NOVEMBER / DECEMBER 2018
VOLUME 24 | NUMBER 6
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BULLETIN THE
Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society
700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org
MEMBER BENEFITS Billing/Collections CME Tracking Discounted Insurance
Feature Articles
8 Diabetes Prevention Program
9 Santa Clara County Diabetes Prevention Initiative
11 STAT Toolkit to Prevent Type 2 Diabetes
Financial Services
14 If Diabetes Self-Management Education Were a Pill, Would You Prescribe It?
Health Information Technology
18 Recognizing Diabetic Clients on Restaurant Menus
Resources
20 HOD Wrap Up and Photos
House of Delegates
25 Identifying the Root Cause of Drug Shortages
Representation Human Resources Services Legal Services/On-Call Library
Departments
5 Welcome New Members
Legislative Advocacy/MICRA
6 Message From the SCCMA President
Membership Directory APP for
7 Message From the MCMS President
the iPhone Physicians’ Confidential Line
12 Opioid Prescription Restrictions at Walmart and CVS Pharmacies
Practice Management
24 Member Spotlight: Philipp M. Lippe, MD, FACS
Resources and Education
26 Medical Times From the Past
Professional Development
27 In Memoriam
Publications
28 SCCMA Award Nominations
Referral Services With
30 Classified Ads
Membership Directory/Website Reimbursement Advocacy/ Coding Services Verizon Discount NOVEMBER / DECEMBER 2018 | THE BULLETIN | 3
The Santa Clara County Medical Association OFFICERS
CHIEF EXECUTIVE OFFICER
COUNCILORS
President Kenneth Blumenfeld, MD President-Elect Seema Sidhu, MD Past President Seham El-Diwany, MD VP-Community Health Cindy Russell, MD VP-External Affairs Erica McEnery, MD VP-Member Services Randal T. Pham, MD VP-Professional Conduct Faith Protsman, MD Secretary Martin Wong, MD Treasurer Anh Nguyen, MD
April Becerra, CAE
El Camino Hospital of Los Gatos: Lewis Osofsky, MD El Camino Hospital: Gloria Wu, MD Good Samaritan Hospital: Vinit Madhvani, MD Kaiser Foundation Hospital - San Jose: Hemali Sudhalkar, MD Kaiser Permanente Hospital: Open O’Connor Hospital: Cathy Angell, MD Regional Medical Center: Heather Taher, MD Saint Louise Regional Hospital: Scott Benninghoven, MD Stanford Health Care / Children's Health: 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 2018 by the Santa Clara County Medical Association.
4 | THE BULLETIN | NOVEMBER / DECEMBER 2018
President Maximiliano Cuevas, MD President-Elect Christopher Burke, MD Past-President Craig Walls, MD PhD Secretary Alfred Sadler, MD Treasurer Steven Harrison, MD
CHIEF EXECUTIVE OFFICER April Becerra, CAE
DIRECTORS E. Valerie Barnes, MD David Holley, MD Jeffrey Keating, MD William Khieu, MD
Phillip Miller, MD Walter Mills, MD James Ramseur, MD Stephen Saglio, MD
MEMBERSHIP
Welcome 192 New Members Santa Clara County Medical Association Name Mandana Abollhassani Natalia Abrikosova Elissa Adatya Felix Adler Regina-Celeste Ahmad Farhan Amanullah Odul Amburgey Neha Anand Melanie Atmadja Rina Balasubramanian Aleksandra Belova Vidya Bhandarkar Minal Bhanushali Komal Bhatt Peter Binkley William Bohman Mark Bomann Jacqueline Chak Philip Chang David Chen Daniel Cheng Heather Cunningham Christopher Daley Emily Daly Thao Dang Simi Davu Patricia De Luna Lejla Delic Margaret Devilliers Robert Diaz Maryam Dolatshahi William Edwards Mohammad Ezzati Charles Feng Anuradha Ganapathy Gary Gechlik Jacob Gibbens Christopher Gouveia James Guetzkow Shilpa Gupta Bob Han Mariam Hasan Jennifer Hoang Grant Hochstein Lukuang Hsu
City Specialty San Jose IM Mountain View FP Santa Clara IM Mountain View DR Los Gatos PDD San Jose R Los Gatos NPM Sunnyvale FP Mountain View PD San Jose AN San Jose PD Mountain View UC Palo Alto N San Jose IM Los Gatos EM Palo Alto AN San Jose AN Santa Clara PD Santa Clara N Mountain View N Santa Clara HOS Gilroy HO San Jose P San Jose OBG Milpitas PD San Jose IM San Jose AN San Francisco GO Los Gatos PD Santa Clara IM San Jose FP Santa Clara AN San Jose REI Sunnyvale AI San Jose EM San Jose EM Santa Clara OBG Santa Clara HNS Los Gatos FP San Jose EM Campbell P San Jose IM San Jose IM Mountain View IM Cupertino P
Name Sara Jalali Micaela Jett Yelena Kabanskaya Irina Kaminsky Ronald Kaufman Justin Kei Eric Kim Yooree Kim Hanjo Ko Mercedes Kwiatkowski Viswanatha Lanka Joon Lee Tim Lee Matthew Levy Debra Linker Michelle Loftis Jane Maclean Madhuri Madabhushi Amin Manuchehry Jennifer Marbella Benjamin Maser William Mccullough Jason Mefford Robert Meints Aung Moe Alireza Mofrad Kalpana Nagarkar Hemalatha Narra Gloria Nguyen Sonia Nhieu Patrick Noone Natasa Popovic Azam Qureshi Anitha Raghavan Anil Ramesh Deepa Rathi Jonathon Redwine Michael Rogers Shiv Sab Per Sandberg Adam Schlifke Luke Schwankl David Scoville Henry Selke Rajni Sethi
City Specialty San Jose EM Santa Clara DBP San Jose IM San Jose IM Pasadena RHU Cupertino P San Jose N San Jose EM Santa Clara ACA Palo Alto CHP Santa Clara IM Palo Alto R San Jose AN Los Gatos IM Mountain View OBG Los Gatos PD San Jose NSP San Jose FP San Jose IRDR Gilroy FP Los Altos PS Santa Clara R Santa Clara EM San Jose AN San Jose IM Santa Clara IM Santa Clara IM Mountain View N Santa Clara D Santa Clara AN San Jose EM San Jose IM San Jose OPH Santa Clara IM Santa Clara IM San Jose IM Santa Cruz GS Santa Clara IM San Jose IM Mountain View NPM San Jose AN San Jose P Santa Clara CS San Jose ID Santa Clara RO
Name City Specialty Sadiya Shamim San Jose AN Tait Shanafelt Stanford HO Silvia Shin San Jose FP Prachi Shukla Dixit Milpitas IM Eduardo Solbes Santa Clara IM Nandita Sriram Santa Clara IM Megan Stephenson Santa Clara OBG Meredith Stern Santa Clara PD Lauren Sumida Santa Clara PTH Nicole Sun San Jose PD John Talley Los Gatos PS Joshua Tamayo-Sarver San Jose MPH Rajeev Tandon San Jose DR Phillip Telefus San Jose AN Kaitlin Thein Mountain View UC David Tsai Mountain View IM Jessica Tsui Santa Clara CCM Powen Tu San Jose NM Mohammad Valikhani San Jose IM Sri Viswanathan San Jose IM Christina Vu Mountain View PD Nicole Weiss Santa Clara PD Shucheng Wong San Jose CHP Anlin Xu San Jose AI Inna Yaskin Mountain View IM Hind Yassin San Jose IM Residents Aditi Arroway San Jose Scott Borison San Jose Jorien Campbell Palo Alto Howard Chiou Lake Forest Aaron Cook San Jose Alex Dalal Menlo Park Brendan Floyd Menlo Park Michael Hwang Menlo Park Julie Lee Santa Clara Katsuri Malaviya San Jose Hedieh Matinrad Sunnyvale Nuriel Moghavem Menlo Park Colin Murphy Stanford Melissa Myo Fremont Ryan Nock San Jose Paris Scott San Jose Sakara Seng Modesto Vipul Sheth Palo Alto Continued on page 13
NOVEMBER / DECEMBER 2018 | THE BULLETIN | 5
President, Santa Clara County Medical Association
KENNETH S. BLUMENFELD, MD, FAANS
MESSAGE FROM THE
SCCMA PRESIDENT
Tolerance
Kenneth S. Blumenfeld, MD, FAANS is the 20182019 president of the Santa Clara County Medical Association. He is a boardcertified Neurological Surgeon with Sutter Health/Palo Alto Medical Foundation and is currently practicing with South Bay Brain and Spine. He also is adjunct clinical professor in Neurological Surgery at UCSF.
I
Tolerance “…the ability or willingness to tolerate something, in particular the existence of opinions or behavior that one does not necessarily agree with…”.
n a world of political correctness and polarization things have gotten downright hostile. Gone are the days of agreeing to disagree. Unspeakable is the thought of debating contentious principled issues and then sitting down to dinner or even a cup of coffee. The breakdown of civility seems traceable to an environment of righteous indignation and personal attacks. While some might argue we are less misogynous, bigoted, racist, and homophobic I am often concerned that we are moving backwards in the march towards human equality and basic rights. Many might envision our planet’s population to be on a path to androgyny and miscegenation. Even if true I would argue we’re not there yet and may never be. It seems paradoxical to embrace the value and benefit of diversity yet strive for uniformity and likeness. But that’s just the physical. It is even more unlikely that the collective consciousness of our world inhabitants will adopt a single set of ideologies or values. In a sense that is why I believe our “American Founders” created a country that would protect freedom of speech and demand tolerance. They understood there would be disagreement, division, derision, and even hateful rhetoric. Sometimes political correctness and public opinion don’t land on immutable truth or irrefutable ethics. It really didn’t matter as long as everyone could be heard, and differences tolerated. It is dangerous when politically incorrect speech or ideology, even when hateful, are deemed criminal.
6 | THE BULLETIN | NOVEMBER / DECEMBER 2018
The consequences of civil action and censorship are similarly deleterious. I have long believed that the only cure for social misdirection is education in the form of lifelong learning. Yes, we need fair, balanced governance, law enforcement, and judicial review. However, the thought of controlling people’s beliefs through legislation and prosecution is abhorrent. We should all strive to be honorable and stand for what we believe. Honorability makes us better. But tolerance like forgiveness makes us kind, civil, and peaceful. Without tolerance we will degenerate into a dysfunctional argumentative society. We will be tribal, disagreeable, if not warlike. Making decisions and compromises for the greater good requires tolerance. Understanding other people’s struggles, needs and aspirations requires tolerance. It would now seem that getting our country, particularly our broken government, back on track will require the restoration of tolerance. Not everyone is black or white, male or female, Judeo-Christian or Muslim, socialist or tea party. Not everyone is brown, nongender, atheist, or independent either. The point is it shouldn’t matter. We can agree to be different but work together evoking the tenants of tolerance. As doctors we do it every day. We must to be empathetic and to fully understand and help our patients. Food for thought as we look forward to another election and a growing political chasm in our government, especially as it plays out for healthcare policy.
Care Coordination: Relationships and Agreements
President, Monterey County Medical Society
MAXIMILIANO CUEVAS, MD, FACOG
MESSAGE FROM THE
agreement fairly quickly as to the post-consult or post-care expectations on whether the consultant will assume care of the patient or send the patient back to our office. My partner mentioned to me that an issue came up with one of the newer consultants in town. We then realized that we will need to set up some time to meet with our “new” consultant to discuss each other’s preferences and expectations. We need to be ready to initiate conversations with our key consultants or hospitals to discuss each other’s preferences and expectations. We have put together “formalized” lists of the information that we believe is necessary on our consult requests to facilitate a referral with all of our consultants and we will discuss these with each of them to get their buyin. We have put together some draft “agreements” that we will present to them in which we list our expectations. In addition, we have added a checkbox to let the consultant know that our expectation for post-consult care is to either have them assume the care when we feel that transferring the care to them
MCMS PRESIDENT
I
s there such a thing as an unnecessary referral? This question came up one morning as my partner and I sat around waiting for our patient to be made ready for surgery. Another surgeon was sitting in the lounge “busily” waiting for her case to be made ready when she asked us about our sources for referrals; in this particular case, she wanted to know about cardiologists that we would recommend. We gave her the names of the various offices that we refer our patients to and when we mentioned the name of one of the cardiologists, she became upset stating that she would never send another patient there again. Her pronouncement shocked us; we have been sending our patients to him for quite some time now. After asking what happened we learned that it took her office about six weeks to get an appointment for her patient and that she felt belittled by the consultant when she tried to get a “curbside consult” to find out what, if any, laboratory tests she should order prior to the consult, only to be told that the cardiologist will order his own tests. Then it got more interesting. When her patient was finally seen by the cardiologist he told the referring physician that the referral never should have been made as the surgeon could have taken care of this patient on her own. Since that day in the operating room lounge we have had a number of ongoing discussions related to the issue of care coordination for referrals that we will make throughout the course of the office schedule. Referrals work best when everyone involved agrees on the purpose and importance of the referrals and the referring physician and the consultant each agree on the role that each will play. We utilize various consultants within the same specialty as each of them has a preference as to what types of cases they prefer to see. We have had a long history for our relationship with our consultants. The information that each one needs is something that we have agreed upon with each office so we have not had issues. The laboratory testing that the various consultants wants is an item that we have learned over the years and occasionally, we will add additional tests if requested. Our consultants send us the consult reports almost immediately after seeing our patients and we reach
Maximiliano Cuevas, MD, FACOG is the 2018-2019 president of the Monterey County Medical Society. He is currently the Chief Executive Officer at Clinica de Salud del Valle de Salinas.
Continued on page 13 NOVEMBER / DECEMBER 2018 | THE BULLETIN | 7
Diabetes Prevention Program By Lorena Madrid and Pamela Harter, Health Program Specialists Chronic Disease & Injury Prevention Unit County of Santa Clara Public Health Department The Centers for Disease and Control and Prevention (CDC), has completed research with the National Institute of Health (NIH) that supports the National Diabetes Prevention Program (DPP) in developing an evidence based prevention program that aims to decelerate or impede the development of type 2 Diabetes. This program, based upon the loss of 5-7% body weight, can reduce the risk of diabetes by 58% within the prediabetes population – 71% of those over the age of 60. From this evidence, the Santa Clara County Diabetes Prevention Initiative (DPI) has focused on promoting the new DPP in our community as a behavior modification program, both in person and online, that supports weight loss through exercise, healthy eating, and intense lifestyle coaching. The DPP core curriculum taught by the lifestyle coach in the DPP classes includes balancing calories, problem solving/coping, overcoming barriers, strategies for eating out, and managing stress. Based on the research studies of 100 adults with diabetes, the possible benefits from DPP is a 58% reduction in incidence of diabetes, a 25% reduction in medication use for hypertension and hyperlipidemia, and 1-2% reduction in absenteeism and productivity loss. The DPP lifestyle coaching class series is provided in two phases; the intervention phase (16 sessions in 4-6 months) and the maintenance phase (1-2 sessions for 6-8 months). The CDC Diabetes Prevention Program encourages the adoption by communities across the nation. Fortunately, the cost is significantly less than the medical claims accompanying the diagnosis of type 2 diabetes. The cost of DPP is only $450- 490 for one year per individual, opposed to approximately $2,700 per individual for type 2 diabetic patients. Medicare, CaLPERS and some health insurance plans cover the cost for DPP as a medical benefit, and Medi-Cal will start covering it beginning January 1, 2019. The number of providers of the National Diabetes Prevention Program (DPP) have increased in Santa Clara County, enhancing the coverage and access to evidence-based and cost effective diabetes prevention 8 | THE BULLETIN | NOVEMBER / DECEMBER 2018
programs in the community. The Santa Clara County Public Health Department, Community Health Partnership, Gardener Family Health Network, YMCA, Santa Clara Family Health Plan, Valley Health Plan, and Indian Health Centers, as well as others from the Diabetes Prevention Initiative, have taken the leadership to promote and implement DPP in Santa Clara County. YMCA- DPP is a local provider and an active partner of pilots at the community health center and county clinics. In addition, the Indian Health Centers is also a provider of DPP and have opened their program to all populations. Santa Clara County Diabetes Prevention Initiative (DPI) collaborating agencies have collectively worked at successfully enrolling over 600 County residents in diabetes prevention programs to date during our three year strategic plan. The DPI Collaborative has engaged local insurance plans and other organizations to provide DPP, and will continue to encourage other plans and employers to offer DPP to their members and employees. Medical providers are encouraged to engage their health insurance plan partners to provide and/or contract with DPP programs in the community, to support your patients with prediabetes. The DPI offers training, shared learning and technical assistance in motivators for increased engagement for DPP providers, by offering health enhancements and incorporating the social determinants of health support modules into their DPP curriculums, to support all community members with prediabetes engaging in the one year program. Join the efforts to prevent type 2 diabetes today, and refer your at risk or prediabetes patient to a DPP program in the Santa Clara County! Interested in becoming a recognized DPP provider? To learn more visit: https://www.cdc.gov/diabetes/prevention/pdf/dprp-standards.pdf. If your agency plans to deliver the CDC Diabetes Prevention Programs (DPP) as an agency provider, it is a requirement of the CDC recognition process for DPP, that one person in the organization must be a Trained Lifestyle Coach by a master trainer. The Santa Clara County Public Health Department & Diabetes Prevention Initiative will host a training with DTTAC -Emory Centers’ Diabetes Training and Technical Assistance Center in November 2018. https://www.cdc.gov/diabetes/prevention/lifestyle-program/staffing-training.html
Santa Clara County Diabetes Prevention Initiative (DPI) Diabetes is increasing in alarming rates across the nation, and local leaders are very concerned about its impact on Santa Clara County. The Santa Clara County Public Health Department launched the Diabetes Prevention Initiative (DPI), to provide prevention awareness, screening and referrals, and to increase coverage for and access to the evidence based Diabetes Prevention Programs- (DPP) among the community. The County initiative strives to ensure better health for all by identifying County residents that have prediabetes or are at risk for type 2 diabetes, and connecting them to prevention education, healthy eating, and active living resources in the community. These efforts aim to increase a healthy lifespan and decrease illness, along with its burdens. The focus of the DPI is to prevent individuals at high risk for type 2 diabetes and prediabetes from developing type 2 diabetes.
The Santa Clara County Public Health Department has been successful and made great strides to raise awareness about the Diabetes Prevention Program (DPP), evidenced based curriculum. Our county has been able to amplify State efforts to support lowering type 2 diabetes in the State. In order to prevent diabetes in our community, the collective efforts of many additional agencies and organizations countywide will be required. Giving county members the continuous support to become more aware of prevention methods, screening and referral resources, and the means to coverage and access will work towards the prevention of type 2 diabetes. Together We Can Prevent Diabetes. www.SCCPreventDiabetes.org.
With over 80 agencies working collectively to improve the health of Santa Clara County residents, the Santa Clara County Diabetes Prevention Initiative has become a leader, in our community work in preventing diabetes. To raise awareness, the DPI has developed a DPI Partner Toolkit and Diabetes Prevention Resource Guide for patients, families, and seniors with community input and testing. The Resource guide lists community resources, along with tips and methods on how to prevent type 2 diabetes. The Partner Tool kit materials and The Resource Guide are distributed in both print and through social media, e-newsletters, and websites. The Partner Tool kit offers materials in a number of languages including English, Spanish, Vietnamese, and Chinese in order to reach county residents. The SCC Public Health Department has also engaged with 20 organizations that are actively providing prediabetes screening. We have provided over six training sessions to encourage other organizations to provide screenings, referrals and prevention materials. NOVEMBER / DECEMBER 2018 | THE BULLETIN | 9
The Medical Provider’s Role in Diabetes Prevention in our Community
The Santa Clara County Diabetes Prevention Initiative –SCC DPI has created a comprehensive DPI Partner Toolkit that can support medical provid- ers and patients. The health education materials have been screened for litera- cy level, cultural appeal and are multilingual-English, Spanish, Vietnamese and Chinese. It includes health education handouts, tools and resources that cover a wide range of topics for prevention such as nutrition, physical activity, stress reduction and reducing sugar consumption. These educational and marketing materials can be used in medical and community settings, and in social media.
The newly published Resource Guide to Preventing Type 2 Diabetes, is a great addition to the toolkit and is currently available in English and Spanish, with a Vietnamese version to be released in the coming year. The Resource Guide con- tains the prediabetes risk factor test,1 plus tips on how to talk to your doctor, and where to find a Diabetes Prevention Program -DPP class. In addition, there are great tips and community resources on ways to live a healthy lifestyle and get support in the community.
The SCC DPI has adopted evidence-based practices and promotion, developed by the State of California Depart- ment of Public Health -CDPH, from the statewide obesity prevention campaign called the Champions for Change Campaign.
Living a healthy lifestyle starts by taking one small step. The small steps and small chang- es add up to success! Which step will you take today? One bite, one choice, one snack, one drink ….?
Please visit: The Santa Clara County Public Health Department, Diabetes Prevention Web- site: www.sccPreventDiabetes.org For more information on the DPI Partner Tool kit ma- terials and training, please email Pamela Harter at Pamela.Harter@phd.sccgov.org. 1
American Diabetes Assn. (2018), Standards of care in Diabetes-2018 Diabetes care, 41(1) S13-17)
10 | THE BULLETIN | NOVEMBER / DECEMBER 2018
STAT Toolkit The STAT Toolkit is recommended by AMA and CDC for type 2 diabetes clinical screening (algorithm) and referral process for the Diabetes Prevention Program (DPP), a lifestyle intervention! The Centers for Disease and Control and Prevention (CDC) and the American Medical Association (AMA) have collaborated to create and implement an innovative and resourceful tool, called the STAT Toolkit. This resource is for physicians and care teams to detect prediabetes in patients. The STAT Toolkit can identify the at risk patient and immediately refer them to a Diabetes Prevention Program (DPP), offered either in person or online. It can also provide feedback from the patient’s progress in the DPP to use in further medical practice. The STAT Toolkit is a great resource to use and will allow your patients, who are at risk for prediabetes, to be introduced to a DPP program that has been proven to prevent or delay the onset of type 2 diabetes and enhance their quality of life. This resource is beneficial not only to your patients, but to your practice as well! The easy and useful STAT Toolkit will allow each, at risk patients to be referred to a program without any burden. A pilot program for prediabetes was conducted in 2015-2017 with the Public Health Department, Community Health Partnership, El Camino Hospital Community Benefits, and Gardener Family Health Network. The AMA & CDC STAT Tool Kit for medical providers was implemented and learnings captured for sharing with local medical providers to support system changes for scaling our clinical diabetes prevention strategy in our County. In the pilot, it included studying workflows and implementing blood glucose screening, and DPP referral, leveraging the registered dietician and medical assistant/ health coach during point of care and retrospective approaches. There were close to 300 patients eligible for the pilot, having type 2
diabetes high risk factors and/or diagnosed with prediabetes. 22% of these patients were engaged by the referral intervention for prediabetes. 55% of referred patients registered and participated in the DPP class series. The Santa Clara Valley Health System has engaged its clinics, to participate in two pilots at the County Clinics-Valley Health Centers starting in November 2018. Santa Clara County committed to identifying innovative strategies and curriculums like the evidenced based DPP for Medi-Cal patients and community members. Learn more about implementing the STAT Tool kit with your patients today! https://preventdiabetesstat.org/toolkit.html Together We Can Prevent Diabetes www.SCCPreventDiabetes.org
NOVEMBER / DECEMBER 2018 | THE BULLETIN | 11
PRACTICE MANAGEMENT
Opioid Prescription Restrictions at Walmart and CVS Pharmacies In 2018, Walmart (including Sam’s Club) and CVS Caremark implemented dosage and duration corporate policies to restrict opioid prescriptions filled at their pharmacies. Specifically: • Walmart restricted initial opioid prescriptions for acute pain to no more than seven days and 50 morphine milligram equivalents (MME). • CVS Caremark restricted initial opioid prescriptions for an acute condition to a seven-day supply and 90 MME, although prescribers may request a prior authorization for higher doses up to 200 MME/day.
Physicians have also reported being asked for extensive medical documentation such as treatment agreements, tried/failed therapies, and diagnoses codes before an opioid prescription will be filled by the pharmacist. CMA is concerned that the effects of these new corporate policies may intrude upon the physician-patient relationship, compromise patient confidentiality, and create barriers for patients who need access to their medications. CMA is monitoring this situation to assess the impact upon patient care. If you or your patients have encountered such policies, please contact CMA’s Center for Legal Affairs at 1-800-786-4262 or legalinfo@ cmadocs.org.
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Legacy offers a one-hour complimentary financial planning check-up to Association members (this is a $500 savings). For more information, please call Michelle Hamilton, CFP®, MBA at (408) 452-7700 or email michelle@lwallc.com.
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12 | THE BULLETIN | NOVEMBER / DECEMBER 2018
New Members, from page 5 Santa Clara County Medical Association, Continued Name City Name City Name City Tara Murty Menlo Park Amelia Bryan Stanford Brandon Shiau San Jose Pooja Parameshwar Stanford Anthony Buzzanco Long Beach Nainwant Singh San Jose Destiny Phillips Mountain View Kaitlin Corbin Campbell Paula Song Palo Alto Nicolas Quach Stanford Michael Dacre Stanford Kardina Thomson Los Gatos Adrian Rodrigues Kirkland Drew Daniel Palo Alto Michelle Wong Hacienda Heights Vinita Shivakumar Stanford Zainub Dhanani Duluth Diane Yang Santa Clara Joshua Tanner Stanford Mark Douglass Santa Rosa Barnabas Yik San Jose Benjamin Teasdale Palo Alto Andrea Fisher Stanford Eric Yoo San Jose Ekaterina Tkachenko Menlo Park Jason Gomez Stanford Michael Zhang Stanford Abd Al-rahman Traboulsi Stanford Charlotte Herber Menlo Park Tian Zhu Fremont Quan Tran Stanford Eric Jenkins Stanford Students Pavin Trinh San Gabriel Suleman Khan Danville Lehi Acosta Orem Kunal Varshneya San Jose Eric Lee Menlo Park David Altman Palo Alto Jonathan You Boston Daniel Liu Stanford Angel Billingsley Palo Alto Michelle Zhang Palo Alto Sruthi Mantri Palo Alto
Monterey County Medical Society Name Johol Chan Shiva Ganji Charles Harris Felicidad Lao-Domingo Pablo Marchevsky
City Specialty Salinas OBG Salinas HOS Salinas FP Salinas AI Pajaro FP
Name City Residents and Students Salinas Name City Adrian Jordan Rose Lovell Salinas Kelsey Capron Salinas Austin Shoener Salinas Alvin Cardona Salinas Jacqulyne Sylvia Salinas Cristian Carrillo Salinas Francesco Tani Salinas Brittany Chamberlain Salinas Brianne Huber Salinas
Care Coordination: Relationships and Agreements, from page 7 is appropriate or return the patient with their recommended on-going care advice. I can make these drafts available if you are interested; send me a note at mcuevas@csvs.org. Currently, we are working with our hospital to figure out a workflow that includes notifying our group when one of our patients presents to the emergency room. One of our partners is always on-call and we would prefer to see the patient if at all possible so that we can transition the patient back to the office, admit them to the hospital, and then transition them back to the office when discharged. This work is moving
slower than we thought, but we will get there. Our surgeon friend is busy establishing relationships with the various offices that she interacts with. Like us, she is learning to formalize her arrangements and agreements with other offices by meeting with the other physicians. She is reviewing our draft agreements and we will get together to go over these. More importantly, she is working with her cardiologist friend who has since apologized for the miscommunication. They have both agreed that the miscommunication also resulted in duplicate testing and increased cost for the health care delivery
system (and the patient). Some of the issues that they identified and are considering include: • Types of patients referred; • Information provided with the referral; • Testing to be completed prior to the referral; • Consult report content and timeliness; • Availability for “curbside consults.” In all human endeavors and collaborations, close personal relationships are very important. It is these relationships that will allow us as physicians to advocate easily for our patients in our offices or at the hospital.
NOVEMBER / DECEMBER 2018 | THE BULLETIN | 13
If Diabetes Self-Management
Education (DSME) were a pill,
would you prescribe it?
By Francine Pack, RD CDE Manager, Diabetes Resource Center – Good Samaritan Hospital An AADE Accredited Outpatient Program 408-358-5686 With 30.3 million people in the United States and 8% of Santa Clara County residents
living with diabetes, we have an immense and extremely important job to do. We are tasked with providing excellent care tailored to the individuals with diabetes for the prevention of diabetes related complications and the optimization of quality of life. With many tools at the providers’ disposal, DSMES (Diabetes Self-management Education and Support) with Medical Nutrition Therapy (MNT) is an excel-
14 | THE BULLETIN | NOVEMBER / DECEMBER 2018
lent tool to prescribe for everyone with diabetes. In a 2016 paper in Diabetes Care by Maggie Powers, PhD, RD, CDE raised the question “IF DSME was a pill, would you prescribe it?”1 In applying the five criteria (efficacy, hypoglycemia risk, weight changes, side effects and cost) used to rate diabetes medication to DSME, Dr. Powers confirms the benefits and value of DSME. Engaging adults with type 2 diabetes in DSMES and MNT results in statistically significant and clinically meaningful improvements in A1c2. The comparison of DSMES to the commonly prescribed metformin underscores the importance of including non-pharmacologic therapy in the treatment plan. Due to their beneficial impact on overall diabetes care and health outcomes, DSMES and MNT are covered benefits through Medicare and many private insurers. Unfortunately, these benefits are greatly underutilized. Within the first year of diagnosis, only 5% of Medicare recipients3 and 6.8% of those privately insured4 received DSMES. This underutilization is unfortunate as persons with diabetes make numerous decisions regarding food, physical activity, medications and more. Changing lifestyle and maintaining these changes can be challenging and overwhelming. DSMES facilitates the adoption of these skills by providing education as well as helping that individual identify barriers,
facilitate problem solving and develop coping skills to achieve effective self-management and behavior change on an ongoing basis. Although different members of the health care team and community can contribute to diabetes education and support, it is important for health care providers and their practice settings to have the resources and a systematic referral process to ensure that patients with type 2 diabetes receive both DSME and DSMS in a consistent manner.5 The Joint Position Statement on DSMES6 describes the four critical times to assess, adjust, provide and refer to meet the needs of the persons with diabetes. The 2018 Consensus Report by the American Diabetes Association and the European Association for the Study of Diabetes (published ahead of print in October) recommends that all people with type 2 diabetes be offered access to ongoing DSMES.7 When persons with diabetes enter DSMES, they learn the principles of healthy eating, being active, monitoring, taking medication, problem solving, reducing risks and healthy coping. Annually, when new complicating factors influence self-management and when transitions in care occur, these seven principles are reviewed and the diabetes educators work with the person to identify, individualize and adjust these self-care behaviors to meet individual needs. The team, patient-centered approach is a very successful model for diabetes care management. Adding diabetes educators from an accredited or recognized DSMES program assures adherence to national standards8 and allows the 25% of seniors with diabetes to utilize their Medicare benefit for DSMES. To find an accredited or recognized DSMES program: https://www.diabeteseducator.org/living-withdiabetes/find-an-education-program. So, when caring for your patients with diabetes, remember that DSMES + MNT scores as favorably as Metformin, increases or improves quality of life, reduces blood pressure and lipids,
and statistically improves A1c. It is an ongoing, underutilized benefit that you have in your tool box of treatments for diabetes. Hopefully now the answer to “If DSME was a pill, would you prescribe it?” is YES!!!
REFERENCES:
1. Powers M. 2016 Health Care & Education Presidential Address: If DSME Were a Pill, Would You Prescribe It? Diabetes Care 2016 Dec; 39(12): 2101-2107. 2. Chrvala CA. Et al. Diabetes selfmanagement education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Educ Couns. 2016 Jun;99(6):926-43. 3. Strawbridge, LM et al Use of Medicare’s Diabetes Self-Management Training Benefit Health Educ Behav. 2015 Aug;42(4):530-8. 4. Diabetes Self-Management Education and Training Among Privately Insured Persons with Newly Diagnosed Diabetes — United States, 2011–2012 Morbidity and Mortality Weekly Report November 21, 2014 / 63(46);1045-1049 https://www.cdc.gov/ mmwr/.
5. Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Hess Fischl A, Maryniuk MD, Siminerio L, Vivian E..Diabetes Self-Management Education and Support in Type 2 Diabetes: A joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators and the Academy of Nutrition and Dietetics Diabetes Educ. 2015 Aug;41(4):417-30. 6. Powers, et al. DSMES Position Statement (2015) Diabetes Care, The Diabetes Educator, Journal of Academy of Nutrition and Dietetics. 7. Davies, Melanie Et al. Management of Hyperglycemia in Type 2 Diabetes, 2018. A consensus Reoprt by the American Diabetes Assiociation (ADA) and the European Association for the Study of Diabetes. Diabetes Care Publish ahead of Print, published online October 4, 2018. 8. Beck, Joni Et al. 2017 National Standards for Diabetes Selfmanagement Education and Support Diabetes Care 2017 Oct; 40(10): 14091419.
NOVEMBER / DECEMBER 2018 | THE BULLETIN | 15
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NOVEMBER / DECEMBER 2018 | THE BULLETIN | 17
Recognizing Diabetic Clients on Restaurant Menus
A
By Ted Mazer, MD Immediate Past President, CMA
s I began my term as President of the California Medical Association, I stated that I wanted to try to work with the restaurants in California to increase awareness of the number of diabetic patrons they serve, and what the restauranteurs and chefs might do to help address this major public health issue. The California Restaurant Association has graciously agreed to work with me, and has published the article below, in hopes that it will at least begin to spark some attention to having items identified on and added to menus that will give more healthy, low-sugar options to the 10 percent of Americans with diabetes. It may only
18 | THE BULLETIN | NOVEMBER / DECEMBER 2018
be a small part of addressing this public health concern, but we have to start somewhere. From the restaurants’ standpoint, sales are clearly a driving force, but helping diabetic diners find better, safer options could have an impact on the choices the diabetic diner chooses. As restauranteurs and chefs become more aware of the numbers of diabetics who must limit their choices from today’s menus, I hope they will begin to identify recipes that extend the options for healthy, high-quality, low-sugar options for the more than 1 in 10 Americans that need them. My wife and I used to frequently enjoy a dessert with coffee or a cappuccino or a glass of port after a dinner out. Her diagnosis of diabetes changed that, although it’s not a big surprise given her strong family history of diabetes. Roughly 10 percent of the U.S. adult population has diabetes, with 95 percent being type 2 (versus type 1). Another one third of Americans have pre-diabetes. That’s over 100 million potential restaurant customers! While I certainly don’t want to encourage excess calorie consumption, especially in someone with type 2 diabetes, the changes my wife and I had to make to eat out have made us aware of the surprising lack of recognition of diabetic patrons and their needs in restaurants nationwide.
And I believe that paying attention to diabetic customers presents an opportunity to both help a major health issue and even increase sales of afterdinner drinks and desserts that can be enjoyed by both diabetic customers and those accompanying them. We have made a regular habit of asking our server whether there are any sugar-free desserts available, aside from the inevitable response of “We can put a fruit plate together.” And, not surprisingly, the answer is almost always “No, so sorry.” With that answer, the meal is usually over … check please … plus a lost opportunity to please a customer and—from the restaurant’s point of view—raise a check average. But on the rare occasion that something actually is available, we will often stay and order coffees and dessert, still watching the overall caloric intake. We spend more time at the table, a bit more on our tab, and remember the restaurant’s thoughtfulness for the future, informing friends as well. Our first such experience was at a Mother’s Day brunch at the Marriott in downtown San Diego. I asked a staff member near the incredible assortment of desserts whether anything was sugar-free on the display. After apologizing, he said he would check with the kitchen. A few minutes later, he found our table and presented a trio of tasty sugar-free pastries for my wife! It was a small gesture with a big impact. After several failed inquiries at the next series of dining venues, we were shocked by a “Yes” answer at the Inn at Biltmore Estate, which served us a sugar-free lemon semifreddo. In planning California Medical Society events, our staff has found several other accommodating venues, including the Disneyland Hotel, with the ability to provide excellent sugar-free desserts for attendees. Most restaurants still offer nothing but fruit for a sweet plate after
dinner for customers trying to watch their sugar intake. Menus often highlight gluten-free options for most courses along with vegetarian and vegan options, although it is estimated that only 1 percent of Americans have true celiac disease, and perhaps up to 7 percent may be gluten sensitive, while an estimated 3 percent of Americans choose to be vegetarians, and less than one quarter of those are vegan. In contrast, I have never seen a menu highlighting diabetic, low-sugar options for main courses or desserts. Diabetic diet awareness goes beyond desserts, as common items like tomato sauces and other sauces often have high sugar content—but they need not be so! My wife makes an exceptional low-sugar tomato sauce that would stand up in any restaurant dish. Restaurants should remember that diabetes is not a choice, but a medical condition that has serious health consequences if not addressed. Perhaps it is time for a collaborative effort to address the disconnect between restaurant offerings and the high prevalence of diabetes in the United States. As restauranteurs and chefs become more aware of the numbers of diabetics who must limit their choices from today’s menus, I hope they will begin to identify recipes that extend the options for healthy, high-quality, low-sugar options for the more than 1 in 10 Americans that need them. They would be helping diabetics find eating out less of a challenge, while increasing potential patronage of venues who pay attention to these needs and contributing to a healthier population. And who knows, maybe having such options and a few diabetic-friendly desserts would result in more people—both the diabetic and their dining companions—ordering another course, a couple of cups of coffee, or even an after-dinner drink, instead of declining so as not to make one diner feel uncomfortable. Let’s have California restaurants help lead the way.
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2018 House of Delegates
CMA Outlines Bold Health Care Agenda to Improve Patient Affordability, Access and Quality
By Lee T. Snook, Jr., MD, CMA Speaker of the House Tanya W. Spirtos, MD, CMA Vice-Speaker of the House Seema Sidhu, MD, Chair, District VII Dirk Bauman, MD, Vice-Chair, District VII Dear Physician Colleagues, California Medical Association (CMA) convened its 147th annual House of Delegates (HOD) meeting in Sacramento on October 13-14, 2018. Over 500 California physicians convened to debate on the most critical issues affecting members, the association and the practice of medicine. The major focus of HOD was the creation of an initial framework for a bold agenda to increase health care affordability, improve health care delivery, create efficiencies throughout the health care system, and improve health outcomes, which includes addressing social determinants of health and expanding telehealth services. Virtually all of us have directly witnessed the impacts on our patients, but the following statistics bear repeating because they reinforce the critical nature of CMA’s charge: • Prescription drug prices have increased 25 percent since 2012 (Health Care Cost Institute). • Health insurance deductibles have more than doubled since 2008, and half of all workers now have a deductible of at least $1,000 for an individual, up from 22 percent in 2009 (Kaiser Family Foundation). • Employer-sponsored insurance premiums have risen from $6,000 in 1999 to more than $18,000 in 2016, and out-of-pocket costs have increased by more than 53 percent between 2006 and 2016 (Economic Policy Institute). • The average American spent $10,345 on health care in 2016, yet roughly 41 percent of Americans say they can’t pay a $400 emergency expense without borrowing or selling something (Centers for Medicare and Medicaid Services, Federal Reserve). • Thirty-three percent of Americans with health insurance said they or a family member had problems affording care in the last year (Kaiser Family Foundation survey). • Twenty-seven percent of our time is spent with patients, while nearly half is spent on electronic health records or other desk work. Spending three hours a day on administrative tasks equals 20 | THE BULLETIN | NOVEMBER / DECEMBER 2018
a loss of 2,200 patient visits per physician per year. (Annals of Internal Medicine). CMA President David H. Aizuss, MD, put it best: “Health care costs continue to grow, with patients paying more and getting less – except for more runarounds, fine print and larger medical bills. This is our current reality and the battle we must fight, because it’s hurting our patients’ ability to access needed care, treatment and medications. No family should have to forego medical care to pay household bills or take on debt, yet that is exactly the situation more Californians are facing. If health care isn’t affordable, then it isn’t accessible, and the California health care system must do better for our patients.” With physicians at the center of health care delivery, CMA has long advocated on behalf of our patients to ensure they are receiving affordable, timely and quality care, and we doubled down on that commitment at HOD. After hearing expert testimony, CMA debated and identified four critical issues that California must address to make health care affordable while improving quality and access: • Reform health care delivery and utilization by making payment and delivery more efficient, as well as expand telehealth. • Expand patient choice and affordability by increasing competition throughout health care with market-based solutions. • Maximize physicians’ time spent with patients by reducing administrative burdens and eliminating duplicative tasks that add unnecessary costs without improving health outcomes. CMA also remains committed to ensuring that all modes of medical practices are financially vibrant. • Ensure patients have access to necessary treatment and medications by addressing pharmaceutical costs. In the coming months, CMA will develop targeted, pragmatic and workable solutions, as well as continue to work with our members, health care stakeholders and policymakers to ensure patients can access quality care in an affordable and timely manner. As a physician-led organization, CMA’s collective strength is derived from the dedication and passion of its membership. We thank the HOD delegates, and we thank you for your continued commitment to patients and the profession. On the following pages you will find more highlights from this year’s House of Delegates.
Highlights from the 2018 House of Delegates 1. Los Angeles ophthalmologist installed as 151st president of CMA CMA installed Los Angeles ophthalmologist David H. Aizuss, MD, as its 151st president during the organization’s annual House of Delegates meeting in Sacramento. In his address to the delegates, Dr. Aizuss said that physician satisfaction and practice sustainability would be among his top priorities in the upcoming year. “Our CMA brand has strength, effectiveness, power and influence,” said Dr. Aizuss. “My goal as your president is to be an effective spokesman and to communicate your concerns, desires, needs and hopes for a professionally satisfying medical practice and effective patient care.” Dr. Aizuss officially took over from Immediate Past President Theodore M. Mazer, MD, at the end of HOD, and will serve a term of one year.
2. Urologist and transplant surgeon named CMA president-elect Urologist and kidney transplant surgeon Peter N. Bretan, Jr., MD, was elected by the CMA House of Delegates as the association’s new presidentelect. Dr. Bretan will be installed as president at the close of the 2019 House of Delegates. He will be the first Filipino-American physician to serve as CMA president. Dr. Bretan practices in Marin, Sonoma and Santa Cruz counties. The full 2018-2019 CMA Executive Committee includes: President: David H. Aizuss, MD, Los Angeles President-Elect: Peter N. Bretan, Jr., MD, Watsonville Chair of the Board: Robert E. Wailes, MD, Oceanside/Encinitas Vice-Chair of the Board: Shannon L. Udovic-Constant, MD, San Francisco Speaker of the House: Lee T. Snook, Jr., MD, Sacramento Vice-Speaker of the House: Tanya W. Spirtos, MD, Redwood City Immediate Past President: Theodore M. Mazer, MD, San Diego
3. Modesto family physician receives CMA’s prestigious “country doctor” award Modesto family physician Silvia Diego, MD, was honored at the 2018 CMA House of Delegates with the association’s most prestigious award, the Frederick K.M. Plessner Memorial Award. The award honors a California physician who best exemplifies the ethics and practice of a rural country practitioner. Learn more about Dr. Diego in our video profile at youtube.com/ cmadocs.
4. Fresno emergency physician receives CMA’s Compassionate Service Award Fresno emergency physician Kenny Banh, MD, was selected as the 2018 recipient of the CMA Compassionate Service Award, which honors a CMA member physician who best illustrates the association’s commitment to community and charity care. Dr. Bahn was honored for his role in creating the first medical student-run mobile health clinic in the Central Valley, with the ultimate goals of training the next generation of San Joaquin Valley physicians, increasing the diversity of the medical profession, and providing a significant and positive impact to the valley for those who do not have the normal access to care.
5. OC psychiatrist receives CMA’s Nye Award for Physician Health and Well-Being Orange County psychiatrist Nicolaas-John Van Nieuwenhuysen, MD, was awarded CMA’s 2018 Gary S. Nye Award for Physician Health
and Well-Being. This annual award honors a CMA member who has made significant contributions toward improving physician health and wellness. Dr. Van Nieuwenhuysen is being honored for his commitment to and passion for helping his fellow physicians find success, happiness and wellbeing in pursuit of their noble profession. He has served as chair of the Orange County Medical Association (OCMA) Physician Wellness Program for more than seven years, growing the program into one of the most established and successful county-medical-society-based wellness programs in the state.
6. San Bernardino pediatrician honored with CMA membership award Apple Valley pediatrician Damodara Rajasekhar, MD, was named the 2018 recipient of CMA’s Dev A. GnanaDev, MD, Membership Award, which recognizes a special or unique effort toward membership recruitment. In 2018, Dr. Rajasekhar played a major role in continuing CMA’s partnership with Loma Linda University Medical Center, leading to membership renewal for 440 Loma Linda physicians.
7. San Jose surgeon receives CMA’s speaker’s recognition award Phillip M. Lippe, MD, was chosen to receive the 2018 Gary F. Krieger Speaker’s Recognition Award. The recipient of this award is hand-selected by the current CMA Speaker of the House for remarkable contributions to CMA and its House of Delegates. The award was presented at CMA’s annual House of Delegates meeting in Sacramento. “The recipient of this year’s Krieger Award is a man whose dedication and service has been profound,” said Lee T. Snook, Jr., MD, Speaker of the CMA House of Delegates. “[Dr. Lippe] continues to contribute his unique and heralded expertise with a drive towards excellence. His contributions cannot be understated, underestimated, nor undervalued.” Dr. Lippe has been a member of CMA for 54 years, and a member of the House of Delegates for 41 years. He has served on many committees and councils, as well as on the Board of Trustees. Dr. Lippe has been instrumental in strengthening CMA’s many scientific inquiries and positions. He was the moving force behind CMA’s landmark white paper on opioids, which greatly influenced the Medical Board of California’s November 2014 Opioid Treatment Guidelines. He also initiated the American Medical Association’s first Pain Summit and founded the Pain and Palliative Medicine Specialty Council. Please see our Member Spotlight on Dr. Lippe (page 24) to read his presentation and acceptance speeches for this award.
Moments captured at HOD To view photos of this year’s HOD, visit flickr.com/californiamedicalassociation.
Get Involved Do you want to help establish CMA policies on major issues that affect the practice of medicine? Physicians interested in influencing CMA’s advocacy agenda can serve in the House of Delegates or on one of CMA’s councils and committees. For more information, contact April Becerra, CEO, at SCCMA-MCMS (408) 998-8850 or email: april@sccma.org..
Save the Date: 2019 House of Delegates The 2019 House of Delegates will be October 26-27, 2019 in Anaheim, at the Disneyland Hotel. NOVEMBER / DECEMBER 2018 | THE BULLETIN | 21
CMA District VII Delegation
Photos From the 2018 House of Delegates
CMA’s Past Presidents pose for a nice group photo at HOD. 22 | THE BULLETIN | NOVEMBER / DECEMBER 2018
Drs. Kenneth Blumenfeld, James Strebig and Peter Bretan, Jr.
SCCMA and CMA Past President Dr. James Hinsdale speaks at the House of Delegates.
Dr. Luther Cobb (CMA Past President) and Dr. James Hinsdale (SCCMA and CMA Past President)
Dr. Kenneth Blumenfeld (SCCMA President and CMA Trustee/Delegate), and his lovely wife Ellen Drs. Cindy Russell and Hemali Sudhalkar.
CEO’s Donna Odryna (Santa Cruz County Medical Society), April Becerra (Santa Clara and Monterey County Medical Associations) and Keith Darby (San Mateo County Medical Association).
Dr. Kenneth Blumenfeld (CMA Trustee and SCCMA President) speaks at HOD.
Dr. Cindy Russell (CMA Delegate), Dr. Seema Sidhu (Chair, District VII), and Dr. Tom Dailey (CMA Trustee/Delegate)
Vice Speaker of the House Dr. Tanya Spirtos, and Speaker of the House Dr. Lee Snook, Jr.
NOVEMBER / DECEMBER 2018 | THE BULLETIN | 23
MEMBER SPOTLIGHT
Philipp M. Lippe, MD, FACS CMA Speaker’s Recognition Gary Krieger Award Philipp M. Lippe, MD was presented with CMA’s 2018 Gary F. Krieger Speaker’s Recognition Award at the House of Delegates meeting on October 13th (please see page 21). We would like to share the following presentation and acceptance speeches:
Dr. Lee Snook, Jr. made the following presentation speech at the Awards gala: We have in our House today an individual deserving of our appreciation and singular recognition. The Speaker’s Recognition Award was created in 1995 and in 2002 became the Gary F. Krieger Speaker’s Recognition Award in honor of our late Speaker and President-Elect. Eligible awardees are current or past members of this House who have not been Officers of the Association, but who have distinguished themselves with their contributions to patients, to the profession, to CMA and to this House of Delegates. The recipient of this year’s Krieger Award is a man whose dedication and service has been profound. We are taking the unprecedented action of recognizing him again, as he is a previous recipient of this prestigious award in 2010 at the 139th annual House of Delegates. We do this because he continues to contribute his unique and heralded expertise with a drive towards excellence. And, just like the Energizer bunny, he just keeps going and going. A pioneer in pain medicine, he founded the American Academy of Pain Medicine and has an award named after him “to a physician for outstanding contributions to the social and political aspect of Pain Medicine.” He is the President of the California Academy of Pain Medicine and is their Delegate to the CMA. He has been a member of CMA for 54 years, and a Delegate of this House for 41 years. He has served on many Committees, Councils, and our Board of Trustees. He extended CMA’s reach to our AMA. He initiated the First Pain Summit at our AMA and Founded the Pain and Palliative Medicine Specialty Council. He was a contributing author of the AMA Guides to the Evaluation of Permanent Impairment, editions 3, 4 and 5 – the current ruling authority in California. He has been instrumental in strengthening
CMA’s many scientific inquiries and positions. He was the moving force behind CMA’s landmark White Paper on Opioids, which greatly influenced the Medical Board of California’s November 2014 Opioid Treatment Guidelines, long before the famous CDC Guidelines. His contributions cannot be understated, underestimated, nor undervalued. Time does not allow me to detail the many contributions this physician continues to make to our profession and our organization. With his ever-present wife Gail, Phil has been a rock for our profession. A mentor, an educator, a leader, and a true friend – Philipp M. Lippe, MD, is recognized for the CMA 2018 Gary Krieger Speaker’s Recognition Award. Dr. Lippe, please come forward to accept this year’s Krieger Award, from your Speakers and this House.
Dr. Philipp Lippe made the following acceptance speech at the Awards gala: Gosh, I’m flabbergasted. Overwhelmed. I’m speechless, well almost. Thank you, Mr. Speaker, for the generous, glowing, if hyperinflated, introduction. If my dearly departed parents were alive, I’m certain they would approve and endorse your remarks. I’m thrilled, happy and feel honored and privileged to receive this award. I humbly accept it on your behalf. Last night I had difficulty falling asleep. In reflection, I am mindful that soon I will be celebrating my 90th birthday. It has been almost a half century since the CMA, and a few years later the HOD, became part of my life. So many reports, so many debaters, so many caucuses, so many meetings. They became a habit, some would say an addiction! You have become my family. Always mindful: Success is not final. Failure is not fatal. It is the courage to continue that counts. While serving in this HOD, I spent most of my career in the Specialty Delegation, and more
24 | THE BULLETIN | NOVEMBER / DECEMBER 2018
recently in the Administrative Medicine Forum, of which I am the Vice Chair. Members of these delegations please rise to be recognized. Customary to graciously thank all those who have supported and promoted my sojourns. I have a list of over 5,000 individuals who I would like to name – but won’t since I stand in the way between you and your lunch. However, if you turn your head to the left and then to the right you will see these individuals. They include all of you. However, I would be sorely remiss, if I failed to mention at least one individual – my dear wife Gail. We have also been together for almost a half century. She has been my pillar of support with her everlasting love, sustenance, and care in good and bad moments. I assure nothing that I may have accomplished would have occurred without her presence. Please help me to publicly thank her. Gail, please rise. Allow me to leave you with one of my favorite poems by Robert Frost, that ends with these words: The woods are lovely, dark & deep, But I have promises to keep, And miles to go before I sleep, And miles to go before I sleep. Thank you from the bottom of my heart. God bless you.
Identifying the Root Cause of Drug Shortages: A Call to Action By John G. Brock-Utne MD, PhD Professor of Anesthesiology (Emeritus) Department of Anesthesiology, Perioperative & Pain Medicine Stanford University Medical Center HOW COULD DRUG SHORTAGES HAPPEN IN A FREE ENTERPRISE COUNTRY LIKE THE U.S.? Actually, it’s pretty simple. There is a kickback system approved by the U.S. Congress that has undermined competition and profitability in the drug/IV fluid market. How? Because many drug makers and other suppliers have been locked out of the hospital marketplace by group purchasing organizations (GPOs), which contract for most of the drugs and supplies used in 5,000 American hospitals and other facilities. Since GPOs award exclusive, often sole-source contracts to favored drug/IV suppliers in return for steep (but secret) “fees” and rebates, companies that don’t get contracts can’t compete and are forced to halt production. But it gets worse. GPOs mandate that their member hospitals (most U.S. hospitals are members of at least one GPO) buy virtually all of their drugs/IV fluids from contracted suppliers. They’re generally not permitted to buy these and other supplies from companies that don’t have GPO contracts. When you attempt to investigate this appalling situation, you hit a stone wall. There is no transparency on GPO contracts and financial arrangements, which include kickbacks and rebates for GPOs and “share backs” and “patronage fees” for hospitals. Not surprisingly, hospitals don’t want to discuss this obvious conflict of interest. Under this perverse system, dominant drug and IV fluid suppliers enjoy a protected market with little or no competition. GPOs, which do nothing more than write exclusive contracts, are making huge profits. CEOs of major GPO shareholder hospitals often get a piece of the action. Everyone is happy, except the unfortunate patient who may have to endure a very painful operation and side effects due to the lack of suitable analgesics and high hospital/insurance expenses. This debacle was created by an obscure 1987 statute, known in shorthand form as the Medicare anti-kickback “safe harbor,” which exempted GPOs from criminal penalties for taking kickbacks and rebates from suppliers. It’s the only industry in America I know of that has gotten a “Get Out of Jail Free Card” from the United States Congress! If that wasn’t enough, in 2003, the Inspector General of the Department of Health & Human Services (HHS) extended the GPO safe harbor to cover pharmacy benefit manager (PBM) rebates, driving up prices of drugs sold by these predatory middlemen. The Trump administration has proposed rescinding this safe harbor administratively. For more on that, see this Washington Post August 28 , 2018 https://www.washingtonpost.com/ opinions/trump-might-actually-lower-drug-prices/2018/08/28/c6c69eaaaa0d-11e8-8f4b-aee063e14538_story.html?noredirect=on&utm_term=. d7912d74df80. But full repeal of the GPO safe harbor requires an act of Congress. So please, Congress, for heaven’s sake, repeal 42. U.S.C. 1320a-7b(b)(3)(C) and direct HHS to revoke any and all rules and regulations that protect
these “legalized” kickbacks and rebates! Drug shortages in an advanced country like the United States are a disgrace, but they can easily be ended by those in power. Trouble is, members of Congress get paid by the GPO and hospital industries and their cohorts to preserve the kickbacks and rebates. Those payments are called campaign contributions.
SO WHAT CAN YOU DO?
1. If you have information on any aspect of the anti-kickback statute, including the GPO safe harbor, that impedes “valuebased” care or have insights and/or examples into how the GPO and PBM safe harbors have also undermined innovation of medical devices, healthcare access and delivery, competition, jobs, and so on, please cite the extensive documentation on this national scandal on the website for Physicians Against Drug Shortages (PADS), which for six years has been leading the charge in trying to reform this corrupt system: www.physiciansagainstdrugshortages.com. 2. On November 27 the Food & Drug Administration is holding an all-day public meeting in Washington on the root cause of drug shortages. If possible, consider attending in person to make your voice heard. Whether you attend or not, please submit a comment to the FDA. Here’s the link: https://s3.amazonaws. com/public-inspection.federalregister.gov/2018-19612.pdf?utm_ campaign=pi%20subscription%20mailing%20list&utm_ source=federalregister.gov&utm_medium=email. DEADLINE FOR FDA COMMENTS ABOVE IS: January 11, 2019. 3. Contact your members of Congress and tell them you’re fed up with the shortages and skyrocketing prices of medications. Insist that they stop the GPO/PBM kickbacks and rebates by repealing the unsafe safe harbor statute. 4. Help get this message out by contacting family, friends, and colleagues via email and your social media pages. 5. Sign the PADS Change.org petition calling for repeal of the safe harbor: https://www.change.org/p/president-trump-andcongress-stop-artificial-shortages-and-skyrocketing-prices-ofgeneric-drug-shortages-by-ending-the-300-billion-healthcaregroup-purchasing-gpo-pay-to-play-kickback-scheme?share_ id=dklbixFLrB&utm_campaign=mailto_link&utm_ medium=email&utm_source=share_petition Together we can restore integrity and competition to the healthcare supply chain and stop the drug shortage travesty! 6. Here are two links (if you don’t take my word for it) that you can also distribute to friends and family. a. To an online article on GPOs and drug shortages published by the Journal of the American Medical Association (JAMA) October 2018: https://jamanetwork.com/journals/ jama/fullarticle/2708613. b. You can also check out this article in Modern Healthcare of October 18 on the JAMA Viewpoint piece by Dr. Martin Makary et al: http://www.modernhealthcare.com/ article/20181019/TRANSFORMATION02/181019863. NOVEMBER / DECEMBER 2018 | THE BULLETIN | 25
Great Moments in Medical History: The Magical Rays By Gerald E. Trobough, MD Leon P. Fox Medical History Committee On Friday, November 8, 1895, in the late afternoon Wilhelm Conrad Rontgen, Professor of Physics at Wurzburg, Germany was investigating the external effects of an electrostatic charge on various types of cathode ray tubes. In a darkened room, he noted “shimmering” emanating from a bench a few feet away from the tube with each electric discharge. A photographic screen coated with barium platinocyanide was on top of the bench. He speculated that a new kind of ray was responsible for the fluorescent effect. Rontgen was overwhelmed with excitement and spent the next two days in his lab. He ate little and slept less while performing countless experiments. He noted that these rays could pass through books, wood, most metals and even flesh. They could even expose photographic plates that were protected from visible light. He had discovered a phenomenon that was unheard of before. He temporarily named the rays, “x-rays,” a mathematical designation of “x” for something unknown. For two weeks, Rontgen conducted more experiments in secret. He feared that teachers and other scientists would think he was losing his mind. What if his observations were incorrect? His reputation may be ruined! The first human he selected to x-ray was Anna, his wife. He used her hand as the subject. When she saw the skeletal image of her hand, she exclaimed “I have seen my death!” Rontgen was born in Linnep, Germany but moved to Holland at the age of three. He had little schooling and was expelled from a secondary school for refusing to name a school prankster. This made it difficult for him to get into higher education. Wilhelm, however, was a bright young 26 | THE BULLETIN | NOVEMBER / DECEMBER 2018
Rontgen and his first x ray. His wife’s hand and ring man and after studying at the University of Utrech, without credit, he was accepted at the Polytechnical School in Zurich, Switzerland. Here he received a degree in Mechanical Engineering. Strangely enough, Rontgen, the great experimental physicist, never had a basic college course in physics. After years of traveling from one University to another to find an acceptable job, he accepted a position in the Physics Department at the University of Wurzburg in 1888. Six years later, he was elected Rector of the University, its highest office. Two months after his discovery of the “x-ray,” Rontgen felt ready to demonstrate his newly discovered rays. On January 23, 1896, before a packed auditorium of scientists, at the University of Wurzburg, Rontgen x-rayed the hand of the famed anatomy Professor Albert von Kolliker. The
demonstration led to a discussion of possible medical applications. The news of the demonstration traveled fast and within a year x-ray equipment was being employed around the world as a diagnostic tool. In 1897, x-rays were used on a military battlefield during the Balkan War to locate bullets and broken bones. Rontgen refused to apply for any patents or realize any commercial gain from his great discovery. In fact, he did no further work on the medi-
cal aspects of x-rays. He was awarded an honorary degree of “Doctor of Medicine” on March 3, 1896, by Wurzburg University. He published three papers on x-rays between 1895 and 1896. In 1901, Rontgen was awarded the first Nobel Prize in Physics. He donated the prize money to the University. In 1923, at the age of 75, Rontgen died penniless of a GI cancer that was not felt to be related to the effects of radiation.
In Memoriam Morton M. Besen, MD
Arthur W. Halliday, MD
Howard Press, MD
David P. Cooney, MD
Roger P. Kennedy, MD
Carmo D. Trindade, MD
Robert Floyd, Jr, MD
William H. Lawler, Jr, MD
Internal Medicine 9/8/1930 – 2018 SCCMA member since 1988
*Oncology-Hematology *Internal Medicine 3/10/1929 – 9/27/2017 SCCMA member since 1966 *Obstetrics & Gynecology 9/7/1935 – 11/25/2017 SCCMA member since 1970
Lynn Giang, MD
Psychiatry 6/02/1954 – 5/11/2018 SCCMA member since 1997
Internal Medicine 2/16/1931 – 8/24/2018 SCCMA member since 1962
*Internal Medicine Infectious Disease 1/11/1933 – 6/19/2018 SCCMA member since 1982 Occupational Medicine *General Surgery 9/17/1928 – 11/08/2017 MCMS member since 1961
*Family Medicine 7/13/1932 – 3/23/2018 MCMS member since 1962 *Orthopaedic Surgery 12/16/1934 – 5/11/2018 SCCMA member since 1979
Charles L. Weidner, MD Family Medicine 1/1/1931 – 4/18/2016 SCCMA member since 1960
Robert D. Leasure, MD *Geriatric Medicine *Internal Medicine 1/1/1937 – 8/27/2018 SCCMA member since 1969
NOVEMBER / DECEMBER 2018 | THE BULLETIN | 27
700 Empey Way • San Jose, CA 95128 • 408/998-8850 • FAX 408/289-1064 December 2018 TO:
All Members, Santa Clara County Medical Association (SCCMA)
FROM:
Seema Sidhu, MD, Chair, 2018-2019 Awards Committee
At the 2019 Medical Association’s annual banquet, the association will honor several individuals with its perpetual awards. These awards are significant honors which reflect the respect, recognition, and appreciation of our membership. The recipients are selected from among our outstanding members who have distinguished themselves with extraordinary service to medicine in general, to the association, to the community, or to medical education. Selections are made by the Awards Committee, with the aid of input from the membership at-large. Your suggestions for recipients for each of the awards, outlined on the next page of this memo, will be appreciated. Please complete the form below to submit suggestions, keeping in mind the requirements for each award as listed on the opposite page. If you would like to nominate more than one person, or for more than one award, please photocopy this form or send a letter. Suggestions must be received by February 15, 2019. Thank you for your recommendations. If you previously suggested a candidate who was not given an award, please feel free to resubmit that name. I THINK _____________________________________________________ WOULD BE A GOOD CANDIDATE FOR THE _____________________________________________________________________________________ . (Name of Award) PLEASE ATTACH ALL SUPPORTING INFORMATION, INCLUDING ACCOMPLISHMENTS AND CONTRIBUTIONS THAT WILL HELP THE AWARDS COMMITTEE EVALUATE THE CANDIDATE FOR THE AWARD SELECTED. YOU MAY MAIL, FAX, OR EMAIL THE INFORMATION TO PAM JENSEN AT SCCMA. SUBMITTED BY: ___________________________________________________________________________________ MD (Please print) MAIL FORM TO: SCCMA Attn: Pam Jensen 700 Empey Way San Jose, CA 95128 EMAIL: pjensen@sccma.org FAX: 408/289-1064 DEADLINE: February 15, 2019 28 | THE BULLETIN | NOVEMBER / DECEMBER 2018
Santa Clara County Medical Association
ANNUAL AWARDS
ROBERT D. BURNETT, MD LEGACY AWARD
For a physician member of the Medical Association who has demonstrated extraordinary visionary leadership, tireless effort, selfless long-term commitment, and success in challenging and advancing the health care community, the wellbeing of patients, and the most exalted goals of the medical profession. Please refer to www.sccma-mcms.org for past recipients of this award.
AWARD FOR OUTSTANDING CONTRIBUTION IN MEDICAL EDUCATION
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more medical education activities over and above that expected of the membership at-large.
BENJAMIN J. CORY, MD AWARD
AWARD FOR OUTSTANDING CONTRIBUTION IN COMMUNITY SERVICE
AWARD FOR OUTSTANDING ACHIEVEMENT IN MEDICINE
CITIZEN’S AWARD
For a physician member of the Medical Association who has displayed forwardlooking, pioneering ideas, enterprise, enthusiasm, and prolonged professional stature and ability.
For a physician member of the Medical Association who, during his/her medical career, has made unique contributions to the betterment of patient care, for which he/she has achieved widespread recognition. Consideration shall be given to research and/or the development of procedures, methods of treatment, pharmaceutical agents, or technological advances in the field of medicine.
AWARD FOR OUTSTANDING CONTRIBUTION TO THE MEDICAL ASSOCIATION
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the Association over and above that expected of the membership at-large.
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the community over and above that expected of the membership at-large. For an individual who is not a member of the Medical Association, who has achieved public recognition for a significant contribution in the health field. (This usually will be a non-physician, although physicians are not categorically excluded.)
WILLIAM C. PARRISH, JR. LEADERSHIP IN HEALTHCARE AWARD
This award is named after the beloved long-time executive director of the Santa Clara County Medical Association and recognizes an individual whose leadership, innovation, and dedication have resulted in profound improvement to healthcare in Santa Clara and has left a lasting impact on the physicians and patients of the County. William Parrish is the first recipient of this award (established in 2018).
For a complete list of ALL award recipients since 1978 please refer to www.sccma-mcms.org. Benjamin J. Cory, MD Award
1997 1998 1999 2000 2001
Outstanding Outstanding Contribution To The Contribution In Medical Association Medical Education
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Bernice S. Comfort
Robert J. Frascino
Mansfield F. W. Smith
Stanley D. Harmon
Howard R. Porter
Donald J. Prolo
Steven S. Fountain
Sharon A. Bogerty ---
Outstanding Achievement In Medicine ---
Outstanding Contribution In Community Service
Citizen’s Award
Michael R. Fischetti
Suzanne Jackson, RN
Burton D. Brent
William A. Johnson
Judge Leonard Edwards
C. Michael Knauer
Jack S. Remington
M. Ellen Mahoney
Rigo Chacon
Stephen H. Jackson
Theodore Fainstat
Richard P. Jobe
Barbara C. Erny
Janet Childs
Roger P. Kennedy
Bert Johnson
Nelson B. Powell / Robert W. Riley
Robert Michael Gould
Tony & Brandon Silveria
Elliot C. Lepler
Allen H. Johnson
Bruce A. Reitz
David Morgan
Tom Campbell / Ted Lempert
Joseph E. Mason, Jr.
Anthony S. Felsovanyi
David A. Stevens
Martin D. Fenstersheib
Michael E. & Mary Ellen Fox
2002 2003
Robert M. Pearl
2004 2005 2006
Robert Wuerflein
Eugene W. Kansky
Barry Miller
D. Craig Miller
Elizabeth Menkin
Jayne Haberman Cohen, DNSc
Harvey J. Cohen
Richard L. Miller
Gus M. Garmel
Rodney Perkins
Elouise Joseph
Doris Hawks, Esq.
Arthur A. Basham
Robert W. R. Archibald
G. David Adamson
Harmeet S. Sachdev
Edward A. Hinshaw, Esq.
2007 2009 2010 2011 2012 2013 2014 2015 2016 2017
Stephen H. Jackson
Cindy L. Russell
Catherine L. Albin
John R. Adler, Jr.
Madhur Bhatnagar
Debbi Ricks
Bernadette Loftus
Martin L. Fishman
George P. Kent
Thomas Krummel
Seham El-Diwany
Peggy Fleming-Jenkins
Melvin Britton
James G. Hinsdale
David Levin
Gary Steinberg
Leo Strutner
Judge Lawrence Terry
Tanya Spirtos
Dennis Siegler
Robert Armstrong
Gary Silver
Kathleen King
Steven S. Fountain
Robert Gould
William Jensen
Eleanor Levin
David Quincy
Assemblymember Jim Beall
James G. Hinsdale
Stephen C. Henry
Rosaline Vasquez
Diane E. Craig
Jeffrey D. Urman
Congresswoman Anna Eshoo
Martin L. Fishman
David H. Campen
Jonathan H. Blum
Gary E. Hartman
Keith A. Fabisiak
Gay Crawford
John P. Sherck
J. Ronald Tacker
James D. Wolfe
Stephen L. Wang
Susan E. Kutner
Senator Jerry Hill
Raj Bhandari
Lynn B. Rosenstock
Danny L. Sam
Daniel I. Jacobs
Paul M. Jackson
Janice Bremis & Robin Riddle
Susan C. Smarr
Howard Sutkin
Patrick J. Kearns, Jr.
Tung B. Le
Kris Karlen
Margaret McLean, PhD & Assemblymember Ash Kalra
2018
Sameer V. Awsare
Thomas M. Dailey
John Tatman
Ruma Kumar
Suchada Nopachai
John & Gini Mitchem
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NOVEMBER / DECEMBER 2018 | THE BULLETIN | 29
Classifieds OFFICE SPACE FOR RENT/LEASE 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. Timeshare also available. Call Betty at 408/8482525.
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 AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building. Please call 408/926-2182 or 408/315-4680.
MEDICAL OFFICE SPACE TO SHARE • CAMPBELL Specialist wanted to share a private office with family practitioner in Campbell. Hamilton/Winchester area. Contact Mary Phan at (408) 364-7600.
MEDICAL OFFICE TO SHARE • LOS GATOS Extra exam room to share, across from El Camino Hospital Los Gatos, for professional. $1,000/mo. Call 408/866-6776.
PREMIUM OFFICE SPACE • LOS GATOS Class A new building with reception, three exam rooms, office, and lab. Walk to Good Sam Hospital. Call 408/805-0026.
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.
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 / 408/8396564.
30 | THE BULLETIN | NOVEMBER / DECEMBER 2018
FOR SALE OFFICE SPACE FOR LEASE AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building. Please call 408/926-2182 or 408/315-4680.
PRIVATE PRACTICE AND BUILDING FOR SALE Family Practice for sale, including inventory, equipment and Real Estate (can also be leased). Great downtown San Jose location. Financing may be available. Minor Laser Surgery performed as well. Call 415/308-3064.
ENDOCRINOLOGY PRACTICE FOR SALE - SAN FRANCISCO SOUTH BAY, CA. Long established practice with revenue of $1.1 million on 2.5 doctors. High referral rates from physicians and other patients. Pent-up demand indicated by long waiting times for appointments. Photos available. Offered at only $403,800. Contact Medical Practices USA. info@MedicalPracticesUSA. com. 800-576-6935. www.MedicalPracticesUSA.com
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NOVEMBER / DECEMBER 2018 | THE BULLETIN | 31
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