit new learning methods, to create structured patterns of inference by mining the scientific literature automatically, and to create true cognitive assistants by supporting free-form dialogue has never been greater,” the report stated.

The report concludes that significant AIrelated advances have already had an impact on North American cities over the past 15 years, and even more substantial developments are expected in the next 15, provided they are judiciously managed.

“Recent advances are largely due to the growth and analysis of large data sets enabled by the Internet, advances in sensory technologies, and more recently, applications of ‘deep learning,’” the report noted. “In the coming years, as the public encounters new AI applications in domains such as transportation and healthcare, they must be introduced in ways that build trust and understanding, and respect human and civil rights.”

MARCH / APRIL 2017 | THE BULLETIN | 9

© Can Stock Photo / bloomua

Stanford’s School of Medicine Creates Digital Health Center to Work Reprinted with Permission of Physicians News Network (www. physiciansnewsnetwork.com) Stanford University School of Medicine has launched the Center for Digital Health in an effort to support collaboration between Stanford faculty and Silicon Valley technology companies to develop, test, and implement new digital health tools.

“Digital health is a space where Stanford should be leading the way,” said Sumbul Desai, MD, clinical associate professor of medicine and executive director of the center, in a statement. “The new center will be focused on leveraging our resources and encouraging collaborations that will lead to better healthcare through digital technology.”

The center grew out of a need to provide support and guidance to faculty who were repeatedly being contacted by both startups and established technology companies with offers to collaborate, Dr. Desai said.

“We wanted to leverage that interest and generate more opportunities for the faculty by providing the infrastructure and resources needed to encourage these relationships,” Dr. Desai said. “We can help connect interested faculty with industry, or vice versa.

Say, for example, there’s a faculty member interested in pulmonary digital

health research. We may know a company with the same interest. We can help connect them.”

Mintu Turakhia, MD, assistant professor of cardiovascular medicine, has been appointed senior director of research and innovation at the center. “There are hundreds upon hundreds of digital health startups now, and it is very difficult for patients, doctors, hospitals, insurers, regulators, and investors to know which solutions will work and which will stick,” said Dr. Turakhia. “High-quality evidence is needed to make informed decisions. We generate this evidence quickly and cheaply, targeting the real-world outcomes that matter for all of these stakeholders.”

The center will provide training to physicians in digital health medicine at Stanford through fellowships, internship opportunities, conferences, and traditional classroom material. In addition, the center will offer educational programs to industry members.

In conjunction with the launch, the center is offering an opportunity for faculty members and instructors to propose healthcare research projects focused on innovative uses for Apple Watches. In addition to providing up to 1,000 of the watches, the center will award $10,000 to the winning project for one year, starting in April.

We wanted to leverage that interest and generate more opportunities for the faculty by providing the infrastructure and resources needed to encourage these relationships.

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THE CONNECTED PHYSICIAN

AMA Releases Guidelines for Use of mHealth Apps and Related Devices

By Sierra Hersek, PNN Staff Writer Reprinted with Permission of Physicians News Network (www. physiciansnewsnetwork.com) In an effort to provide guidance and clarity in the new era of mHealth (mobile health applications) and associated digital health devices, trackers, and sensors, the American Medical Association (AMA) has announced eight guiding principles to help physicians navigate coverage, payment, and financial incentive mechanisms for mHealth apps.

“The new AMA principles aim to foster the integration of digital health innovations into clinical practice by promoting coverage and payment policies that are contingent upon whether mHealth apps and related devices are evidencebased, validated, interoperable, and actionable,” said AMA Immediate Past President Steven J. Stack, MD, in a statement.

“It is essential for mHealth apps to support care delivery that is patientcentered, promotes care coordination and facilitates team-based communication.”

The following eight principles will be used to support the use of mHealth apps and associated devices, trackers, and sensors: 1. Support a strong patient-physician relationship.

2. Possess a clinical evidence base to ensure mHealth app safety and effectiveness.

3. Follow evidence-based practice guidelines to boost patient safety, quality of care and positive health outcomes.

4. Promote care delivery that is patient-centered, coordinated, and based on team communication.

5. Support data portability and interoperability to foster care

It is essential for mHealth apps to support care delivery that is patientcentered, promotes care coordination and facilitates team-based communication.

coordination through medical home and accountable care models.

6. Follow state licensure laws and state medical practice laws and requirements in line with where the patient is using the app.

7. Mandate providers delivering services through the app hold licensure in the state where the patient receives services.

8. Ensure that the delivery of any services via the app be consistent with the state’s scope of practice laws.

The AMA also noted that many physicians are unsure of their own liability when using, recommending, or prescribing mHealth apps. Accordingly, the AMA plans to “assess the potential liability risks to physicians for using, recommending, or prescribing mHealth apps, including risk under federal and state medical liability, privacy, and security laws.”

While physicians are optimistic about digital health and its potential medical benefits, as reported on PNN, the AMA policy acknowledges the need to expand the evidence base necessary to show the accuracy, effectiveness, safety, and security of mHealth apps.

MARCH / APRIL 2017 | THE BULLETIN | 11

Stanford Joins UC BRAID Health Research Alliance Reprinted with Permission of Physicians News Network (www.physiciansnewsnetwork.com) Stanford University has joined five University of California campuses in a consortium dedicated to removing administrative barriers to sharing research resources, talent, productivity tools and bioinformatics expertise.

This consortium, launched in 2010 by the University of California Biomedical Research Acceleration, Integration and Development program, called UC BRAID, began with five University of California campuses: Davis, Irvine, Los Angeles, San Diego and San Francisco. Since then, UC BRAID has developed several ways to streamline research processes, including UC ReX Data Explorer, a secure, online system that enables cross-institution access to clinical data from millions of de-identified patient records.

Leaders of the consortium say that by making it easier for research teams to leverage specialized resources and experts across member institutions, overhead costs can be reduced and

healthcare projects can move forward at a more rapid pace, benefiting Californians and the nation at large.

“In the emerging era of team science and big data, we could hardly enjoy a greater opportunity to advance medicine for the benefit of all Californians than to partner with our colleagues at UC biomedical research centers,” said Mark Cullen, MD, and Harry Greenberg, MD, co-directors of Stanford’s Clinical and Translational Science Awards (CTSA) institution, Spectrum.

Stanford, the newest member of the consortium, will join new and ongoing efforts to develop tools that help researchers recruit study participants, improve interactions with healthcare industry partners and speed regulatory approvals.

In addition, all UC BRAID members are working together to comply with the National Institutes of Health mandate that requires that all human-subject protection reviews for federally funded, multisite studies be coordinated

through a single institution.

Each UC BRAID member is funded by a Clinical and Translational Science Award from the National Center for Advancing Translational Sciences at the NIH. Rachael Sak, BSN, MPH, director of UC BRAID, explains: “Our common goal is to improve health. By sharing resources and our collective expertise, we can accelerate our progress and deliver cutting-edge treatments to patients sooner and more effectively than we could alone.”

While the partnership is already bearing fruit, leaders from the six institutions see this as a stepping stone toward further collaboration.

Summarizing the potential, Steven Dubinett, MD, director of the CTSA at UCLA and incoming chair of UC BRAID, stated: “Enhancing our capacity for creative team science across our campuses will afford new opportunities to translate the most important research discoveries to the benefit of all of our communities.”

Power Collaboration Aims to Improve mHealth

By Sierra Hersek, PNN Staff Writer Reprinted with Permission of Physicians News Network (www. physiciansnewsnetwork.com) Four large organizations are coming together in an effort to “advance the body of knowledge around clinical content, usability, privacy and security, interoperability and evidence of efficacy” for mHealth apps (mobile health applications). The American Medical Association (AMA), American Heart Association (AHA), Healthcare Information and Management Systems Society (HIMSS) and DHX Group have partnered to launch Xcertia.

“The collaboration builds on each organization’s ongoing efforts to foster safe, effective and reputable health technologies, while complementing our mutual commitment to advancing innovation in medicine, and improving the health of the nation,” the four organizations said in a joint statement. “Our combined expertise, along with a diverse membership, will leverage the insights of clinicians, patients and industry experts to help improve patient care and increase access to data.”

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This announcement comes just a month after the AMA released a new set of guidelines designed to support physicians using mHealth devices and apps while calling for better regulation of apps.

Xcertia joins a growing number of organizations looking to shed light on the multitude of mHealth apps for both patients and providers, such as RxUniverse out of the Sinai App Lab at the Icahn School of Medicine at Mount Sinai Health System, as reported by PNN. Also, the Hacking Medicine Institute’s RANKED Health program, a nonprofit launched out of Harvard and MIT, evaluates apps based on both health outcomes and consumer use.

But Xcertia is addressing the issue a little differently, its website states.

Xcertia will not engage in certifying mHealth apps; it will encourage others to apply its principles and guidelines in the development and curation of safe and effective mobile health apps.

Xcertia’s membership and governing board may look different than others, as it will include broad representation from consumers, developers, payers, clinicians, academia and others with an interest in the development of guidelines for mobile health apps.

THE CONNECTED PHYSICIAN

Lucile Packard Children’s Hospital Pioneers Use of VR for Patient Care Reprinted with Permission of Physicians News Network (www. physiciansnewsnetwork.com) Pediatric cardiologists at Lucile Packard Children’s Hospital Stanford are taking inspiration from the video game and consumer technology industries to leverage virtual reality (VR) as a vital tool for providers and patients alike. The Virtual Reality Program at the Children’s Heart Center is going beyond gaming with three VR projects that are already improving patients’ education, health and hospital experience and helping physicians treat cardiac patients more effectively, according to a statement.

“Because we are situated in Silicon Valley, we are in an ideal position to be a vanguard in this space and to partner with the companies that are on the cutting edge of this technology,” says Stephen Roth, MD, MPH, chief of pediatric cardiology and director of the Children’s Heart Center.

There are numerous ways that care teams at Packard Children’s are introducing VR use in the hospital. The Children’s Heart Center, which performs about 2,000 cardiac procedures each year, has several projects aimed at developing and testing some of these groundbreaking VR tools, each of which addresses a unique component of cardiac care: • Project 1: The Stanford Virtual Heart — Revolutionizing education for congenital heart defects | The Stanford Virtual Heart allows users to “teleport” inside the heart to understand complex congenital heart defects, which can be some of the most difficult medical conditions to grasp. Users wear a VR headset and engage handheld controllers to rotate and inspect the heart’s different pieces, understand the circulation of blood throughout the organ, and see where defects exist, allowing patients and families to more easily understand how their specific defect would be repaired, and for trainees, the program’s immersive experience is revolutionizing medical education.

• Project 2: Project Brave Heart — Pilot study exploring the impact of VR therapy | Project Brave Heart is a pilot study exploring the use of VR for “stress inoculation therapy” aiming to help young patients mitigate pre-procedure anxiety through cognitive behavioral therapy techniques. The Project Brave Heart VR experience leads study participants — patients ages 8-25 who have planned cardiac catheterization procedures — through a virtual tour of what they will experience on the day of their procedure. Throughout the virtual tour, patients also have opportunities to enter therapeutic VR relaxation and meditation experiences during moments of stress or anxiety.

• Project 3: 3-D virtual imaging technology inside the operating room helps surgeons map their route | VR technology is allowing pediatric cardiac surgeons to do a virtual run-through of a procedure before surgery using 3-D models that are constructed from CT and MRI scans. True3D virtual imaging technology is being used to digitally convert computed tomography (CT)

and magnetic resonance imaging (MRI) scans into 3-D images that can be viewed prior to surgery as well as in the operating room. “When you print an anatomical model using 3-D printing techniques, you can cut the model open once and that’s it,” says Frandics Chan, MD, PhD, associate professor of radiology at the Stanford School of Medicine. “In virtual reality, you can put it back together, cut it again in a different place and magnify it with the flick of your hand.”

Although all three cardiac VR programs are in the early phases of implementation, doctors’ sights are set on how VR can be expanded across the hospital’s departments in the future. According to a statement from Stanford Children’s Health, once The Stanford Virtual Heart program is complete, there’s potential to develop a comprehensive VR education lab at Packard Children’s where patients with all types of conditions — cancer, neurological diseases, hearing issues and the need for organ transplants — will be able to learn more about their conditions using the technology.

MARCH / APRIL 2017 | THE BULLETIN | 13

What Physicians Need to Know about Supervising Physician Assistants

By Britt Durham, MD

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Š Can Stock Photo / zastavkin

Medical Board of California Health Quality Investigation Unit, Tustin Office This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 141, Winter 2017.

The traditional role of physicians as the single health care clinicians has evolved over recent decades into a system that includes numerous health care providers with many titles, different training, varied scopes of practice, and diverse regulatory requirements.

Non-physician health care providers integrated into the formal health care system include physician assistants (PA), nurse practitioners (NP), midwives, and pharmacists.

These providers have formal certification and accreditation through different governmental licensing bodies. All are restricted in their health care practice by California state laws. It is the objective of this article to review the relevant regulations regarding the physician’s responsibilities for clinical patient care collaboration with PAs. Most importantly, all care provided to a patient by a PA is the ultimate responsibility of the supervising physician.

A PA is a licensed health care professional, trained to provide patient evaluation, education, and health care services. NPs and PAs are often referred to as mid-level physician health extenders. A PA works with a physician to provide medical care and is regulated by the Physician Assistant Board (PAB).

Physicians who plan to supervise PAs should carefully review Business and Professions (B&P) Code sections 3502 and

3502.1 and Section 1399.545 of Title 16 of the California Code of Regulations (CCR). A complete listing of supervision requirements is available on the PAB’s website www.pac.ca.gov.

Current law allows a physician to supervise no more than four PAs at any moment in time with some exceptions. Per 16 CCR section 1399.545, the physician must be available in person to the PA or be available via electronic communications at all times when the PA is caring for patients.

PA issues regarding health care regulations related to the Medical Practice Act of California are reviewed by the PAB and may include quality of care, felony charges, peer review B&P Code section 805 reporting, overprescribing, sexual misconduct, impairment, corporate practice of medicine, and misleading advertisement. These investigations, as with investigations of physicians, are integrated with the Department of Justice.

Physicians should review a PA’s background in the context of these issues before a supervision agreement is considered.

Before authorizing a PA to perform any medical procedure, the supervising physician is responsible for evaluating the PA’s education, experience, knowledge, and ability to perform the procedure safely and competently. In addition, the physician should verify that the PA has a current California license issued by the PAB. Physicians have been prosecuted for allowing PAs without current licenses to practice medicine on patients and have been found guilty of aiding and abetting the unlicensed practice of medicine.

The supervising physician is required to adopt written protocols that specifically guide the actions of the PA. The supervising physician must use one or more of the following mechanisms to ensure adequate supervision of the PA: 1. The supervising physician shall review, countersign, and date a sample consisting of, at a minimum, 5 percent of the medical records of patients treated by the PA functioning under the protocols within 30 days of the date of treatment by the PA; and/ or 2. The supervising physician and PA shall conduct a medical records review meeting at least once a month during at least 10 months of the year. During any month in which a medical records review meeting occurs, the supervising physician and PA shall review an aggregate of at least 10 medical records of patients treated by the PA functioning under protocols.

Documentation of medical records reviewed during the month shall be jointly signed and dated by the supervising physician and surgeon and the PA; and/or 3. The supervising physician shall review a sample of at least 10 medical records per month, at least 10 months during the year, using a combination of the countersignature mechanism described in (1) and the medical records review mechanism described in (2). During each month for which a sample is reviewed, at least one of the medical records in the sample shall be reviewed using the mechanism in (1) and at least one of the medical records in the sample shall be reviewed using the mechanism described in (2).

The supervising physician shall select for review those cases that by diagnosis, problem, treatment, or procedure represent, in his or her judgment, the most significant risk to the patient.

The PA Practice Act and PA regulations require a supervising physician to delegate in writing, for each supervised PA, those medical services which the PA may provide. That document is referred to as a Delegation of Services Agreement (DSA). The DSA is used by supervising physicians and PAs to meet requirements of B&P Code section 3502. The DSA is the foundation of the relationship between a supervising physician and the PA, and specifies the name of the supervising physician and the PA, what

types of medical services the PA can perform, how they are performed, how the physician will provide supervision, and what type of medications the PA will transmit on behalf of the supervising physician.

Medical tasks, which are delegated by a supervising physician, may be only those that are usual and customary to the physician’s practice. Physicians have been investigated and disciplinary action has been taken by the Medical Board of California (Board) against supervising physicians who do not have appropriate training to oversee the PA’s practice. PAs may not be majority owners of a medical practice per the portion of the Corporations Code dealing with professional corporations, beginning with section 13400. Furthermore, PAs may not hire their supervisors. For further details, refer to corporate practice of medicine laws. In one case reviewed by the Board, a physician anesthesiologist without liposuction training was listed as the supervising physician of a PA who was performing liposculpting procedures. The PA had opened the body sculpting business and hired the anesthesiologist. Both the physician and the PA were disciplined.

Current law permits PAs to write and sign prescription drug orders when authorized to do so by their supervising physician for Schedule II-V medications upon meeting certain conditions. B&P Code section 4024 authorizes licensed pharmacists to dispense drugs or devices based on a PA’s drug order. Current law also allows PAs to obtain their own U.S. Drug Enforcement Administration (DEA) numbers for use when writing prescription drug orders for controlled substances. A PA cannot administer, provide, or issue a drug order to a patient for Schedule II through Schedule V controlled substances without advance approval by the supervising physician unless the PA has completed an education course that covers controlled substances and meets standards approved by the PAB. If the PA will administer, provide, or issue a drug order for Schedule II controlled substances, the course must contain a minimum of three hours exclusively on Schedule II controlled substances. Completion of these training requirements must be verified and documented.

The supervising physician must use one or more of the following mechanisms to ensure adequate supervision of the administration, provision, or issuance by a PA of a prescription drug order to a patient for Schedule II controlled substances: 1. The physician supervisor must review, sign, and date the patient’s medical record, within seven days; or 2. If the PA has completed the education course identified above, the supervising physician must review, sign and date, within seven days, a sample consisting of the medical records of at least 20 percent of the patients cared for by the PA. All California-licensed health care providers, including PAs authorized to prescribe, order, administer, furnish, or dispense Schedule II, III, and IV controlled substances, must be registered to access CURES (Controlled Substance Utilization Review and Evaluation System) as required

by California Health and Safety Code section 11165.1.

Health care providers who provide continued pain management to patients should be familiar with the Guidelines for Prescribing Controlled Substances for Pain published by the Board at www.mbc.ca.gov/licensees/ prescribing/pain_guidelines.pdf. Many PAs and their supervising physicians have received disciplinary action against their licenses by the PAB and the Board for departing from the standards of care regarding controlled substances prescribing.

Physicians who plan to supervise PAs should educate themselves about the significant responsibilities they take on as supervising physicians. Overlooking these responsibilities can, and often do, trigger action by the Board against the supervising physician’s license, but knowing and following the law protects patients as well as the physician’s license.

MARCH / APRIL 2017 | THE BULLETIN | 15

© Can Stock Photo / Wisky

16 | THE BULLETIN | MARCH / APRIL 2017

By Susan Wolbarst, Managing Editor MBC Newsletter This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 140, Fall 2016.

An unknown number (thought to be in the thousands) of men, women and children are being “trafficked,” coerced and exploited for money earned selling their sex and/or labor in the United States. California was cited as one of the top four destinations for trafficking in the U.S. by California Attorney General Kamala Harris in a 2012 report.

“For trafficking, solid data are sorely lacking,” stated Dr. Susie Baldwin, a co- founder and president of HEAL Trafficking, a non-profit organization of healthcare professionals addressing the problem.

Victims can be largely invisible. They live as prisoners -- intimidated, constantly supervised and controlled by their traffickers. The trafficker may even be a family member. Fewer than one percent of trafficking victims in the U.S. are identified, according to a 2014 report by the U.S. Department of State.

When trafficking victims seek medical care, as they do 28-88% of the time, according to various studies, medical providers usually fail to recognize that their patients are being exploited. “It’s our responsibility to identify and assist them,” Dr. Baldwin said.

Physicians should be on the lookout for red flags, such as controlling behavior by the person who accompanies and speaks for, and/or translates for, the patient.

Other clues that the patient may be a trafficking victim include: patient fear, nervousness, and depressed affect; patient memory gaps; patient reluctance to speak; and/or a patient who doesn’t know where he or she lives. The patient may be branded or tattooed with a bar code, a name, or other mark of “ownership.” The patient, who may have motel keys and multiple cell phones if he or she is being trafficked for sex, usually pays in cash.

“We have to create environments where people feel safe and secure,” Dr. Baldwin said. “The setting must be private, unhurried and trauma-informed ... We have to ask the right questions in the right way.”

Suggested screening questions include: Are you safe at home? Do you owe your employer money? Does anyone force you to have sex when you don’t want to? Has anyone threatened your family? Has your identification or documentation been taken from you?

“The holy grail is to ask and figure out what’s going on for each of these patients,” she said.

Common diagnoses of trafficking survivors include: abdominal pain, abnormal Pap smears, anemia, acid reflux, anxiety, depression, headaches, low back pain, other musculoskeletal pain, pelvic pain, pregnancy, sexually transmitted infections, skin problems, and sleep disorders. In a majority of cases, the patient has many concurrent symptoms and may have delayed seeking medical care.

“We have to improve the system so individual doctors and nurses aren’t left without knowing about resources and ways to link victims to them,” Dr. Baldwin said. The HEAL Trafficking website ( https://healtrafficking.org/) lists many resources. Physicians and other health care providers can call the Coalition to Abolish Slavery and Trafficking (CAST) Hotline at (888) 539-2373 or the National Human Trafficking Resource Center Hotline at (888) 373-7888 if they suspect that a patient is being trafficked.

“The number one thing is protecting a patient’s safety,” Dr. Baldwin said. In California, if the patient is under 18, trafficking is recognized as child abuse and the physician must report it to local law enforcement, the county probation department, or the county welfare department, per Penal Code sections 11165.7(a)(21), 11165.9, 11166(a) (c). If the patient is 18 or older, the appropriate response may be contacting police, linking the victim to a social worker, or finding him or her a safe place to spend the night, depending on the victim’s wishes.

Webinars offering physicians more information about recognizing and assisting trafficking victims can be found at Introduction to Labor and Sex Trafficking: A Health Care & Human Rights Challenge: https://www.futureswithoutviolence.org/14599-2/ and Addressing Human Trafficking in Health Care Settings: http://www.essentialaccess.org/learning-exchange/addressing-human-trafficking-health-care-settings-0. Continuing Medical Education (CME) credits are available.

MARCH / APRIL 2017 | THE BULLETIN | 17

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Californians With Medi-Cal Face Hurdles to See Specialists Throughout the State

By Elizabeth Zima CMA Staff Writer California’s communities face a severe shortage of physicians, which is expected to get exponentially worse as the population continues to grow and our aging physician workforce moves toward retirement.

Medi-Cal enrollment has surged since 2014, but the percentage of California physicians serving Medi-Cal patients has dropped, a trend that is hampering access to care for enrollees. One in every three Californians (14 million) is dependent on Medi-Cal for health care, so this disparity also negatively impacts a patient’s ability to access needed treatment, according to a recent study by the California Health Care Foundation.

There is a fundamental problem with MediCal that is hindering patient access to care, and to specialists in particular – Medi-Cal physician reimbursement is so low that physicians cannot cover the cost of providing care. Currently, California has some of the lowest reimbursement rates for providers ($18 for an office visit), creating an unsustainable disparity between the number of Medi-Cal patients and the physicians who are able to accept them as patients.

“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” said Mark Dressner, MD, a Long Beach clinic family physician and former president of the California Academy of Family Physicians. “We’re really disappointed and concerned with what it’s going to do for patient access.”

The volume of poor and uninsured patients that need to see specialists has overwhelmed the 20 | THE BULLETIN | MARCH / APRIL 2017

health care system in Los Angeles causing appointment delays.

Dr. Dressner says he is extremely frustrated with the problem. “If I have patients that need a rheumatology consultation, it can take two years for them to get an appointment,” he explains. Some of his patients have to travel over 50 miles to see specialists who will take MediCal because none of the specialists in the immediate area will.

Not only are physicians frustrated with the lack of access to care, the patients themselves are frustrated with their treatment. Barbara Appling, a 56-year-old diabetic, was referred to an orthopedist in the Los Angeles area near her home.

“I called the office repeatedly for an appointment. It took four months to get one. Then, when I went to the office, I was there for 40 minutes waiting to be seen – until the office manager told me they could not see me.” Appling has both Medi-Cal and Medicare insurance. The office staff member told her the doctor didn’t take either.

“I’m very frustrated that I cannot see a doctor when I need to. People have refused to take Medi-Cal since I got it,” she said. Due to low Medi-Cal reimbursement rates, physicians who see Medi-Cal patients often do so at a financial loss to their practices. In order to maintain viable practices that can continue to serve their communities, physicians who take Medi-Cal often need to limit the number of Medi-Cal patients that can be treated in their practice.

Because they do not have ready access to physicians, Medi-Cal patients are more likely to postpone needed care due to long appointment

wait times. They are also twice as likely to use emergency room visits to access specialty care (compared to individuals with private insurance or Medicare).

In areas where the numbers of specialists are low, physicians are more likely to report difficulty obtaining referrals for Medi-Cal patients than for privately insured patients.

Debra Lupeika, MD, a family physician providing care through the Shasta Community Health Center in Redding, says some of the most difficult issues she faces are getting her sickest patients referrals to specialty providers.

The frustration of not being able to refer wears on her – like the time her patient suffered without an appointment. “She had complicated medical problems, and she was homeless,” Dr. Lupeika says. “She had a cancer on her face that had been partly removed, but it came back. We couldn’t get a biopsy. It is really hard to get our patients into specialists due to insurance issues.”

Lack of access to specialists also plagues San Diego County.

“The challenge that we face is that reimbursement to physicians is the third-lowest in the country. So that limits access to specialty care,” says Patrick Tellez, MD, MPH, a pediatric allergy and immunology specialist and Chief Medical Officer for North County Health Services, which provides health care to a diverse community of low-income patients at 13 health centers in North San Diego and Riverside counties.

“Our mission, as a primary medical, dental, and behavioral health practice attending to over 65,000 patients annually, is to assure that our patients are able to access and receive needed

Governor Jerry Brown’s $120 billion budget proposal for the 2017-18 fiscal year appropriates $1.2 billion of the Prop. 56 tobacco tax money to cover cost increases for the Medi-Cal program.

Although the measure was written to explicitly prohibit the use of the new tobacco tax revenue to offset general fund obligations, Governor Brown’s budget does exactly that – rather than using those funds to improve California’s dismal provider reimbursement rates, as the voters intended.

With more than 14 million Californians relying on Medi-Cal programs to provide basic and specialty care for serious diseases, the stakes are high. Californians voted for the tobacco tax to remove these barriers to reliable and quality care. California cannot afford to continue starving this program by diverting Prop. 56 revenues to cover the state’s general fund obligations.

“The language of Prop. 56 was clear – the people voted overwhelmingly in support of improving payments for programs and providers to ensure that patients can see a doctor when

a n d where they need one,” says CMA President Ruth Haskins, MD. “We must honor the will of the voters and use the estimated $1 billion in new health care revenue for its intended purpose, instead of writing a blank check to the general fund.”

CMA is working with the legislature and the Brown administration to develop a solution that doesn’t supplant the will of California voters or put low-income families and communities at risk.

Elizabeth Zima is a staff writer with the California Medical Association. If you have a story to tell about how low Medi-Cal reimbursements have adversely affected your ability to care for patients, contact CMA at communications@cmanet. org.

© Can Stock Photo / Kurhan

primary and specialty care that meets the high standards that every one of us expects when we are the patient,” says Dr. Tellez. “However, when the reimbursement for specialty care is so low, specialists can only afford to accept a small percentage of patients that truly need and deserve the care.”

“So, while in an average month we as primary care providers may make about 2,500 or more referrals to specialty care, due to affordability, wait times and constrained access, less than half are able to be seen. As a result, this has the long-term adverse impact of increasing the cost of care for everyone. Improving access to specialty care has been shown to help prevent preventable complications of chronic disease, which lowers the long-term cost of care… it acts like a rising tide that floats all boats.”

Of California’s 58 counties, Merced County has the 43rd worst physicia n-to pat ient-r at io, with just 45.4 family physicians per 100,000 residents.

That’s far less than California’s statewide ratio of 77.3 doctors per 100,000 residents. According to the Merced County 2016 Community Health Assessment, the entire county is considered a health-professional shortage area.

Eduardo T. Villarama, MD, family physician and regional medical director of Golden Valley Health Centers in Merced, says he is aware of many instances when patients who needed to see a specialist were turned away. “We have more than 70 percent Medi-Cal patient population, and specialty care providers regularly turn them away or are not able to accommodate the demand because the specialists are not reimbursed appropriately.”

He says a few of his patients, “one with a seizure disorder and the other we suspect to have multiple sclerosis,” have had to wait for at least six months to be seen by a specialist in neurology. “I know for a fact that the patients being insured by Medi-Cal played a role in our abilities to get them in sooner.”

Ample research demonstrates that the Medi-Cal system is struggling from persistent underfunding. Last year, the California Medical Association (CMA) co-sponsored the Proposition 56 tobacco tax to raise money to improve access to, and quality of medical services for all Californians – especially our most vulnerable communities – who rely on Medi-Cal .

MARCH / APRIL 2017 | THE BULLETIN | 21

CHPI Launches New Site Rating California Physicians Reprinted with Permission of Physicians News Network (www.physiciansnewsnetwork.com) A new ratings website, launched by the California Healthcare Performance Information (CHPI) System, provides ratings of one to four stars for more than 10,000 California physicians in eight medical specialties. The free site, CAqualityratings.org, is being touted as a “first-of-itskind” consumer resource “that can empower the consumer’s ability to talk with their physician and compare how other providers are rated throughout California.”

“These ratings are based on physician-led methodology to help drive further improvements in California’s healthcare system,” said Parag Agnihotri, MD, medical director, Continuum of Care, Sharp Rees Stealy Medical Group and chair, CHPI Physician Advisory Group. “The goal is to empower patients to have a conversation with their physician to increase communications and build trust — improving the overall care experience.”

According to the website, “Most of this information has not been reviewed by each doctor.

Doctors were given the opportunity to review their CHPI data for inaccuracies, but few doctors took advantage of this opportunity.” Additionally, a “Physician Advisory Group, comprised of 12 physician experts representing relevant specialties, continuously monitors and improves CHPI’s rating methodology.”

Data from 2014 on more than 10 million patients was analyzed to create the ratings, which measure how well physicians and practice sites provided recommended medical tests and procedures for patients with certain healthcare conditions.

“Access to physician information will help equip California consumers with the tools they need to make good health choices and be effective advocates for their own care,” said Liz Helms, president and CEO, California Chronic Care Coalition and CHPI board member. “CAqualityratings.org is a first-of-its kind consumer resource that can empower the consumer’s ability to talk

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with their physician and compare how other providers are rated throughout California.”

Consumers can use the performance ratings to answer questions, such as: • Are physicians meeting the highest standards for ensuring their patients are regularly screened for breast cancer?

• How often do physicians monitor the medications their patients are taking?

• How often do physicians provide recommended treatments (especially for those with chronic diseases, such as diabetes and high blood pressure)?

Data for CAqualityratings.org was provided

by Anthem Blue Cross of California, Blue Shield of California, UnitedHealthcare of California, and the Centers for Medicare & Medicaid Services (CMS). CMS has certified CHPI’s methods to rate physicians, the process for physicians to review and correct their results, and plans to publish ratings for the public — one of only 16 programs nationwide to receive this designation.

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MARCH / APRIL 2017 | THE BULLETIN | 25

Medical Plus Psychosocial Support:

Providing Complete Cancer Care for Your Patients © Can Stock Photo / Bialasiewicz

By Rob Tufel, MSW, MPH and Paula Reed, RN, OCN Cancer CAREpoint is the only local nonprofit organization in San Jose that provides a comprehensive selection of direct, personalized support services to anyone in Silicon Valley impacted by cancer – no matter the cancer type, where they are receiving medical care, insurance status or ability to pay. Our programs, which support patients from every medical center in the South Bay and complement their medical care, have the goal of improving the health-related quality of life of cancer patients and their family members.

Despite the excellent medical care provided in the South Bay, Cancer CAREpoint was founded in recognition of the limited psychosocial and practical support services provided to the approximately 10,000 individuals in our region diagnosed with cancer each year and their family caregivers.

The mission of Cancer CAREpoint aligns with the Institute of Medicine recommendations in its’ seminal study, “Cancer Care for the Whole Patient: Meeting Psychosocial Health,” that “it is not possible to deliver good-quality cancer care without addressing patients’ psychosocial health needs.”

Since opening our Cancer Resource Center in 2013, we have supported over 3,000 cancer patients and their family members. Our programs include private counseling with a master’s level social worker, support groups, nutrition classes, exercise, therapeutic massage, guided imagery/ meditation, Wig Bank, Healing Touch, and art therapy. We have also created two model programs: a Family CARE Program for parents with cancer and their children and a Survivorship Workshop for patients post treatment. All of our programs are supported by donations from individuals, businesses and foundations.

The Cancer CAREpoint Survivorship program has been highly successful given the rising number of cancer survivors and their on-going need for support post-treatment. It complements the medical care provided by both oncologists and primary care physicians. In addition to offering the program at our Cancer Resource Center in San Jose, we have partnered with El Camino Hospital and PAMF to offer our Survivorship Program at their locations. This 8-week program utilizes a curriculum developed by our Cancer CAREpoint social worker and focuses on the psychosocial impact of a cancer diagnosis. It reflects the guidelines developed by 26 | THE BULLETIN | MARCH / APRIL 2017

the National Comprehensive Care Network for general survivorship care and the Commission on Cancer’s program standard 3.3, which requires the development and implementation of “a follow-up plan to patients who have completed treatment.”

Cancer CAREpoint also targets low-income patients and families by providing programs out in the community. We have partnered with Valley Medical Center to provide an on-site wig bank and are developing programs to be offered in East San Jose.

Besides providing practical support, many of our programs focus on stress reduction. According to the National Cancer Institute, anxiety and distress may “affect a patient’s ability to cope with a cancer diagnosis or treatment…cause patients to miss check-ups, delay treatment” and “increase pain, affect sleep, and cause nausea and vomiting.”

Our guided imagery sessions and meditation classes help cancer patients learn practical mind-body techniques that can counteract feelings of panic, anxiety, loss of control, sleeplessness and pain. Guided imagery is focused relaxation that helps prepare patients for treatments and surgery.

It is a complementary therapy that is acknowledged by respected medical centers such as the Mayo Clinic, Memorial Sloan Kettering Cancer Center, and MD Anderson Cancer Center as a safe adjunct to medical treatments for all forms of cancer under the guidance of a trained health professional.

We are diligent about collecting quantitative and qualitative data on how clients benefit from these services, and the results underscore the need for psychosocial support to be part of a cancer patient’s treatment, recovery and return to health. Eighty-seven percent of participants in our guided imagery program reported their stress level was reduced to a mild or moderate level and eighty-three percent reported reduced pain. Many also said that guided imagery techniques helped them control nausea and vomiting after chemotherapy.

Cancer CAREpoint is pleased to be a partner with medical providers in Silicon Valley to ensure that residents have the best opportunities for cancer care and recovery. For more information about how Cancer CAREpoint can support your patients, please contact Rob Tufel at rob@ cancercarepoint.org or 408.402.6282. More information is also available on our website at www.cancercarepoint.org.

Rob Tufel, MSW, MPH is the Executive Director and Paula Reed, RN, OCN is a board member of Cancer CAREpoint.

New Tools Developed to Increase Prediabetes Awareness and Ease of Program Referrals This article is reprinted with the permission of the Medical Board of California, originally printed in their Newsletter, Vol. 140, Fall 2016.

A recent study released by the UCLA Center for Health Policy Research found that nearly half (46%) of the adult population in California (13 million) have prediabetes (higher-than-normal blood glucose levels but not high enough to be considered type 2 diabetes) or diabetes.

Research found that 15%-30% of overweight people with prediabetes will develop type 2 diabetes within five years unless they lose weight and increase their physical activity. The National Diabetes Prevention Program (National DPP) is an evidence-based lifestyle change program delivered by a trained lifestyle coach over a 12-month period during which small groups of participants learn to make manageable healthy changes.

The American Medical Association (AMA) and the Centers for Disease Control and Prevention (CDC) have supported this program by

developing the Prevent Diabetes STAT (Screen, Test, Act - TodayTM) initiative. Prevent Diabetes STAT is a multi-year initiative focusing on prediabetes as a critical and serious medical condition. The AMA and CDC co-developed a Provider Toolkit meant to serve as a guide for physicians on the best methods to screen and refer high-risk patients to National DPPs in their communities.

In addition, the AMA and CDC partnered with the American Diabetes Association and the Ad Council to develop an awareness campaign with the tag line, “Do I Have Prediabetes.� Medical offices are encouraged to utilize the suite of materials, including audio and video advertisements, posters, and social media graphics to help promote the message to their patient population. To learn more about the Prevent Diabetes STAT initiative or to find a CDC-recognized National DPP near you, visit DoIHavePrediabetes.org.

Research found that 15%-30% of overweight people with prediabetes will develop type 2 diabetes within five years unless they lose weight and increase their physical activity.

MARCH / APRIL 2017 | THE BULLETIN | 27

INTERESTING FACTS THAT MAY AFFECT HEALTHCARE

Some Facts on Immigration that Reprinted with Permission of Physicians News Network (www. physiciansnewsnetwork.com) With questions looming and confusion building about the impact of immigration issues on healthcare and the medical profession, below is a brief look at some immigration statistics, the buzzwords you may be hearing, how the immigration policies are impacting medical schools and exactly what it takes to become a U.S. citizen.

WHO ARE THE DREAMERS WE KEEP HEARING ABOUT?

In 2010, the DREAM Act (Development, Relief and Education for Alien Minors) failed to pass the House. It specified a six-year path for illegal aliens to eventually become U.S. citizens if they met certain criteria.

DREAMers | While the DREAM Act failed, the name stuck, and now the term DREAMers applies generally to illegal aliens under the age of 35 seeking full or partial legalization/amnesty and/or taxpayer subsidized tuition.

DACA - Deferred Action for Childhood Arrivals | In 2012, President Obama unilaterally implemented a new program called Deferred Action for Childhood Arrivals (DACA). The Mitigation Policy Institute (MPI) estimates there are 1.2 million DREAMers to whom this action applies.

Under DACA, illegal aliens are offered two years of amnesty (“deferred action” — meaning a stay of deportation), are given a Social Security number, and are allowed to apply for a work permit. It should be noted that a grant of DACA status does not confer lawful immigration status, provide a path to citizenship (amnesty), or alter an illegal alien’s existing immigration status.

• Nationwide, more than 2 million undocumented immigrants arrived here as children (more than 500,000 in California, including about 279,000 ages 3-17).

• More than 680,000 undocumented youth nationwide have received DACA benefits.

• Researchers estimate that nearly 1.5 million undocumented youth in the U.S. are currently eligible for DACA, and another 400,000 children will become eligible in the next few years.

DREAMERS AND MEDICAL SCHOOL

• While not all medical schools allow undocumented students who have received DACA to attend, the first undocumented immigrants to openly apply to medical school graduated last year, according to StatNews.

• There are only an estimated 65 DACA medical students currently enrolled in medical schools across the nation, according to a December 2016 article in StatNews story on the topic.

• Admission policies at schools throughout California and the country vary.

• Undocumented students are not eligible for federal financial aid, however: California’s Medical DREAMER Opportunity Act | Introduced by Sen. Ricardo Lara, D-Bell Gardens, and signed by Gov. Brown last September, SB 1139 took effect in January and is designed to help address the chronic shortage of medical professionals in underserved communities by ensuring that all people, regardless of their immigration status, have access to the state’s scholarship and loan forgiveness programs for health

Report Examines California Prim Reprinted with Permission of Physicians News Network (www.physiciansnewsnetwork.com) A new report from UC San Francisco Healthforce Center reveals that California doesn’t have enough doctors in most regions to handle its primary healthcare demands, and the problem is becoming more acute because of an aging physician workforce, a growing patient population and expanded coverage through the Affordable Care Act. According to the study: • Most regions of California have shortages of primary care physicians as measured by a national benchmark.

• One-third of physicians and onethird of nurse practitioners (NPs) in California are over age 55, which 28 | THE BULLETIN | MARCH / APRIL 2017

Previously identified deficits in California’s primary care workforce persist and will be exacerbated in the coming decade because large percentages of MDs and NPs are reaching retirement age.

suggests that California will face a more severe shortage of primary care clinicians in the coming decade regardless of whether the Affordable Care Act is repealed.

• The number of NPs and physician assistants (PAs) in California is growing more rapidly than the number of physicians, but physicians still constitute the majority of primary care clinicians.

• While MDs make up the greatest number of licensed clinicians, only a fraction of them provide primary care (36%). Among MDs practicing more than 20 hours per week, the same proportion is in primary care.

• Latinos and African-Americans are

INTERESTING FACTS THAT MAY AFFECT HEALTHCARE

t May Affect Healthcare professionals.

A survey conducted by California’s Pre-Health Dreamers (PHD), a network of more than 800 health career-bound undocumented students in more than 40 states, found that more than 94% want to practice health services in underserved areas.

IMMIGRATION STATISTICS:

• Approximately 50% of the 11 million undocumented immigrants in the U.S. are from Mexico.

• The largest portion of the undocumented population live in California — about 3 million, or more than a quarter in the nation.

• This includes about 142,000 in Santa Clara County (58% from Mexico; 31% from Asia).

• Approximately 70% of California’s undocumented population comes from Mexico.

• About 40% overstayed their visa, while others crossed the border illegally.

• Almost two-thirds of undocumented immigrants are believed to have been in the U.S. for more than 10 years.

• 47% of illegal immigrant households are couples with at least one child, compared with 21% of non-immigrant households.

• The undocumented immigrant population has been steadily falling since 2007.

• An estimated 5% to 10% of undocumented high school graduates go on to enroll in an institution of higher education and far fewer graduate with a degree.

• An estimated 200,000 to 250,000 undocumented students are enrolled in college nationwide, or about 2% of all college students, according to the Pew Research Center.

WHAT IS A SANCTUARY CITY?

A sanctuary city is a city in the United States or Canada that adopts local policies designed to not prosecute people solely for being an undocumented individual in the country in which they are currently living. There are over 140 sanctuary jurisdictions (cities and counties) across the U.S., including at least 37 cities. In California that includes Santa Clara, San Mateo, Los Angeles and Orange among others.

WHAT DOES IT TAKE TO BECOME A CITIZEN?

According to TheSkimm.com, which recently published a simplified guide on who qualifies and what the steps are to become a U.S. citizen, you must: • Be 18 or older; • Be a permanent resident for at least five years and have a permanent resident card (aka a green card); or • Be married to a U.S. citizen for at least three years; • Read, write and speak basic English; • Go through a lengthy interview process; • Know the basics of U.S. history and how the government works; • Have never deserted the U.S. Armed forces; and • Have “good moral character.” Read more at theSkimm.com.

mary Care Shortage underrepresented among California’s primary care clinicians.

• Only two regions of California (the Greater Bay Area and Sacramento) have ratios of primary care physicians per population above the minimum ratio recommended by the Council on Graduate Medical Education (60 primary care physicians per 100,000 people).

Some estimates show that California will need an additional 8,243 primary care physicians by 2030 – a 32% increase. In an effort to increase California’s primary care physician workforce, the state Legislature passed a budget in 2016 that included historic support for and expansion of primary care graduate medical education (GME), committing to invest $100

million over three years to support primary care residency programs in medically underserved areas. Unfortunately, Gov. Jerry Brown’s proposed 2017 budget takes a huge step backward, according to the California Medical Association, (CMA), eliminating $33.4 million of that healthcare workforce funding and redirecting $50 million in Proposition 56 funding that was intended to go to GME programs.

A robust and well-trained primary care workforce is essential to meeting the healthcare demands of all Californians, CMA reported.

Inadequate funding for residency programs exacerbates access problems: Every year hundreds of graduating medical students don’t find a residency slot in California to continue their training, forcing talented, young doctors who want to stay and practice in California to other states

and communities.

The UCSF report concludes that the supply of primary care physicians in California is insufficient to meet the population’s needs. Only 36% of MDs provide primary care. A larger percentage of DOs provide primary care, but their numbers are so small relative to MDs that they do not fully compensate for the shortage of primary care MDs. Primary care physicians are poorly distributed across the state with smaller ratios to population in rural areas than in urban areas.

Future workforce planning would improve substantially if California invested more resources in the collection and analysis of standardized, comprehensive data on the primary care workforce.

MARCH / APRIL 2017 | THE BULLETIN | 29

HOSPITAL NEWS

LOCAL HOSPITALS PART OF NEWLY BRANDED GOOD SAMARITAN HEALTH SYSTEM Reprinted with Permission of Physicians News Network (www. physiciansnewsnetwork.com) Regional Medical Center of San Jose and Good Samaritan Hospital, both owned by the Hospital Corporation of America (HCA), recently announced they are part of the newly branded Good Samaritan Health System (GSHS).

The two health facilities join three San Jose HCA-owned surgery centers, five San Jose-based CareNow Urgent Care Centers scheduled to open in 2017 and the physicians associated with the Santa Clara County Independent Practice Association, according to a statement.

“We are part of the same system, and the new brand makes it easier for the public to access clinical excellence at any facility within the GSHS,” said Mike Johnson, CEO of Regional Medical Center of San Jose. “Our goal is a team approach of physicians, nurses and staff who are commit-

ted to the individual’s needs, while providing Silicon Valley residents with quality care at our system locations.”

Each facility and organization under the GSHS umbrella operates independently with its own existing management, though the entities will continue to work together to provide the best healthcare options for every patient.

Good Samaritan Hospital, a 474-bed acute care hospital, recently embarked on a $30 million expansion of its Emergency Department. Its two locations include the main campus in San Jose and the Mission Oaks campus in Los Gatos.

Regional Medical Center in San Jose, a Level II Trauma Center, recently completed a $350 million expansion, including a new inpatient tower and Emergency Department renovation.

INFRASTRUCTURE & INVESTMENT NEW VALLEY HEALTH CENTER OPENS

Valley Health Center Downtown in San Jose has opened its doors.

The 62,000-square-foot county health center is located on the grounds of the old San Jose Medical Center, which closed in 2004, and is owned and operated by Santa Clara Valley Medical Center and Gardner Family Health Network. The facility provides family medicine, pediatrics, OB/ GYN, laboratory, pharmacy, radiology, and behavioral health services and includes an urgent care clinic. Architectural features of the $38 million project include a colorful façade of rainbow-colored glass fins and integrated horizontal sunshade screens with use of multicolor glass panels throughout the building, creating a strong visual identity to the building.

The physician offices were designed to be converted into clinical spaces without requiring a remodel. The site will also allow for addition of a new medical office building by replacing the existing surface parking lot with a multilevel structure.

STANFORD PARTNERS WITH VETERANS AFFAIRS TO BUILD FIRST HADRON CENTER

The U.S. Department of Veterans Affairs (VA) and Stanford Medicine announced recently that they are collaborating to establish the nation’s first Hadron Center in Palo Alto for the benefit of veteran and non-veteran cancer patients who could benefit from hadron therapy. The Hadron Center is anticipated to be a clinical facility, designed to deliver particle radiation beam therapy for the treatment of cancer patients. Presently, the

30 | THE BULLETIN | MARCH / APRIL 2017

most common radiation beams used for cancer treatment are photons and electrons, which are easy to target to a tumor but can result in damage to normal tissue. Particle beam radiotherapy, on the other hand, uses beams of charged particles such as proton, | The other ions to allow more precise targeting anywhere inside the patient’s body, resulting in less damage to normal tissue. Particle beam therapy can be more effective at killing radiation-resistant tumors that are difficult to treat using conventional radiation therapy. Judicious and innovative application of particle therapy can result in improved cure rates for cancer.

EL CAMINO HOSPITAL STARTS CONSTRUCTION ON NEW MENTAL HEALTH INPATIENT CENTER

El Camino Hospital broke ground on a new mental health inpatient center aimed at making the Mountain View hospital a center for behavioral health in the Bay Area. The groundbreaking ceremony was held on Nov. 3. The new building will be more than 60,000 square feet and covered in zinc siding and glass curtain walls, giving it a modern and open look. It will have 36 beds and should be complete by 2021. Donna and John Shoemaker, co-chairs of the Philanthropy Council for Mental Health, discussed their role in helping fund the construction. “It’s the right thing to do,” said Donna Shoemaker, citing El Camino Hospital’s founders’ promise to devote resources to mental health. “We are keeping the promise to the founders of this hospital, and we would never give up.”

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Tuberculosis Hospitals of Santa Clara Valley

By Gerald E. Trobough, MD Leon P. Fox Medical History Committee During the early 1900’s the most common cause of death was Tuberculosis. Many of the patients with this disease were sent to the South San Francisco Bay Area because of it’s “healing climate.” The first effective treatment of Tuberculosis occurred in health resorts referred to as Sanitariums. The first Sanitarium in the United States was founded by Dr. Edward Livingston Trudeau in Saranac Lake, New York in 1885. The treatment was called a rest cure. Patients were prescribed increased rest, good nutrition, sunshine and open air. The facility was called the Adirondack Cottage Sanitarium.

The first Sanitarium in the Santa Clara Valley was located on Montevina Road, two miles South of Los Gatos in the Santa Cruz foothills. The Oaks Sanitarium was built in 1913. It was owned by a group of physicians who hired Dr. William Voorsanger to be the medical director. Voorsanger, a graduate of Cooper Medical School in San Francisco, had international training in Pulmonary Medicine and was considered an expert in treating Tuberculosis. He founded the San Francisco Tuberculosis Association in 1908. In 1917, because of financial problems at the facility, Dr Voorsanger bought out his partners and became the sole owner of the “Oaks.”

The Oaks had 60 beds and was established to provide care to TB patients of “small means.” The patients were charged only for the cost of food and maintenance. Those eligible for admittance had to have monthly incomes of less than $200. Despite the financial difficulties, the Oaks remained open until 1939.

The second Sanitarium in the Valley was the Boonshaft Sanitarium.

Louis Boonshaft was a resident physician at The Oaks Sanitarium and was trained by Dr. William Voorsanger. He opened the new Sanitarium in 32 | THE BULLETIN | MARCH / APRIL 2017

1922 in the San Jose Eastern Foothills. It was billed as a hospital for Diseases of the Lungs and Throat.

The facility later changed its name to the Alum Rock Sanitarium. In 1957 it was remodeled and licensed as a Medical Hospital. In 1958, under the medical directorship of Dr. Gerald Scarborough, the Sanitarium merged with San Jose Hospital. The facility had 19 medical beds and 48 pulmonary beds. It was located on nine acres on Crothers Road.

The other large Tuberculosis facility was located at Santa Clara County Hospital. The South Wing of the Tuberculosis Sanitarium was built in 1910, the middle wing built in 1918, and the third wing completed in 1927.

The facility had a 144-bed Tuberculosis Isolation Ward. In the 1950’s, as new antibiotics and other treatments were instituted, the number of isolation beds decreased. In 1959, the “Old Chest Clinic” was torn down and replaced with a new Psychiatric Building. The last directors of the Tuberculosis Ward were Dr. Mort Manson and Dr. Robert Rowan.

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CAPTIVE ALTERNATIVES

Bay Area Doctor Creates Private Insurance Company to Protect Practice Reputation Reprinted with Permission of Physicians News Network (www.physiciansnewsnetwork.com) When Basil M. Hantash, MD, PhD, MBA, and his partner acquired a dermatology practice located 90 miles outside the San Francisco Bay Area, they thought hiring might be challenging in their rural location. They quickly found that despite exercising due diligence in the candidate evaluation process, not all their new hires were going to make it. The resulting terminations threatened to derail the upward trajectory of their thriving dermatology practice, which had grown from a 1,200-square-foot office and a staff of two to a 7,400-square-foot office and staff of 28.

“We have had difficulties ranging from embezzlement to disgruntled employees posting negative comments about us on the Internet and voicing negative comments to members in our community,” explains Dr. Hantash.

“There is a lot of liability built into this profession, and we began to investigate options for mitigating those risks.”

When he approached the traditional insurance carriers and brokers he was already working with for help containing the reputational risk associated with damaging public opinions, he could not find the coverage he needed.

“They said they don’t write (coverage for) these types of risk,” he said. In fact, physicians often face the dilemma of having to match their unique individual exposures to commercial insurance products\ that are often ill-fitting, or expensive.

Colleagues with similar workplace challenges suggested Dr. Hantash consider forming a Private Insurance Company to secure the specialty risk coverage, indemnification against damage to the practice’s reputation, he was seeking. Not being an expert in insurance or risk, Dr. Hantash researched his options for forming a Private Insurance Com-

pany and discovered that independent companies provide management services for these companies. Dr. Hantash delegated the setup and ongoing management of his Private Insurance Company to Captive Alternatives, an Atlanta-based risk management consulting firm, freeing him to spend his time and attention on helping his practice grow.

When Dr. Hantash’s Private Insurance Company was set up in 2016, it covered the practice for billing audits, employee theft, managerial liability, reputational harm, technology risk, HIPAA risk and ransom risk, as well as all of the traditional medical-related risks of the practice. “The Private Insurance Company gives us an additional level of comfort in making prompt decisions around employment and termination,” he said.

Dr. Hantash says that owning a Private Insurance Company hasn’t made hiring easier but it has given him a new confidence about his hiring process. “If someone does something that has a negative effect on our practice, we can make the decision quickly to let them go and be protected. We have the coverage to make it right,” he said.

For more information about setting up your own Private Insurance Company, go to Captive Alternatives www.captivealternatives. com.

When he approached the traditional insurance carriers and brokers he was already working with for help mitigating the reputational risk associated with damaging public opinions, he could not find the coverage he needed. “They said they don’t write (coverage for) these types of risk,” he said.

34 | THE BULLETIN | MARCH / APRIL 2017

In Memoriam Walter J. Aagesen, MD

Leonard M. Goldberg, MD

Morgan L. Lucid, MD

*Otolaryngology 3/12/1907 – 1/30/2005 SCCMA member since 1974

*Internal Medicine 1/13/1933 – 10/06/2015 SCCMA member since 1976

*Plastic Surgery 3/14/1926 – 10/06/2015 SCCMA member since 1955

Richard P. Alexander, MD

Thomas A. Hodge, MD

Andrew D. Lucine, MD

*General Surgery 12/11/1925 – 10/08/2015 SCCMA member since 1958

*Diagnostic Radiology 9/05/1929 – 12/05/2016 SCCMA member since 1961

*General Surgery 1/01/1929 – 12/11/2015 SCCMA member since 1963

Bernard J. Axelrad, MD

Gregory F. Hooper, MD

Chas B. MacGlashan Jr., MD

Internal Medicine 8/31/1925 – 12/05/2012 SCCMA member since 1954

Gynecology 10/05/1961 – 11/26/2016 SCCMA member since 1993

*Ophthalmology 6/06/1924 – 7/22/2016 SCCMA member since 1955

Davis W. Baldwin, MD

Marek S. Klem, MD

William L. Schneiderman, MD

*Obstetrics and Gynecology 7/10/1927 – 11/22/2016 SCCMA member since 1961

Obstetrics and Gynecology 5/7/1946 – 12/07/2016 SCCMA member since 1995

Obstetrics and Gynecology 6/19/1944 – 11/10/2016 SCCMA member since 1987

C. Walter Brown, MD

R. Hewlett Lee, MD

Thomas A. Stamey, MD

Pediatric Allergy 4/17/1918 – 2/11/2016 SCCMA member since 1960

*General Surgery 5/19/1926 – 1/20/2016 SCCMA member since 1957 Past President 1969-70

*Urology 4/26/1928 – 9/04/2015 SCCMA member since 1996

Gordon S. Leonard, MD

*Orthopaedic Surgery 4/16/1918 – 12/05/2016 SCCMA member since 1955

James M. Cuthbertson, MD General Practice 7/3/1924 – 12/05/2016 SCCMA member since 1955

Lawrence T. DeBusk, MD *General Surgery 1/20/1926 – 4/29/2016 SCCMA member since 1957

Family Medicine 1/1/1930 – 10/29/2016 SCCMA member since 1963

Joseph B. Tanner, MD

Herman A. Lorberbaum, MD Pathology 2/28/1922 – 11/01/2016 SCCMA member since 1953

MARCH / APRIL 2017 | THE BULLETIN | 35

MEMBERSHIP

Welcome 167 New Members Santa Clara County Medical Association Name Marce Abare Shelley Aggarwal Anahita Aghaei Lasboo Adriana Anavitarte Praveen Anchala Kerri Ashling Julie Barzilay Darrell Brooks Sharon Buzi John Cannon Thomas Caradonna Allison Chan Raymond Chan Trevor Chan Neha Chandra Justine Chang Jonathan Chao Tiffany Chao Rick Chavez Rae-Pei Cherng Tiffany Chin Mary Chiou Clara Choi Shara Cohn Julia Cronin Kathryn Crozier Panos Danopoulos Linh Dao Andres Deluna Katherine Dickerson Ha Do Jeffrey Edwards Emanuel Elias Derick En'Wezoh Rosanne Estrada Nicholas Faberowski Terry Farsani Clarissa Fernandez-Pol Tamara Frankenberg Kory Gebhardt Nicole Glenn Richa Goyal Margaret Guo Iliana Harrysson Eve Henry

City Specialty San Jose IM San Jose PD San Jose N San Jose PD San Jose DR Palo Alto UC Stanford US San Jose PS Santa Clara OBG Palo Alto US San Jose IM Los Gatos PD San Jose IM San Jose AN San Jose IM Mountain View OBG Palo Alto IM San Jose GS San Jose FP San Jose OBG Santa Clara IM San Jose PD San Jose RO San Jose AN Mountain View AI Santa Clara N Los Gatos IM San Jose IM San Jose CD Stanford US Modesto D Stanford US Santa Clara SME Los Altos Hills US San Jose PD San Jose OPH Mountain View D Santa Clara PD San Jose PD Santa Clara EM Sunnyvale PD Santa Clara FP Menlo Park US Palo Alto PD Palo Alto IM

Name Kevin Herrick Lawrence Hsu Richard Hsu Yinn Htwe Liang Huan Kay Hung Elizabeth Hyde Natalia Isaza Rajashri Iyengar Vibha Iyengar Mitra Javandel Sara Jeevanjee Yanting Jiang Alejandro Jimenez Jae Joh Brianna Johnson Sudarshan Kadirvelu Bina Kakusa Dylan Kann Svetlana Katsnelson Patrick Kearns Alyn Kim Yoo Jung Kim Patty Ku Anusha Kumar Jeffrey Kwong Richard Lau Siew Lau Charles Lee Fachyi Lee Jennifer Lin Mona Luke-Zeitoun Jeffrey Maclean Chrisy Mafnas Kristie Manning Dennis Martinez Larry Mo Sharleen Mulliken Kuljeet Multani David Mundy Varsha Nair Tejvir Nanda Reena Nanjireddy Jeffrey Nekomoto Nicole Nemeth

City Specialty Hollister IM Palo Alto UC Palo Alto AN San Jose IM Sunnyvale PD Palo Alto US Stanford US Santa Clara PTH Palo Alto A Mountain View GM San Jose OSM San Jose IM Palo Alto US San Jose IM San Jose EM Mountain View US Santa Clara FP Stanford US Santa Clara PDI Santa Clara END Los Gatos IM San Jose HNS Stanford US Mountain View PD Menlo Park US Saratoga US Santa Clara RHU San Jose AN Stanford US San Jose HO Santa Clara FP Palo Alto PDP San Jose OTO Stanford PTH Santa Clara PD San Jose EM San Jose EM Menlo Park HOS Sunnyvale IM Palo Alto US Mountain View IM Santa Clara R San Jose N San Jose IM Mountain View OSM

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City Specialty San Jose IM Santa Clara OPH San Jose FP Los Gatos PEM San Jose GE San Jose P Santa Clara PD Palo Alto FP San Jose OPH San Jose PM Stanford US San Jose P Sunnyvale SM Stanford US Stanford US Berkeley US Mountain View MFM Gilroy OBG San Jose US Stanford US Santa Cruz GS Santa Clara FP Santa Clara D San Jose OTO Stanford US San Jose OBG San Jose PD Mountain View PD San Jose PD Mountain View FP San Jose SM San Jose CD San Jose IM Gilroy FP Stanford US San Jose PD Redwood City US Palo Alto US Santa Clara IM San Jose FP Cupertino D Santa Clara FP Stanford US San Jose END Menlo Park ID

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City Specialty Stanford US San Jose EM Los Gatos IM San Jose P San Jose OBG San Jose TRS

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Monterey County Medical Society Name Allen Andrews James Beckwith Jill Bolstad Cy Cedar Alison Clarke

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Classifieds OFFICE SPACE FOR RENT/LEASE OFFICE FOR LEASE/SUBLEASE

front office. Total office size 3,000 sq. ft.

Available now. Call 408/376-3305 or marlene@svspine.com.

O’Connor Hospital area with office lease/ sublease. Please contact Dr. Maggie Chau at 408/799-7842 for details.

MEDICAL OFFICE SPACE TO SUBLET • MTN VIEW

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.

LOS GATOS OFFICE TO SHARE Newly-remodeled office next to ECHLG, including private office, four exam rooms, lab, reception, and waiting areas. Can share staff. Contact Dr. Maia Chakerian at 408/832-3930.

MEDICAL OFFICE SPACE TO SHARE • CAMPBELL Convenient location. 5+ exam rooms M-F. In-office digital x-ray. Two large private offices, shared waiting room and

smile.amazon.com A great way to support your Alliance When you shop at AmazonSmile, Amazon donates 0.5% of the purchase price to Santa Clara Medical Association Alliance Foundation Inc. Bookmark the link http://smile.amazon.com/ ch/27-1977428 and support us every time you shop.

38 | THE BULLETIN | MARCH / APRIL 2017

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, utilities included. Large treatment rooms, small lab space, bathroom, private office, etc. Call Dr. Klein. Cell 650/269-1030.

BEAUTIFUL MENLO PARK OFFICE TO SHARE New office, upscale and modern – to share with existing pain management practice. Ideal for psychologist or psychiatrist. Contact Dr. Maia Chakerian at 408/832-3930.

OFFICE SPACE FOR LEASE Office space, located at 999 Saratoga Avenue, San Jose, is suitable for medical/ dental office; 2,100 sq. ft. – 2,700 sq. ft.

Contact 650/796-1887.

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 408/228-0454 or e-mail riflovin@ allianceoccmed.com for additional information.

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.

WANTED FAMILY PHYSICIAN Family medicine physician needed to share a growing outpatient practice. Start at 16 hours/week and share patient load.

Practice caters to 75% PPO, rest Medicare and HMO. Contact ntnbhat@yahoo. com / 408/839-6564.

PRIMARY CARE PHYSICIAN Busy primary care office is looking for board certified Internal or Family Medicine Physician. Contact inna@dryaskin. com or call 650/318-3384.

FOR SALE PEDIATRICS PRACTICE FOR SALE Decent well-established Pediatric solo practice for sale in South Bay with experienced staff and EHR. If interested please call 408/710-3008.

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© Can Stock Photo / Sutichak

Two Old Dogs

By Richard A. Mahrer, MD

Dr. Mahrer has been a regular contributor of articles for The Bulletin for many years. On behalf of the members, “Thank you for sharing your entertaining and humorous articles through the years, Dr. Mahrer!” At 91 years old, Dr. Mahrer informs us that he is considering retirement. The following is his latest contribution for your enjoyment.

Richard and Suzy are their names. They are inseparable, loving and mutually interdependent. The former is a nearly 92-year-old human physician; the latter is a canine caretaker, nearly 75 years old if one figures the time equivalent of the two species.

Suzy was rescued nearly ten years ago and is a gorgeous 16 pound tan and white Pomeranian-mix. A certain beauty winner if she had ever been entered in competition. Much has been written about the deep emotional relationship between the two species. Recently a middle aged male patient came to our office sobbing. He had just lost his beloved companion (his dog, not his wife). I understood and we talked and talked about the depth of the mutual love and respect existing between our two species, which in this chaotic world is really unique.

When I said he came to our office, I meant the “our” to mean Suzy and me. My lovely wife worked in the office for many years, but as patient numbers declined as expected, she said there wasn’t enough left of the practice to keep her busy and she left me and Suzy last year to do our best given the short time left for us. When my wife worked in the office, I often felt patients really wanted to see her rather than me. And I feel the same way about Suzy – patients and non-patients love her beauty and demeanor.

Suzy tells me in her way when the few remaining patients arrive and escorts them into the examining room, listens briefly, then quietly departs;

and patients know confidentiality is always safe with her!

But now, after nearly 63 years in practice, it’s really past time to stop being a doctor (of course, that never really happens), and send the few remaining loyal patients to young computerized physicians who prescribe medications I can’t even pronounce. But it is hard for Suzy and I to leave this second home, or more aptly termed, the “medical museum.”

But now none of my anatomical systems are working Richard A. Mahrer, MD properly and Suzy is having her SCCMA Member Since 1955 share of medical problems also, but I take many more medications than she does.

I don’t know what these two old dogs will do without the enjoyable decades of practice, but summer is coming and perhaps one of us will sit on a park bench, with many memories, while the other of the twosome sitting underneath is close and content with wonderful affection uniting us in a special way as the curtain of life slowly descends as it must around the two of us.

MARCH / APRIL 2017 | THE BULLETIN | 39

2017 American Conference on Physician Health The 2017 American Conference on Physician Health (ACPH) will be presented by the Stanford Department of MD Wellness and sponsored by the Stanford University School of Medicine in collaboration with the American Medical Association and the Mayo Clinic.

The conference will take place October 12-13, 2017 at The Palace Hotel. The hotel is located at 2 New Montgomery Street, San Francisco, CA 94105.

The theme of the conference is Creating an Organizational Foundation to Achieve Joy in Medicine which focuses on structuring an organization so that it contributes to, rather than distracts from, physician wellness. The overarching goal of this joint scientific conference is to promote

scientific research and discourse on the topic of physician health and wellness. The conference will showcase research into the infrastructure of the health care system and what organizations can do to help combat burnout and promote well-being.

The conference will provide a forum for practitioners and researchers to present recent findings, innovative methods and support systems, and educational programs in the area of physicians’ health. The friendly and informal conference environment will promote networking, exchange of experience and information, and leisure activity focused on staying healthy.

Free Pocket Guide to Tapering Opioids for Chronic Pain Available from CDC The Centers for Disease Control and Prevention (CDC) has prepared a free pocket guide to help physicians considering reducing or eliminating opioid dosage to chronic pain patients.

The guide aims to help physicians understand how and when to begin the tapering process and minimize withdrawal symptoms while

maximizing non-opioid pain treatments.

Physicians who have reviewed the guide have praised its succinct language and the ease of using it in practice. The guide is available at https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf.

Free CME: Six Steps to Improve Physician Resiliency Increasing administrative responsibilities – due to regulatory pressures and evolving payment and care delivery models – reduce the amount of time physicians spend delivering direct patient care. Physicians often experience burnout caused by demanding workloads, nights on call, and other common stressors. Learning resiliency helps physicians have longer, more satisfying careers and reduces the risk of burnout. The American Medical Association (AMA) STEPS ForwardTM collection includes a module, “Improving Physician Resiliency,” that includes six ways to prevent 40 | THE BULLETIN | MARCH / APRIL 2017

burnout. The module will help physicians identify tools and resources to increase resiliency, assess personal and professional contributors to stress, and identify and prioritize values in all aspects of their lives. Launched

by AMA in June 2015, STEPS Forward now includes 43 free interactive educational modules aimed at helping physicians redesign their medical practices to minimize stress and reignite professional fulfillment in their work. Continuing medical education (CME) credit can be earned from each module. For more information, visit www.stepsforward.org.

© Can Stock Photo / OlegDoroshin

Medical Board of California Newsletter, Winter 2017 issue

CMA Alert, April 3, 2017 issue

ACA Repeal and Replace Bill Dies: What’s Next for Health Care?

On Friday, March 24, House Speaker Paul Ryan and President Donald Trump pulled the American Health Care Act (AHCA) after it failed to garner enough votes within the House Republican caucus. The move followed a six-week sprint to repeal and replace the Affordable Care Act (ACA).

Conceding defeat, Speaker Ryan called it a “major setback” and said Congress and the Trump Administration are moving on to other issues, such as tax reform.

The defeat of the AHCA comes on the heels of intense lobbying by President Trump and the House Republican leadership to unite support within the differing factions of the Republican Caucus. As the President made more concessions to the conservative Freedom Caucus (formerly the Tea Party Caucus), it eroded support among more moderate Republicans.

The Freedom Caucus wanted a total repeal of the ACA, and they argued that the AHCA’s proposed tax credits constituted another entitlement program. The more moderate Republicans were concerned about the Medicaid cuts and the loss of insurance coverage.

The bill ultimately failed because of the negative impact it would have had on millions of Americans, which moved moderates to oppose it.

While the ACA needs improvement, the AHCA was seriously flawed.

The California Medical Association (CMA) expressed concerns with the AHCA and urged Republican leaders to make significant changes before moving the bill forward. It would have caused a further erosion in patients’ access to doctors, and at least three million more Californians would have been uninsured (24 million nationwide) over the next decade, had the bill passed. It would have cut California’s Medicaid funding by at least $24 billion ($880 billion nationwide). And because it lacked income-based tax credits, many low- to moderate-income families and older Californians

wouldn’t have been able to afford coverage.

Throughout our 161-year history, CMA physicians have advocated for health care coverage for all Californians and improved access to care.

These priorities continue to guide our advocacy as Congress debates the ACA and future health care reform proposals. CMA’s overriding goal is to ensure that Californians maintain access to doctors and meaningful, affordable coverage. CMA physicians remain committed to the health and well-being of our patients and improving our health care system.

CMA thanks all of the physicians who made calls and met with their Members of Congress to help them understand the detrimental effect the AHCA would have had on California and the nation. It made a real difference.

While Congress has turned its immediate attention to other legislative priorities, they will return to health care reform. CMA will stay vigilant and focused on achieving a bipartisan solution to improve access to physicians and affordable health care coverage. CMA will continue to work with the Trump Administration and Congress on a bipartisan basis to protect the parts of the ACA that are working and fix that parts that are not.

MARCH / APRIL 2017 | THE BULLETIN | 41

CMA Alert, March 6, 2017 issue

CMS Awards $100 Million to Help Small Practices Succeed The Centers for Medicare & Medicaid Services (CMS) has awarded $20 million to 11 organizations for the first year of a five-year project to provide on-the-ground training and education about the Quality Payment Program, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), for clinicians in individual or small group practices. CMS intends to invest up to an additional $80 million over the remaining four years.

Health Services Advisory Group was awarded the contract to help small practices in Arizona, California, Hawaii, New Mexico and the U.S. Virgin Islands prepare for and participate in the new Quality Payment Program, established by MACRA. This local, experienced, community-based organization will provide hands-on training to help small practices (15 clinicians or fewer), especially those that practice in rural and under-resourced areas. The training and

education resources should be available immediately and will be provided at no cost to eligible clinicians and practices.

According to CMS, clinicians will receive help choosing and reporting on quality measures, as well as guidance with all aspects of the program, including supporting change management and strategic planning, and assessing and optimizing health information technology.

The California Medical Association and the American Medical Association fought to include language in the Medicare reform law to provide this direct assistance to small and rural practices to help them comply with MACRA’s Merit-Based Incentive Payment System and transition to new payment models. As part of that outreach effort, CMS also launched a new helpline for clinicians seeking assistance with the Quality Payment Program. The helpline can be reached by calling (866) 288-8292 from 8 a.m. to 8 p.m. EST, or emailing qpp@cms.hhs.gov.

CMA Alert, March 20, 2017 issue

CMA Unveils Plan to Recoup Prop 56 Funding to Improve Access to Care The California Medical Association (CMA), in partnership with the California Dental Association (CDA), unveiled a budget proposal to improve access to medical and dental care for the state’s 14.3 million Medi-Cal and Denti-Cal patients. The proposal focuses on targeted Medi-Cal investments to increase the number of doctors — both physicians and dentists — who participate in these programs and enable them to accept more patients in order to improve Medi-Cal patients’ access to care provided in California.

Gov. Jerry Brown’s 2017-18 current budget proposal takes $1.2 billion in Proposition 56 tobacco tax funds that were intended to improve access to care and instead, uses them for state general fund purposes. The Legislative Analyst’s Office report on Prop 56 points out that this use of tobacco tax funds goes against the “common sense view” of the initiative’s non-supplantation provision and would be subject to legal challenge.

The governor’s proposal also conflicts with the plain language of the tobacco tax initiative that directs funds to be spent to improve access by improving provider payments; the governor’s proposal does nothing to improve access, cover42 | THE BULLETIN | MARCH / APRIL 2017

age or care.

“As a physician who has seen firsthand the escalating numbers of patients unable to find a doctor who can viably accept them into their practice, it is clear that tobacco tax must be put to its intended use of increasing patient access,” said CMA President Ruth Haskins, MD. “This proposal honors the will of voters and the letter of the law for common sense investments in the Medi-Cal system that will result in vulnerable patients gaining timely access to care.”

The CMA/CDA plan is fiscally prudent – providing supplemental payments based on a sliding scale to correspond with a provider’s level of participation in the Medi-Cal program without exceeding budgeted special funds.

By tethering the supplemental reimbursements directly to the percentage of Medi-Cal or Denti-Cal patients a physician or dentist serves, the plan will produce measurable results for patients; it will be straightforward for the Department of Health Care Services to administer; and it can be implemented regardless of Medicaid funding decisions on the federal level. Most importantly, it will directly increase access to treatment and services for patients who currently face significant barriers to care.

California’s Medi-Cal and Denti-Cal provider networks suffer from chronic underfunding that directly affects patient care. California provider rates are among the lowest in the nation – 48th of 50 states. As a result, only 20 percent of dentists in California are able to accept Denti-Cal patients and 16 California counties either have no Denti-Cal providers, or none accepting new patients. Forty percent of California physicians provide 80 percent of Medi-Cal visits.

Since California’s Medi-Cal and Denti-Cal programs are the nation’s largest, covering more than a third of California’s residents and 60 percent of children, the state needs a robust provider network to meet the medical and dental needs of these 14 million Californians.

The proposal is a common sense solution that targets investments to strengthen California’s Medi-Cal and Denti-Cal provider network and improve patient access to care. Investing tobacco tax revenues as the voters intended will lead to better health outcomes for Medi-Cal and Denti-Cal enrollees and result in long-term savings to the state.

CMA Alert, March 20, 2017 issue

CMS Accepting 2016 Meaningful Use Hardship Exceptions The Centers for Medicare and Medicaid Services (CMS) announced that it is now accepting hardship exceptions from the meaningful use requirements of the electronic health record (EHR) incentive payment program for the 2016 reporting year. Physicians who can show that demonstrating meaningful use would result in a significant hardship can apply for a one-year exception and avoid a negative payment adjustment in 2018. The deadline to apply is July 1, 2017.

To be considered for an exemption (to avoid a payment adjustment), you must complete a hardship exception application and provide proof of the hardship. If approved, the hardship exemption is valid for one payment year. You would need to submit a new application for subsequent years.

Physicians who have never before successfully attested to meaningful use under the EHR incentive program and are transitioning in 2017 to the new Merit-Based Incentive Payment Sys-

tem (MIPS) may also apply for a one-time hardship exception to avoid a 2018 payment adjustment.

The exception deadline for physicians transitioning to MIPS is October 1, 2017.

For more information and applications, visit https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/ PaymentAdj_Hardship.html.

CMA Alert, April 3, 2017 issue

CMA Urges CMS to Create “Administrative Burden” Hardship Exemptions The California Medical Association (CMA) has joined the American Medical Association and other medical associations to urge the Centers for Medicare and Medicaid Services (CMS) to establish a new “administrative burden” category of hardship exemption for the 2016 meaningful use and physician quality reporting system (PQRS) performance year.

When the Medicare Access and CHIP Reauthorization Act (MACRA) was passed, Congress recognized that existing Medicare reporting programs like meaningful use and PQRS needed to be streamlined. Indeed, MACRA’s Merit-Based Incentive Payment System will consolidate and streamline these programs when it is implemented next year. Because of this, CMA and AMA are urging the administration to take a series of steps to address these same challenges for meaningful use and PQRS prior to their replacement by MACRA to minimize penalties for physicians who tried to participate in these programs.

Physicians should not be penalized for focusing on providing quality patient care rather than the arbitrary “check the box” requirements of meaningful use. Creating an “administrative burden” hardship exemption

would provide immediate relief for those impacted by the programs that predate MACRA. CMA and AMA are also urging CMS to create a hardship exemption for physicians who attempted to report PQRS in 2016 but were unsuccessful due to the complexity of the reporting requirements and the significant number of measures that were required. Many physicians tried and were unsuccessful in their efforts to report on the 2016 PQRS measure because they were unable to find nine measures that were applicable and meaningful for their specialty. CMA and AMA are recommending that CMS create a hardship exemption that would allow physicians who successfully reported on any number of PQRS measures in 2016 to avoid the 2 percent penalty in 2018.

With the passage of MACRA and its final regulations, policy makers in Congress clearly understand that fair and accurate measurement of physicians’ performance will not be possible until better tools become available.

MARCH / APRIL 2017 | THE BULLETIN | 43

© Can Stock Photo / japanachai

CMA Alert, March 6, 2017 issue

CDPH Publishes New Zika Resources for Physicians The California Department of Public Health (CDPH) has published new and revised Zika virus resources for physicians on its website.

The evolving Zika virus outbreak and science have presented challenges for providers who are asked to educate, counsel, screen, monitor and manage patients with Zika virus exposure. “We hope these resources will aid health care providers in meeting the needs of California’s families,” the agency said.

These materials can be accessed through the CDPH Zika webpage.

The new resources include: 1) CDPH Zika Screening Algorithm; 2) CDPH Zika Virus Information for Healthcare Providers; 3) Zika Virus Exposure Patient Self-Assessment, English and Spanish; 4) Evaluation and Follow-Up Procedures for Suspected Congenital Zika Virus Infection – Fetus, Newborn and Infant; 5) Risk-based Testing for Local Zika Virus Transmission; and 6) Patient Educational Materials.

In addition to these California-specific materials, CDPH is also highlighting a Centers for Disease Control and Prevention (CDC) program called Zika Care Connect (ZCC), a new resource being developed by the

44 | THE BULLETIN | MARCH / APRIL 2017

agency in collaboration with March of Dimes. ZCC establishes a network (searchable online) of specialized health care providers who can care for patients and families affected by the Zika virus.

“ZCC will help California families find specialty health care services, and health care providers can also use ZCC as a resource for coordinating care for patients affected by Zika who need access to other specialists.”

For more information about Zika Care Connect, contact Lindsay Rechtman at lrechtman@mcking.com or (404) 683-4394, or Chrissy Hillard at vns3@cdc.gov or (404) 498-3819.

TOTAL OF 505 ZIKA INFECTIONS IDENTIFIED IN CALIFORNIA

According to CDPH, there have been a total of 505 Zika infections identified in California, with six new infections reported in the week of February 24, 2017. Not one of these infections was locally acquired. Cumulatively, there have been six infections due to sexual transmissions, with the number of infections in pregnant women totaling 88. There have been four infants born with birth defects caused by the Zika virus.

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