KAISER PERMANENTE MEDICAL GROUP MOSES ELAM, MD PHYSICIAN-IN-CHIEF
PLUS: Community Health Forum CMA 2012 Wrap Ups Featured Winter 2012
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id you know that CMA/San Joaquin Medical Society members can save 5% on their workers’ compensation insurance? And,
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VOLUME 60, NUMBER 4 • DECEMBER 2012
HOD 2012
{FEATURES}
12 22 34 44 WINTER 2012
HOUSE OF DELEGATES
{DEPARTMENTS}
CMA delegates set policy at annual meeting
38 PUBLIC HEALTH UPDATE
ONE MUST IMAGINE SISYPHUS HAPPY
40 11TH ANNUAL
The California Medical Association’s 2012 Legislative Wrap-Up
WHAT TO KNOW
before you store patients credit card numbers
Read about the latest in health news Community Health Forum
52 IN THE NEWS
New Faces and Announcements
61 IN MEMORIAM 67 NEW MEMBERS
MOSES ELAM, MD
Kaiser Permanente Medical Group Cover Photo Credit: Dale Goff www.goffphotography.com
SAN JOAQUIN PHYSICIAN 3
PRESIDENT Raissa Hill, DO PRESIDENT-ELECT Thomas McKenzie, MD PAST-PRESIDENT George M. Khoury, MD SECRETARY-TREASURER Ramin Manshadi, MD BOARD MEMBERS Lawrence R. Frank, MD, Moses Elam, MD, Peter Drummond, DO, Dan Vongtama, MD, Susan McDonald, MD, James J. Scillian, MD, Karen Furst, MD, Kwabena Adubofour, MD, Kristin M. Bennett, MD
MEDICAL SOCIETY STAFF EXECUTIVE DIRECTOR Michael Steenburgh DEPUTY DIRECTOR Nikki West COMMUNITY PROJECT MANAGER Vanessa Armendariz MEMBERSHIP COORDINATOR Jessica Peluso
SAN JOAQUIN PHYSICIAN MAGAZINE EDITOR Moris Senegor, MD EDITORIAL COMMITTEE Moris Senegor, MD, Kwabena Adubofour, MD, Mike Steenburgh MANAGING EDITOR Michael Steenburgh CREATIVE DIRECTOR Sherry Roberts
COMMITTEE CHAIRPERSONS MRAC F. Karl F. Karl Gregorius, MD
CONTRIBUTING WRITERS James Noonan, Elizabeth Zima, William West
DECISION MEDICINE Kwabena Adubofour, MD ETHICS & PATIENT RELATIONS to be appointed COMMUNICATIONS Moris Senegor, MD
THE SAN JOAQUIN PHYSICIAN MAGAZINE is produced by the San Joaquin Medical Society
LEGISLATIVE Jasbir Gill, MD COMMUNITY RELATIONS Joseph Serra, MD AUDIT & FINANCE Marvin Primack, MD MEMBER BENEFITS Jasbir Gill, MD NOMINATING Hosahalli Padmesh, MD
SUGGESTIONS, story ideas or completed stories written by current San Joaquin Medical Society members are welcome and will be reviewed by the Editorial Committee.
MEMBERSHIP Ramin Manshadi, MD PUBLIC HEALTH Karen Furst, MD
PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO:
SCHOLARSHIP LOAN FUND Eric Chapa, MD
San Joaquin Physician Magazine
NORCAP COUNCIL Thomas McKenzie, MD
3031 W. March Lane, Suite 222W Stockton, CA 95219
CMA HOUSE OF DELEGATES REPRESENTATIVES Robin Wong, MD, Lawrence R. Frank, MD,
Phone: 209-952-5299 Fax: 209-952-5298 Email Address: nikki@sjcms.org
James R. Halderman, MD, Patricia Hatton, MD, James J. Scillian, MD, Peter Oliver, MD, Roland Hart, MD Kwabena Adubofour, MD,
MEDICAL SOCIETY OFFICE HOURS: Monday through Friday 9:00 AM to 5:00 PM
Gabriel K. Tanson, MD, Ramin Manshadi, MD
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Letter From The Executive Director
STAFF REPORT
2013 WILL BE A YEAR OF SIGNIFICANT CHANGE AND WE’RE HERE TO HELP YOU THROUGH IT
I
n five years of serving as your Executive Director, I have not seen a more demanding number of changes in the form of opportunities and challenges coming to our physicians and the way they practice medicine. This issue is full of significant updates and invitations to stay informed of what 2013 and beyond holds for you and how to be best prepared when it arrives.
MIKE STEENBURGH
From the impending introduction of ICD-10 in October 2014 to the massive overhaul of Workers Comp rates and regulations taking effect in just a few months, we all have concerns on how these radical changes will affect our daily lives and your practices. Furthermore, we all learned of the decision of CMS (Medicare) to move the Medicare Administrative Contractor (MAC) contract in 2013 away from Palmetto GBA to Noridian Administrative Services. In recent meetings discussing the transition, I’ve heard assurances that it won’t be as disruptive as last time (I’m sure we all remember the frequent and lengthy payment delays), but I’ll remain “cautiously optimistic” in my opinion until we learn more from CMS. Obviously the move to ICD-10 will affect nearly every practice within the reach of our four-county medical society membership, and in partnership with CMA we have many informational and training opportunities for your consideration which will include free webinars, live in-person trainings held here in Stockton, and future coding certification courses planned for late 2013 and 2014. One of our most successful membership benefits and methods for our members to stay informed of these issues is our free monthly Office Managers Forum, which is held every second Wednesday of the month from 11 a.m. – 1 p.m. at Papapavlo’s in Lincoln Center. These networking luncheons feature expert yet interesting presenters on a variety of topics. Recent topics have included E & M Guidelines andManaging Difficult Employees, and this December attendees will learn everything about changing Medicare policies for 2013 from CMA’s Medicare expert Michele Kelly. And don’t let the name fool you – in addition to dozens of practice managers, we always welcome a few physicians as well! Wishing you and yours the very best during this festive time of year!
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A message from our President – Raissa Hill, DO
Promise on the Horizon? Elections are over and now we must move forward.
There is bound to be stumbling along the way towards a new norm. But the hope of a healthier community and economy is our motivator.
ABOUT THE AUTHOR Dr. Raissa Hill is President of the San Joaquin Medical Society and is a second-generation physician who practices family medicine in Stockton.
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The Affordable Care Act will be taking effect. We cannot run and hide at this point lest we emerge from the dark at a later point to find ourselves deep within the change. All we can do is buckle down, pull our boot straps up, and trudge forward. Our livelihood depends on it; the profession depends on it. Our patients depend on us to look out for their interests as well. The goal is quality AND affordable healthcare. Kaiser has been successful at developing a highly integrated, cost saving system. This includes physicians, both primary care and specialists, nurses, therapists, social workers, laboratory services, imaging, hospital care, and more. They have had years to perfect their system. Even their commercials and ads hit the heart strings in just that way. Pilot sites around the country have been successful at mimicking this system. They too have shown cost savings. In our state of California and
its large healthcare costs and need for hefty safety net monies, the name of the game is cost savings. The current healthcare cost curve is unsustainable. Similarly, for independent and small group practices the overhead costs continue to rise with decreasing reimbursement. On the patient and employer side, the premiums and copays/deductibles have also seemed to continuously increase. The aim is shared cost savings for all parties. The main theme involves the participation of all parties, the patients, physicians, hospitals, and payors, to work for a common goal of quality health with affordability. In nearby Sacramento, one of the successful pilot test sites took place between Blue Shield, Dignity Health System, and Hill Physician network of independent physicians. Blue Shield and other payors are planning to extend this model to other regions. In our own San Joaquin County, large strides are being made towards
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trying to integrate health information electronically. The Hill Physician network has recently instituted enterprise charts, which electronically links all network physicians currently using their electronic medical record (Next Gen). In the same vane, Health Plan of San Joaquin has been working on efforts to establish a county wide health information exchange (HIE) as well. Another upcoming advancement towards clinical integration is the Patient-Centered Medical Home (PCMH). This provides a home base for each patient with their primary care physician at the helm. Within this home base is a team providing enhanced coordination of care for each individual i.e. coordinating referrals, improving communication among specialists and hospitals, and increasing patient access. This includes more intensive disease management, care coordination, and utilization of other clinical staff. In this way, the future horizon is promising though full of change. There is bound to be stumbling along the way towards a new norm. But the hope of a healthier community and economy is our motivator.
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SAN JOAQUIN PHYSICIAN 9
A Message From The Editor - Moris Senegor, MD
Life With Kaiser
When it comes to business decisions every hospital administrator considers the welfare of his or her institution first, before that of others. In the years following his fateful decision to associate with Kaiser, for the remainder of his tenure and beyond, Arismendi’s act was indeed fruitful for his hospital.
ABOUT THE AUTHORMoris Senegor, MD serves as the Chairperson of the Publications Committee for the San Joaquin Medical Society and Editor of its flagship publication the San Joaquin Physician.
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W
hether we realize it or not, in our day to day medical practices we all wear different hats, one moment a bedside clinician, another a social worker, yet another, administrator or business owner, as I do. I write this donning my editor’s hat, aware that I owe allegiance to all fellow Medical Society members from disparate walks of life. It is with this spirit that the current issue of our magazine was prepared, featuring an organization from the other side of my tracks, an important one that comprises over one third of our membership and displays unabashed civic responsibility towards the Society. The idea of featuring Kaiser Permanente in one of our issues was tossed around for years. I felt that the magazine’s coverage of our local medical scene chronically short changed Kaiser, and that something needed to be done about this. Somehow it failed to come to fruition until recently. As I took on the assignment of meeting their chief medical officer Dr. Moses Elam, I reflected upon the two decades of divide that has existed between us traditional community practitioners, and Kaiser, which in that interval rose from a small seed into a behemoth. The advent of pre-paid, integrated health care, employing its own doctors in a closed model was a threat to traditional
fee-for-service practice from its inception. The growth of Kaiser, a flag-bearer of this model, was a major impetus for the creation of the San Joaquin Foundation for Medical Care in 1954. This was a precursor of modern HMO’s founded for the purpose of keeping Kaiser in check. Many Stockton physicians who are aware of this history feel proud that their obscure hometown (that is, before our bankruptcy) played a pioneering role in the history of health care delivery. The Foundation for Medical Care arguably did succeed in its mission for a while. The local ascendance of Kaiser did not truly take place until the 1990’s when HMO’s generally took off. Ironically the Foundation was created by none other than the very same San Joaquin Medical Society which now aims to publicly recognize the importance of Kaiser as one of its members. How times change. In the early 1990’s, just as Kaiser was quietly firing up its booster rockets, our county was an amalgam of numerous private and government payers, IPA’s, and open-model HMO’s. The only institution which was a semi-closed organization with salaried physicians was San Joaquin General Hospital, historic and much venerated, and considered important in filtering the indigent from the patient pool, a sort of giant economic kidney,
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thus indirectly serving local physicians. As Kaiser arrived it was viewed with emotions ranging from alarm, to fear, to anger. Far from a benevolent organ, Kaiser seemed like a flesh-eating bacterium, threatening to gobble up good, paying patients, and denying them to the remainder of the community. A crucial anchor which enabled Kaiser’s first bridgehead in Stockton was Dameron Hospital, then run by the late Luis Arismendi. His collaboration with this institution was viewed by
of thousands of well- paying patients, but also considerable local talent in doctors and ancillary personnel. Kaiser indeed was everything the community physicians of the 1950’s and 60’s had feared. But under Gilliland’s leadership they did this with panache and minimal confrontation. Moses Elam comes from the same ilk as his predecessor, and like him displays ambition in expanding his institution while maintaining smooth relations with community. This is evidenced by Kaiser’s consistent participation in local charity and its unflinching support for the Medical Society, despite the cold shoulder it still gets from community physicians. I suspect that maintaining fragile bonds with A crucial anchor which enabled Kaiser’s first the fee-for-service community is ingrained into Kaiser’s culture, both for business and political bridgehead in Stockton was Dameron Hospital, reasons. After all they do lay their foundations then run by the late Luis Arismendi. His in any new community in collaboration with local physicians, what Dr. Elam labeled a collaboration with this institution was viewed by “hybrid-model”. They are also highly sensitive many at the time as none other than an act of about their image and do not wish to be seen as being somehow parasitic, especially as it treason, an opening of the city gates to the enemy pertains to sharing the burden of emergency that had laid siege to it. coverage and indigents. I did not cover this issue in my interview with Dr. Elam, but I know for a fact that during their two decade presence at Dameron Hospital, Kaiser devoted many at the time as none other than an act of treason, an opening significant medicine and surgery resources to cover its E.R. and take of the city gates to the enemy that had laid siege to it. Many never care of its uninsured. It still does. forgave Arismendi for this. Arriving in 1991, a few years after the In the aftermath of considerable consolidation, our current Kaiser-Dameron engagement, I heard many caustic comments medical community is mostly aligned with a small number of large on the subject form veteran physicians. As a novice devoid of preentities, Sutter and Dignity Health (Formerly Catholic Healthcare conceived notions, I observed their animosity in silent interest and West) at the forefront, with San Joaquin General still alive, albeit wondered if it was on target. Dr. Elam who arrived here nearly a somewhat fragile. UC Davis prepares to enter our community, once decade later and never knew Dr. Arismendi personally, nevertheless again thanks to Dameron Hospital. Is this a coincidence, or a survival knows the local history well. He candidly confirmed to me that tactic? I suspect the latter is more accurate. without Dr. Arismendi’s gesture Kaiser’s early foothold in Stockton However no one is outraged or complaining any more. Our would have indeed been more slippery. medical community has become like traditional Mongolian tribes Lou Arismendi was a controversial figure, and he ruffled many that live in the Central Asian desert. Multiple families live under feathers in this town. Those who still remember him can say what large individual tents, yurts, and observe those residing in others they will, but one fact is certain: he was intensely devoted and loyal to with suspicion, while maintain cautious friendships, interrupted his hospital and did what he considered best for Dameron, regardless with occasional raids. The few individuals left behind await the large of the ripples he caused elsewhere. Looking at his decision today, broom of the U.S. government which will sweep them into one yurt it is hard to blame him for what he did. When it comes to business or another. In the desert like wilderness that medical economics has decisions every hospital administrator considers the welfare of his become, individual survival while exposed to the elements poses or her institution first, before that of others. In the years following great hardship. his fateful decision to associate with Kaiser, for the remainder of In such an environment Kaiser is no longer a threat. It is merely his tenure and beyond, Arismendi’s act was indeed fruitful for his a larger, richer tribe which rose to remarkable heights from humble hospital. beginnings, like that of Genghis Khan, and it promises to lead Kaiser’s early Chief Medical Officer was Jack Gilliland, a mild the marketplace as new government reforms are implemented. It mannered, benevolent and polite pediatrician from Lodi. He was has also risen from employer of last resort in decades past, to that candid and devoid of administration-speak. His magnanimous of top choice among young physicians searching for work. Selfpersonality gave his organization a friendly, non-confrontational employment is no longer in vogue. As community physicians we can face, while it embarked upon a remarkable expansion in San finally and non-begrudgingly acknowledge Kaiser as part of us. Joaquin County, devouring not only thousands and then hundreds
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SAN JOAQUIN PHYSICIAN 11
2012 Lifetime Achievement Award
HOUSE DELEGATES OF
CMA DELEGATES SET POLICY AT ANNUAL MEETING More than 700
CALIFORNIA PHYSICIANS convened in Sacramento October 13-15 for the 2012 House of Delegates (HOD), the annual meeting of the California Medical Association (CMA). Each year, PHYSICIANS FROM ALL 53 CALIFORNIA COUNTIES, representing all modes of practice, meet to discuss issues related to health care policy, medicine and patient care and to elect CMA officers. 12
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Dameron Hospital > 100 Years
120 resolutions were introduced and debated in reference committees on Saturday, October 13, 2012.
OVER
president elect Richard E. Thorp, M.D., could have his mustache shaved off by his wife – part of a fundraising challenge.
Over the next two days, the complete house met again to debate and vote on reference committee recommendations. A total of 97 resolutions were adopted.
On Sunday the House elected new officers, including Sacramento pediatrician, Paul R. Phinney, M.D., as the 2012-2013 CMA President, and the now clean shaven Dr. Thorp as president-elect. The rest of the CMA Executive Committee were affirmed by the HOD including the immediate past-president, James T. Hay, M.D., speaker, Luther F. Cobb, M.D., vice-speaker, Theodore M. Mazer, M.D., board chair, Steven E. Larson, M.D., and board vice-chair, David H. Aizuss, M.D.
The debates were passionate, polite and sometimes humorous. For example, during a debate on the health hazards of sitting, one speaker suggested that the House stand for the rest of the debate. In another instance, during a contentious debate on whether to support nurse practitioners’ ability to sign POLST forms, the debate was interrupted so that former CALPAC chair, and newly-elected CMA WINTER 2012
The following are summaries of some of the resolutions that were adopted as policy. SAN JOAQUIN PHYSICIAN 13
House of Delegates > 2012
FINAL ACTIONS OF THE 2012 HOUSE OF DELEGATES REVISED BLOOD DONOR DEFERRAL CRITERIA (RESOLUTION 108-12)
The delegates expressed support for the use of rational, scientifically-based deferral periods for blood donations, applied based on level of risk rather than on sexual orientation.
The delegates voted to oppose financial penalties by any payor for physicians who do not adopt health information technology, such as electronic medical records and electronic prescribing.
AWARENESS AND PREVENTION OF BULLYING
HEALTH CARE EQUALITY FOR SAME-SEX HOUSEHOLD MEMBERS
(RESOLUTION 113-12)
(RESOLUTION 505-12)
The delegates called on CMA to support awareness and prevention of bullying in all its forms and to support the development of family, school and community programs and referral services for victims and perpetrators of bullying.
The delegates voted to recognize that denying civil marriage contributes to poorer health outcomes for gay and lesbian individuals, couples and their families. The resolution also calls on CMA to support measures providing same-sex households with the same rights and privileges to health care, health insurance and survivor benefits afforded to opposite sex households.
AB 32 AND CALIFORNIA’S CLEAN AIR LEADERSHIP (RESOLUTION 117-12)
The delegates voted that CMA should support implementation of the California Global Warming Solutions Act of 2006, which protects the health of Californians from climate change.
PHARMACIST’S SUBSTITUTION OF PHYSICIAN PRESCRIPTIONS
SAFER FURNITURE FLAMMABILITY STANDARDS
The delegates asked that CMA consider legislation to make it illegal for pharmacists to receive financial incentives to substitute a physician’s prescription.
(RESOLUTION 125-12)
The delegates asked that CMA endorse a revision of the California TB 117 furniture flammability standards, which would not require harmful flame retardants yet provide more effective fire safety using barrier technology and flame resistant fabric covers.
SUPPORT FOR AMENDING THE AFFORDABLE CARE ACT (RESOLUTION 201-12)
The delegates directed CMA to support amending the Affordable Care Act to address issues of concern to the practice of medicine.
DUEL ELIGIBLE MONITORING AND REPORTING (RESOLUTION 208-12)
This resolution directs CMA to collect data from its membership regarding difficulties with the planned transition of dual eligibles to managed care plans and to report the findings to the California Department of Health Care Services, the California Department of Managed Health Care and the federal Centers for Medicare & Medicaid Services.
ELECTRONIC PRESCRIBING AND EHR PAYMENT REDUCTIONS (RESOLUTION 214-12)
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(RESOLUTION 507-12)
INCREASING UTILIZATION OF POLST ORDERS (RESOLUTION 512-12)
The delegates approved a resolution that calls on CMA to support awareness and use of Physicians Orders for Life-Sustaining Treatment (POLST) forms by physicians in all appropriate instances where medical services are provided to patients at the end of life.
HIPAA AND MEDICAL RECORD ACCESSIBILITY (RESOLUTION 606-12)
The delegates asked CMA support a study on the extent to which HIPAA laws impede the timely transfer of medical information necessary for the appropriate coordination of care.
HELPING PHYSICIANS IMPROVE THEIR HEALTH (RESOLUTION 610-12)
The delegates voted to encourage all physicians and physicians-in-training to properly manage their own physical and mental health and to serve as exemplars of healthy behaviors. The complete and final actions of the 2012 House of Delegates are available to members at www.cmanet.org/hod under “Documents.”
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SACRAMENTO PEDIATRICIAN ELECTED CMA PRESIDENT
SACRAMENTO PHYSICIAN PAUL R. PHINNEY, M.D., WAS INSTALLED AS THE 145TH PRESIDENT OF THE CALIFORNIA MEDICAL ASSOCIATION (CMA) DURING THE ORGANIZATION’S ANNUAL HOUSE OF DELEGATES HELD IN SACRAMENTO OCTOBER 13-15. Dr. Phinney is a pediatrician at Kaiser Permanente and has been a member of CMA since 1988. He has served in a number of leadership roles, including president-elect, chair of the CMA Board of Trustees and previously served on the CMA Council on Legislation and on the CMA Political Action Committee (CALPAC) Board of Directors. Addressing the group of nearly 1,000 physicians, residents, medical students and others on Sunday, Dr. Phinney challenged his colleagues to lead change rather than succumb to the “default future.” “We owe it to the public and to our profession to be leaders in health care reform – to create a better future that we help invent,” he said to the crowd. “We live in turbulent and uncertain times that very likely will produce the most rapid change in the delivery of health care that the nation has seen in decades, and I look forward to tackling those challenges head on in my term as president,” concluded Dr. Phinney. Speaking to his goals for the next year, Dr. Phinney acknowledged the next generation of students entering medicine. “Mentorship deserves our attention, and will be an area of my focus over the next year. A healthy future requires up-front investment,” he said. Dr. Phinney’s complete address to the delegates can be watched on CMA’s YouTube channel, www.youtube.com/cmaphysicians.
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ALSO SERVING ON CMA’S 2012-2013 EXECUTIVE COMMITTEE ARE: Immediate Past President James T. Hay, M.D., a San Diego family physician President-Elect Richard E. Thorp, M.D., an internal medicine physician in Paradise Speaker of the House Luther F. Cobb, M.D., a surgeon in Humboldt County Vice Speaker of the House Theodore M. Mazer, M.D., a San Diego ear, nose and throat specialist Chair of the Board of Trustees, Steven E. Larson, M.D., an internist infectious diseases consultant in Riverside County Vice Chair of the Board of Trustees, David H. Aizuss, M.D., a Los Angeles ophthalmologist
SAN JOAQUIN PHYSICIAN 15
House of Delegates > 2012
CMA SAYS DENIAL OF CIVIL MARRIAGE TO SAME SEX COUPLES HAS NEGATIVE HEALTH IMPACT On Sunday, October 14, 2012, the California Medical Association (CMA) House of Delegates passed a resolution calling for health care equality for same sex households. Hundreds of physician representatives from across the state voted to support a resolution that states “denying civil marriage contributes to poorer health outcomes for gay and lesbian individuals, couples and their families.” In written testimony, the sponsors of the measure, the CMA Residents and Fellows Section, said, “legal protections afforded to same-sex couples are crucial given that marriage is a strong predictor of health insurance in the U.S. In particular, women in same-sex households tend to have less health insurance than women in opposite-sex households. “As a consequence, children in same-sex households lack the protections of health insurance afforded by marriage,”
the document continues. “Having health insurance does not provide same-sex couples with the financial and legal protections that married couples receive. Same-sex couples are not covered by the protections of COBRA or the Family and Medical Leave Act. Same sex couples are also not typically recognized as family by blood or marriage and are denied the right to make surrogate health care decisions for their loved ones.” The resolution (505-12) would also require CMA to work to reduce health care disparities among members of same-sex households, including minor children. It also calls on CMA to support measures providing same-sex households with the same rights and privileges to health care, health insurance and survivor benefits afforded by opposite-sex households.
CMA DELEGATES CALL FOR INCREASED ADVOCACY ON DUALS TRANSITION Recognizing the challenges that California’s planned shift of Medicare and Medi-Cal dual eligible patients to managed care plans will pose to patients and the physicians that serve them, the California Medical Association (CMA) has adopted policy to help keep physician concerns in clear view of the agencies orchestrating the transition. The policy (Resolution 208-12), which was adopted at the CMA’s annual House of Delegates meeting, calls on the association to collect data from its membership regarding difficulties with the planned duals transition and, if difficulties are found to be widespread, report them to the California Department of Health Care Services, the California Department of Managed Health Care and the federal Centers for Medicare and Medicaid Services. During the floor debate regarding the issue, delegates noted that the state’s Coordinated Care Initiative, which includes a pilot program to passively enroll patients eligible for both Medicare and Medi-Cal in eight of California’s largest counties, would see more than 75 percent of the state’s dual eligibles transitioned to managed care plans. The shift, speakers said, would likely lead to considerable confusion among patients and almost certainly interrupt relationships that have been established with their existing physicians. Under the pilot program, patients will be enrolled in a
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managed care plan unless they actively opt out. In addition to asking that CMA monitor the transition, the newly adopted policy also requests that the association advocate that the appropriate state agencies provide “full and clear disclosure” on options and consequences facing patients affected by the pilot program. More information regarding the dual eligible transition can be found in CMA’s online duals resource center, at www. cmanet.org/duals.
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Dameron Hospital accounts for over 90% of all orthopedic surgeries in San Joaquin County. In the past 10 years over 5,000 joint surgeries have been performed at Dameron. The Hospital is fully equipped with the highest level of medical technology in support of orthopedic procedures.
“In my job I do a lot of traveling. Having experienced 10 operations in my life in 6 different hospitals, I will tell you, Dameron Hospital was absolutely the best experience I’ve ever had. Stockton should be proud of the job this hospital is doing. I entered the Hospital early Friday, March 2 nd and from moment one the feeling was one of care and confidence a rare combination. I recommend it highly, I’m glad I chose Dameron.”
Morgan Mayfield Vice President of Sales,
Dorfman Pacific
Dameron Hospital Patient, Full Knee Replacement Surgery
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SAN JOAQUIN PHYSICIAN 17
CMA Center for Economic Services
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DIPLOMATS OF THE AMERICAN BOARD OF OBSTETRICS & GYNECOLOGY
75,000 HEALTHY BABIES DELIVERED Experience Matters
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DELEGATES STRONGLY OPPOSE MEDICARE RAC AUDITS
MEMBERS OF THE CALIFORNIA MEDICAL ASSOCIATION’S (CMA) HOUSE OF DELEGATES SPOKE OUT STRONGLY AGAINST AGGRESSIVE DOWN CODING EFFORTS BEING TAKEN UP BY MEDICARE’S RECOVERY AUDIT CONTRACTOR (RAC) FIRM, AND HAVE ADOPTED POLICY THAT OFFICIALLY PUTS THE ASSOCIATION ON RECORD AS OPPOSING THE PRACTICE. The resolution, 222-12, stems from an ongoing problem of an out-of-state auditing firm, Connolly Healthcare, selectively down coding claims on behalf of Medicare, forcing physicians to undertake costly and time-consuming appeals. The audits and subsequent down codes, which several speakers equated to financial “bounty hunting” on behalf of the Centers for Medicare & Medicaid Services (CMS), were almost always reversed upon physician appeal, which suggested that they were of little merit to begin with, speakers said. “I can’t tell you how outraged we doctors should be
that this is going on,” James Hinsdale, M.D., a past CMA president, said during the resolution’s floor debate. In addition to asking that CMA work to stop the audit practice, the resolution also requests that, if efforts to halt the practice are unsuccessful, CMA urge CMS to reimburse physicians who file successful appeals for the time and resources expended in the appeal efforts. Successful passage of the resolution brought CMA in line with the American Medical Association’s (AMA) position on the matter. AMA has been actively lobbying CMS to halt the recovery audits.
ACA TOPIC OF HEATED DEBATE AT HOUSE OF DELEGATES Since the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, it’s been virtually a certainty that delegates at the annual House of Delegates meeting would debate to influence policy regarding the landmark reform bill. This year’s gathering was no exception, as resolutions touching upon various aspects of the ACA were introduced, and in some cases, adopted as official California Medical Association (CMA) policy. Of the resolutions introduced and debated over the weekend, it appears that Resolution 202-12 will produce some of the most immediate results. The resolution, which deals with the California Health
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Benefits Exchange, asks that CMA support several actions that will help ease the transition of roughly 1.6 million new enrollees to the state’s Medi-Cal program, as well as a list of requirements that will help protect physicians when contracting with plans offered through the exchange’s online marketplace. Specifically, the resolution asks that county and state funding sources that currently help provide care for medically indigent adults follow those individuals when Medi-Cal is expanded in 2014, and that the exchange takes a more active role in monitoring network adequacy of its offered plans. The issue of network adequacy has already garnered a
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House of Delegates > 2012
significant amount of attention from CMA staff, but an agreeable solution has yet to be reached with exchange leadership. A separate resolution, 201-12, reaffirmed CMA’s position of continuing to work toward amending the ACA to “address issues of concern to the practice of medicine,” and was adopted by the House. Finally, two resolutions, 204-12 and 205-12, launched the seemingly annual debate over single payor coverage in California. During the reference committee hearings, supporters and opponents of single payor in California took to the microphone to voice their opinions on the matter, providing
some of the most passionate and ideologically divided debate of the weekend. Ultimately, reference committee members recommended that delegates disapprove both resolution, noting that CMA has “well thought out and longstanding” policy on the issue of single payor. (CMA’s Policy Compendium is available to members at www.cmanet.org/ policies. The new policies passed this year will be added to the compendium soon.) For more information on any of these resolutions, or general reform activities in California, please subscribe to CMA’s regular reform newsletter, CMA Reform Essentials at www.cmanet.org/reform-essentials.
CMA DEBATES RESOLUTION THAT CALLS ON INSURERS TO COVER E-MAIL CONSULTATIONS AS ADVANCES IN TECHNOLOGY CONTINUE TO REDEFINE HEALTH CARE, THE CALIFORNIA MEDICAL ASSOCIATION (CMA) IS TAKING STEPS TO BRING THE PHYSICIAN-PATIENT RELATIONSHIP INTO THE 21ST CENTURY. During the association’s annual House of Delegates meeting, a resolution was introduced that would ask CMA to support legislation requiring insurance providers in California to
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include “telephone or other electronic patient management services” in their covered services, while also allowing physicians to bill patients directly for the provision of such services. Currently, insurance providers are not required to cover consultations that occur via telephone or email, and physicians in most instances have no legal way of billing patients or payers for such services. Throughout a lengthy period of floor debate, several speakers noted that patients are becoming increasingly reliant upon remote interaction with their physicians, while insurers only cover services offered in a face-to-face setting, with few exceptions. If this does not change, speakers noted, physicians would be facing considerable financial losses as the trend toward remote interaction continues. While support for the concept of requiring insurers to pay for telephone and email consults was nearly unanimous, the specific language of the resolution drew input from across the House, leading to nearly an hour of open discussion of the issue. Ultimately, recognizing the importance of the matter and the limited time available for debate, delegates opted to refer the resolution to the CMA Board of Trustees for decision, an action which supporters claimed would allow the language to be crafted more thoughtfully. The matter will likely be taken up during the board’s January meeting and CMA staff will keep members updated on the resolution’s progress.
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– last year’s three-day fundraising record of $110,000 and a fully mustachioed chair posing a challenge to delegates in attendance. In the end, neither would emerge from the weekend unscathed. In a record-setting show of support for CALPAC, CMA members contributed a total of roughly $152,000, besting last year’s mark while also exceeding the $150,000 goal established before the House of Delegates. Throughout the weekend, attendees were informed that, should the goal be met, outgoing CALPAC Chair and new CMA President-Elect Richard Thorp, M.D., would shave his moustache during the full house session held on Monday morning. With the final tally confirmed, Dr. Thorp took to the stage to have his upper lip shorn clean by his wife, Vicki. (Check out the photos on CMA’s facebook page, www.facebook.com/cmaphysicians.) While the record breaking weekend was a House-wide effort, several counties, including San Diego, San Francisco and Santa Clara, were recognized for their outstanding participation. The donations collected over the weekend, as well as all contributions made to CALPAC, will be used to support candidates who share medicine’s agenda and priorities and will work to affect policies beneficial to the House of Medicine.
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SAN JOAQUIN PHYSICIAN 21
ONE MUST IMAGINE SISYPHUS HAPPY
THE CALIFORNIA MEDICAL ASSOCIATION’S 2012 LEGISLATIVE WRAP-UP CMA FIGHT
cma fights for physicians
2012 LEGISLATION with over 400 bills
MICRA OPPONENTS
evil micra devils try to hurt us
In years past, the California Medical Association (CMA) has defended physicians in battles waged by hospitals, health plans and mid-level practitioners, but this year we initiated a few fights of our own. CMA did what physicians do best: We fought to protect patients. CMA fought to keep patients out of the middle of billing disputes, to educate parents about immunizations, to require mandatory flu vaccinations for health care workers, to remove sugared beverages from schools, to create a physician health program, to expand residency programs and a last minute effort to save the
Healthy Families Program. By Jodi Hicks, CMA VP of Government Relations
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Illustration by Brett Johnson
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Legislative Wrap Up > 2012
Sponsoring legislation is the equivalent of pushing rocks up a hill… or rather big righteous boulders. The CMA Government Relations team struggled to push those rocks up the legislative hill while fighting off the enemies trying to get in the way, and at the same time stopping the many other rocks being thrown down at physicians. Sounds dramatic, but by all accounts, it was a crazy, precarious, contentious, hazardous and dramatic pathway to the finish line. We finished with some big wins and although we lost a few along the way, CMA fought for physicians and their patients until the very end. Out of the gate in January, CMA came out swinging. We introduced AB 1742 (Pan), which would have enabled patients to assign their benefits directly to the provider furnishing medical services. Sounds simple enough, but the bill soon came under attack from the health plans and culminated in what was described on one blog as the “juiciest” health committee hearings of the year. After much back and forth, the bill came up one vote short before reaching a legislative deadline to move the bill. That same week, CMA battled the unions, championing a bill through both a health and labor committee that would mandate flu vaccines for health care providers in hospitals. Against all odds and much opposition, SB 1318 (Wolk) moved through the Senate in a decisive win for public health. Though CMA was able to maneuver this contentious bill all the way through the Legislature, it was subsequently vetoed by the Governor. CMA also joined a large coalition of health care providers in a valiant attempt to create a physician health program in California. The coalition worked tirelessly to address the opposition’s concerns surrounding funding, oversight and standards, and the bill made it all the way through both committee hearings and was on its way to the floor when it stalled. Despite the coalition’s diligence, the overwhelming demands of the opposition damaged the bill beyond repair before the last legislative deadline. Despite an end to this bill, we are confident that the conversation can continue and this will be
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an issue CMA will look to advance next year. And then came Rob Schneider. CMA, along with the American Academy of Pediatricians, the Health Officers Association of California and the California Immunization Coalition, sponsored AB 2109 (Pan) in an attempt to decrease the number of parents exempting their children from being vaccinated before entering public
medical diagnosis after 30 days of direct treatment. The Assembly Appropriations Committee passed the bill, adding in medical diagnosis as a requirement for direct access. The California Physical Therapy Association again amended the bill on the floor, changing the language so that instead of requiring a diagnosis it would require an examination or a diagnosis… and as the game of semantics wore on, the
THE CMA GOVERNMENT RELATIONS TEAM STRUGGLED TO PUSH THOSE ROCKS UP THE LEGISLATIVE HILL WHILE FIGHTING OFF THE ENEMIES TRYING TO GET IN THE WAY, AND AT THE SAME TIME STOPPING THE MANY OTHER ROCKS BEING THROWN DOWN AT PHYSICIANS.
schools. Hundreds of anti-vaccine activists flooded the committee hearings to oppose the measure and eventually were joined by Saturday Night Live alum Rob Schneider. Now armed with “celebrity” status, the opposition was able to secure public rallies, television time and spread of social media to oppose our efforts. Despite attempts at negative media attention by the opposition, Governor Brown signed AB 2109 into law hours before the deadline. The year wouldn’t be complete without CMA revisiting some oldies but goodies, physical therapy and MICRA being no exceptions. Unfinished business from 2011, SB 924 (Steinberg/Price) would have fixed the ambiguity in law as to whether or not medical corporations can legally employ physical therapists, but it would have also allowed patients to directly access physical therapy treatment for 30 business days, at which time a physician would have to sign off on a physical therapy treatment plan. CMA had an official “Oppose unless Amended” position on the bill, asking for amendments that would have required a
bill was quickly sent to Assembly Rules Committee where it stayed until its demise. Two bills that would have weakened the protections of MICRA, SB 1528 (Steinberg) and AB 1062 (Dickenson) were amended the last week of session adding to the flurry of the chaos in the final days. The provider community strongly opposed both bills and thanks to letters and phone calls from physicians across the state, they were ultimately killed with astoundingly low vote counts. The legislative session officially ended early Saturday morning, September 1, 2012, and CMA’s Government Relations team was at the Capitol until the very end. In the waning hours of the 2011-2012 Legislative Session, CMA successfully negotiated key amendments into the Workers’ Compensation bill and proudly fought to reinstate the Healthy Families program as part of a multi-part deal that died sometime after 1:00 am. Despite bipartisan support for our efforts, the Healthy Families program became collateral damage to partisan politics. CMA continues to work with
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stakeholders on the transition of kids to Medi-Cal. More to come on this issue… “The Myth of Sisyphus” tells us that toil is not futile, and hard work can be noble. CMA toiled throughout the year for physicians, honoring the labor physicians do for their patients every day. The struggle to push those legislative rocks up the hill was performed with pride, and as the essay reads, “The struggle itself toward the heights is enough to fill a man’s heart. One must imagine Sisyphus happy.” Of course, Sisyphus was not pushing the rock while simultaneously fighting labor lobbyists or Rob Schneider–but I still imagine him happy. On the following pages are details on the major bills that CMA followed this year.
CMA SPONSORED LEGISLATION AB 826 (SWANSON/WILLIAMS/PEREA): HEALTHY FAMILIES This CMA-sponsored bill was substantially amended in August at CMA’s request to include language to both (1) extend the Managed Care Organization (MCO) tax by one year, and to use the funding for the Healthy Families program, and (2) eliminate the transition of Healthy Families enrollees to Medi-Cal (done through the budget this year), thereby preserving the Healthy Families program. This bill is a critical part of CMA’s ongoing push to protect the successful Healthy Families program. Status: Failed pursuant to legislative deadline.
AB 1742 (PAN): ASSIGNMENT OF BENEFITS This bill requires Knox-Keene regulated PPO products to authorize and permit assignment of an enrollee’s or subscriber’s right to reimbursement to the provider furnishing those services. This bill provides for the direct payment of individual insurance medical benefits by a health insurer to the person who provided the
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hospitalization or medical or surgical aid. It limits the amount of the reimbursement to the amount of the benefit covered by the policy. Status: Failed pursuant to legislative deadline.
AB 1746 (WILLIAMS): SALE OF SPORTS DRINKS IN SCHOOLS Current California law restricts the sale of soda and most other sweetened beverages on elementary, middle, and high school campuses. However, current law does allow the sale of one type of sugar-sweetened beverage – “sports drinks” – on middle and high school campuses. There is a common misconception that sports drinks are healthy. Yet many contain high fructose corn syrup and/or other calorie-laden sweeteners that have been linked to the rise in childhood obesity, the primary cause of type-2 diabetes. Sports drinks are designed to replace fluids after intense exercise and generally contain sodium and potassium to improve fluid absorption in the body; they are not designed to be an afternoon substitute for soda. A recent study indicated that eight of the top 10 beverages sold a la carte in California’s public high schools are sports drinks, clearly becoming the drink of choice for those students wanting a substitute for soda. To close the loophole in current law that allows high-sugar sports drinks on school campuses, AB 1746 would prohibit electrolyte replacement beverages (sports drinks) from being sold to middle or high school students during school hours. Status: Failed pursuant to legislative deadline.
AB 1848 (ATKINS): MEDICAL EXPERT WITNESSES The goals of this legislation are twofold. It would (1) Authorize the state to discipline or deny licensure to physicians who offer deceptive or fraudulent expert witness testimony related to the practice of medicine; and (2) Require out-of-state expert witnesses to apply and become registered by the Medical Board of California to testify as a medical expert witness in California. Registration would require the completion of a written
application accompanied by a fee. In the event a registered out-of-state medical expert witness deceives or commits fraud as an expert witness, the medical board could revoke his/her registration to prevent the individual from re-offending in any other potential court cases. Status: Failed pursuant to legislative deadline.
AB 2064 (V.M. PEREZ): VACCINE REIMBURSEMENT This bill requires a health care service plan or health insurer that provides coverage for childhood and adolescent immunization to reimburse a physician or physician group in an amount not less than the actual cost of acquiring the vaccine plus the cost of administering the vaccine. It prohibits the imposition of deductibles, coinsurance or other cost sharing mechanism for the administration of childhood or adolescent immunizations or related procedures. It also prohibits provider contracts from containing a dollar limit provision for the administration of childhood and adolescent immunizations or including the cost of those immunizations in a dollar limit provision. This bill applies the current prohibition of a physician or physician group from assuming financial risk for the acquisition costs or required immunizations to all contracts between plans and physicians and physician groups. Additionally, it prohibits a plan from requiring a physician or physician group to assume financial risk for immunizations, whether or not those immunizations are part of the current contract, and prohibits plans from including administration cost in the capitation rate of a physician who is individually capitated. Status: Failed pursuant to legislative deadline.
AB 2109 (PAN): CHILDHOOD IMMUNIZATIONS California is one of 20 states that allows for the broad use of the personal belief exemption (PBE) from immunizations that are required for children to enter school. In California, obtaining a personal belief exemption is simple–parents are
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Legislative Wrap Up > 2012
only required to sign their name to a twosentence standard exemption statement on the back of the California School Immunization Record or provide a signed written statement. Over the past decade, the number of parents choosing to exempt their children from school immunization requirements has increased significantly, leading to more school children left vulnerable to preventable diseases. Parents have the right to make choices about immunizing their children; however, these choices should not be based on misinformation or lack of information. AB 2109 requires a parent or guardian seeking a personal belief exemption for their child to obtain a document signed by themselves and a licensed health care practitioner. The document will state that the health
Healthy Families program). This bill is a critical part of CMA’s ongoing push to protect the successful Healthy Families program. Status: Failed pursuant to legislative deadline.
SB 1318 (WOLK): INFLUENZA VACCINATIONS FOR HEALTH CARE PROVIDERS IN HEALTH FACILITIES On a daily basis, health care workers come in contact with vulnerable populations such as seniors, young children and others with certain health conditions who may have depressed immune systems and cannot afford to catch the flu. The best way to ensure this does not happen is to have every health care worker vaccinated for the flu.
WE FINISHED WITH SOME BIG WINS AND ALTHOUGH WE LOST A FEW ALONG THE WAY, CMA FOUGHT FOR PHYSICIANS AND THEIR PATIENTS UNTIL THE VERY END.
care practitioner has informed the parent or guardian of the benefits and risks of the immunization, as well as the health risks of the diseases that a child could contract if left unvaccinated. Status: Enrolled and sent to Governor. Signed into law 9/30/12.
SB 301 (DESAULNIER/CANNELLA/ PAVLEY/RUBIO/STRICKLAND/YEE): HEALTHY FAMILIES This CMA-sponsored bill was substantially amended in August at CMA’s request to include language to both (1) extend the Managed Care Organization (MCO) tax by one year, and to use the funding for the Healthy Families program, and (2) eliminate the transition of Healthy Families enrollees to Medi-Cal (done through the budget this year, thereby preserving the
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Health care workers who get vaccinated reduce the transmission of influenza, staff illness and absenteeism, and influenzarelated illness and death, especially among people at increased risk for severe influenza illness. Unfortunately, despite the benefits, many health care workers still voluntarily go unvaccinated. During the 2010-2011 influenza season, coverage for influenza vaccination among health care workers was estimated at 63.5 percent. However, those health facilities that had policies in place that required their health care workers to be vaccinated had a compliance rate at 98.1 percent. This discrepancy shows the great success of the required flu vaccination programs; programs that should be emulated. SB 1318 requires all health facilities and clinics to implement measures, including vaccine education programs, to help maximize influenza vaccination
rates among their health care workers and medical staff. Workers who decline the vaccine will be required to declare in writing that they will adhere to the policy determined by the health facility or clinic to be the most effective measures to prevent workers from contracting or transmitting the virus. Any facility or clinic that fails to achieve a 90 percent or higher influenza immunization rate by January 1, 2015, will be required to adopt the model “mandatory vaccination policy” determined by the California Department of Public Health to be the most effective in achieving the 90 percent or higher goal. Status: Enrolled and sent to Governor. Vetoed 9/30/12.
SB 1416 (RUBIO): PHYSICIAN WORKFORCE This proposal would lay the groundwork to create the Graduate Medical Education Trust fund, to be administered by the Office of Statewide Health Planning and Development for the purposes of administering grants to expand the state’s residency programs. As currently drafted, funding for this bill is dependent upon private donations. Status: Failed pursuant to legislative deadline.
SB 1483 (STEINBERG): ESTABLISHING A PHYSICIAN Health Program in California This bill would establish a physician health program in California to refer physicians for treatment and monitoring services when they are suffering from substance abuse, mental and behavioral health issues. California is one of only five states in the nation that does not have such a program, following the Medical Board of California’s decision to eliminate its 27-year-old Diversion Program in 2007. This program will be structured fundamentally different than its predecessor, in that instead of taking on physicians who are under disciplinary review by the board, the program will be a voluntary model, encouraging physicians to actively seek treatment before their problems progress to the level that would
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Legislative Wrap Up > 2012
lead to possible complaints and patients being put at risk. The program will be run by an external, private entity that contracts with the state, as opposed to the Diversion Program, which was run by the medical board. The program will be under the purview of the state Department of Consumer Affairs, instead of the medical board. The program will be funded by a fee charged to all new and renewed medical licenses issued in California, and will be periodically audited to ensure accountability. Status: Failed pursuant to legislative deadline.
AB 589 (PEREA): MEDICAL SCHOOL SCHOLARSHIPS Prior CMA sponsored legislation provided $1,000,000 per year in funding for the Steve Thompson Loan Repayment Program, which gives physicians up to $105,000 in loan repayment if they agree to practice in an underserved area for at least 3 years. This bill mirrors the loan repayment program and would create the Steve Thompson Scholarship Program, which would provide scholarships to medical students who agree to practice in one of California’s medically underserved areas upon completion of residency. Status: Enrolled and sent to Governor. Signed into law 9/17/12.
CMA OPPOSED LEGISLATION AB 1062 (DICKINSON): ELDER ABUSE/MICRA This bill was gutted and amended to lower the standard of evidence in elder abuse cases. It reduces proof required in elder abuse cases from clear and convincing to preponderance of the evidence. If enacted, it would encourage use of the elder abuse law to get around the MICRA cap and plaintiff attorney fee limits. Status: Failed pursuant to legislative deadline.
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SB 924 (PRICE): PHYSICAL THERAPISTS–DIRECT ACCESS TO SERVICES/PROFESSIONAL CORPORATIONS This bill addresses two significant issues pertaining to the practice of physical therapy. First, it allows physical therapists to remain employed in medical corporations, as well as create their own corporations, and requires the corporations to disclose to the patient that they are free to seek services elsewhere if they so choose. Second, it provides a framework where physical therapists may treat a patient directly without first seeing a physician, also known as “direct access.” Specifically, this bill allows physical therapists to treat patients for 30 business days, or 12 visits, without first seeing a physician. After the time limit, treatment would only be allowed
SB 1373 (LIEU): HEALTH CARE COVERAGE– OUT-OF-NETWORK COVERAGE This bill would require that prior to providing out-of-network services a health care provider shall in writing inform the enrollee that he or she is out of network and that the health plan may not cover some of the services, provide an estimate of the cost of the services and direct the enrollee to contact the health plan for a list of contracted providers. Additionally, it prohibits a health facility or provider group from stating that it is part of a network unless all of the providers working at the facility are contracted with the insurer. The bill also requires plans to pay out-ofnetwork providers the same rate as they pay in network providers on a non-capitated basis within the same geographic region
“THE MYTH OF SISYPHUS” TELLS US THAT TOIL IS NOT FUTILE, AND HARD WORK CAN BE NOBLE. CMA TOILED THROUGHOUT THE YEAR FOR PHYSICIANS, HONORING THE LABOR PHYSICIANS DO FOR THEIR PATIENTS EVERY DAY.
to continue if the physical therapist’s plan of care was approved by a physician, which would include a physical exam. Current law requires that no physical therapy treatment may commence without a medical diagnosis. While CMA may wish to consider allowing a certain amount of treatment prior to a diagnosis, there must still be a diagnosis requirement at some point and 30 business days is just too long. Amendments should be adopted that would limit the amount of treatment to 30 calendar days and require at the end of the 30 days, that a medical diagnosis be obtained for treatment to continue. Status: Failed pursuant to legislative deadline.
as the contracted provider. A potential amendment would be to require disclosure language on an assignment of benefit agreement between a patient and a provider. Status: Failed pursuant to legislative deadline.
SB 1528 (STEINBERG): DAMAGES–MEDICAL SERVICES This bill would overturn the, Howell v. Hamilton Meats case, by allowing an injured party of medical services to be compensated based upon the reasonable value of services rather than amount actually paid. Despite the trial attorneys’ assertion that the bill doesn’t affect damages under 3333.1, it would dramatically increase economic damage awards in ALL personal injury cases in the state. The rationale stated
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A FREE Member Benefit:
Sponsored by
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Legislative Wrap Up > 2012
TWO BILLS THAT WOULD HAVE WEAKENED THE PROTECTIONS OF MICRA, SB 1528 (STEINBERG) AND AB 1062 (DICKENSON) WERE AMENDED THE LAST WEEK OF SESSION ADDING TO THE FLURRY OF THE CHAOS IN THE FINAL DAYS. for the bill is flawed – that every person be treated the same regardless of how much was paid. Damages are intended to make someone whole. For medical expenses, that means giving them back in monetary damages the amount that was put out on their behalf – i.e., the amount paid. Lawsuits are not supposed to be like winning the lottery where you are put in a position more favorable than where you began. In other words, monetary damages are not supposed to go beyond recouping what was lost–for medical expenses, those are the dollars spent on medical care. Non-economic or emotional distress damages are the damages that compensate for the pain and suffering caused by the injury. This bill is going to bring up discussions about physicians billing practices and the definitions of, and differences between, billed amounts, usual and customary charges and reasonable value. Status: Failed pursuant to legislative deadline.
BILLS OF INTEREST AB 369 (HUFFMAN): STEP THERAPY REFORM (CMA POSITION: SUPPORT) This bill would limit a health plan’s or health insurer’s ability to use step therapy or “fail first” protocols for the treatment of pain. The bill would require that the duration of any step therapy or fail first protocol be determined by the prescribing physician and would prohibit a health plan or health
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insurer from requiring that a patient try and fail on more than two pain medications before allowing the patient access to other pain medication prescribed by the physician. This bill would still allow step therapy to be used, but closes loopholes and puts the medical decisions back in the doctor’s hands so the patient can get the right medication in a timely fashion. Status: Enrolled and sent to Governor. Vetoed 9/30/12.
AB 1000 (PEREA) HEALTH CARE COVERAGE: CANCER TREATMENT (CMA POSITION: SUPPORT) This bill would help ensure that cancer patients are not denied the most appropriate and effective treatment by putting costs above care. According to the author, “there are significantly greater patient out-ofpocket costs for oral cancer therapies covered under the pharmacy benefit than IV therapies covered under the medical benefit. These out-of-pocket costs become a de facto denial of access, which, in a study by Prime Therapeutics, resulted in 1 in 6 patients not receiving treatment solely due to cost. Therefore, patient access to potentially the only life-saving cancer therapy available to them is restricted. Status: Enrolled and sent to Governor. Vetoed 9/30/12.
AB 1533 (MITCHELL): INTERNATIONAL MEDICAL GRADUATES (CMA POSITION: SUPPORT) This bill would allow the UCLA International Medical Graduate program
to create a five-year pilot for participants to engage in a physician supervised patient care activities, as part of an approved and supervised clinical clerkship/ rotation at UCLA. With this legislation, UCLA International Medical Graduates would receive valuable clinical learning opportunities and not be at risk for disciplinary action by the Medical Board of California. In light of California’s physician supply crisis, this bill would have a more immediate impact toward increasing the amount of licensed physicians that could practice in the state. Status: Enrolled and sent to Governor. Signed into law 7/25/12.
AB 1808 (WILLIAMS): MEYERSMILIAS-BROWN, ACT PUBLIC EMPLOYEES (CMA POSITION: SUPPORT) This bill would only impact County of Ventura employed physicians that have, since 2006, sought union recognition. Since 2006, the county has rejected multiple legal opinions by the Public Employee Relations Board (PERB) that has sided with the physicians’ efforts for unionization. This bill simply includes the definition of “joint employer” used in the 2009 PERB decision, which would remove any doubt as to whether or not Ventura County is the employer of the physicians at the Ventura County Clinics. Status: Failed pursuant to legislative deadline.
SB 863 (DE LEON): WORKERS’ COMPENSATION (CMA POSITION: SUPPORT) This bill was substantially amended in the final weeks of session to contain a package of policy changes in the name of reforming the state’s workers’ compensation system. The bill’s text was initially developed by labor and business interests, but CMA was able to negotiate a number of significant amendments to the bill. When those amendments were adopted, CMA took a support position on the measure. SB 863 does many things, but a couple of the biggest changes for physicians are that it
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Legislative Wrap Up > 2012
directs the state to adopt the Medicare fee schedule—based on the Resource-Based Relative Value Scale (RBRVS)—as well as establishing Independent Medical Review and Independent Bill Review in an effort to utilize third-party processes to adjudicate treatment and billing disputes, instead of the court system. CMA was able to secure many important changes to the bill, including medical provider network reforms, expanding categories of payment for physicians, as well as increasing the entire funding allocation for physician services and protecting physicians’ ability to own an ambulatory surgery center. Based on these changes (including mandatory and ongoing coding updates by carriers and discarding ACOEM guidelines in favor of an expanded hierarchy of evidence), CMA took a support position on the measure.
SB 1538 (SIMITIAN): MAMMOGRAMS (CMA POSITION: NEUTRAL) This bill would require physicians to notify mammography patients with highly dense breasts about the density of their breast tissue. This issue has been debated within the house of medicine for nearly two years, but physician advocates were able to secure amendments to the bill that allowed both CMA as well as ACOG District IX to take neutral positions. Status: Enrolled and sent to Governor. Signed into law 9/22/12.
AB 1461 (MONNING) / SB 961 (HERNANDEZ): INDIVIDUAL MARKET REFORMS (CMA POSITION: SUPPORT) These bills conform state law to the Affordable Care Act in 2012, establishing guaranteed issue, Exchange open and special enrollment periods, rating (age, geographic region, and family size only), and same regions as PERS. Status: Enrolled and sent to Governor. Vetoed 9/30/12.
AB 1761 (JOHN PEREZ): DECEPTIVE MARKETING (CMA POSITION: SUPPORT) This bill would prohibit deceptive marketing by outlawing “copy cats” from representing themselves as part of the California Health Benefit Exchange.
Status: Enrolled and sent to Governor. Signed into law 9/18/12.
BILLS IMPACTING HEALTH CARE REFORM
SB 1524 (HERNANDEZ): NURSE PRACTITIONERS (CMA POSITION: WATCH)
AB 43 (MONNING): MEDI-CAL ELIGIBILITY (CMA POSITION: SUPPORT IF AMENDED)
AB 1846 (GORDON): CO-OPS (CMA POSITION: WATCH)
This bill deletes the statutory requirement that nurse practitioners complete at least six months of physician and surgeon supervised experience in the furnishing or ordering of drugs and a course in pharmacology covering the drugs that will be furnished. The author contends this statute is antiquated and was put into place before there was any significant training in pharmacology. He contends the proper training and proper education now exists and the six month requirement only delays employment of new advanced practice registered nurses (APRN). However, not everyone’s experience and education is equal and should be dealt with on a case-by-case basis. CMA recommended amendments, which the author accepted, that clarified that the physician may include a six month supervised experience (or longer) requirement in the standardized protocol between the physician and the APRN. Status: Enrolled and sent to Governor. Signed into law 9/29/12.
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This bill would require the Department of Health Care Services to establish, by January 1, 2014, eligibility for Medi-Cal benefits for any person who meets these eligibility requirements. This bill would permit the department, to the extent permitted by federal law, to phase in coverage for those individuals. Status: Failed pursuant to legislative deadline.
AB 1453 (MONNING) / SB 951 (HERNANDEZ): ESSENTIAL HEALTH BENEFITS (CMA POSITION: SUPPORT) These two bills, which are virtually identical, would establish a set of essential health benefits (EHBs) that insurers and health plans in California’s Health Benefit Exchange will be required to cover. This pair of bills would adopt the Kaiser small group HMO as the state’s EHB benchmark. Status: Enrolled and sent to Governor. Signed into law 9/30/12.
Status: Enrolled and sent to Governor. Signed into law 9/30/12.
This bill authorizes Insurance Commissioner to issue a certificate of authority to Consumer Operated and Oriented Plans (CO-OPs). The Affordable Care Act calls for the creation of the CO-OPs, which are private, consumergoverned, non-profit health insurance plans that will be operated by its community beneficiaries (consumers, providers and employers). Status: Enrolled and sent to Governor. Signed into law 9/30/12.
SB 970 (DE LEON): CalHEERS HORIZONTAL INTEGRATION (CMA POSITION: SUPPORT) This bill adds human services programs, such as CalWORKS and CalFresh, to those screened by the California Healthcare Elgibility, Enrollment and Retention System (CalHEERS), which will be used for California Health Benefit Exchange and Medi-Cal enrollment. Status: Enrolled and sent to Governor. Vetoed 9/30/12.
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SAN JOAQUIN PHYSICIAN 33
By Fran Cain l Information Technology Department NORCAL Mutual Insurance Company
BEFORE YOU STORE PATIENT
CREDIT CARD
NUMBERS
E
veryone uses credit cards. Patients love to rack up points for travel and cash-back rewards. But before you store a credit card number in your practice database, be aware of
the consequences if your patient records ever become compromised. Credit card companies can impose huge fines if your office system is not securing patient credit card information adequately and it becomes compromised — to the tune of up to $100,000 per incident. After reviewing this article and weighing the risks, ask yourself, “Does my practice really need to store credit card information on file?”
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SAN JOAQUIN PHYSICIAN 35
TIPS
FROM
THE PAYMENT CARD INDUSTRY WEBSITE: Encrypt all credit card numbers if stored in any system or database, including but not limited to logs and backups. Ensure the network has adequate firewall and up-to-date antivirus software. Use strong encryption for transmission of cardholder date over the Internet. Regularly apply all systems and software security patches. Quarterly, run external vulnerability scans or penetration tests on the network. Limit access to cardholder information to staff with a legitimate business need. Enforce strong passwords. Avoid printing any card data on paper, but if any exists, it must be carefully secured and destroyed when no longer needed. Maintain data security policies that provide clear guidance to staff about handling of sensitive data (e.g., never e-mail Primary Account Numbers or PANs) and how to respond in case they discover data is compromised.
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QUICK TIPS
HERE ARE SOME
I have a small practice. How does this apply to me? All credit card companies belong to the Payment Card Industry (PCI). PCI has established a Security Standards Council to set and manage standards known as the Data Security Standard, or PCI DSS. If your practice accepts or processes payment cards, you must comply with the PCI DSS.
Patients prefer that I keep their credit card numbers on file. What if I want to store credit card numbers? There are many rules to follow to be in compliance. You will be required to build and maintain a strong network; protect cardholder data; maintain a vulnerability management program; implement strong access control measures; regularly monitor and test networks; and maintain an information security policy. You must assess your business systems and processes annually to ensure you are in compliance. The PCI website can help you to assess your environment. You may be able to use a SelfAssessment Questionnaire, which must be completed annually, depending on the bank card. For example Master Card allows you to self-assess if you process less than 50,000 transactions annually, while JCB International allows you up to 1 million transactions. Check with each credit card company or look on its website to determine your merchant level and the requirements for your business. If you are allowed to self-assess, it is not necessary to submit a report to the credit card companies or PCI, but compliance is still required at all times. There are several different self-assessment questionnaires, and it may be confusing to decide which one to use. Use the chart on the website to choose the questionnaire that most closely fits with your credit card collection practices. If you are not allowed to self-assess, you will need to use a Qualified Security Assessor (QSA) to conduct annual assessments.
What happens if I store credit card numbers and a practice computer is lost or stolen, or some other breach of my system occurs? You must be able to demonstrate that you have been in compliance with PCI DSS. If your practice computers, network and/or database are compromised in any way, you must notify the credit card companies. If you cannot demonstrate that the data was completely protected and that you have been in compliance with PCI DSS, you will be subject to significant fines and lawsuits. If the credit card company does not terminate the
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contract, you may be treated the same as a higher level merchant and be required to conduct annual on-site assessments and validation by a Qualified Security Assessor. Expect the annual on-site assessments to cost in the $10,000–20,000 range or more. You will be required to remediate any inadequacies discovered during the annual assessments at your own expense.
Who enforces compliance of the PCI DSS? American Express, Discover Financial Services, JCB International, MasterCard Worldwide, and Visa Inc. Each of these institutions posts compliance guidance which may be slightly different from the others. Before going to each credit card company website, read, understand, and follow all guidelines provided by PCI.
Why aren’t card readers or software applications safe enough from hackers? According to the PCI, there are many reasons credit card readers or applications may not be secure. Card readers may inadvertently store magnetic stripe data which contains Sensitive Authentication Data or card verification codes; they may not be installed properly or securely and might be easily compromised; default settings or passwords may not have been changed on readers or in applications; security patches were not kept updated; the credit card data on the network is not properly segregated to be secure; data may not be properly encrypted; web applications may not be hardened against vulnerabilities.
What if I complete a selfassessment and uncover deficiencies? If the self-assessment uncovers deficiencies, remediation is necessary. A remediation
plan, known as an Action Plan for NonCompliant Status, should be completed. PCI allows 12 months to remediate, but progress must be demonstrable. All remediation is at the expense of the merchant. If your practice is very large and you process many transactions, you will need to work with a data security firm. PCI provides a list of qualified assessors on its website.
Now that you know some of the risks and requirements of storing credit card information, do you really need them on file? For more information, visit the Payment Card Industry website at www.pcisecuritystandards.org. Fran Cain is the Network Systems Manager for NORCAL Mutual Insurance Company. Copyright 2012 NORCAL Mutual Insurance Company. All rights reserved.
ASSESMENTS
HOW DO I
AVOID
THE NEED FOR ASSESSMENTS ALTOGETHER?
If you accept credit cards for payment, an annual assessment is required. But if you successfully follow these guidelines, the self-assessment questionnaire is short and painless: Secure your credit card readers. Use a virtual terminal solution provider validated by the PCI. Do not store credit card numbers, or any of the information from the credit card on any computer or system.
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Do not store the Primary Account Number (PAN) commonly known as the credit card number.
Never store the data from the magnetic stripe or, if present, the chip.
Never store sensitive authentication data.
Never store the Personal Identification Number (PIN).
If the PAN is displayed, it must be masked. Only the first six and last four digits may be displayed.
Never store the card security code, the 3-digit number on the back of most credit cards or the 4-digit code on the front of American Express cards. SAN JOAQUIN PHYSICIAN 37
Public Health
Update
Laboratory
Testing Influenza testing is encouraged for patients with ILI symptoms who are hospitalized in an intensive care unit (ICU), fatal cases, in ILI outbreaks, and in patients with ILI who had recent swine exposure or contact with a confirmed case of variant (swine) influenza. It is important to remember that the rapid flu tests may have a high false positive rate when influenza prevalence is low. So it is recommended that a positive rapid flu test be followed up with a confirmatory test. Also a recent CDC study found
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that rapid flu tests have limited ability to detect variant (swine) influenza viruses. Polymerase chain reaction (RT-PCR) is the preferred testing method when there is strong clinical suspicion, even if the rapid test is negative. Public Health Services Contact Information: For questions about influenza reporting and outbreaks call SJCPHS Communicable Disease Program at 468-3822. For laboratory testing questions call SJCPHS Laboratory at 468-3460.
Referrals to FAMILY
HEALTH PROGRAMS WELCOMED The SJCPHS Family Health programs (these include Black Infant Health, Adolescent Family Life, and Nurse Home Visiting) are now accepting referrals. Please consider referring pregnant women and teens, as well as young children under the age of 1 whom you feel would benefit from public health nursing and other family health services. Examples of circumstances prompting referrals include first time mothers, parenting teens, poor social support or other family risks, smokers in the home, and pregnant women with a history of low birth weight babies or other perinatal problems. Depending on the individual situation, services may include support groups and classes, case management, home visits, and referrals and linkages to community resources. For more information, please contact Family Health Programs at 468-3004 or visit sjcphs.org/information/special_ services. Please also consider referring parents of young children for a car seat safety check (468-8914) and to the WIC nutrition program (468-3820).
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A message from
Karen Furst, MD, MPH, Health Officer and Cora Hoover, MD, MPH, Assistant Health Officer, San Joaquin County Public Health Services San Joaquin Medical Society’s Public Health Committee offered valuable input concerning community health issues Every 3 years San Joaquin County’s not-forprofit hospitals, community clinics, and San Joaquin County Public Health Services (SJCPHS) collaborate on a Community Health Needs Assessment. This year’s needs assessment is being conducted by Valley Vision, a Sacramentobased organization with expertise in the use of both quantitative and qualitative research to illuminate community health issues. On October 25, members of the Medical Society’s Public Health Committee, along with other Medical Society members, met with Valley Vision’s 2013 Community Health Needs Assessment team to offer their insights concerning health issues affecting residents of San Joaquin County. The physician focus group was one of multiple focus groups conducted throughout the County with service providers and community members. Participants in the physician focus group discussed San Joaquin County’s heath challenges and environmental and behavioral factors that contribute to these challenges. The discussion also addressed ways to engage the medical community and leaders from other sectors in developing a community health improvement plan.
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Influenza reporting requirements and laboratory testing recommendations for the 2012-13 influenza season
REPORTING TO SJCPHS
All cases of laboratory-confirmed influenza in patients ages 0-64 years that are fatal or that require intensive care are to be reported to SJCPHS. In addition, please report any acute outbreaks of influenza-like illness (ILI) in institutions or other congregate settings, especially when associated with hospitalizations or fatalities. (ILI is defined as fever (>100°F or 37.8°C) and cough and/or sore throat, in the absence of a known cause.)
As part of surveillance for variant (swine) influenza (e.g. H3N2v or H1N2v), please report all cases or outbreaks of ILI if there was recent exposure to swine or in people who were close contacts to a confirmed case of variant (swine) influenza. Contact the SJCPHS Communicable Disease Program (468-3822) for all suspected cases of variant (swine) influenza. At this time no cases of variant (swine) influenza have been reported in California.
SAN JOAQUIN PHYSICIAN 39
11 ANNUAL TH
W
e designed it this way, and now we can change it. That was the underlying theme of the 11th annual Community Health Forum held at the University of the Pacific on November 7, 2012. “Improving Community Health: Implications for Health System Efficiency” was the topic that drew 130 health, education and business leaders to engage in dialogue and identify the contributing factors that create barriers and opportunities for a healthier San
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Joaquin community. The latest findings of the Community Needs Assessment for San Joaquin County were presented by William Mitchell, MPH, Director of San Joaquin County Public Health Services and Dale Ainsworth, Managing Partner of Valley Vision. “The convening provided an opportunity for leaders in San Joaquin County to identify and prioritize the major health issues in our community, and begin to set an agenda for
our collective efforts to improve the health of San Joaquin County residents, “according to Mitchell. The presentation was laden with data pertaining to health indicators, environmental and behavioral indicators, and matched against social demographics. Colorful maps revealed frequencies of ER visits related to diabetes, hypertension, mental health and assault. Even more detailed maps portrayed the frequency of ER visits due to diabetes for female heads
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COMMUNITY HEALTH FORUM Is Inequality Making Us Sick?
of household in poverty. This was not the head-bobbing PowerPoint presentation. Forum participants actively engaged in the analysis through lively small group discussions. An underlying thread emerged with the question, “Is inequality making us sick?” “The notion that community health is in the hands of the community at large is changing,” said Ainsworth. “It’s not the health care system’s issue anymore. It’s
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everybody’s issue, including education, law enforcement, policy-makers, planners and more.” That concept is reinforced by the perspective of the Chair of Community Health Forum. San Joaquin County Supervisor Ken Vogel addressed the important role of Forum participants. “Community health assessments are core functions of a public health department,” said Vogel. But without the individual
by Lita Wallach
“The notion that community health is in the hands of the community at large is changing,”
SAN JOAQUIN PHYSICIAN 41
Community Health Forum
commitment to change health habits, progress will be slow. Community Health Forum provides an opportunity to identify our priorities and to move towards a healthier community through health education, public safety and environmental improvements.” The University of the Pacific has hosted the Community Health Forum for the past eleven years. A CHF steering committee meets monthly to discuss critical issues and to brainstorm ways to include community
partners in issues related to community health, health care reform, workforce and education. According to Pamela Eibeck, PhD, President, University of the Pacific, “The Community Health Forum is a great fit with University of the Pacific’s ongoing community engagement priorities. The data-driven dialogue generated by health, education and business leaders during the Forum focused on the critical relationship between education and health disparities.
You Have a Choice Choose Quality (209) 957-3888 www.hospicesj.org James Saffier, MD On-Site Medical Director Hospice & Palliative Care Internal Medicine
Joint Commission Accredited
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SAN JOAQUIN PHYSICIAN
Education is our core mission, of course, and it’s one of the community’s most promising means of improving quality of life for all residents. Pacific is looking forward to the next Community Health Forum as an opportunity to prioritize and plan in this collaborative process.” From a physician’s perspective, prioritizing efforts and reducing barriers to health access are urgent issues. “As physicians, we live with barriers every day that affect our ability to provide quality care for our patients,” said Patricia Hatton, M.D. “We need to plan for improved access now. This means access to interpreters, culturally sensitive educational materials and language specific brochures. We need more opportunities like the Forum so that we can share information, not only physician-to-physician but more importantly physicians with other health care stakeholders.” The Community Needs Assessment will be completed by the end of the year and a final report will be made widely available during the spring, 2013. Community Health Forum welcomes these next steps and encourages participant’s contributions to the process. Ainsworth added, “From my point of view, there is something very unique about San Joaquin County, including the partners of the Community Health Forum. Having worked in multiple community health assessments, San Joaquin County is head and shoulders above many other communities in its willingness to collaborate across multiple sectors. “ The newest participant of Community Health Forum noted on his second day in town, “I was impressed with the collaboration that was expressed at the Community Health Forum. It was a virtual who’s who of business, education and health leaders identifying common needs with a shared commitment to improve the quality of the community. At California Correctional Health Care Services, we want to be an active partner in this process. We have more to learn about Stockton and San Joaquin County. What’s impressive here is the integrated coordination of health, education and business in this community,” said Larry Fong, M.P.H., Chief Executive Officer, California Correctional Health Care Services, Health Care Facility.
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SAN JOAQUIN PHYSICIAN 43
KAISER PERMANENTE 44
SAN JOAQUIN PHYSICIAN
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MOSES
ELAM, MD KAISER PERMANENTE MEDICAL GROUP photos by Dale Goff
PHYSICIAN-IN-CHIEF
There is only one constant in the world of medicine and that is change. As we approach 2014 when further transformation is in store, many are daunted or maybe exhausted. Dr. Moses Elam is not one of them.
A
s Physician-in-Chief of The Permanente Medical Group Central Valley, Dr. Elam seems to thrive in an uncertain environment with optimism and enthusiasm. “Pre-paid, integrated health care delivery has demonstrated itself to be effective, efficient, offering great value to its members”. His organization is most suited to adapt to what is ahead. Dr. Elam oversees The Permanente Medical Group - Central Valley operations in San Joaquin and Stanislaus Counties, covering various Kaiser Permanente owned clinics in Stockton, Modesto, Tracy, and Manteca as well as Chief of Staff at Kaiser Foundation Hospitals, Modesto, and Manteca. In these, 460 Kaiser Permanente physicians deliver care to a population of 260,000 members, according to Dr. Elam. Nowadays being a Kaiser Permanente doctor is one of the most sought out careers for new physicians in primary care and specialty care alike and its physician satisfaction rate is very high. “We have a turnover rate of 2%”, says Elam, “and that includes retirees.” This is, as opposed to a general community rate of 16-18%. Traditional fee-for-service community physicians and large academic centers had viewed Kaiser Permanente for numerous
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story by Moris Senegor, MD
decades with skeptism. Everyone has heard of the famed Oakland shipyards and their owner Henry J Kaiser who pioneered the organization in conjunction with Dr. Sidney Garfield. The concept however, pre-dates these precursors of “prepaid healthcare models” all the way back to the early 1900’s in Southern California and Oklahoma. Kaiser’s Permanente’s own roots originate in 1933 delivering care to construction workers in tiny Desert Center, California, followed by larger projects including the construction on the Colorado River Aqueduct and the Grand Coulee Dam. With the latter the Kaiser construction company found itself in need to expand its coverage beyond the workers, and to their dependents, this sets the stage for the Oakland shipyards of World War II with its massive industrial output and workforce now covered via a pre-paid health plan. The visionary collaboration between the industrialist, Henry J Kaiser and Dr. Sidney Garfield, the innovative physician leader who proposed prepaid health care thus began with a clinic serving 20,000 people, which opened in Oakland in 1942. Since then Kaiser Permanente has grown to a multi-state behemoth with approximately nine million members across the country. It offers services in various regions including Northern and Southern California, as well as Colorado, Georgia, Ohio, Hawaii, the Pacific Northwest and MidAtlantic states. The system is an amalgamation of three distinct entities. The Kaiser Foundation Health Plan which is their insurance branch responsible for underwriting benefits and collecting premiums. Kaiser Foundation Health medical office buildings are where patients receive their care and The Permanente Medical Group (TPMG) is a professional corporation of physicians who oversee the care to the members.
SAN JOAQUIN PHYSICIAN 45
Moses Elam, MD
FROM ITS INCEPTION, KAISER PERMANENTE EMPHASIZED PREVENTIVE CARE, AND THIS REMAINS A MAJOR PART OF THEIR MISSION. From its inception, Kaiser Permanente emphasized preventive care, and this remains a major part of their mission. Nowadays preventive care is intimately tied to our electronic medical records (EMR), states Dr. Elam. As an example he points out through their PHP (preventive health prompt) system, and chronic care management programs, all patients are screened and monitored appropriately for such essentials as immunization, mammography, colonoscopy, cervical cancer screening, Hemoglobin A1C and LDL’s. Elam proudly points out that their EMR is accessible system-wide within all facilities throughout Northern California. Work is under way to expand compatibility of the system between Northern and Southern California. In our local community, Kaiser Permanente began as a hybrid model of HMO employed physicians and community providers in San Joaquin County, with Dameron Hospital as their main inpatient facility until recently. The hybrid physician model
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SAN JOAQUIN PHYSICIAN
remains in effect in Modesto, except that in 2008 hospital services became available as the new Kaiser Foundation Hospital opened. In San Joaquin County where Kaiser expanded prior to Stanislaus, the hybrid model was gradually replaced by exclusively Kaiser Permanente physicians. “We believe that the best quality and most efficient care is done within our facilities and by our physicians,” Dr. Elam points out. Their headquartering clinic on West Lane, which opened in 1992, is a main anchor of their services in our county. Dr. Elam strongly feels that freedom from fee-forservice medicine in a pre-paid, salaried environment aligns better incentives for efficiency and quality and at the same time cost-effectiveness. He points out that phone appointment visits are a regular part of their physician schedule, along with electronic messaging with patients through e-mail. A so-called “E-consult” system allows primary care physicians to engage Kaiser Specialists for advice via email or they can directly make an appointment with that specialist. Another, innovative initiative allows
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MICROSURGERY:
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SAN JOAQUIN PHYSICIAN 47
Moses Elam, MD
primary care to assess by phone, often while the patient is in the room. As a result, 30% of the time this results in prevention of referral to a specialist, the issue being resolved by the consult. Another 30% of the time necessary pre-testing is ordered prior to the referral, saving unnecessary visits. “Such practices are inconceivable in fee for service community practice”, he says because of their need to have the patient physically present in order to establish reimbursement.
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When I inquired how often these are used, his answer was, “every day, all the time!” Kaiser Permanente currently holds a 42% market share in the Bay Area, and 37% in the Central Valley. It also enjoys a populous applicant pool as employment in integrated delivery systems has become more desirable among young doctors. Currently the organization takes one out of every eight to ten physician applicants who seek a career opportunity with The Permanente Medical Group. As medical care delivery increasingly expands into large integrated groups and away from the traditional independent physician model, does Kaiser Permanente benefit from this or would they prefer to see a thriving local presence of solo physicians in the communities they serve? Dr. Elam points out that this is an issue determined by market forces. Purchasers and employers are seeking new and innovative ways to deliver care to their employees, in a high quality, cost efficient manner and at an affordable price. They say health care is too expensive, after all health care costs represent 16% of GDP nationally. When you look at our per capita spending, the U.S. spends almost twice as much as other industrialized countries. Throughout its presence in San Joaquin County, Kaiser Permanente has shown a strong commitment to community service, as exemplified by its multi-year participation in Su Salud, at the time the nation’s largest all volunteer health fair for the uninsured. Su Salud eventually moved out of the fairgrounds and into Kaiser Permanente’s West Lane Medical Center where it served uninsured residents for over 10 years. The organization has also provided steady support to the San Joaquin Medial Society. Currently with around 225 members, TPMG comprises approximately 38% of the active membership. All their doctors automatically become members unless they choose to opt-out. According to Mike Steenburgh, Executive Director of the society, largely due to Dr. Elam’s influence Kaiser has provided over a
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Moses Elam, MD
“I LIKE THE ABILITY TO SIMPLY BE ABLE TO GO INTO THE EXAM ROOM AND TAKE CARE OF THE DERMATOLOGY NEEDS OF MY PATIENT, WITHOUT WORRYING ABOUT GENERATING
decade of additional financial support for membership OVERHEAD EXPENSES,” programs and educational offerings, and, along with the Health Plan of San Joaquin to wide, toothy smile. His passion for what the society’s Decision Medicine program. he perceives as a mission to provide high When I pointed this out to Dr. Elam he said, quality, cost effective care is underscored “as physicians we are all in this together.” by his spirited and expressive body He then added that there is a need to search mannerisms with which he emphasizes his for joint solutions to the problem of cost points. containment in medical care. Dr. Elam was not always a pre-paid, In addition to his executive duties integrated health care advocate. A Cornell involving the oversight of operations trained dermatologist, he began his career and medical staff in a diverse group of as a traditional fee-for-service physician in entities spread over two counties, Dr. Elam New Jersey for ten years. He then joined emphasized his own personal community Kaiser Permanente in Raleigh, North commitment on several boards and Carolina, to be close to his family. When advisory committees including Stockton asked what he loves about his practice, Unified School Districts Health Careers “I like the ability to simply be able to Academy, Gallo Arts, Cal State Stanislaus, go into the exam room and take care of and UC Merced. He has also served the dermatology needs of my patient, two terms on our own society board of without worrying about generating directors. overhead expenses,” he says. When Kaiser An impeccably dressed and mannered Permanente left North Carolina in 2000, man, Elam gives a rather formal first he chose to stay with the organization impression. However, after a few minutes and relocated to Stockton where, with his of conversation, he eludes a certain ease wife Marcia he has raised two daughters, and charm, frequently enhanced by a Meghan and Morgan. Currently he still
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sees patients one day a week, while devoting the remainder of his time to his executive duties. “It has been great”, he says about his move to Stockton. Dr. Elam considers it a privilege and blessing to have been nominated and elected by his physician colleagues to serve as the Chief Medical officer of TPMG Central Valley “I have been blessed with a great career” In the meanwhile, Kaiser Permanente stands to easily fit into what has come to be known as “Obamacare”, the health care reform program soon to be implemented. With integrated, efficient, and costconscious care, already featuring an advanced and pervasive EMR system, the organization views itself at the vanguard of the direction in which government reforms are leading health care delivery. Still Dr. Elam sees more work ahead, and is eager to continue pushing the care-delivery envelope.
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SAN JOAQUIN PHYSICIAN 51
In The News
IN THE
NEWS
Dr. Tran Dr. Tran joins Millsbridge and Trinity Clinics The Lodi Memorial Community Clinics are pleased to welcome family practitioner Tony Tran, MD. Dr. Tran attended medical school at Ross University in Dominica. He completed family practice residencies at Regions Family Practice in St. Paul, MN, Loma Linda University and Hanford Family Practice in Hanford, CA. He practiced family medicine for three years at Mark Twain St. Joseph’s Hospital Clinic in Valley Springs. Most recently, he has worked as an urgent care physician in Sonora. Dr. Tran sees patients of all ages, and he speaks English and Vietnamese fluently. Dr. Tran practices at the Lodi Memorial Community Clinic – Millsbridge, located at 1901 West Kettleman Lane, in Lodi and Lodi Memorial Community Clinic – Trinity, located at 10200 Trinity Parkway, in Stockton. New patients and most insurances are accepted. Call 334-8540 in Lodi, or 948-0808 in Stockton, for appointments.
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Providing staff, physicians and patients with relevant & up to date information
UC Davis Medical Center and Dameron Hospital form joint venture UC Davis Medical Center in Sacramento and Dameron Hospital in Stockton will be forming a joint venture that will allow Dameron Hospital to strengthen its core medical services while delivering more care locally, and advances UC Davis’ historic land-grant mission to identify and help meet important societal needs. The University of California Board of Regents approved UC Davis Medical Center’s formation of Dameron Davis Management Company, a limited liability company (LLC) with Dameron Hospital, at its meeting yesterday in San Francisco. The LLC will own and operate Dameron Hospital. The collaboration is expected to create a financially self-supporting enterprise that advances the common and unifying health-care, charitable and educational missions of both organizations. “We are excited to team up with Dameron Hospital and look forward to working with our partners there to serve the residents of Stockton and the greater Central Valley,” said Ann Madden Rice, chief executive officer of UC Davis Medical Center. “Dameron has a distinguished, century-long history of serving the communities of San Joaquin County and beyond, and we eagerly anticipate joining their rich tradition.” “It is an honor for us to join forces with UC Davis, which not only has a top-flight academic hospital and medical and nursing schools, but a long history of high-quality care and close ties to the San Joaquin Valley in a variety of disciplines,” said Lorraine P. Auerbach, president and CEO of Dameron Hospital. “UC Davis is a natural partner for us, and we look forward to our collaboration improving the health care of people in Stockton and the Central Valley.” UC Davis Medical Center and the faculty physicians in the UC Davis School of Medicine operate as a hub for specialized care in a 33-county service area in inland Northern California. The medical center operates a 619-bed acute care adult and pediatric hospital that provides the region’s only level 1 burn center, level 1 adult and pediatric trauma centers, and full-service children’s hospital. The medical center also is nationally recognized for its NCI-designated Comprehensive Cancer Center, as well as the UC Davis Cancer Care Network, an affiliation of cancer centers around Northern and Central California that work together to offer their patients first-rate, cutting-edge care close to home. Among the network’s affiliates is the
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Lorraine P. Auerbach Mercy Cancer Center in Merced. Dameron Hospital is a fully accredited, independent, not-for-profit, non-sectarian 202-bed general acute-care hospital. With more than 1,200 employees and over 400 affiliated physicians, Dameron serves the greater San Joaquin County, including several cities and adjacent areas, as well as its rural and agricultural communities providing adult and pediatric acute medical and surgical care since 1912. Dameron offers a broad range of medical, surgical and emergency care, with strengths in orthopaedics, neonatology and cardiovascular services. The hospital ranks as one of the leading providers for deliveries in the county and is an essential provider of emergency care to the community, with more than 38,000 visits annually to the Dameron Emergency Department in recent years. The LLC will further the community engagement mission of UC Davis to improve the quality of health care in the Central Valley. The expertise of UC Davis Medical Center will help deliver evidence-based advances in clinical care to Central Valley patients and families. Because of its longstanding programs and focus on community and rural health, the impact of health disparities and the social determinants of health, UC Davis is well
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prepared to address these areas as a partner with Dameron in the Central Valley. The venture will provide an avenue for the large, diverse populations of the Stockton region to participate in the many research studies conducted by UC Davis that investigate today’s newest drugs and potential breakthrough treatments, before they become widely available. UC Davis and Dameron both have significant histories in the San Joaquin Valley. UC Davis’ specialty physicians provide expert care via telemedicine consultations, and medical residents and graduates train and work in the valley’s hospitals and clinics. Collaborations in the area include work with UC Merced to train new physicians to work in rural communities through the UC Davis San Joaquin Valley PRIME (Programs in Medical Education) Program. Other major UC Davis programs that extend into the valley include Public Health Sciences, Agricultural and Environmental Sciences, and Veterinary Medicine. UC Davis and Dameron officials expect to finalize the formation of the LLC over the next several months, launching the venture in spring 2013. The non-profit LLC will be governed by a Board of Managers appointed by UC Davis and Dameron. Dameron Hospital Appoints Lorraine P. Auerbach as New President & CEO Dameron Hospital announced that Mrs. Lorraine P. Auerbach, FACHE has been appointed its new President and CEO by a unanimous decision of the Dameron Hospital Board of Directors. The announcement was made at the hospital’s 100th Anniversary Celebration held Saturday evening. Mrs. Auerbach has had repeated successes in her more than 25 year tenure as a health care leader and CEO. She has worked with large and small organizations across the state and has broad and diverse expertise as a hospital CEO. Most recently, Mrs. Auerbach served as President & CEO of Seton and Seton
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SAN JOAQUIN PHYSICIAN 53
In The News
IN THE
NEWS “We are very pleased and excited by the expertise and energy Mrs. Auerbach brings to Dameron Hospital. Our Board believes that under her leadership, we are well-positioned to explore a range of opportunities that will prepare us for the future,” - Dr. Corky Hull,
Coastside Medical Centers in the Bay Area. At Seton, Mrs. Auerbach developed and implemented a strategic direction and vision for the medical centers. She raised the bar significantly on quality and service, created a more sound financial footing for the hospitals, and repositioned them to be more connected to the community. She expanded the hospitals’ market share and developed strong partnerships with key physicians and area medical groups. She changed the culture to one of transparency and trust, and strengthened Seton’s key programs and services. Mrs. Auerbach’s successes at Seton Medical Center/Seton Coastside have been recognized both nationally and locally. Seton was named by US News and World Report in 2011 as the “5th Best Hospital” out of 44 hospitals in the Bay Area. And Mrs. Auerbach herself was recognized that same year by the San Francisco business community as one of the “Most Admired CEOs” in the Bay Area and for two years in a row as one of the Bay Area’s “Most
Influential Women in Business.” Mrs. Auerbach currently serves as a member of the Board of Directors of the Hospital Council of Northern and Central California and, among other prestigious appointments, has served as Chairman of the national CEO Committee of the American College of Healthcare Executives. She is board certified in healthcare administration and is a Fellow of the American College of Healthcare Executives. “We are very pleased and excited by the expertise and energy Mrs. Auerbach brings to Dameron Hospital. Our Board believes that under her leadership, we are well-positioned to explore a range of opportunities that will prepare us for the future,” said Dr. Corky Hull, a Board member and leader of the CEO search process. “The future holds many opportunities for Dameron Hospital. I am excited to be a part of its leadership team. On the eve of its 100th anniversary, Dameron’s future is bright,” said Mrs. Auerbach.
HAVE SOMETHING TO SHARE? We welcome submissions to our In-the-News Section from our community healthcare partners. We prefer Word files and .jpg images and may edit for space restrictions. Send your files to nikki@sjcms.org one month prior to publication (Aug 1 for the Fall issue, Nov 1 for the Winter issue, Feb 1 for our 2013 Spring issue and May 1 for our 2013 Summer issue).
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THE NEED FOR HEALTH-CARE SERVICES IS CRITICAL, AND DONATIONS CONTINUE TO BE ACCEPTED FOR THIS CAUSE.
LMH RN LEAVES US TO FORM ETHIOPIAN CLINIC AFTER 16 YEARS OF SERVICE, LMH ICU NURSE SHELLIE CARLSON BID LMH – AND THE U.S. – FAREWELL ON AUG. 27. HER DESTINATION: ETHIOPIA. HER MISSION: TO HELP OPEN AN AMERICAN MEDICAL CLINIC IN ADDIS ABABA, THE NATION’S CAPITAL.
While this might seem like a drastic change of scenery to some, for Shellie, she’s returning home. Shellie’s parents moved the family to Ethiopia as missionaries when she was five months old. Her nanny, an Ethiopian native, spoke only Amharic, Ethiopia’s national language, so Shellie learned at home while her parents took language classes. Ethiopia is known at the cradle of civilization, as earliest human origins can be traced back to the region. The country faced civil war in the mid-1970s, during which Ethiopian Emperor Haile Salassie was deposed. Shellie’s family was forced to flee the country then – taking with them 10 of the emperor’s grandchildren who would have been imprisoned or executed. Shellie was 15 when her family left their home behind. Last year when Shellie was able to return to Ethiopia for the first time since her family fled, she met the founder of St. Yared Hospital in Addis Ababa, Akeza Teame, MD. Dr. Teame is Ethiopian-born but was educated in the U.S. He was thrilled to discover she was fluent in the language, and
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invited her to join him in a venture to open a new clinic in the region. This clinic’s opening could not be more timely. Ethiopia’s population tops 84 million. Its physician population numbers only 1,800. That’s one doctor for every 46,000 patients. And pediatricians are fewer and far between – there are only 50. HIV infection is highly prevalent in the region, and many children are orphaned and/or infected. The need for health-care services is critical, and donations continue to be accepted for this cause. Shellie won’t be alone in her venture. Her mother, her 13-year-old daughter and her husband will join her soon. Shellie’s mother has established a charitable organization called Humani, Inc. for women with HIV and their children – a sustainable farm where they can grow their own food and earn their own income. But additionally, she may soon receive a visit from LMH president and CEO Joe Harrington. Joe, who has taken an interest in the clinic, has been awarded a fellowship to research international health issues, and he hopes to travel to see the clinic
personally. LMH’s support and interest doesn’t end there. Once staff learned of Shellie’s plans, extra efforts were made to help her procure the supplies needed to open a medical clinic in a third world country. The LMH Facilities Management Department was instrumental in helping her acquire used hospital beds, crash carts, a gurney and multitudes of medical supplies that were no longer usable by LMH. Shellie says she’s been overwhelmed by the outpouring of generosity and support of her “LMH family.” From items left at her locker to her doorstep at home, Shellie has acquired a cache of equipment that will be shipped by container halfway across the world to supply the new clinic. To read Shellie’s reports from Ethiopia, including more detail on her history and photos, or for information on how to help the clinic, visit the LMH employee bulletin board, www.lmhemployees.org or email Shellie directly at naturesblessings74@ gmail.com
SAN JOAQUIN PHYSICIAN 55
practice manager Free to SJMS/CMA Members!
resources
The Office Manager’s Forum empowers physicians and their medical staff with valuable tools via expert led educational sessions from industry professionals who are committed to delivering quality health care. For more than 130 years, the San Joaquin Medical Society (SJMS) has been at the forefront of current medicine, providing its physician’s and their staff with assistance and valuable practice resources. SJMS is proud to offer the Office Manager’s Forum, a monthly educational seminar designed to enhance the healthcare environment with professional development opportunities while providing solutions to some of the challenges that come from managing a practice. Attendees gain knowledge on a broad array of topics related to the field of medical staff services, office management, billing and coding, human resources, accounting and back office support. The Office Manager’s Forum is held on the second Wednesday of each month from 11:00AM – 1:00PM at Papapavlo’s in Stockton and includes a complimentary lunch. Attendance is always FREE to our members. Non-members are welcome and may attend for one month at no cost to experience one of the quality benefits that comes with Society Membership ($35.00 thereafter). Registration required. For more information or to be added to the mailing list email Jessica Peluso, SJMS Membership coordinator, at Jessica@SJCMS. org or call (209) 952-5299.
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DECEMBER 12TH, 2012:
MEDICARE UPDATE 2013 11:00AM to 2:00PM Join us for our annual Medicare Update workshop for physicians and office staff. This 3 hour seminar will cover relevant information about current, future and proposed changes for the coming year. Michele Kelly, Associate Director, CMA’s Center for Economic Services, provides one-on-one assistance to physician members and their staff on reimbursement and practice operations issues. Assistance ranges from coaching and education, to direct intervention with payors or regulators.
JANUARY 9TH, 2013:
CALIFORNIA’S CHANGING INSURANCE MARKETPLACE- WHAT PHYSICIANS NEED TO KNOW 11:00AM to 1:00PM This seminar covers the California Health Benefits Exchange and how it will affect your practice. Additional topics to be covered include, updates on Critical Payor Issues, the Duals Demonstration Project, the expansion of Medi-cal Managed Care, and the impact of the ACA on the Medi-cal Program.
Jodi Black, Senior Director of California Medical Association’s Center for Economic Services provides member physicians and their office staff with assistance in improving the success of their practices through education and intervention with payer issues.
FEBRUARY 13TH, 2013:
TAKING CHARGE-A STEP BY STEP GUIDE TO EVALUATE AND PREPARE FOR NEGOTIATIONS WITH MANAGED CARE PAYORS 10:00AM to 1:00PM In this 3 hour information packed presentation, you will learn how to maximize success in negotiating with a high-level review on contract terms and provisions as well as identifying contracts that are beneficial and cutting ties with those that aren’t. Kristine Marck, from CMA’s Center for Economic Resources
MARCH 13TH, 2013:
“DIRECTOR OF FIRST IMPRESSIONS” 11:00AM to 1:00PM The adage that first impressions count can be applied to any real-life scenario, but it is even more important when it relates to intimate issues like health. First Impressions play a role in the success of your Medical Practice, and Part 3 of the Office Managers Educational Series is designed to provide you with the tools to help your office staff with Customer Service, Telephone and Patient Relations Techniques. Debra Phairas, President of Practice Liability Consultants comes to you with 20 years of experience and is here to assist you by providing superior practice management and customer service.
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2012/2013 Education Series
Jan. 9: HIPAA and Meaningful Use: What You Need to Do for a Legal Attestation David Ginsberg • 12:15 – 1:15 p.m. Both Stage One and the 2014 Edition (Stage Two) Meaningful Use Objectives include the HIPAA Security Risk Analyses and related requirements. Since physicians must attest to having met these requirements, it is imperative to understand what is necessary. This webinar will focus on the specific HIPAA meaningful use measures as well as practical guidance in meeting these. Jan. 16: Medi-Cal Application Forms Training and Regulations Update DHCS • 12:15 – 1:45 p.m. The California Department of Health Care Services (DHCS) will soon be notifying physicians that they must re-enroll in Medi-Cal as one of the provisions of the Affordable Care Act (ACA). This training will give applicants basic instructions and guidelines on the proper way to complete a Provider Enrollment Application Package. Representatives from the Department of Health Care Services will discuss the importance of reviewing and understanding program requirements and how to avoid mistakes when completing the forms. Jan. 23: Understanding ARC and CARC Revenue Codes David Ginsberg • 12:15 – 1:15 p.m. The use of remark codes and claims adjustment reason codes became standardized under HIPAA. The recent introduction of the 5010 standards further emphasizes use of these codes on remittance advices and payments made to medical offices by health insurers. Understanding the codes can assist medical practices in more effective payment posting and follow up on denials or payment reductions. Feb. 6: HIPAA Compliance: The Final HITECH Rule David Ginsberg • 12:15 – 1:15 p.m. The HITECH Act created the extensive funding incentives and standards for adopting electronic health records; it also created new HIPAA rules or modified existing ones. This webinar will provide an overview of the changes to HIPAA and key steps medical practices can take to comply with these changes. Feb. 7: Impact of ICD-10 AAPC • 12:15 – 1:45 p.m. ICD-10 will bring about some massive changes in healthcare. No matter what the implementation date, you need to understand how you will be impacted and what you should be doing now to prepare. The above webinars are being hosted by the California Medical Association. Please register at www.cmanet.org/events. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar. Questions? Call the CMA Member Help Line at (800)786-4262.
Please note that this calendar does not include CMA’s SAN JOAQUIN PHYSICIAN 57 in 2012. ICD-10 training courses to be offered
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In Memoriam
In Memoriam Robert F. Nejedly M.D. • Edwin Swillinger • Michel G. Khoury
Dr. Nejedly practiced in Stockton for over 35 years and was a very prominent physician. He joined the San Joaquin Medical Society in 1954 and was with the California Medical Association for 38 years.
ROBERT F. NEJEDLY M.D. July 12, 1925 - July 27, 2012 Member Since 1954 – 38 Years Robert Francis Nejedly, MD, passed away on July 27, 2012 peacefully at his home. He was born in Chicago, Illinois to Frank and Julia Nejedly. A graduate of De La Selle High School, he attended St. Mary’s College in Winona, Minnesota. After transferring and serving as a corpsman at the Great Lakes Naval Hospital, Robert completed medical school at the University of Illinois. He completed his internship at St. Francis Hospital in Evanston, where he met his wife, Dolores. After serving as a naval officer in the Korean War, Dr. Nejedly completed his internal medicine residency at the V.A. Hospital outside Chicago. Bob and Delores married in 1954 and moved to Stockton, raising five children. Dr. Nejedly practiced in Stockton for over 35 years and was a very prominent physician. He joined the San Joaquin Medical Society in 1954 and was with the California Medical Association for 38 years. He was an instructor for the intern and residency program at the San Joaquin General Hospital, the director of Foundation for Medical Care, and was the chief of staff at St. Joseph’s Hospital, where he later served on their Board of Trustees. Bob was also active in his community, being a member of Rotary, Serra Club, and the Stockton Symphony Association. Dr. Nejedly was truly a family man and was grateful for the wonderful times that he spent with his family. He is survived by his wife: Dolores Nejedly, his children: Anne and Rady Mallett, Bob Nejedly, Donald and Julie Nejedly, Mary Nejedly, Susan and Bill Filios, his sister: Phyllis Polacek, and his grandchildren: Charlie Nejedly, Sam Nejedly, Melissa Mallett, and Emily Mallett.
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SAN JOAQUIN PHYSICIAN 61
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In Memoriam
EDWIN SWILLINGER August 11, 1927 - August 19, 2012 Member since 1957 – 33 years Edwin Swillinger, MD, passed away peacefully on August 19, 2012. He was 85. Edwin was born in Cincinnati, Ohio and grew up near the University of Cincinnati Medical School, where he later attended medical school. In being a corporal in the U.S. Army of Occupation in Japan, Dr. Swillinger was known for providing old-school services and abiding by rigorous standards that he set for himself. He completed his internship at Los Angeles County Hospital, where he met his wife, Margery, of 42 years. Before establishing his private practice in Stockton, Dr.Swillinger completed residencies at San Francisco General Hospital and San Joaquin General Hospital. He became a member of the San Joaquin Medical Society in 1957 and practiced in Stockton for 40 years. Even after retirement in 1977, Dr. Swillinger remained active in his community. He volunteered at St. Mary’s Health Clinic for the homeless, St. Joseph’s Medical Library, and the Chronic Fatigue Lab at the University of the Pacific. Dr. Swillinger also co-authored “Managing Your Health Care,” which advocated for allowing patients to be active in making their medical decisions. His personal interests included war history, aviation, and travel. Dr. Swillinger was also talented in music, playing the clarinet for the Stockton Concert Band, the Delta College Jazz Band, and more. Dr. Swillinger is survived by his son, two daughters: Rebecca and Heidi, and his twin brother, Richard Swillinger. He was predeceased by his wife, Margaret, his daughter Lisa, and his son Andrew.
MICHEL G. KHOURY February 18, 1930 - October 29, 2012 Michel G. Khoury was a pragmatist. He always took what life dealt him in gracious stride and with a positive outlook. This did not come easily but he managed for over 80 years to carry out every action or decision with seeming ease, even at the very end of his life. His friends, colleagues, relatives and employees know this first-hand. Michel is often described as a gentleman’s gentlemen: always gracious, kind and companionate. He listened intently to others and formulated a response when needed, dispensing
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advice only when asked and never in a demeaning manner. My two brothers, 11 uncles and aunts, and extended cousins all over the world had the opportunity to interact with my father and all always looked up to him. He was indeed the true manifestation of a Modern Day Patriarch. From humble beginnings in Ramallah, Palestine under English rule, Michel’s journey through life included an understanding and appreciation for people from conflicting and differing backgrounds. His family moved from Ramallah to Gaza, Palestine where his father worked for the Palestinian Health Department under the auspices of the British government as a health inspector. He would travel throughout Palestine, as it was known then, and on occasion took Michel with him. This was Michel’s introduction to the world of medicine: going to immunization clinics and hospitals, as well as restaurant and food inspections. He encountered an astounding array of different people from different religious and cultural backgrounds, infused with the interaction between eastern and western ideologies that is unique to the region. From those early pre-pubescent years Michel started to understand that life is a complex journey, where every action always has more than one interpretation. Michel excelled academically and enjoyed the learning environment from a young age. In the 8th grade, Michel’s academic standing as one of the top students within the matriculating student body in all of Palestine enabled him to attend the prestigious Arab College for Boys in Jerusalem. Away from his family at boarding school, he completed his education at the age of sixteen. Too young to attend University, Michel spent another year at the Rashidiya College Preparatory School (equivalent to the freshman year college in the United States). After succeeding there, Michel attended the American University of Beirut where he completed his college and medical school education in six years. By 1954, the political upheavals throughout the region, including the creation of Israel, rendered Michel a citizen of the world, but a man without a country of citizenship. This was yet another experience he endured and learned from, one that profoundly affected his life and shaped his political views for years to come. The exodus out of Palestine by its native peoples in the late 1940s included Michel’s immediate family members, following which they found themselves settled in Lebanon. Despite the move, Michel’s lack of citizenship prevented him from practicing medicine in Lebanon. His best option in overcoming this barrier and attaining citizenship required his joining the Jordanian military. Just prior to his departure to the army, Michel received notice that an American oil company called Tapline wanted to recruit physicians to their hospitals in Saudi Arabia. Tapline operated as an oil pipeline company that pumped oil from Saudi Arabian oil fields to Lebanon for refinement, following which oil tankers shipped it off to the United States. There were thousands of miles of
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In Memoriam
is a gift we learned to appreciate and treasure. We looked forward to school vacations during which we could fly back to Saudi Arabia and reunite with our father as well as childhood friends.
pipeline with several pumping stations along the route from Saudi Arabia to Lebanon; these stations became communities housing hundreds of people. Employees and their families living at these stations required necessary accommodations, such as medical centers. Luckily for us future children, Michel opted to go to Saudi Arabia. This also resulted in expediting his residency status, whereby Michel became a Lebanese citizen. His choice in going to Saudi Arabia unexpectedly reunited him with my mother, Nadia, whom he met while in medical school. She was a nursing student; the story of how our parents met originally is as acquaintances, and not romantic. Both young with lofty goals of helping the world, their paths seemingly diverged. Two years following their meeting, however, Michel and Nadia crossed paths again in Saudi Arabia, having both agreed to work for Tapline. A year later in 1956 they married. Michel’s years in Saudi Arabia also allowed him to spend a year in England training in Tropical Medicine (currently referred to today as infectious disease). Shortly after, he became medical director of the Main Hospital in Badanah, Saudi Arabia. This position enabled Michel to develop valuable skills as negotiator between the Americans and the local Saudi Arabian government, establishing excellent mutual relations between the two as well as extending health care to the Saudi Arabians and Bedouins. During these years, my parents started their family, which included my two brothers, Ramzi and Sami and me. Once we required higher education, the three of us attended boarding school in Lebanon. The next three years of long distances and boarding school proved too difficult for all, and our mother eventually moved to Lebanon, allowing us to attend school as regular day students. My father traveled every six weeks from Saudi Arabia to see us, but the distance and separation challenged our family. This sacrifice by our parents is one of many lessons we learned regarding responsible parenting. None of us ever took anything for granted; simply being together as a whole family
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Saudi Arabia seemed an unlikely place for us to learn about the American Dream. To us as children this place we currently lived in was already a dream come true. We grew up with Americans, Brits, and Europeans as well as Arabs from all countries. However, we didn’t see such harmonized living in Beirut. Our reality in Lebanon included the1967 war with Israel; refugee camps, Israeli fighter jets patrolling the skies, brewing animosities between the Palestinian refugees and Lebanese, the occasional tanks on the streets dominated daily life. We lived in fear wondering where the next bomb would land. Palestinian guerrillas routinely struck Israel, resulting in retaliation. This world became too unsafe and not what our parents envisioned for us. The political nightmare rapidly brewed, and we could only watch as Lebanon stood upon the brink. Our parents started the process to immigrate to the United States, which took 4 years. Having worked for Tapline from 1954 to 1971 as an internist, Michel changed careers and applied to a Radiology Residency program. In the late 1960s, an evolution in the science of radiology was changing its role and interaction with medicine on multiple levels. This was an intriguing development that Michel witnessed firsthand as director of the hospital; he began utilizing cutting-edge x-rays procedures in medicine and surgery. Radiotherapy, nuclear medicine and ultrasound were to become the new fields in medicine, and Michel felt this was his new career direction. Michel started all over again with a three year radiology residency at Roanoke Hospital, Virginia. Like many foreign graduate physicians in this country, Michel swallowed his pride; despite his reputation as a well-respected, knowledgeable physician, he graciously complied and willingly started over as a lowly resident. He was 41 years old then, with three children in high school. Our family went from being wellto-do in the Middle East to learning to live on a resident’s salary in a donated house for residents with families, occasionally having to eat dinners at the hospital cafeteria. Despite these hardships, we never felt lacking for anything. We learned
the difference between wanting and needing, the meaning of delayed gratification, and, most importantly, that the end does justify the journey even when it is a hard road to pursue. All of us children have relived this principle in pursuing our respective careers. We kids studied late into the night throughout high school alongside our dad, who also worked late hours reading his radiology texts and journals. To stay awake he would eat peanuts, but typical of our father he would eat them with a spoon as so as not to get oil on his books. His on-call and long hours only fueled our combined resolve to get through it together. Our parents, once again, put their life on hold for the benefit of their children. After finally graduating from his residency
program, Michel pursued a year fellowship at Johns Hopkins Medical School in advanced imaging. He chose the promising technology of ultrasound, which he pioneered in bringing to Stockton. Both Michel and I graduated together in 1975: he from fellowship and me from high school. The rest of my brothers followed subsequently, eventually all three attending University of Pacific, which in turn closed the final chapters of Michel’s life. Michel and Nadia made their final move to Stockton, California in 1977, where they spent the next 35 years. Stockton welcomed them warmly; not only did both our parents have family in the area but the medical community similarly welcomed them with open arms. Help came from a variety of established physicians in town, including Joe Barakett, Anthony Rishwain, and Henry Zeiter. Michel opened his private practice in the Hunter Medical Building where he developed a long-term friendship with Anthony Ferrari, M.D. Over the years he pursued relationships with the other radiologists and physicians in Stockton through the social
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In Memoriam
gatherings of the Medical Society. Getting involved with his community as well as with the medical society taught us the great joys in serving one’s community. Michel believed that the goal of becoming a physician is not just to excel academically or professionally, but to serve your community the best possible way with whatever means available. After two previous attempts, he ultimately retired in 2010; Michel finally felt comfortable
with the idea of not having to go to work. Nadia and Michel traveled extensively prior to retiring, visiting almost all continents except for Antarctica. At the age of 80 they preferred local short vacations, and mostly enjoyed playing golf and bridge. He looked forward to his weekly Thursday meeting with the DOGs, or Distinguished Old Gentlemen, his dear friends including David Bernard, Ron Duncan, Hans Frey, Alfred Dahlke, Lony Kamenetsky, Walter Kushner, Orest Wesley. They enjoyed debating
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different perspectives that doubtlessly enriched their appreciation for diversity, enhanced by the exchange of life experiences. True to his form, Michel continued to prove that he always strived to learn new things and always desired to listen to others’ perspectives, sometimes at the risk of changing his own opinions! Michel advocated strongly for the medical society, and when I joined his practice, he emphasized the importance of joining the Medical Society, the CMA, and the AMA, in addition to the Radiology specialty societies. Despite differences in ideologies amongst the groups, Michel insisted that we are first and foremost physicians with a responsibility to be part of the larger group in order to affect change. Through the Medical Society, Michel actively took part in outreach programs for the community including Su Salud, contributed to charities of his father’s parish St. Basil, and many other charities in Stockton, United States and the Middle East. He proudly watched all his children, nieces, and nephews grow and accomplish personal and career goals. It is also with great joy Michel inspired and encouraged his grandchildren to pursue challenging, rewarding careers. He valued the great privilege of seeing his grandchildren grow; he attended soccer games, high school graduations, and college graduations. He did not have the luxury of seeing any of his grandchildren marry and give him great-grandchildren, although his legacy doubtless will continue to influence his family to pursue his inspiring path. To all who knew Michel, interacted with him, and taught him he always shared his profound thanks and appreciation for all. He hoped for more to come, but when the time came for him to leave this world, as typical of his nature, he prepared all that was necessary long before it was due. Just as he lived, he thought only of others in his last hours, especially of Nadia and his family. His legacy continues within every member of our family, and will always inspire us to walk the difficult but rewarding path together. Nadia, George, Kari, Ramzi, Bobbie, and Sami thank you all for the thoughtful and caring wishes and condolences you shared with us.
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New Members
33 NEW
MEMBERS IN THE PAST 60 DAYS!
...and even more on the way. Al Khan Alsua, M.D. Family Medicine Kaiser Permanente-Tracy (209) 839-3200 2185 Grant Line Rd, Tracy, CA 95377 University of Santo Tomas Faculty of Medicine and Surgery: 1999 Poonam Arora, M.D. Family Medicine Kaiser Permanente-Manteca (209) 824-5051 1721 W. Yosemite Ave, Manteca, CA 95337 GSVM Medical College, Kanpur University: 1992 Zhiqiang Chen, M.D. Occupational Medicine Kaiser Permanente-Manteca (209) 825-3700 1721 W. Yosemite Ave, Manteca, CA 95337 Hunan Medical University: 1998 Laura A Gabriele, M.D. Obstetrics and Gynecology Kaiser Permanente-Stockton (209) 735-5000 7373 West Lane, Stockton, CA 95210 University of California School of Medicine- Davis: 1994 Kerstin Guevarra-Vitug, M.D. Family Medicine Kaiser Permanente-Stockton
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(209) 476-2000 7373 West Lane, Stockton, CA 95210 University of Santo Tomas Faculty of Medicine and Surgery: 2002 Ilia Gur, M.D. General Surgery Sutter Gould Medical Foundation (209) 941-0127 2545 W. Hammer Lane, Stockton, CA 95209 Technion-Israel Institute of Technology: 2004 Asma Jafri, M.D. Family Medicine San Joaquin General Hospital (209) 468-6768 500 W. Hospital Road, French Camp, CA 95231 Punjab University, Government Medical College: 1977 Samira Jahangiri, M.D. Family Practice St. Joseph’s Medical Group (209) 475-5500 3132 W. March Lane, Ste 5, Stockton, CA 95219 King Edward Medical College: 2003 John Kim, M.D. Obstetrics and Gynecology Gill Obstetrics & Gynecology (209) 466-8546 1617 N. California St, Suite 2A, Stockton, CA 95204 Chicago Medical School: 1990
Sneha Kishorenath, M.D. Hospitalist Sutter Gould Medical Foundation (209) 524-1211 2505 W. Hammer Lane, Stockton, CA 95209 Bangalore University: 2002 Jun Lu, M.D. Allergy & Immunology, Internal Medicine Sutter Gould Medical Foundation (209) 954-3370 2505 W. Hammer Lane, Stockton, CA 95209 SUNY Downstate College of Medicine: 2003 John Macapinlac, M.D. Pediatrics Kaiser Permanente-Stockton (209) 476-2080 7373 West Lane, Stockton, CA 95210 American University of the Caribbean: 1997 Melissa Manaig, M.D. Pediatrics Sutter Gould Medical Foundation (209) 944-2799 2505 W. Hammer Lane, Stockton, CA 95209 Far Eastern University: 2002 Max Miller, M.D. Emercency Medicine Kaiser Permanente-Manteca (209) 525-7212 1777 W. Yosemite Ave, Manteca, CA 95337 Medical College of Wisconsin: 1984
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New Members
Maya Nambisan, M.D. OB&GYN P Gill OB&GYN Medical Group (209) 824-2202 1234 E. North St #102, Manteca, CA 95336 University of Illinois: 2008 Harry Newman, M.D. Family Practice Office: (209) 835-4141 1212 West Center Street, Ste 52, Manteca, CA 95337 Oregon Health Science University: 1972 Chun Ng, M.D. Hematology Kaiser Permanente-Stockton (209) 476-2000 7373 West Lane, Stockton, CA 95210 New York Medical School: 2006 Peter Ngo, M.D. Family Medicine Kaiser Permanente-Manteca (209) 825-3700 1721 W. Yosemite Ave, Manteca, CA 95337 University of Virginia School of Medicine: 2002 Kristen Patters, M.D. OB/GYN Kaiser Permanente-Stockton (209) 476-2080 7373 West Lane, Stockton, CA 95210 Creighton University: 2008 Prasad Perumbeti V, M.D. Anesthesiology Sutter Gould Medical Foundation (209) 524-1211 2505 W. Hammer Lane, Stockton, CA 95209 Madras Medical College: 1973 Alex Phan, M.D. Interventional Pain Alpine Orthopaedic Medical Group (209) 948-3333 2488 N. California Street, Stockton, CA 95204 New York Medical College: 2001
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Archana Reddy, M.D. Endocrinology San Joaquin General Hospital (209) 468-6618 500 W. Hospital Road, French Camp, CA 95231 NTR University of Health Sciences, Gandhi Medical College: 1997 Shamsunder Samant, M.D. Emercency Medicine Kaiser Permanente-Manteca (209) 735-4176 1777 W. Yosemite Ave, Manteca, CA 95337 Karnatak Medical College, Karnatak University: 1972 Amin Shamal, M.D. Psychiatry Kaiser Permanente-Manteca (209) 858-7749 1777 W. Yosemite Ave, Manteca, CA 95337 Kabul Medical University Faculty of Medicine: 1987 Anupender Sidhu, M.D. Family Practice Kaiser Permanente-Manteca (209) 824-5051 1721 W. Yosemite Ave, Manteca, CA 95337 Rashtrasant Tukadoji Maharaj Nagpur University: 2003 Leena Sumitra, M.D. Psychiatry Kaiser Permanente-Tracy (209) 557-1650 2185 W. Grant Line Rd, Tracy, CA 95377 Medical College of Virginia Commonwealth University School Medicine: 2001 Betty Tsang, M.D. Pediatrics Kaiser Permanente-Manteca (209) 825-3700 1721 W. Yosemite Ave, Manteca, CA 95337 Drexel University College of Medicine: 2009
(209) 476-2080 7373 West Lane, Stockton, CA 95210 Ross University School of Medicine: 2008 Agnes Wang, M.D. Urology Kaiser Permanente-Manteca (209) 858-7770 1789 W. Yosemite Ave, Sierra Building, 2nd Floor, Manteca, CA 95337 University of Texas Southwestern: 2005 John Weedin, M.D. Urology Kaiser Permanente-Manteca (209) 825-3700 1721 W. Yosemite Ave, Manteca, CA 95337 University of California San Diego School of Medicine: 2006 Clyde Wong, M.D. Family Medicine St. Joseph’s Medical Group (209) 475-5500 3132 W. March Lane, Stockton, CA 95219 Stanford University: 1983 Khaleedah Young, M.D. Family Medicine Kaiser Permanente-Manteca (209) 824-5051 1721 W. Yosemite Ave, Manteca, CA 95337 Western University of Health Sciences: 2007 Joseph E. Zeiter, M.D. Internal Medicine, Ophthalmology Zeiter Eye Medical Group (209) 747-2121 255 E. Weber Ave, Stockton, CA 95202 Wayne State University School of Medicine: 2008
Kim Vo, M.D. Family Medicine Kaiser Permanente-Stockton
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San Joaquin Medical Society 3031 W. March Lane, Suite 222W Stockton, California 95219-6568
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