October 2016 | San Mateo County Physician Magazine by Los Angeles County Medical Association

S a n M at e o C o u n t y

October 2016

IN S ID E

S A N M AT E O C O U N T Y M E D I C A L A S S O C I AT I O N

Volume 5 Issue 9

Physician PATIENTS, PRACTICE & PUBLIC HEALTH

VOTE 2016

Vote 2016: Patients, Practice & Public Health

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Physician

EDITORIAL COMMITTEE

Russ Granich, MD , Chair | Judy Chang, MD | Uli Chettipally, MD Sharon Clark, MD | Carri Allen Jones, MD | Edward Morhauser, MD Gurpreet Padam, MD

October 2016 - Volume 5, Issue 9

Sue U. Malone | Executive Director SMCMA LEADERSHIP

Russ Granich, MD | President Alexander Ding, MD | President-Elect Sara Whitehead, MD | Secretary- Treasurer Michael Norris, MD | Immediate Past President Janet Chaikind, MD Uli Chettipally, MD Mamatha Chivukula, MD Paul Jemelian, MD Alex Lakowsky, MD Richard Moore, MD Joshua Parker, MD Xiushui (Mike) Ren, MD Brian Tang, MD Dirk Baumann, MD | AMA Alternate Delgate Scott A. Morrow, MD | Health Officer, County of San Mateo www.SMCMA.org facebook.com/smcma | twitter.com/SMCMedAssoc.

Columns President’s Message: Seeing Is Believing 2 Russ Granich, MD

Feature Articles My Approach to Voting 4 Vote 2016: Patients, Practice & Public Health

EDITORIAL

San Mateo County Physician is published ten times per year by Physicians News Network (PNN) and the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of PNN or SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

Of Interest Upcoming events, classified ads 12

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President’s Message

Seeingisbelieving ...or is it? OVER THE 30 YEARS OF MY CAREER,

We talk of consciousness or sentience, yet what is it really?

I’ve had experiences or observed things that I could not explain. One incident particularly stands out. As a hospitalist and then palliative care and hospice physician, I have pronounced many patients as dead. I could walk into a hospital room, and from across the room, I knew the patient had died. I always felt this was due to subtle cues, such as no movement of the chest, no rippling of the skin caused by blood flow, only seen at a subliminal level. But maybe it was something else. Several years ago I was seeing a patient at a nursing facility and the patient died while Photo by Scott Buschman I was in the building. There were no respirations, no pulse, clearly deceased. However, I felt doubt; I did not feel that he had died, but the evidence was there. It was as if there was a part of him that usually departs or disappears at death that was still there. We talk of consciousness or sentience, yet what is it really? Is it just a bunch of cells and pathways, or is it more? Let’s just look at what our bodies are made of. If you removed all the spaces between our atomic nuclei, all of humanity would be compressed to the size of a single cube of sugar. The protons and neutrons that make up that infinitesimal speck of your body are held apart by energy and forces we don’t truly understand. In essence, we are beings of energy more than matter.

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Many Eastern philosophies embrace the concept of energy that encompasses not only ourselves but the world and universe around us. In Hinduism there is the concept of the “subtle body,” which is the non-physical body and prana, or life force. Chakras, in yoga and Hinduism, are energy points throughout the body with seven main points. These are often associated with the seven colors of sunlight, namely the rainbow. They also happen to coincide with the seven main ganglia in the spinal cord. Chakras represent certain aspects of the human condition, from basic survival to enlightenment, and correlate with certain anatomical functions that the ancients many thousands of years ago would not have understood. Astronaut Ed Mitchell, the sixth man to walk on the moon, had a samadhi experience (the state of being one with the divine, to live totally in the moment) when he was returning to Earth. “The presence of divinity became almost palpable, and I knew that life in the universe was not just an accident based on random processes.” He felt that everyone’s consciousness was interconnected and part of a greater whole. What this all means I’ll leave to each of us to decide. I find it quite remarkable how much descriptions of energy that predate any medical knowledge can align with what we now know. Perhaps it is an energy form of deism—rather than knowing that there is the divine by observation of the natural world, it is by experiencing the “subtle” world. However, take this thought with you: When we treat our patients, are we just treating a body, or are they a vessel that carries more than what we can see and perhaps understand?

When we treat our patients, are we just treating a body, or are they a vessel that carries more than what we can see and perhaps understand?

Russ Granich, MD President

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My Approach to

Voting By Judy Chang, MD, FAASM, D, ABSM

I decide how to vote by trying to find objective sources of information to determine where the candidates stand on the issues and what the pros and cons of each ballot measure are. Figuring out who’s funding which candidate and ballot measure can also help clarify the true intent behind some candidates and ballot measures. Some of the sources I’ve found helpful include • The League of Women Voters www.lwv.org/ • Ballotpedia www.ballotpedia.org/main_page • Project Vote Smart www.votesmart.org/ While I read the Official Voter Information Guide provided by the California Secretary of State available at www.voterguide.sos.ca.gov/, some candidates don’t have a statement, and the wording of some propositions can be confusing. In these situations, tracing funding can clear up what the ballot measure really means. The Center for Responsive Politics’ website www.opensecrets.org/ has information regarding the flow of money in elections. Questionnaires such as one created by iSideWith www.isidewith. com/politicalquiz are useful to identify which candidate holds the position most similar to mine on issues. Personally, I tend to vote more based on the issues than along the party line. I hope this is helpful. How do you decide how to vote? Judy Chang, MD, FAASM, D, ABSM, is a board-certified adult neurologist as well as an adult and pediatric sleep specialist. She trained at Harvard and Stanford University, and has practiced clinical medicine in a variety of settings, including academic medical centers, county hospitals, managed care and private practice. Dr. Chang emphasizes patient education and behavioral and lifestyle modification in conjunction with pharmacologic management of sleep disorders.

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PATIENTS, VOTE PRACTICE & 2016 PUBLIC HEALTH YES

P H Y S I C I A N S A N D H E A LT H C A R E P R O V I D E R S in San Mateo County and throughout the state face not only the polarizing presidential election this November, but also an unprecedented 18 state ballot initiatives, many of which have direct implications for their patients, practices and public health. At least six of the ballot measures have the potential to directly impact the local healthcare community. In advance of this important election, this issue of San Mateo County Physician Magazine summarizes these six initiatives for our physician readers and details what your vote will mean as you head to the polls.

Voter Approval to Divert Hospital Fee Revenue Dedicated to Medi-Cal* State Fees on Hospitals. Federal MediCal Matching Funds. Initiated Statutory and Constitutional Amendment.

YES supports requiring voter approval to change the dedicated use of certain fees from hospitals used to draw matching federal money and fund Medi-Cal services. The initiative was also designed to require a two-thirds majority vote of the Legislature to end the hospital fee program. NO opposes this initiative, allowing the Legislature to change, extend or eliminate the hospital fee program with a majority vote.

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MORE INFORMATION | One of the more politically and financially complex issues on the upcoming ballot, Prop. 52 would make permanent the Hospital Quality Assurance Fee, which the state collects from private hospitals to bring in additional federal dollars for Medi-Cal. The federal government matches money that California puts up to fund Medi-Cal services. Hospitals like the fee, which has been in place since 2009, because it gives them a big financial boost in what they say is an underfunded government health program, according to a California Healthline article. In the 2015-2016 fiscal year, hospitals received an additional $3.5 billion to pay for services they provided to Medi-Cal patients, according to the state Legislative Analysts Office. According to the California Healthline article, the arcane details of the measure might be too much for many voters

to sort out, and a lot of them “won’t do any homework,” said Wesley Hussey, associate professor of government at Sacramento State University. “In general, the more complex an issue is, voters usually respond by either skipping the issue itself . . . or by voting no,” he said. Kevin Riggs, spokesman for the Yes on 52 campaign, which is sponsored by California hospitals, sought to demystify the initiative. “If you care about . . . access to Medi-Cal for kids and old people and working families in California, this is a way to protect [that] program,” he said. The fee is an important part of sustaining hospital care for Medi-Cal enrollees because government payments for patients covered by the program are $8 billion short of what it costs hospitals to provide the services, Riggs said. The revenue generated by the fee totals around $3 billion a year, offsetting about 40% of hospitals’ Medi-Cal losses. Opponents, who include Californians for Hospital Accountability and Quality Care, make the arguments that the proposition would divert resources from patients and communities to special interests and would not require any sort of accountability for hospital CEOs and lobbyists regarding how money is spent, Additionally, they claim the proposition would not guarantee that funds are spent on healthcare and would only favor corporations and hospital CEOs.

Extension of the Proposition 30 Income Tax Increase Tax Extension to Fund Education and Healthcare. Initiated Constitutional Amendment.

YES supports extending for 12 years the personal income tax increases on incomes over $250,000 approved in 2012 in order to fund education and healthcare. NO opposes extending for 12 years the personal income tax increases on incomes over $250,000 approved in 2012, allowing the tax increase to expire in 2019. MORE INFORMATION | In 2012, when Gov. Brown backed and campaigned for the passage of Proposition 30 to raise taxes to prevent $6 billion in cuts to the education budget for California state schools, the measure was approved by California voters 55% to 45%.

Tobacco Tax Increase Cigarette Tax to Fund Healthcare, Tobacco Use Prevention, Research, and Law Enforcement. Combined initiated Constitutional Amendment and State Statute.

YES favors increasing the cigarette tax by $2 per pack, with equivalent increases on other tobacco products and electronic cigarettes. NO opposes increasing the cigarette tax by $2 per pack, with equivalent increases on other tobacco products and electronic cigarettes. MORE INFORMATION | Supporters of Prop. 56 tout the measure as a way to fund existing health programs as well as research to find much needed treatments for cancer and other illnesses caused by smoking and tobacco products. California taxpayers pay $3.5 billion annually to treat cancer and other tobacco-related diseases through Medi-Cal. Proponents of Prop. 56 see a user fee on cigarettes as only being fair since it shifts the fiscal burden for these medical programs, smoking prevention and research to smokers as the Prop. 56 is expected to generate up to $1.4 billion in tax revenue its first year if passed. The funds would go into a special fund to help pay for Medi-Cal rather than into the General Fund, according to PolitifactCalifornia.com. Opponents of Prop. 56, including the No on 56 campaign funded by tobacco companies Philip Morris and R.J. Reynolds, argue that this aspect of the measure “cheats schools out of at least $600 million a year.” However, experts interviewed by PolitifactCalifornia said that this proposal is nothing new. In 1988 and 1998 tobacco taxes also established special funds rather than sending money to the General Fund. State Superintendent of Public Instruction Tom Torlakson also rejected the claim that the new tax measure cheats schools, writing in a letter that “Proposition 56 will not divert a dime away from schools. Rather it will raise revenues for school-based tobacco prevention and intervention programs.”

Drug Price Standards State Prescription Drug Purchases. Pricing Standards. Initiated State Statute.

YES supports regulating drug prices by requiring state agencies to pay the same prices that the U.S. Department of Veterans Affairs (USDVA) pays for prescription drugs. NO opposes regulating drug prices by requiring state agencies to pay the same prices that the U.S. Department of Veterans Affairs (USDVA) pays for prescription drugs. MORE INFORMATION | In August Prop. 61 supporters lost a state court bid to alter the wording of a key analysis that may affect the outcome of Prop. 61.

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Supporters of the measure, launched by the AIDSHealthcare Foundation, which operates clinics and pharmacies in multiple states, argue that a leading industry “scare tactic” is to warn that the measure will hurt veterans because drug makers will raise prices rather than agree to provide the state with prices offered to the VA. A consumer activist argued that federal law already protects veterans and that the state analysis didn’t mention that federal law “restrains” VA drug pricing. He reportedly asked a state court judge to order the Legislative Analyst’s Office to add the phrase “drug manufacturers might choose to raise VA drug prices, subject to federal price caps on brand-name drugs” rather than simply stating that “drug manufacturers might choose to raise VA drug prices.” But California Superior Court Judge Christopher Krueger denied the petition saying, “The Court finds it sufficient to inform voters that although drug manufacturers might choose to raise VA drug prices, there are federally imposed ‘upper limits’ on their ability to do so. Particularly given the Legislative Analyst’s considerable latitude in preparing the analysis, the court finds that this is not the type of clear case where the failure to specifically state that the VA price increases would be ‘subject to federal price caps’ renders the analysis misleading.”

Background Checks for Ammunition Purchases and Large-Capacity Ammunition Magazine Ban Firearms. Ammunition Sales. Initiated State Statute.

YES will be a vote in favor of prohibiting the possession of large-capacity ammunition magazines. NO will be a vote against prohibiting the possession of large-capacity ammunition magazines. MORE INFORMATION | Proposition 63 would require individuals who wish to purchase ammunition to first obtain a four-year permit from the California Department of Justice. Dealers would be required to check this permit before selling ammunition. The Department of Justice would be authorized to charge up to $50 for permits to support administrative and enforcement costs. California enacted legislation in July 2016 that, in addition to Proposition 63’s requirements, would mandate dealers to check with the Department of Justice to determine if the buyer is authorized to purchase.

Marijuana Legalization Marijuana Legalization. Initiated State Statute.

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PRESCRIPTION DRUG COSTS IN THE U.S. are on the rise, and with high-profile examples like the 400% jump in EpiPen pricing, they are increasingly on the radar of healthcare providers. Prescription drugs cost about twice as much in the United States compared to other advanced nations, and according to a recent study published in the Journal of the American Medical Association (JAMA), between 2013 and 2015 American prescription drug costs went up 20%. The report states: “Per capita prescription drug spending in the United States exceeds that in all other countries, largely driven by brand-name drug prices that have been increasing in recent years at rates far beyond the consumer price index.” While only about 10% of all prescription drugs in the country are brand-name drugs, such as the EpiPen, they account for a whopping 72% of drugs being sold, the researchers discovered. While the issue of drug pricing involves pharmaceutical companies and government regulations, the fact that the study was published in JAMA is meaningful, according to those outside the study, because the authors are able to speak directly to doctors. “I think the most significant thing about this is not necessarily what he’s saying but who he’s saying it to,” said Kenneth Kaitin, who directs the Tufts Center for the Study of Drug Development, in an interview with Kaiser Health News. “In part, the concern over rising drug prices is something that physicians have been more aware of lately… They’ve still been for the most part on the sidelines of these issues.”

YES supports legalizing recreational marijuana and hemp under state law and enacting certain sales and cultivation taxes.

RESULTS OF THE STUDY According to the study, “there is little evidence of an association between research and development costs and drug prices; rather, prescription drugs are priced in the United States primarily on the basis of what the market will bear.” “I continue to be impressed by the complexity of the issue. It is not as easy as saying, ‘Let’s let Medicare negotiate for Part D drugs,’ or any simple fix,” said lead author of the study, Aaron Kesselheim, MD, an associate professor at Harvard Medical School and associate physician at Brigham and Women’s Hospital, in an interview with CNN. “There are problems at every level — including inefficient government policies, Food and Drug Administration regulatory rules, physician prescribing practices — that contribute to manufacturers’ abilities to charge high prices, leading to high drug spending, and unfortunately suboptimal public health outcomes,” Dr. Kesselheim added. “It is going to be very important to consider the impact of any proposed changes on the many different contributors to the issue.” KEY FINDINGS OF THE REPORT INCLUDE: 1. Drug manufacturers in the U.S. set their own prices, and that’s not the norm elsewhere in the world. 2. We allow “government-protected monopolies” for certain drugs, preventing generics from coming to market to reduce prices. 3. The FDA takes a long time to approve generic drugs. 4. Sometimes, state laws and other “wellintentioned” federal policies limit generics’ abilities to keep costs down. 5. Drug prices aren’t really justified by R&D.

NO opposes legalizing recreational marijuana and hemp under state law and enacting certain sales and cultivation taxes, thereby continuing to only allow the use of medical marijuana. MORE INFORMATION | Although medical marijuana has been legal in California for 20 years, and come November Californians will have the chance to legalize marijuana across the board, there is no state-required training for physicians prescribing the drug, leaving many physicians feeling unprepared. “Education is essential, given the complexity of how marijuana interacts with the body and how little physicians know,” said Stephen Corn, MD, an associate professor of anesthesiology specializing in perioperative and pain medicine at Harvard Medical School, in an interview with California Healthline. “You need a multi-hour course to learn where the medical cannabis works within the body,” Dr. Corn said. “As a patient, would you want a doctor blindly recommending something without knowing how it’s going to interact with your other medications? What to expect from it? What not to expect?” Some medical schools have added medical education on marijuana to the curriculum. However, Susan Masters, a dean for curriculum at the University of California, San Francisco School of Medicine, acknowledges that while it is a topic of discussion in several courses, not a huge amount of time is devoted to medical marijuana. Due to the classification of marijuana as a schedule 1 drug by the federal Drug Enforcement Agency (DEA), researchers have a difficult time accessing the drug for study with human subjects. “Despite what the DEA says, their scheduling creates an enormous difficulty to researchers using marijuana or its derivatives,” said Daniele Piomelli, MD, UC Irvine School of Medicine professor of anatomy and neurobiology who has studied marijuana for the last 25 years, in an interview in LA Weekly. “Even harmless derivatives that happen to be present in the plant have been subjected to the same limitations as marijuana.” In August the White House rejected a petition to reclassify the drug to a less-strict category; however, federal authorities say they will allow more marijuana growth for the purpose of research.

*Source for ballot measure names, voting descriptions: Ballotpedia.com

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Making

Fall Prevention Part of Your Practice Scott Morrow, MD, MPH, MBA, FACPM San Mateo County Health Department Health Officer

National statistics say that an estimated one in three older adults, aged 65 years and older, fall each year. In our county, 1 in 10 people over the age of 65 are hospitalized for falls each year. For those over 85, a very high 1 in 5 are hospitalized. In 2014, 1,431 older San Mateo residents were admitted into the hospital; 4,508 older adults were seen in our emergency departments. Many more visited physician offices, urgent care centers or called 911 for lift assists because they had fallen — causing a strain on our medical system while contributing to a poor quality of life for our older adults. A fall is often the event that leads to loss of independence for our patients. You have the ability, within your practice, to help reduce these numbers. The Centers for Disease Control and Prevention (CDC) has a tool kit available for healthcare providers called STEADI — Stopping Elderly Accidents, Deaths & Injuries. The STEADI tool kit is based on a simple algorithm (adapted from the American and British Geriatric Societies’ Clinical Practice Guideline). All of the STEADI tool kit materials are free and can be ordered or downloaded from the CDC website — www.cdc.gov/steadi/ — or call Fall Prevention Coalition of San Mateo County at 1-844-NOFALLS (663-2557).

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WHAT YOU CAN DO 1. Incorporate the Welcome to Medicare Exam and Medicare Annual Wellness Visit elements in your EHR. 2. Incorporate fall assessment in your EHR. 3. CDC’s STEADI encourages doctors to: • Screen all adults 65 years or older for fall risk: The Stay Independent — Are You at Risk? brochure (part of the STEADI tool kit) is useful in getting the discussion of falls started with your clients. • Review medications (four or more medications are considered a significant fall risk factor). • Balance training is key and often overlooked. Refer to fall prevention programs and classes, exercise classes, physical or occupational therapy, as indicated by the screening. • Recommend 800 IU/day of vitamin D with calcium. The Fall Prevention Coalition of San Mateo County can assist you and your patients with written materials, including the Stay Independent — Are You at Risk? brochure, and referrals to local fall prevention resources such as home safety and modification services, exercise programs and evidence-based fall prevention programs. Refer your patients to 1-844-NOFALLS (663-2557) or www.smcfallprevention.org for more information.

DISEASE DETECTIVE Dr. D.A. Henderson Dr. D.A. Henderson showing his Presidential Medal of Freedom, the nation’s highest civilian honor

Dr. Donald Henderson working in the field CREDIT: WORLD HEALTH ORGANIZATION

D.A. HENDERSON, MD, who is credited with saving tens of millions of lives, died Aug. 19 at a hospice facility in Towson, Md. He was 87. Dr. Donald “D.A.” Henderson is best known for his leadership of the World Health Organization’s global smallpox eradication campaign from 1966 onward. He achieved success remarkably quickly with the last known case found in Somalia in 1977. He was instrumental in initiating the WHO’s global program of immunization, which now vaccinates approximately 80% of the world’s children against six major diseases. Dr. Henderson’s government service includes time at the Office of Science and Technology Policy and the Department of Health and Human Services in the early 1990s. In 1986, he was awarded the National Medal of Science.

Dr. Henderson (first man on left) as part of the CDC’s smallpox eradication team in 1966

Long after smallpox was officially declared

eradicated in 1980, Dr. Henderson, a self-described “disease detective,” remained in the field as a dean

of what is now the Johns Hopkins Bloomberg School

of Public Health and as an adviser on bioterrorism to several presidents.

He received the Presidential Medal of Freedom, the

nation’s highest civilian honor, in 2002. Although there

was talk of a Nobel Prize, none has ever been given for

the eradication of smallpox. Most of the field’s leaders agreed that no one person should get it.

Dr. Henderson is survived by his wife, Nana Irene

Bragg, two sons and a daughter.

The Lessons from the Eradacation of Small-Pox

Interview with Dr. D.A. Henderson can be found here: rstb.royalsocietypublishing.org/content/ 368/ 1623/20130113

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IMQ 2016 Medical Staff Conference Registration Is Open! The IMQ 2016 Medical Staff Conference on October 27 at the Embassy Suites SFO (Gateway) Hotel in South San Francisco will deliver the information, solutions and best practices that physicians need to successfully lead their medical staffs. The Conference will tackle some of the difficult decisions that face medical staffs, such as credentialing, granting privileges, proctoring practitioners for remote technology (telemedicine) and privileging policies for the new technology. It also will tackle the difficult issue of the aging physician and how a hospital can best identify, craft and implement policy to appropriately utilize the Well Being Committee to assist with issues surrounding aging physicians. Through examples and discussion, faculty will demonstrate how they can best position the medical staff to modernize quality improvement and update peer review systems. The Conference also will provide an update on Joint Commission standards and discuss standards that are most often found noncompliant. Ashby Wolfe, MD, Chief Medical Officer of CMS Region IX, will discuss CMS initiatives related to patient safety, quality reporting and electronic medical record usage. The conference has been approved for 5.5 AMA PRA Category 1 creditTM as well as 5.5 NAMSS credit. If you are a Physician, Hospital Leader, Medical Staff Director, Credentialing Specialist, or Quality Improvement professional, you want to attend this one day course that addresses the critical challenges facing your medical staff. Early bird rates and CMA member discounts are available. For more information and to register, please visit our website at www.imq.org or contact:

Leslie Anne Iacopi at 415-882-5167 liacopi@imq.org

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CMA/San Mateo County Medical Association sponsored Health Insurance Program

Is your health insurance open enrollment soon? Are your rates going up? Want to shop? Whether you are an individual policyholder or a member of a group health plan, it’s time to think about your health coverage for 2017. The open enrollment period for individual and family plans starts on November 1, 2016. Many practices have open enrollment periods for small groups on December 1 or January 1. Did you know that you can get the right insurance though the CMA/San Mateo County Medical Association sponsored Health Insurance program with Mercer? If you are covering yourself, or if you’re responsible for providing coverage for your family or employees, working with Mercer online or in person with a licensed agent, can get you the benefits you need, utilizing the physicians you want to see, at a price that fits your budget. Working with the largest insurers in California, Mercer can help you determine what’s best for you. Call today at 800-842-3761 or visit www.CountyCMAMemberInsurance.com.