December 2006

VOL.79 NO.9 December 2006 $5.00

SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Money & Medicine

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CONTENTS SAN FRANCISCO MEDICINE December 2006 Volume 79, Number 9 Money & Medicine FEATURE ARTICLES

MONTHLY COLUMNS

10 The Soul of Money in Medical Practice A Conversation with Lynne Twist

4 On Your Behalf 5 Upcoming SFMS Events

12 Primary Care: Undervalued and at Risk Toni Brayer, MD, FACP 14 The Cost of Medical Education Manisha Bahl 16 Major Surgery Is the Only Cure David Lazarus 17 San Francisco Health Access Program Mitchell H. Katz, MD 18 Health Savings Accounts: The Wave of the Future?

Stephen Askin, MD 19 The Consumer Era in Health Care Greg Scandlen

7 President’s Message Gordon Fung, MD, MPH 9 Editorial Mike Denney, MD, PhD 24 Hospital News 25 Classified Ads 27 In Memoriam Nancy Thomson, MD

Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129

21 Fundamentals of Prudent Investing George Pendergast and Beth Rabbitt

Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org

OF INTEREST Subscriptions:

23 Book Review: The Soul of Money Nancy Thomson, MD

$45 per year; $5 per issue Advertising information is available on our website, www.sfms.org, or can be sent upon request.

26 Dispatches From the 2006 CMA House of Delegates Brian Lewis, MD, and Steve Heilig, MPH

Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605

How Does This Issue of SFM Look?

We are trying a few new things at San Francisco Medicine Magazine and would appreciate your feedback. If you have any comments on the look, style, or printing quality of this issue, please let us know! All comments should be directed to Amanda Denz, our managing editor, by calling (415) 561-0850 extension 261 or sending an e-mail to adenz@sfms.org.

www.sfms.org

december 2006 San Francisco Medicine

ON YOUR BEHALF

December 2006 Volume 79, Number 9

A sampling of activities and actions of interest to SFMS members Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artist Amanda Denz

SFMS Annual Dinner

Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin Judith Mates

Notes from the Membership Department

Leo van der Reis

Wade Aubry

Ricki Pollycove Jerome Fishgold

Toni Brayer

Jordan Shlain

Corey Maas

Leonard Shlain Gretchen Gooding

Erica Goode

David Smith

Samuel Kao

Stephen Walsh Kathleen Unger

Thomas Lee

Arthur Lyons

Alan Greenwald Rita Melkonian Kenneth Maybury

SFMS Officers President Gordon L. Fung President-Elect Stephen E. Follansbee Secretary Charles J. Wibbelsman Treasurer Stephen H. Fugaro Editor Mike Denney Immediate Past President Alan Greenwald SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve L. Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Board of Directors Mei-Ling E. Fong

John W. Pierce

Thomas H. Lee

Daniel M. Raybin

Carolyn D. Mar

Michael H. Siu

Rodman S. Rogers

Richard L. Caplin

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Brian J. Lewis

Gary L. Chan

Michael Rokeach

George A. Fouras

Jordan Shlain

Jeffrey Newman

Alan M. Teitelbaum

Thomas J. Peitz CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate Judith L. Mates, AMA’s Women Physicians Congress Governing Committee

The SFMS Annual Dinner will be January 25, 2007, at the Concordia-Argonaut. Please watch your mailbox for an invitation.

and politics in Sacramento to the CMA at a crucial moment in our 150-year history,” says Sexton. “Joe has vision, intellect, and passion. He will greatly enhance our ability to advocate for quality care for our patients, protect the profession, improve the public health, expand access to care for all, and maintain practice viability for the physicians of California.”

Something New & Fun Coming in January!

Blue Shield to Offer Free Online Mark your calendars for Thursday, January 18, 2007, for the SFMS Tennis Mixer at the San Francisco Tennis Club.

Starting at 6:30 p.m., enjoy tennis clinics taught by top-notch pros from the club, followed by a Margarita Mixer with light appetizers. No tennis experience necessary—players will be arranged according to their levels. Anticipated cost will be $15.00 for SFMS members, and $20.00 for nonmembers. More details available soon.

The Membership Department and the physician members of the Membership Committee are actively exploring future events and services to benefit SFMS members. 2007 will see more fun social events, as well as other benefits of use to our members. Suggestions from the membership for proposed events and benefits are greatly appreciated and will help the Committee and the Membership Department with their work. Please feel free to contact Therese Porter, Director of Membership Services, at (415) 561-0850 extension 268 or tporter@ sfms.org.

Senator Joe Dunn Named CMA CEO The CMA Board of Trustees appointed Joe Dunn, a state senator from Orange County, as the new Chief Executive Officer of the CMA. Dunn was selected following a national search from a “field of outstanding candidates as the right leader at the right time for the CMA,” says CMA President Michael Sexton, MD. “Joe Dunn brings extraordinary talents and a wealth of knowledge about California

San Francisco Medicine december 2006

Training for Doctors Treating Domestic Violence An innovative online training and education program to help California doctors better fulfill their important role in treating victims of domestic violence is now available at www.respondtodv.org. The free, web-based education program meets two vital goals: It provides doctors the tools and information they need to help patients who may be victims of domestic violence, and it simultaneously allows doctors to meet state requirements for continuing education.

The Blue Shield of California Foundation is making the training available to all doctors at no charge for two years. California-licensed physicians who use the program can receive up to sixteen Continuing Medical Education (CME) credits—also at no charge—for completing the course. The online CME program includes text-based simulations, multimedia tutorials, video presentations by domestic violence experts, downloadable practice tools, and links to National Library of Medicine journal abstracts. It was developed under a grant from the National Institute of Mental Health to Medical Directions, Inc. (MDI) of Tucson, Ariz. Earlier this year, MDI received an Alliance for Continuing Medical Education award for its research in developing the program. MDI and BSCF hope that at least 10 percent of California’s 130,000 physicians will use the online program over the next two years. The project has already been endorsed by the California Medical Association, the Family Violence Prevention Fund, and the Permanente Medical Group. www.sfms.org

Deadline to Change Medicare Participation Status Is December 31

We Don’t Mean to Nag, But Have You Completed Your Pain CME Yet?

Physicians who wish to change their Medicare participation status for 2007 must do so by December 31. Physicians can change their Medicare status between participating and nonparticipating only during Medicare’s annual open enrollment period. A participating physician must accept Medicare allowed charges as payment in full for all their Medicare patients. A nonparticipating provider can choose to accept or not accept assignment on Medicare claims on a claim-by-claim basis. Once made, Medicare participation decisions are binding for the entire year.

Physicians may also choose to opt out of the Medicare program entirely. Physicians who opt out of Medicare are bound only by their private contracts with their patients (although Medicare specifies that these contracts contain certain terms). You may choose to opt out at any point in the year, but once you opt out, you cannot opt back in for two years.

The CMA also encourages physicians to review any of private payor contracts that tie their payment rates to Medicare.

For more information contact CMA’s Reimbursement Help Line, (888) 401-5911, or visit www.cmanet.org.

California law (AB 487) requires physicians to complete twelve hours of continuing medical education (CME) in pain management and the care of terminally ill and dying patients. Physicians have until December 31 to satisfy this requirement. See www.cmanet.org for ways to satisfy this requirement.

2006 SFMS General Meeting The San Francisco Medical Society Annual General Meeting, held on September 11, 2006, was an interesting and informative event. Guest speakers included Mayor Gavin Newsom (pictured on right addressing the SFMS Board of Directors) and CMA President Elect Anmol Mahal, MD (pictured top right with CMA President, Michael Sexton, MD, and SFMS President, Gordon Fung, MD, MPH).

Mayor Newsom Spoke about disaster preparedness, the health of the homeless population in San Francisco, the rebuilding of San Francisco General Hospital, and San Francisco’s Health Access Program. For more information about the Health Access Program from the Department of Public Health, see page 17.

Upcoming SFMS Event January 28—30, 2007 UCSF-CHE Summit on Environmental Challenges to Reproductive Health and Fertility Mission Bay Conference Center, UCSF, San Francsico. Join fellow research, health care, community, and advocacy leaders in a pioneering national conference that will explore the critical relevance of environmental health science to reproductive and developmental health. Preeminent researchers will review the impacts of environmental contaminants on female and male reproductive health (including fertility), with focus on: periconceptional/ fetal origins of developmental, pubertal, and adult disorders; adult exposures; priority concern contaminants; and gene-environment interactions. Participant discussions and break-out groups will focus on: translation of research to clinical care and prevention-oriented public health policy; the nexus of reproductive advocacy and environmental health/justice; and critical research directions.

For more information, visit www.ucsf.edu/coe/prhesummit.html or contact Mary Wade, (415) 476-2563 or wadem@obgyn. ucsf.edu. Be sure to register soon for the best rate. This event is cosponsored by SFMS.

www.sfms.org

december 2006 San Francisco Medicine

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president’s Message Gordon Fung, MD, MPH

Money, Medicine, and the Future

n this—my last—message as your president, I find the theme to be one of the most pertinent to clinicians in practice. There are many aspects of “Money and Medicine” that were never taught in medical school, nor during residency and fellowship training.

Many physicians feel quite unprepared to run a small business and are unaware of the multiple sources of payment that do not usually include the patient. Because of this, many physicians choose to join groups of various sizes—from small-group practices to very large practices or foundations. Some decide to stay in academia; but even in academia, there is a need to be aware of these issues since salaries are based in part on clinical income. For small practices or businesses, the physicians are usually the CEOs of the enterprise and make all the decisions, not only about practice but also about personnel, expenses, and facilities. In larger practices, hired administrators can take on the business side of the practice. They have more time to undertake the many responsibilities pertaining to personnel decisions, facilities upkeep, billing, and advising providers on the appropriate wording and methods of coding—an important task to achieve maximum reimbursement for any procedure, from the simple office visit to the complex consultation and the numerous minor and major surgeries.

Many of these issues are usually addressed through legislation and regulations at the state level, with our colleagues at the CMA as our main advocates, to keep third-party payers ethical in dealing with providers. The CMA now meets annually in October at the House of Delegates to bring the collective wisdom of medical leaders, specialty societies, different practice forums, legal experts, and a very experienced advocacy staff to bear on the issues of major importance to the physicians practicing in California. There are Reference Committees that hear testimony and review piles of information on public health issues, ethical issues, practice issues, and insurance issues; they make resolutions to direct the agenda for the board of trustees for the coming year. There are also many issues that need to be addressed at the national level, so we usually have a delegation charged with bringing these issues from the CMA to the AMA. 2006 was particularly challenging for the House of Delegates, since many issues had accumulated over the eighteen months since the group had last convened. This was a result of transitioning the annual meeting from March to October to better coordinate with

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the state legislative session. See page 26 to read about the great accomplishments of our San Francisco representatives.

This year also brings change, since San Francisco is embarking on a program of Universal Healthcare Access for un- and underinsured residents, which will cover the cost of caring for some 82,000 San Franciscans. Dr. Mitchell Katz, Director of Public Health for San Francisco, will give us an update on the current status of this program on page 17. The program is before an implementation committee called the Health Access Program Committee, on which I sit as your representative. This program is entirely new and thus has no models to follow. We are indeed breaking ground and making history. It is important that every physician know about this program, since it may impact all those who see patients in the hospital or who are on call for the emergency departments and are in a position to admit uninsured San Francisco residents.

This issue will also include two opinion pieces on Health Savings Accounts (see pages 18 and 19), which provide a new way to pay for health care that will impact physicians whose patients opt for this system.

On a final note, I would like to thank all San Francisco Medical Society members for the opportunity to have served as president in 2006. This was indeed a very challenging year for SFMS, but also an exciting one, with the move, change in staff, and the refocus of our energies to be consistent with our new mission statement. I would also like to take this opportunity to extend a personal invitation to all member physicians to attend the Annual President’s Dinner on January 25, 2007. Please watch your mailboxes for invitations. At the dinner we will install Dr. Stephen Follansbee as the next president. Steve’s dedication to the SFMS and its mission to advocate on behalf of all San Francisco physicians and advance the health and well-being of our patients and communities, coupled with his intelligence and wisdom, make him the best person to lead us into the future—we are in good hands. Thank you again for all your support throughout the year.

december 2006 San Francisco Medicine

!TTENTION $OCTORS AND (OSPITALS

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Q. Did you know that no contract is necessary with Humana to treat our PFFS members?

A. You see your patients as you do today. Nothing changes but whom you bill.

Q. Did you realize the billing process is similar to what you experience today with Original Medicare?

A. Humana’s PFFS plan follows all Original Medicare medical policies and reimbursement methodologies.

Your patients will appreciate benefits like: • Affordable prescription coverage not available with most Medicare supplement plans • Significant reductions in monthly plan premiums

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DEPARTMENT TITLE HERE Editorial Mike Denney, MD, PhD

The Alchemical Gold

T

he roofs of medieval castles were occasionally blasted skyward when kings, barons, and earls who, in their alchemical zeal to transform base metals into gold, were bold enough to heat volatile mixtures like saltpeter, sulfur, and charcoal in boiling cauldrons. And when physicians such as Paracelsus began prescribing “elixirs of life,” alchemical concoctions that contained mercury, lead, antimony, and arsenic, it was not rare for individuals to manifest skin discoloration, alopecia, memory loss, paresthesia, diarrhea, vertigo, and liver and renal failure caused by heavy metal poisoning.

Such famous scientists as Roger Bacon, John Hooke, Isaac Newton, and Robert Boyle were avid alchemists, and later Priestly, Lavoisier, and others converted this mysterious craft into modern chemistry. But this factual story is only a vain literalization of true alchemy, which was actually a spiritual practice founded, it was said, by the Egyptian god Toth, and later adapted by other religions.

This theology espoused that “whatever is below is like that which is above, and whatever is above is like that which is below, to accomplish the miracle of one thing.” In other words, humans, the heavens, and the elements are one—a kind of prescientific spiritual rendering of the atomic theory.

Medieval texts in this mystery tradition were often written in obscure codes, using Latin terminology both for the phases of changes of metals and for the relationship of humans to the divine—such phases of change as solutio, coagulatio, sublimatio, putrefactio, and mortificatio. Most important, the yearned-for alchemical “gold” was not the literal precious metal but a symbol for universal truth, the “philosophers’ stone.” Alchemy was, indeed, a sacred task.

One of these phases of change was called massa confusa, and it may offer the most appropriate alchemical description of this issue of San Francisco Medicine, with its theme of “Money and Medicine.”

According to the old texts, massa confusa occurs as metals cook in boiling acids, and the rising pungent vapors form a nigredo, or black cloud. In this “cloud of the unknowing,” the alchemist is cast into a state of bewilderment, stripped of intellectual conception, and surrounded by utter confusion as he awaits the uncertain outcome of this opus magnus.

In our massa confusa regarding money and medicine, we find a new book, written by Maggie Mahar and called Money-Driven www.sfms.org

Medicine, which purports to tell us “the real reason health care costs so much.” Mahar begins with the oft-quoted statistics about rising medical spending and costs, which show that in 1970 health care accounted for only 7 percent of the gross domestic product (GDP), but that by 2005 it was up to 16 percent. A medical alchemist might ask, “Why is Mahar’s report so confusa?” Well, it may be because the GDP is not a measure of spending or costs—it is a measure of productivity. Health care contributes 16 percent of the economic vitality of the United States in the form of products, services, and jobs—actually, nine million jobs, 7 percent of the entire workforce.

BusinessWeek magazine concludes that it would probably be better if Americans actually spent more on health care, noting that each treatment for heart attack, for example, results in a $60,000 gain to the overall economy, and each year of life attained through medical treatment results in a $150,000 gain to the economy.

The cloud of unknowing grows larger. Every winter at ski resorts, thousands of people suffer injuries and need orthopedic care. Should this cost be assigned to the health care industry, or is it more accurately a cost of the ski industry? How much money is spent each year on medical care for sports, transportation, cosmetics, manufacturing, cigarette smoking, alcohol consumption, and illegal drug use? Why are these costs assigned pejoratively to the health care industry? Furthermore, employers complain about the rising cost of health insurance, but isn’t that cost an agreement about compensation packages for employees, without which employers would have to compensate their employees with higher pay?

It seems nigh impossible for physicians, whose incomes have fallen steadily since 1997, to find an alchemical solutio to medicine’s economic woes. Without expertise or clout, we remain in the alchemical massa confusa, bewildered, stripped of intellectual conception, and surrounded by confusion. We cannot provoke a coagulatio to bring about a sublimatio, but must remain immersed in the putrefactio and the mortificatio.

Yet somehow, through it all, we resolutely continue to practice ethically and expertly, thus acknowledging that the alchemical gold we seek, our opus magnus, is the profound reality that our healing work is, indeed, a sacred task.

december 2006 San Francisco Medicine

Money & Medicine

The Soul of Money in Medical Practice A Conversation with Lynne Twist Mike Denney

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ward-winning global activist, fundraiser, and author Lynne Twist has discussed money with the poorest and the richest people on earth. In her book The Soul of Money, she asks readers to examine their relationships with money, thus to learn how to align their financial resources with their most deeply held, lifeaffirming values.

Early in her work as an executive with the Hunger Project, Lynne personally accepted a donation of $50,000 from a hesitant corporate executive who seemed to view his contribution as strictly business, a way to embellish the reputation of his struggling company. Later, after having received much smaller but more heartfelt donations from members of a small church congregation, Lynne returned the check to the businessman, thanking him but noting that it did not come from his heart. A few years later she heard again from the businessman. He thanked her for her life-affirming gesture and included a new check—this one for $250,000.

Nowadays, Lynne’s philosophy might seem especially pertinent to the world of healing, which, paradoxically, seems inherently life-affirming yet caught up in the worst of relationships with money. This month, San Francisco Medicine had the opportunity to discuss with Lynne some of the current issues in medical economics and to hear her views about how a new relationship with money might help the medical profession.

SFM: Physicians often experience the business aspects of a money-driven medical system to be an obstacle to an otherwise life-affirming career. Does The Soul of Money relate to this problem?

Twist: Many people are reduced to “making a dying” rather than “making a living,” doing work that they don’t love, work that doesn’t use their creative skills and doesn’t allow them to make a contribution or serve others. Physicians, on the other hand, have the great privilege of being servants to the human family, engaged intimately in heal-

context. And I think that’s where people have real power to shift their relationship with money. To me, it’s important to see money as an instrument, a tool that facilitates our lives, not something of which we have to always have more. Our lens can shift, and in a new context a dedicated physician can see the deep appreciation that money carries as it flows to the power of healing.

SFM: A few years ago, Ivan Illich published a book called Medical Nemesis, in which he talks about the “medicalization” of our culture, noting that people seem to be buying unnecessary care rather than appreciating and taking care of the health they have.

ing others. They certainly deserve to be compensated; and that remuneration can carry with it a kind of love, an appreciation for having been cared for. After all, money is neutral. It is not good, it is not bad, but it is a conduit, like water that flows in and out of every life. I think it would be appropriate for doctors to hold the idea of money and remuneration as a part of the healing process.

SFM: In a book named The Gift, the author Lewis Hyde compares gifts with payments and seems to conclude that gifts flow to places of need, while profits flow to places of power. Does that have importance here?

Twist: I think it’s all dependent upon the

10 San Francisco Medicine december 2006

Twist: We seem to live in a tyranny of consumerism. We are pummeled into believing that we need more of everything—[to be] thinner, taller, younger, more beautiful, more handsome—more of this and more of that. We aren’t always aware of these demands to have more of everything, particularly more money. I call it the lie of scarcity. And maybe “more” is what some people want to buy from their doctors. Yet how much healthier it might be to appreciate what we have, and to take care of our bodies rather than trying to “acquire” health. I like to say that what is appreciated, appreciates.

SFM: Most people agree that the patient-doctor relationship is a collaboration, and your ideas seem to include the money relationship as well as the healing relationship.

Twist: What I mean by collaboration is that everyone has assets. I don’t see the world as “haves” and “have-nots.” I’ve worked all www.sfms.org

over the world among the neediest people, and what I’m talking about is that when we perceive someone as poor, we tend to create that kind of a world. But when we collaborate and bring our assets together, there is a kind of synergy. In my relationship to the medical world, for example, I really do know a lot about my own body. I know when I feel weak, I know when I feel strong, and I bring a consciousness about myself that the doctor cannot know. Then the doctor has the diagnostic skills and the training to be able to read those signs. If we see that partnership as a responsibility to bring our own assets, then we are in collaboration, both in the healing and in the money exchange.

SFM: A few months ago, we published an issue of San Francisco Medicine that focused on doctors providing services free of charge to the needy in third-world countries. Is there a difference between providing services for free and providing them for money?

improve the role of money in healing?

Twist: I make a distinction between taking a position and taking a stand. When you take a position, you may become angry or defiant and say that you’re not going to take it anymore. But when you take a stand, you can transcend the arguments and begin to see all positions without taking a position.

This is what great leaders do.

A few years ago, I was a patient of Dr. Erica Goode at California Pacific Medical Center, and she was a physician who took a stand. When I first saw her, she stated clearly that she would take all the time that we needed. And she made it clear that this was the way we would work together and this was what it would cost. I truly applaud the way she practiced. While it seems to me that many physicians portray themselves and act as though they are trapped in the system, Dr. Goode took a stand. And for me, it was a true healing experience.

your hospital and your world hold money and medicine in the context of the life affirming values that you espouse. As Ghandi said, “Be the change that you wish to see in the world.”

Lynne Twist is Founder and Director of The Soul of Money Institute, an organization dedicated to inspiring, educating, and empowering people to realign the acquisition and allocation of their financial resources with their most deeply held values. Her book, The Soul of Money, has recently come out in paperback. She can be contacted at www. soulofmoney.org.

The San Francisco Medical Society would like to welcome the following new members: Lawrence L. Chao, MD Jennifer Do, MD Sumeer K. Gupta, MD Robert Hindi, MD

Twist: This is what I mean when I speak of changing the context in which we hold money. Serving someone in, say, Bangladesh rather than San Francisco General Hospital, there is somehow a frame we put on that to make it meaningful. We can think of it as “we have to go help these poor people,” or we can think of altruism as being a collaboration. As we say in the Hunger Project, we don’t have a billion mouths to feed, we have a billion people—incredible, courageous people who are working on the front lines of world hunger—and we have the privilege of joining them. And so it can be with medical practice when doctors hold patients in a way that honors them, whether it is in Bangladesh or it is with someone who has been shot on a local street by a gang member. I deeply empathize with doctors who feel trapped in a money-driven system, and I understand how offering altruistic care in a foreign land can be a release of that entrapment. One cannot help but wonder, however, whether shifting our context about money might help [bring that same feeling of] release when treating someone right here.

SFM: In your book, you speak of taking a stand. How can physicians take a stand to www.sfms.org

SFM: I wonder if physicians can expand that concept of taking a stand to politics?

Michelle Li, MD Gary Rust, MD Cheng-Yang Tuan, MD

Twist: I think they can. Perhaps it’s time for doctors to stand up and say, “This moneydriven system isn’t working for the healing we’re committed to doing.” The choices doctors make now will be passed on to future generations.

From the California Emergency Physicians Medical Group: Grant Stuart Lipman, MD From the Permanente Medical Group: Michelle Allen, MD

SFM: In terms of The Soul of Money, what might an individual physician do to improve the situation?

Herkanwal Khaira, MD Diana I. Bojorquez, MD Ofer M. Eibschutz, MD Kimberly Newell, MD

Twist: We all feel caught up in this giant dream of a macroeconomic system that has gone out of control. If you have the courage and it is your role and you are committed to being a real change-maker, and you work for that, then that is one whole set of choices.

Become an activist, join your political action committee, run for office. Go for it.

If that big picture isn’t your chosen role, maybe you can serve the same purpose by being an exemplary physician. You won’t let the system get in your way, you won’t surrender, but you will do your work in a way that the system cannot constrain you.

You will express your commitment by example, to make sure that your patients and

Elena E. Torello, MD Doris Yu, MD New Student Members: Jennifer Albon Pratheepa Sivaswarupan Jennifer Hsiao Jordan Cloyd Rajesh Jaganath Patrick Newman Latifat Apatira Anthony Sossony David Kaufman Margaret Cooke Jenna Kay Jay Pandit Vignrsh Arasu Cara Torruellas Ian Kratter Carrie Cunningham Albert Lee Jason Park Jihane Benhammou Sinae Vogel Ehrine Manzana Margaret Dingeldein Margaret Menzel Daniel Perez Kristin Bixel J. Bianca Watsin Iris Ma Michael Frederick Mary Montgomery Solmaz Poursattar Danielle Chammas Lindsey Yarlman Emily Nelson Katelyn Gamson Edwin Rodriguez Craig Chen Cynthia Zamara Sara GoniasMary Zhang Sonia Samagh Alexander Nguyen Jonathan Chou Marco Gonzalez Tasce Simon Emily Clark Hekena Hart

december 2006 San Francisco Medicine 11

Money & Medicine

Primary Care Undervalued and at Risk Toni Brayer, MD, FACP

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uch has been written about the impending demise of primary care—about general internal medicine, family practice, and general pediatrics. Like global warming, the crisis in Darfur, and AIDS in Africa, the economic problems facing United States health care system seem overwhelming. It is hard to envision a solution; many people react by going about their business and hoping it won’t get worse. But the U.S. health care financing and delivery system is so dysfunctional that we face a crisis that will hit us hard if we don’t address it.

Health care spending of $1.7 trillion per year should be sufficient to place the United States in the lead in health and health care outcomes. We have the highest health care spending of any developed country, yet the U.S. ranks lowest in its primary care functions, chronic disease management, and health care outcomes.

How is this possible?

Americans are getting older and fatter, and there are more of us. The huge wave of Baby Boomers is hitting Medicare age, and 45 percent of the U.S. population has a chronic medical condition. Within nine years (by 2015), an estimated 150 million Americans will have at least one chronic condition. The population aged eighty-five and older, who are most likely to require chronic care services for multiple conditions, will increase by 50 percent from 2000 to 2010—and that is just around the corner.

Despite these facts, there has been a 50 percent decline in medical students choosing primary care since 1997, and in 2003 only 19 percent of first-year internal medicine residents planned to pursue careers in general medicine. Each year, that number

goes down.

The consequences of having fewer primary care physicians to deal with this population will be escalating costs, more uninsured persons, lower quality of care, greater inefficiency, and growing patient and physician dissatisfaction. Careful geographic studies of health care have shown that communities with more primary care physicians are correlated with better outcomes at lower cost. The worst outcomes at higher cost oc-

“We have the highest health care spending of any developed country, yet the U.S. ranks lowest in its primary care functions, chronic disease management, and health care outcomes.” cur where specialty care is excessive.

Every developed country has built its population health around primary care.

What has happened to primary care in America? Why is it so unattractive to our young physicians? The answers are simple: lifestyle and money. Young physicians are smart enough to plan their professional futures, and the landscape ahead of them leads to some obvious choices.

Specialties such as dermatology, radiology, pathology, emergency medicine, anesthesiology, and hospitalist medicine offer lifestyle stability with no beepers and no nighttime or weekend calls. Primary care physicians are overwhelmed with the total care responsibilities, government and administrative regulations, pace in the office,

12 San Francisco Medicine december 2006

and sheer volume of work. Most don’t have the technology infrastructure to improve quality, participate in pay-for-performance, or improve efficiency in their offices.

Our young doctors see this and are discouraged from choosing this professional lifestyle. As one young physician said, “If you don’t assert some type of control over medicine, it will consume you. I really enjoy taking care of people, but I don’t think I can take care of [other] people until I take care of myself.”

A second internal medicine resident summed it up by saying, “Most doctors were previously attracted to primary care because of the relationships that you can develop with patients and their families over time.

But in this day and age of feeling crunched for time to see so many patients a day, to meet the financial obligations of the office or institution, that relationship is much more difficult to foster and nurture. So that fulfilling aspect of the specialty seems less attainable in the present climate.”

Primary care specialties have also seen a decline in their net income since 1995.

Between 1995 and 2003, average physician net income from the practice of medicine declined about 7 percent after adjusting for inflation. Primary care physicians and general surgeons fared the worst in keeping pace with inflation, while medical specialties fared the best. Primary care physicians, already the lowest earning of all doctors, have lost (by -10.2 percent) to inflation since the mid-1990s. While Medicare fees have declined in real terms since 1995, the trend for private insurer payments to physicians has lagged even more. In 1995, commercial fees were 1.43 times Medicare fees on average; by 2003, this fee ratio had fallen to 1.23. This is another hit that was www.sfms.org

worse for primary care, whose billing codes are primarily cognitive evaluation and management. Primary care doctors see their GI, radiology, surgery, and cardiology colleagues partnering in successful surgicenters and imaging centers at the same time that they are trying to increase patient flow just to keep up with expenses. It doesn’t pencil out at the bottom line, and it is not satisfying to be that busy.

A recent study from the Department of Health Affairs, comparing seven developed countries, reported that primary care is valued and financially protected for the benefit of the population’s health in all but the United States. In Canada and Europe, a general practitioner makes 70 to 80 percent of the salary of a specialist. In the U.S., the earnings are often less than half the specialist salary because of our payment system.

Another problem for primary care is medical education debt. In 2005, the AMA reports, the average debt was $120,280, with 66.7 percent of medical students carrying more than $100,000 in debt. A young physician looking at career choices is influenced by a high debt burden, and it has been shown to be responsible for the measurable decline in students entering primary care fields.

One internal medicine resident says she speaks for her colleagues when she says, “Honestly, I think income is one of the most, if not the most, significant reason why fewer residents are choosing primary care.

When I think about it, I would have much less hesitation about my interest in primary care if I felt like the income was comparable, or at least somewhat close to, that of a cardiologist. Then I would feel like all the hassles of primary care would be well worth the effort. I could imagine a totally different outlook from everyone if the income was as attractive as in other specialties. I think the culture of medicine has developed a decline in respect for the primary care MD. To me, this is very sad, as the primary care doctor has, potentially, a larger impact in patients’ lives than any other specialist could.” This is how our young doctors see things.

A hospital administrator recently said to me, “This is just a cycle. I’ve heard primary care was dead over and over in the past, and this current shortage will pass.” I www.sfms.org

hope he is right, but unfortunately the evidence just doesn’t support it. It takes about ten years to reverse a workforce trend, and we have not yet hit the nadir.

As a nation, we lack the political will to reorient our system to primary care and to provide coverage and access to health care for all Americans.

Dr. Tom Bodenheimer said it best in his recent New England Journal of Medicine article: “Public policy on primary care does not exist. The fortunes of primary care are dictated not by the health care needs of the country, but by a specialty-rich, quantity-based reimbursement system.”

If we really want primary care to survive, we must make it attractive to our best and brightest young physicians. Volumebased, episodic, fee-for-service medicine is a failed model for primary care. We need to change how primary care is financed

and protect it from financial cannibalism by appealing, expensive new technologies.

It is time to reengineer our primary care structure, including training, research, education, and reimbursement, if we want physicians to choose these specialties. The return on investment would benefit payers, employers, the specialty community, and, most importantly, patients, who deserve to be at the top of health outcomes, not the bottom.

“If we really want primary care to survive, we must make it attractive to our best and brightest young physicians.”

Toni Brayer, MD, FACP, has practiced Internal Medicine at CPMC for more than twenty years. She is past president of San Francisco Medical Society and past editor of San Francisco Medicine. She is the Regional Chief Medical Officer for Sutter Health and believes that primary care is the linchpin for medical quality.

december 2006 San Francisco Medicine 13

Money & Medicine

The Cost of Medical Education How Does the Rising Cost of Medical Education Affect the Profession?

Manisha Bahl, UCSF Second-Year Medical Student

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ccording to the American Associa- has grown from $22,558 in 1985 to $67,911 Health Service Corps and the Indian Health tion of Medical Colleges (AAMC), in 2005. According to Carrie Steere-Salazar, Service Scholarship Program. The National a medical education is far less af- Director of UCSF Student Financial Ser- Institutes of Health also offers loan repayfordable to students today than it was two vices, this increase in debt reflects the fact ment in exchange for clinical and research decades ago. The median tuition and fees, that “the cost of education [has] increased commitments. which have increased by more than 150 significantly, but the percentage of ‘free’ An informal survey at UCSF revealed percent at private medical schools and by money (grants and scholarships, including that, in addition to loans and university more than 300 percent at public medical those from extramural sources) awarded to grants, medical students finance their eduschools—the latter partly in response to students as part of their financial aid pack- cation through family resources, personal tight state government savings, private scholarbudgets—are growing Tuition and Fees for First-Year Medical Students at UCSF from 1996–2006 ships, and part-time work $25,000 much more rapidly than during medical school. the Consumer Price InCurrent students report dex. At UCSF, the last earning extra money $20,000 decade alone has seen through working as an increase of more than research assistants for a 150 percent in tuition clinical and basic science $15,000 and fees, from less than projects, interning in $9,000 in 1996-97 to administrative offices or $23,000 in 2006-07. local nonprofit agencies, $10,000 Rising tuition and participating as subjects fees translate to increased in research studies at $5,000 educational indebtedUCSF, baby-sitting, barness. Other causes of intending, and proctoring creased medical student exams at local universi$0 debt include the accrual ties.

One student sells 1996 1997-2002 2003 2004 2005 2006 of interest on long-term photography on the web loans over time and larger and at national and local undergraduate debt burdens. Tuition and age, has remained steady [since 1985].” The venues, and another current student works fees, of course, do not include the cost of liv- bottom line, she says, is that students pay part-time as a freelance model to offset the ing. At UCSF, given the high cost of living about two-thirds of their costs in loans or costs of medical school. in the Bay Area, a twelve-month medical other resources.

Ultimately, can medical school gradustudent budget for housing, food, books and While educational indebtedness has ates afford to repay their loans? According to supplies (including national board applica- certainly increased, loans are readily avail- the AAMC, physicians’ incomes are higher tion fees), and transportation adds another able, and some programs exist to ease the than incomes in most other occupations, $20,000 to a student’s annual costs. repayment burden. For example, debt con- allowing repayment of even relatively high Nationwide, the average educational solidation allows borrowers to combine all levels of debt once a practice is established. debt of medical school graduates is $100,000 federal loans into one package at a blended UCSF, in fact, has a 0 percent default rate for public schools and $135,000 for private rate of interest and to extend payments for Federal Family Education loans and a schools. At UCSF, more than 85 percent for up to thirty years. Another alterna- 0.051 percent rate for Federal Perkins Loans. of students receive some form of financial tive comes through service-related loan Since 1990, medical graduate indebtedness assistance, and the average debt of graduates forgiveness programs, such as the National has increased more rapidly than income, so 14 San Francisco Medicine december 2006

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repayment of educational loans is more difficult today than it ever has been before.

While significant debt loads burden medical students during medical school and beyond, increases in debt may adversely affect patient care and the entire health care system. Students with significant debt may be less likely to pursue family practice and primary care specialties and instead seek out higher-income medical specialties in order to pay off debt sooner. There exists little convincing evidence, however, that medical students choose their specialty because of debt. Graduates choose specialties based on a number of factors, including intellectual challenge, desire to serve, lifestyle, employment opportunities, income level, and required training time. The AAMC suggests that one reason for the lack of a major effect of indebtedness on specialty choice might be that the higher practice incomes of the more specialized disciplines are offset, at least in part, by the longer training times they generally require, and a graduate with a significant amount of debt may choose a discipline where it is possible to begin practice sooner.

The high cost of tuition could also prevent well-qualified students from applying to and attending medical school. A

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recent survey by the AAMC revealed that the cost of medical school and subsequent debt is one of the most-cited reasons that well-qualified students do not apply for medical school. It is the number-one deterrent among AfricanAmerican, Hispanic, and Native American students, thus hindering the recruitment of a diverse physician workforce. According to the American Medical Student Association, patient care is affected by high levels of physician indebtedness because residents with significant debt burdens are more likely to “moonlight” during residency, which contributes to fatigue and, consequently, the occurrence of medical errors.

Despite these challenges, the AAMC contends that a medical education continues to be a sound investment. The median income for college graduates is less than one-fourth of a physician’s estimated annual income. In addition, tuition at top law schools and business schools is comparable to medical school tuition, and the prospects

for employment are much less certain than for medicine. Plus, the limited data available suggest that the lifetime incomes of most lawyers and business school graduates are lower than those of the average physician.

How are we to resolve this dilemma, and encourage more students to enter more areas of medicine? In 2002, former AAMC President Jordan Cohen said, “It’s time for us to put our heads together and come up with creative ways to lift some of [the] burden [of medical school debt].”

He suggested five theoretical possibilities: advocate for more federal support for undergraduate medical education, counsel students about debt management, strengthen loan forgiveness programs, provide more scholarships, and hold tuition down. It may seem impossible to cap or reduce medical school tuition, but, says Cohen, “our credibility as stewards of medicine’s future may demand just that.”

“A recent survey by the AAMC revealed that the cost of medical school and subsequent debt is one of the most-cited reasons that well-qualified students do not apply for medical school.”

december 2006 San Francisco Medicine 15

Money & Medicine

Major Surgery Is the Only Cure One San Francisco Chronicle Columnist’s View on Health Care David Lazarus

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ur health care system is in shambles. Here’s yet more proof: • Insurance premiums paid by employers and workers have nearly doubled since 2000, according to a new report from Menlo Park’s Kaiser Family Foundation.

The 7.7 percent increase this year is more than twice the rate of inflation.

• San Pablo’s Doctors Medical Center says it expects to file for bankruptcy protection after losing about one million dollars a month for the past two years. The obstetrics department is scheduled to close and the hospital’s eleven emergency-room physicians have given notice that they’ll quit.

• Governor Arnold Schwarzenegger has vetoed state legislation that would have established universal health coverage for all Californians. He offered no alternative plan to help the state’s roughly seven million uninsured.

“We’re watching the health care system collapse around us,” said James Kahn, a professor of health policy at UCSF. A recent Kaiser report serves as a frightening reminder for all families that health insurance in the United States is an increasingly costly and, for many, unobtainable goal. Premiums have increased 87 percent during the past six years, the report shows. Family health coverage now costs an average $11,480 annually, with employers paying the bulk of that amount and workers paying an average $2,973. That’s about $1,354 more than the typical worker had

to pay in 2000.

This year’s 7.7 percent hike in premiums is the slowest growth rate in six years, but it’s still more than double the annual increase in wages (3.8 percent) and the overall cost of living (3.5 percent).

“The bottom line here is that health care costs are increasing dramatically faster than wages, and that’s why people are feeling pain,” said Drew Altman, president of the Kaiser Family Foundation. “We’re seeing a slow unraveling of the employment-based health insurance system.”

Nationwide, about forty-seven million Americans lack health coverage—a number that’s steadily rising as more companies abandon health programs for workers.

(About 61 percent of businesses now offer coverage to at least some employees, according to Kaiser. That’s down from 69 percent in 2000.)

“Health insurance is becoming increasingly unaffordable for businesses and working people,” Altman said.

The financial woes plaguing Doctors Medical Center in the East Bay illustrate how dysfunctional the U.S. health care system has become. The hospital, which serves some of the more economically challenged communities of Contra Costa County, was run by Tenet Healthcare until 2004. It lost twenty-four million dollars that year alone.

The facility was taken over by the West Contra County Healthcare District, which cut the deficit to fifteen million dollars in 2005 but now foresees even more red ink

“Nationwide, about forty-seven million Americans lack health coverage—a number that’s steadily rising as more companies abandon health programs for workers.”

16 San Francisco Medicine december 2006

due to lower-than-expected patient volume, technology upgrades, and other factors.

Perhaps the biggest problem faced by the hospital is the fact that about a third of ER patients have no insurance and can’t pay their bills. About 10 percent of all patients arriving at the facility lack health coverage.

To help turn things around, the hospital’s board last week approved a contract for up to eighty-four million dollars to treat at least eight San Quentin inmates every day for the next few years.

“The prison contract offsets some of the losses we’re seeing in other areas,” said Gisela Hernandez, a hospital spokeswoman.

“But it’s not the entire solution.”

For this reason, she said a bankruptcy filing is all but certain. And even then, the future of Doctors Medical Center remains uncertain. “Without an immediate infusion of cash, it’s going to be tough,” Hernandez said. ER doctors gave notice recently because they say they haven’t been paid for six months. Hernandez said universal coverage would go a long way toward keeping hospitals like Doctors afloat. “If everyone had health insurance,” she observed, “we wouldn’t have any uninsured people in the emergency room.” However, it looks like that won’t be happening anytime soon. The governor recently vetoed legislation—SB840—that would have used taxpayer funds to establish a universal health insurance system for all Californians. Independent analysts say such a system would be cheaper than existing insurance payments for most businesses and workers. But Schwarzenegger, bowing to pressure from the insurance industry, said the system envisioned by the bill would be tantamount to socialism.

“Socialized medicine is not the solution Continued on Page 27... www.sfms.org

Money & Medicine

San Francisco Health Access Program Moving Our City Toward Universal Health Care Mitchell H. Katz, MD

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an Francisco is on the exciting edge of providing low-cost health care services to all of the City’s 82,000 uninsured residents. The new initiative is called the San Francisco Health Access Program (SF HAP).

SF HAP will provide uninsured San Franciscans access to health care services at an affordable cost. The San Francisco Health Plan is our partner in implementing the program. The health services provided

by SF HAP include: • Routine health screening and physical exams • Substance abuse prevention and care • Mental health care • Primary care • Prescription drugs • Hospitalization • Emergency services SF HAP was designed by the Universal Healthcare Council (UHC) advisory group, appointed by Mayor Gavin Newsom and comprised of representatives from health care, business, labor, advocacy organizations, philanthropy, and research. Dr. Sandra Hernandez of the San Francisco Foundation, and Lloyd Dean, CEO of Catholic Healthcare West, cochaired the Council.

As a result of a series of meetings, the UHC recommended development and implementation of SF HAP. Following this, Mayor Newsom introduced enabling legislation to implement it.

The San Francisco Health Care Security Ordinance (HCSO), which combined Supervisor Tom Ammiano’s Workplace Security Ordinance with the enabling HAP legislation, was passed by the Board www.sfms.org

of Supervisors and signed into law in early August 2006. SF HAP is one vehicle by which employers can meet the HCSO requirements. Under the new ordinance, employers in San Francisco with twenty or more employees must spend a minimum amount on employee health care or pay the following amount to the City: 20–99 employees = $1.11 per employee hour 100+ employees = $1.68 per employee hour Employees must work at least twelve hours per week to be covered by the legislation, and companies that offer health coverage but do not meet the minimum spending requirement would be required to increase their health expenditures. The legislation would cap at $180 per worker per month, the maximum amount a larger business would need to spend on the employee’s health care. Cost increases in the first three years of the plan would be held to an annual rate of 5 percent to give companies time to adjust.

Employers have options in choosing how to fulfill their required health care expenditure. The choices include health insurance, medical savings accounts, direct reimbursement of employees for medical expenses, and SF HAP. The best outcome is that most employees will get insurance, thereby decreasing the number of uninsured in San Francisco. However, it is clear that there will still be a number of uninsured individuals who are unemployed, employed for less than twelve hours per week, or employed by a business with fewer than twenty employees.

All uninsured San Francisco residents, regardless of employment or immigration status, will be eligible for SF HAP. Coverage under SF HAP will not be portable, and individuals who enroll must be willing to apply for state and federal health benefits to which they are eligible. The program will be funded through contributions by businesses, individuals, and the City and County of San Francisco.

SF HAP will begin a phased-in implementation process beginning in the summer of 2007. Ideally, every provider in the City will agree to see some SF HAP participants.

The prospect of 82,000 individuals qualifying for a health care services program is a tremendous potential challenge. However, the benefits to the people of San Francisco are equally great.

Mitchell H. Katz, MD, is the Director of Public Health in San Francisco.

Send Your Message to 2,500 Health Care Professionals The San Francisco Medical Society offers multiple advertising opportunities ranging from full-page, 4-color display ads to classified ads with discounted rates for members. Please contact Galen Foster for more information, (415) 5610850 extension 240 or foster@sfms.org.

december 2006 San Francisco Medicine 17

Money & Medicine

Health Savings Accounts The Wave of the Future?

Stephen Askin, MD

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hat is a health savings account (HSA)? An HSA is a relatively new system for financing health care. It has two essential elements: a high deductible health insurance policy, and a savings account paid for by tax-deferred dollars. The minimal deductible is $1,000 for an individual and $2,000 for a family; the maximums are $2,700 and $5,450, respectively.

This type of policy is significantly cheaper than a low-deductible policy and is therefore an appealing option for some people. The trustee for the account may be the insurance company, a bank, or a PPO, and the annual contribution is usually close to the amount of the deductible. The money in the account may be invested in an appropriate manner and is to be spent for health care. If used for nonmedical purposes, tax must be paid, as well as a 10 percent penalty. When the insured turns sixty-five, the money can be withdrawn tax-free. When the deductible has been met, the insurance is available for serious and expensive illnesses, thus serving as catastrophic insurance. The HSA embodies our “ownership society” in the health care sector, which reflects a philosophical shift in emphasis from collective to individual responsibility for the management and financing of care.

The concept of HSAs, or medical savings accounts (MSAs), as they were initially called, was first discussed by the AMA and others in the 1980s. Then in 1996, as part of HIPAA legislation, the law enabled formation of MSAs on a trial basis. They were to be used only for individuals or businesses with fifty or fewer employees, and a maximum of 750,000 plans were permitted nationwide. Congress originally allowed the plans to operate on a four-year trial basis and then planned to reconsider them. There

was considerable political opposition to the MSAs from HMOs and others who were not interested in competition, as well as those advocating a national health plan. By 1999, only about 100,000 plans were operating, and in 2000 the trials were extended for an additional two years.

In 2003, new legislation—part of the Medicare Improvement Act—gave MSAs a new name, Health Saving Accounts (HSAs) and removed many of their restrictions. There was no sunset, the number of plans was unlimited, and the fine for nonmedical use was reduced from $150 to $100.

The MSA permitted either the employer or the employee to contribute; the HSAs permitted a sharing of the funding. HSAs seemed to gain popularity.

So what are the advantages? HSAs control costs. Sixty-seven percent of patients pay less than $5,000 per year for health care. Having a traditional, low-deductible health plan is extremely inefficient in dealing with low-cost services. Since all services must be verified, there are relatively high administrative costs. When the patient pays for a service by cash or check, overhead is minimal. Patients also find it appealing to make choices and decisions regarding their physician, tests, and treatment. From 1974 to 1982, the RAND Corporation studied 2,500 families who had health plans with out-of-pocket costs ranging from 0 to 95 percent of the first $1,000. Patients with no deductible spent 67 percent more for outpatient services, and 30 percent more for hospital services. The study concluded that catastrophic insurance reduces expenditures by 30 percent because people are more motivated to conserve their own money. Patients with their own wallets in mind might possibly negotiate lower prices

for drugs, lab tests, x-ray studies, and even physicians’ fees.

An HSA plan improves access to health care funding, even for those in belowaverage economic brackets. For starters, the insurance is relatively cheap. Employers may help fund the savings account. If there is a temporary stoppage of income, contributions can be deferred, making up the funds at the time of a bonus or unexpected income.

The HSA is portable, allowing patients to change jobs without losing health coverage. According to the General Accounting Office, 40 percent of people signing up in the MSA pilot project were previously uninsured, showing its appeal to many in this group.

HSA plans expand consumer choice and control. There is no limitation on specialists, labs, hospitals, drugs, etc., as long as the consumer hasn’t met the deductible.

HSA plans also increase savings. Most people will not spend all the funds in the account but will let them accumulate taxfree, with dividends and interest leading to a nice nest egg available at age sixty-five, when the money can be withdrawn without tax or penalty.

What does the future hold for HSAs? According to an estimate by Diamond Cluster International, a management consulting firm, by 2010 more than 15 million Americans, or about 10 percent of all insured, will have a health savings account. And according to a New York Times article dated January 27, 2006, Wall Street groups—including banks and money managers—are positioning themselves to become central players in the business of health care by offering to manage HSAs. Maybe HSAs fill a need for a category of patients that currently has no other appealing options?

18 San Francisco Medicine december 2006

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Money & Medicine

The Consumer Era in Health Care From the Year 2000 to ????

Greg Scandlen

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hat we experienced in the 1990s was a clumsy effort at coming up with the right balance of access, cost, and quality. For many years costs had gone up too fast, so employers stepped in with managed care programs to curtail further increases. Then patients got upset that cost had become more important than access and quality. They felt their best interests were being sacrificed in the name of cost control, so government wanted to step in with “patient protections” to correct the balance.

How to find the balance is the right question, but the wrong parties are making the decisions. The right balance is an individual value judgment that will vary from person to person and from time to time. The only way to accommodate these individualized values is through a market mechanism. Restoring effective market functions to the health care system will take time, but other industries have been deregulated with great success, and health care can be as well. At this writing we are already well into a new era of health care reform—the Consumer Era. It is far too early to tell how the Consumer Era will develop. It began with the enactment of Medical Savings Accounts (MSAs) in 1996. These were available only to small employers and the self-employed—not the most innovative segments of the benefits market. The program was very tentative and restrictive and did not fare well in the market.

But it did force a rethinking of the role consumers could play in controlling health care resources. As the “managed care backlash” unfolded, human resource executives in large companies began to explore how MSA principles could be apwww.sfms.org

plied to their own benefit programs. They drew on their successful experience with pension programs, which had gone from “defined benefit” programs (traditional company-paid retirement plans that promise a certain level of monthly benefits regardless of the state of the economy or the solvency of the company) to “defined contribution” approaches, such as 401k’s that prefund a set amount of annual contribution, which is then the property of the employee and fully portable as workers move from job to job (Scandlen 2000). In revising pension programs, employers were able to move from virtually unlimited and unknowable future obligations to a prefunded and fixed annual liability.

To replicate this experience in the health arena, employers created what the Internal Revenue Service later termed “Health Reimbursement Arrangements” (HRAs). Using existing tax laws, employers created MSA look-alike programs, with higher deductibles and “personal health accounts” that would roll over from year to year and build up if not spent. The funds were “notional” (unfunded) accounts that were allocated to each employee, but not owned by them. Employers using these programs pressed the IRS for private-letter rulings that would clarify that such programs were in compliance with current tax law.

Under this pressure, the IRS went further than most people expected and issued a comprehensive Notice and Revenue Ruling in June 2002, laying out the rules of the road for HRAs. Armed with this new guidance, increasing numbers of employers began establishing HRA programs, as well as the infrastructure to implement them. This change of mindset by benefits executives at large corporations

encouraged Congress to enact Health Savings Accounts (HSAs) as part of the Medicare Modernization Act of 2003 (www.cms. hhs.gov/MMAUpdate/). When Congress was considering MSAs in the mid 1990s, most large employers were at best indifferent to the idea, and more often hostile to it. They had put their eggs in the managed care basket, and they viewed MSAs as a distraction. Seven years later, however, managed care had become a dead-end, and companies were looking around for alternative approaches. Now HSAs are sizzling in the market. In two years, they have attracted more than 3 million customers (America’s Health Insurance Plans [AHIP] 2006). According to Professor Regina Herzlinger, they are being adopted at a faster rate than IRAs were, and certainly faster than HMOs or 401k’s ever were (Herzlinger 2006).

But this is just the beginning of a total transformation of the American health care system. Once patients control the money, they will demand (and already are demanding) the information needed to spend their money wisely. Once they have both money and information, they will demand changes in the way health care services are delivered.

It will become more accountable, convenient, efficient, affordable, and of better quality (Scandlen 2005). There will be a thorough housecleaning of a system that is currently bloated with waste, bureaucracy, and inefficiency.

Greg Scandlen is the founder of Consumers for Health Care Choices in Washington, D.C. This article was excerpted from a longer piece entitled “100 Years of Market Distortions.” To view the entire article, please visit www.chcchoices.org/publications.html.

december 2006 San Francisco Medicine 19

Dental Open Enrollment Effective Date: January 1, 2007!

It’s Open Enrollment time for the San Francisco Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care.

This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers).

• During Open Enrollment only, members may join as an individual or as a group with your employees.

• Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families).

• Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage applications must be received during the special open enrollment period that ends on December 31, 2006.

Call a Client Service Representative at (800) 842-3761 for more information, a brochure and an application. Or e-mail CMACounty.Insurance@marsh.com.

Sponsored by:

Underwritten by:

Administered by:

Affinity Group Services

DentalGuard is underwritten by The Guardian Life Insurance Company of America, New York, NY. Group Contract #G-271907

© 2006 Seabury & Smith Insurance Program Management • CA Insurance License #0633005

777 South Figueroa Street, Los Angeles, CA 90017 • (800) 842-3761 • CMACounty.Insurance@marsh.com• www.MarshAffinity.com • 10/06

Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Putnam Investments, Mercer Human Resource Consulting (including Mercer Health & Benefits, Mercer HR Services, Mercer Investment Consulting, and Mercer Global Investments), and Mercer specialty consulting businesses (including Mercer Management Consulting, Mercer Oliver Wyman, Mercer Delta Organizational Consulting, NERA Economic Consulting, and Lippincott Mercer).

20 San Francisco Medicine december 2006 www.sfms.org

Money & Medicine

Fundamentals of Prudent Investing Advice from the Financial Consultants at Cambridge Associates George Pendergast and Beth Rabbitt

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hen thinking about success- The strategy needed to have investment ful investing practices and gains over the long haul is very differasset management, many ent from that of choosing an individual harbor the stereotypical Wall investment and measuring its Street Week mentality—with performance on a day-to-day a broker on speed dial and a basis. Most stocks perform gazillion megabytes of Interwell at some point in their net analysis and information history. When investing for on hand, you can operate your future, what you want with the certainty that there is more than incredibly good are endless opportunities out returns at one point in time.

Figure 1: What really matters there to buy unfollowed stocks What is needed in this case at five dollars and sell at three hundred is a consistent pattern of long-term dollars, achieving amazing day-trading performance. profits and a portfolio that always beats the market.

What really matters in long-term Although this notion is romantic, it investing? is hardly practical for the rest of us. PickMost people point to individual ing individual investments is a risky and stock selection and market timing as the time-consuming proposition, and the whole number-one factor in success. However, process of personal investing in this fashion the findings of several researchers are can be intimidating and overwhelming. powerful reminders that what people However, as will be discussed in this article, think does not necessarily translate to successful, prudent personal investing does reality. not require preternatural short-term abiliIt turns out that what is most imties, but rather long-term focus, discipline, portant is not the specific stocks you and perspective. Using the right tools in pick but the overall composition of your your own portfolio can simplify the process investment portfolio or asset allocation. and help ensure that you meet your goals. This crucial composition accounts for To use a tired Boston investing adage, “It’s 90 percent of your investment results a marathon, not a sprint.” over time.

The bottom line is that, although What is investing for long-term success? it is tempting to think that investment Although it is tempting to focus on success is mostly about being great at the short-term results of investments (for picking individual stocks—a myth many example, my portfolio is up 4 percent day-traders take to the extreme—in the this month, down 2 percent the next), long run, it is the allocation of your asit is more important to think about sets that really drives performance. The your goals with a long-term perspective. impact of market timing and individual When preparing for future retirement, stock selection pales in comparison to we are often talking about time periods the impact of getting your allocation of ten years or more, not days or months. right. Once you have put the time into www.sfms.org

creating an asset allocation policy that is right for you, given your timeline and objectives, what is really required is staying focused and being disciplined in implementing your investment plan.

Creating an appropriate personal asset allocation policy All investments share two common characteristics: return, or how much an asset increases in value over time; and risk, or how volatile the value of the asset can be on a short-term basis (in the investment world, risk is often measured in standard deviation). Generally these two characteristics have a positive relationship—as expected return increases, so does risk.

Creating a personal asset allocation therefore starts with one simple decision: How much return do you want and how much risk are you willing to accept to get it? This fundamental tradeoff should form the basis for any investment decision you make.

The choices people make usually are dependent on their investment horizon (when they plan to retire or will need to tap into their funds) and their own affinity for risk. A highly risk-averse investor—for example, a surgeon who plans to retire in a few years—will most likely decide to choose an allocation with lower return in exchange for the security of knowing that the chance of losing a portion of his or her assets is slim. Conversely, recent medical school graduates with forty years before retirement can invest more aggressively because they have a longer time to see the returns on their investment as well as recoup any losses in down periods.

december 2006 San Francisco Medicine 21

The case for diversification Despite the fact that it is a cliché, the old saying that you should not put all of your eggs in one basket is particularly true when it comes to personal investing. The more diversified you are, the better return you can get for any given amount of risk.

The table on the lower right Figure 2

Tools of the trade: Equities, bonds, and cash Given that inflation averages approximately 3 percent a year, you need to seek a return of greater than that to merely preserve your personal wealth. When it comes down to it, most amateur market watchers have three choices for investing assets: stocks, bonds, and cash. Stocks (or “equities”) offer the highest potential for return. However, they are generally the most volatile. Bonds offer a safer bet, but in most markets, you can expect a significantly lower return. Cash and its equivalents, such as money markets, are a safe bet for short-term use, but you can incur a higher opportunity cost (or loss of benefits from investing those funds elsewhere) for holding on to too much of it.

Figure 2 shows the cumulative real gain of a dollar invested in the three asset classes since 1900. As you will see, stocks clearly beat bonds and cash in the long run, providing the highest return over time.

However, what also is clear is the fact that stocks are more volatile, and the variability of the peaks and valleys in the return line in Figure 2 shows this fact. If you invested 100 percent of your assets in stocks at the wrong time, you could risk losing a significant portion of your assets in one year alone. In order to hedge against this downside risk, you need to use an asset allocation that is appropriately diversified. Diversification is a powerful tool for reducing overall risk and increasing the probability of achieving a consistent pattern of returns.

in the end that are fairly comparable to the more aggressive position.

Obviously, this scenario simplifies the story a bit. As an investor today, you have many options beyond just investing in U.S. stocks and bonds. Mutual funds offer an opportunity to access a more diverse group of investments, through a pool of funds, than you would have on your own. Global investments also offer a way to diversify into different markets. Finally, investing in specific sectors such as real estate or energy can also tap into new opportunities for return and tend to be less correlated with one another, which is another way of diversifying your risk.

What now?

Meeting with a financial advisor

Bureau of Labor Statistics, Citigroup Global Markets, Common-Stock Indexes (Cowles Commission), Federal Reserve, Global Financial Data, Merrill Lynch & Company, Standard & Poor’s, and Thomson Datastream. Cumulative wealth indices are shown on a logarithmic scale.

shows the risk and return profiles of four investors with four different personal asset allocations.

Investor 1 is highly conservative, investing all his assets in a U.S. bond fund.

Investor 4, on the opposite end, is highly aggressive, putting all her cash into the U.S. stock market fund. Investors 2 and 3 take a more moderate approach, investing their assets in a mixture of U.S. stocks and bonds.

If each of these investors invested one hundred dollars in their respective allocations, rebalancing their portfolios back to their targets over a ten-year period, where would they be now? Figure 3 simulates the returns of the four portfolios.

Despite the fact that Investor 4 does end up in a marginally wealthier position at the end of the ten-year period, this investor experienced a much higher level of risk and endured a roller-coaster ride in the market.

Depending on when she needed to retire, the probability of being able to predict her financial position would be low. Conversely, through diversification, Investors 2 and 3 experienced a much smoother ride with less risk and more certainty and enjoyed returns

22 San Francisco Medicine december 2006

These data use the S&P 500 Index as the basis for a U.S. equity investment and the Lehman Brothers Aggregate Bond Index as the basis of a U.S. bond investment.

can be a great way to start the process of creating a diversified asset allocation that fits your time horizon and objectives. Many mutual fund companies will offer free assessments online or in person. Once you have figured out an allocation that works for you, stick with it. Consistent rebalancing back to your targets on a regular basis (such as annually) will lower your risk and help you meet your goals. Rebalancing requires diligent discipline, primarily because it often means selling your most successful investments and adding to your underperforming ones. It is the opposite of “momentum” or “markettiming” investing, which, in the long run, is a good thing. By staying focused, you will have a greater potential of achieving your investment objectives prudently.

Editor’s Note: This article was reprinted with permission from the American College of Surgeons Bulletin. www.sfms.org

book review Nancy Thomson, MD

The Soul of Money Transforming Your Relationship with Money and Life

E

veryone has a relationship with money. In her book The Soul of Money (Lynne Twist with Teresa Barker, W.W. Norton and Co., 2003), Lynne Twist evaluates the role it has, and should have, in everyone’s family—including her own.

In the 1970s, the Twists and their three children were seduced by the “siren song of success,” using their financial achievements to find happiness in material goods.

But the launch of the Hunger Project, a global initiative to end world hunger, took Twist back to her childhood, when she first heard about people in the world without enough to eat. She resolved to end the chase for things material and instead devote her energy to helping build a life for all people, as she explains in her first chapter, “Money and Me, Money and Us.” Twist now believes that in recognizing the soul of money and changing our relationship with it, we can create a new and profound spiritual experience. As she quotes Teilhard de Chardin: “We are not human beings having a spiritual experience, but spiritual beings having a human experience.”

Connecting Compassion and Wealth Twist’s story continues with a journey to India in 1983. Amid the hunger and poverty, she discovered “startling truths about money and wealth, about human nature, and human potential.”

According to Twist, begging is an industry in India, and people sometimes mutilate their children so they will seem more pitiful. During her visit, Twist walked the streets of Bombay with Ramakrishna, Ghandi’s adopted son. As an industrialist, he has established several projects for the common good but ignores the beggars, so as not to support and perpetuate this “industry.” In May of 1991, Twist visited Mother Teresa in Delhi, who was familiar with the Hunger Project. Finding an abandoned baby girl on the steps as she walked in, Twist bathed numerous infants while waiting to see Mother Teresa. However, their visit was interrupted by a wealthy couple who barged in and insisted on having their picture taken with Mother Teresa. Twist was livid and, realizing her limited compassion, she later wrote Mother Teresa a letter of apology. In her response, Mother Teresa said the cycle of poverty was widely known, but the vicious cycle of wealth—its burden leading to poverty of the soul—was not, and those affected by wealth need compassion too. www.sfms.org

Lessons from around the World The latter part of the book deals with “Scarcity: The Great Lie” and its three “Toxic Myths”: There is not enough, more is better, and that’s just the way it is. The book then covers “Sufficiency: The Three Surprising Truths,” headed by the subtitle, “Money is a current, a carrier, a conduit for our intentions. Money carries the imprimatur of our soul.” This portion of the journey takes Twist to many locations throughout the world.

In the Amazon jungle, for example, Twist met the Achuar people, who have a fable about the Eagle and the Condor, symbolizing two groups of people developing in different ways. The Eagles are highly scientific and intellectual; the Condors are attuned to nature and the intuitive realm. The Eagles (Western culture) develop technologies bringing wealth, while the Condors (indigenous peoples) develop relationships with the natural world. In the myth the two groups, needing to interact to save their existences, reconnect, flying together in the sky.

Twist begins the fourth section of the book, entitled “Change the Dream,” by using Martin Luther King’s famous quote. She continues to describe several of her experiences around the globe, including her attendance at a 1995 women’s conference in Bejing.

At this conference, more than fifty thousand women gathered to show that money can flow to us and through us to support others.

In her last section, “The Turning Tide,” Twist describes a retreat of thirty global activists, who gathered in Cadine, Italy, for a Synthesis Dialogue with the Dalai Lama. His Holiness said that there is a universal desire to be happy and avoid suffering, and when we bring a spiritual presence to money it expands, enlarges, and magnifies its value.

Lynne Twist is a global activist and fund-raiser who has raised more than $150 million in individual contributions for charitable causes. Her book concludes with forty-three pages listing individual organizations working in various ways to help ease the world’s problems.

The Soul of Money has recently come out in paperback.

december 2006 San Francisco Medicine 23

hospital news Chinese

Fred Hom, MD

Congratulations to Clinical Laboratory Services and the entire Chinese Hospital staff for the excellent outcome after the JCAHO survey. One key finding that the medical staff should heed is the requirement to read back critical values given over the telephone, which is similar to the procedure used in telephone orders. Special thanks go to Mr. Ray Fung, Lab Manager; Dr. Roderick Snow, Medical Director; Patricia Chung, Survey Coordinator; and the entire JCAHO Continuous Preparation team.

Kudos also to the participants of the Chinese Hospital Annual Golf and Fund-Raising Tournament at the Olympic Club. Medical Staff golfers were James Yan, Edmund Tsoi, David Kang, Roger Eng, Kevin Man, Karen Tuan, Randall Low, and Gustin Ho. Dr. Ho was the star of the day with the “Closest to Pin” award, coming within eight inches at the fifteenth hole of the Lake Course. Another star was Dr. Shu-Wing Chan, who made a generous donation toward the new building’s Capital Campaign drive. Dr. Chan will spearhead the campaign, but there is not yet a decision to name the new building the “Shu-Wing Wing.”

review all medication orders before dispensing medications, and creating procedures to avoid wrong-site surgery. The goal is to give consumers information to help them compare the health care quality of different hospitals. More than 1,260 hospitals nationwide voluntarily took part in the survey.

Dr. Allan Pont was appointed VPMA and Chief Medical Officer effective October 1, 2006.

Dr. Pont had served as Chair of the Department of Medicine since 1995.

Dr. Lory Wiviott was appointed Acting Chair of the Department of Medicine. Dr. Wiviott served as Department Vice-Chair prior to his appointment as Acting Chair.

Community Health Programs, on behalf of CPMC, coordinated the annual Chinatown Community Health Fair on Saturday, October 21, at Donaldina Cameron House in the heart of Chinatown. This important fair offered free health screenings and information to lowincome, monolingual Asian immigrants in San Francisco. CPMC, in collaboration with Community Health Resource Center, provided glucose and cholesterol screenings to 220 individuals. CPMC also offered valuable breast health education.

Kaiser

Robert Mithun, MD

Unfortunately, the transferred cost does not fall equally on all employees, as those who are the most in need of medical care will pay the most.

With comprehensive benefits, the insurance premiums paid by healthier people subsidize the care of sicker people. Imagine that healthier people now have the option of switching away from comprehensive coverage, to a high-deductible plan with a lower monthly premium. When these healthier people leave comprehensive insurance and take their premium dollars with them, the sicker people left in the comprehensive insurance pool will find themselves with much higher premiums.

Unfortunately, the matter isn’t as simple as “comprehensive = good,” “high-deductible = bad.” There are those who argue that highdeductible plans will give patients a needed incentive to pay attention to the cost of their care. And what if the choice isn’t between comprehensive and high-deductible insurance, but between high-deductible insurance and no insurance at all? As a society, we have not only to ask how much of our GDP we want to spend on health care, but how we would like the cost of health care to be distributed between the healthy and the sick. Physicians must be part of this important conversation.

Saint Francis

Guido Gores, MD

CPMC

Damian Augustyn, MD

California Pacific Medical Center has been named one of the top fifty hospitals in the U.S. by the Leapfrog Group, a nonprofit organization that measures hospital quality and safety. CPMC was recognized for the steps taken to improve safe patient-care practices and reduce errors. The Leapfrog survey looked at thirty different practices within hospitals, such as having pharmacists

While society grapples with the rising cost of health care, a quiet change has been taking place in the world of health insurance.

This change may have profound effects on our patients, and it is important that physicians understand it.

The key development is the rise of the high-deductible benefit design. Comprehensive health insurance benefits are expensive; highdeductible benefit designs have lower up-front premium costs. Switching from comprehensive to high-deductible is therefore an economically rational move on the part of employers, because it transfers cost from the employer to the employee.

24 San Francisco Medicine december 2006

At Saint Francis Memorial Hospital, part of financial planning means investing in the health of San Francisco’s underserved populations. Saint Francis is committed to partnering with the community to develop programs to serve the most needy. During FY 2006, the hospital contributed more than thirty million dollars in Community Benefit Dollars, which includes more than four million dollars in direct charity care services.

As a partner with the Public Health Institute in the Advancing the State of the Art in Community Benefit (ASACB) program, Saint Francis has established a system that ensures www.sfms.org

hospital news benefit programs operate effectively. Currently, the system focuses on the following: discharge services for homeless, disenfranchised, or elderly; enhancing capacity of programs that care for our community’s chronic public inebriates; providing cultural competency services to targeted populations; exploring ways to improve health care access for un- and underinsured and enhancing the capacity of programs that currently provide these services; and helping support housing for homeless and disenfranchised individuals.

Recently Saint Francis made a major investment in the community with the completion of our new, state-of-the-art Emergency Department, where many of the city’s underserved receive care. The $12.6 million project expanded the department to nineteen patient beds in more than ten thousand square feet. We expect to see twenty-nine thousand patients this year. The opening was saluted in the San Francisco Examiner by Ken Garcia, who quoted the CMA’s CEO Jack Lewin, MD: “The staff and management at Saint Francis understand the need for more emergency care, even if it’s not profitable. It’s a decision that definitely goes against the grain, but it’s heartening to see that one facility has decided to step up. We have to tip our hats to Saint Francis for taking this important step.” We were honored to be recognized in this way.

St. Mary’s

Kenneth Mills, MD

and private organizations to improve quality and avoid unnecessary health care costs.

The purpose of pay-for-performance is to improve the quality of patient care for Medicare beneficiaries by giving financial incentives to almost three-hundred hospitals that exhibit highquality care. CMS is collecting data on thirtyfour quality measures relating to five clinical conditions. Each hospital’s specific performance will be publicly reported on the CMS website.

Hospitals that score in the top ten percent of a given set of quality measures will receive a twopercent bonus payment on top of the standard DRG payment for the relative discharges. Those scoring in the next-highest ten percent will receive a one-percent bonus.

St. Mary’s staff of hospitalists, hospitalbased physicians, clinical staff, and house staff are all on board. Medical staff leadership is also encouraging the private sector to get involved with pay-for-performance. Pay-for-performance initiative dovetails with quality. At St. Mary’s, quality is part of our mission. Our goal is to deliver high-quality, low-cost care to all of our patients, and to constantly strive for improving patient satisfaction. Pay-for-performance provides one way for us to ensure that our patients are getting the best possible care. We also value high levels of patient satisfaction, and are always interested in new ways to give our patients excellent care.

Veterans

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Diana Nicoll, MD, PhD, MPA

St. Mary’s Medical Center and Catholic Healthcare West (CHW) are gearing up for the implementation of pay-for-performance, a new initiative created by Centers of Medicare and Medicaid Services (CMS). The foundation of effective pay-for-performance initiatives is collaboration with providers and other stakeholders to ensure that valid quality measures are used, that providers aren’t pulled in conflicting directions, and that hospitals have support for achieving actual improvement. CMS is collaborating with a variety of other public agencies www.sfms.org

six percent in very poor health had it. Noting current publicity campaigns urging all men to get screened, Dr. Walter said, “We need to educate the public more about the downsides of screening tests. This isn’t about cost-cutting. It’s about not doing harm by not subjecting elderly men with less than ten years’ life expectancy to tests and procedures they don’t need.”

Doctors are as likely to underprescribe medications for elders as they are to overprescribe, according to a study in the October 2006 issue of the Journal of the American Geriatrics Society. The study authors, led by SFVAMC staff physician Michael Steinman, MD, analyzed the medical records and medication lists of 196 VA outpatients aged sixty-five and older who were taking five or more prescribed medications. Sixty-five percent were taking a medically inappropriate or duplicative drug. Sixty-four percent were not taking a drug that would have been beneficial.

Forty-two percent were simultaneously taking an inappropriate drug and not taking an appropriate drug. Inappropriate use rose with the number of medications prescribed, while all patients were equally likely to not be taking at least one appropriate drug. “Perhaps in patients taking relatively few medications, we should focus more on what other drugs might be beneficial,” concluded Dr. Steinman. “In patients taking many medications, we need to be vigilant about drugs that are underused as well as those that are overused.”

Send Electronic Claims Using Your Own Software! Save time and money! FREE trial offer! Call Signature Claims toll free (877) 744-2561 A study of 597,642 men aged seventy and older revealed that fifty-six percent had a routine prostate-specific antigen (PSA) screening, even though no treatment guidelines recommend PSA screening for elderly men. The study, led by staff physician Louise Walter, MD, of SFVAMC, appeared in the November 15, 2006, issue of JAMA. Screening rates went down with age, but overall health made little or no difference.

Among men eighty-five and older, thirty-four percent in good health had the test, while thirty-

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december 2006 San Francisco Medicine 25

Dispatches from the 2006 CMA Meeting Brian Lewis, MD, and Steve Heilig, MPH

T

he annual meeting of the CMA’s House of Delegates is an ultimate Shu, MD, and Charles Wibblesman, MD) demonstration of democracy—both its boons and frustrations. 7. CONFLICT OF INTEREST REGARDING MEDICINE AND THE This year, approximately five hundred physicians gathered in PHARMACEUTICAL INDUSTRY (George Susens, MD) Sacramento to chart the future of CMA policy and to advocate for dozens of 8. CANNABIS MEDICAL USE AND RESEARCH­ (Stephen Follansissues. This includes not only the usual election of bee, MD) leadership, but intensive consideration of almost 150 policy proposals, which can be submitted by Some of these proposed resolutions, as SAN FRANCISCO DELEGATES any CMA member. Such proposals range from the might be imagined, stimulated heated debate.

AT THE 2006 CMA MEETING brilliant and important to the mildly outlandish.

In almost all cases, we were able to get them (and some local specialty and The collective wisdom of the elected delegates adopted as CMA policy, either intact as writother representatives who joined in): was fairly effective in determining where each ten or in revised form (and in one case where Edward Chow proposal fit on that scale, and representatives acted the resolution was defeated, the assisted-dying Stephen Follansbee accordingly. Rather than conducting an exercise resolution, there were some “process” questions Gordon Fung in irrelevant hot air, the CMA plays a powerful that are being looked into). Details of all finalBrian Lewis role in California’s healthcare politics and beyond, ized policy from this year’s meeting are available Dexter Louie and the effect of any policies adopted each year on the CMA website at www.calphys.org/html/ Judith Mates can have a real-world impact on our lives and news.asp; or, regarding SFMS-generated poliE. Ann Myers those of our patients. cies, by contacting Steve Heilig at (561) 0850 George Susens Your San Francisco delegation, relatively extension 270 or at heilig@sfms.org.

H. Hugh Vincent small in number compared to some delegations Some other contentious issues threatened Lucy Crain representing much larger geographical locales, the relative peace of the process. The CMA’s James Davis makes a disproportionate, and positive, impact position on Proposition 86, the tobacco tax, Mei-Ling Fong each year. A number of our delegates (Drs. Crain, came in for some heated opposition, mostly Rita Melkonian Fong, Follansbee, and Shu) took one further step from Southern California (the SFMS joined the Rachel Shu and served on one of the conference committees CMA in judging that, on balance, the positive Peter Sullivan that hear testimony on proposed policy and formuimpacts of this proposition would outweigh the Robert Margolin negative; and we refused to join any side taken late recommendations for the full House. Former Eric Tabas by the tobacco industry, which spent more than state Senator Joe Dunn, the new CMA CEO who Gary Chan fifty million dollars to defeat prop 86). Our replaces the otherwise irreplaceable Jack Lewin, Charles Wibbelsman perception was that the opposition was mostly MD, in fact acknowledged our reputation to us, Suketu Sanghvi based upon self-interest, mainly financial, saying, “I have heard of your group and want to William Andereck which was unfortunate. And we could not help work with you,” and we think he was sincere.

Thomas Addison but observe that some of the anti-86 television This year, in addition to our considered Andrew Calman spots were the first appearance by physicians in input on a number of California medical and Edward Sheen white coats in a tobacco-sponsored campaign in public health issues, we brought eight proposed Craig Kliger at least a generation, which embarrassed more resolutions for consideration by CMA: Rolland Lowe than a few of the delegates present.

Another heated debate concerned 1. AIR QUALITY STANDARDS AND HUproposed restrictions on balance billing, which some physicians see as MAN HEALTH (Gordon Fung, MD) 2. METHAMPHETAMINE: CONFRONTING THE EPIDEMIC OF an unrestricted right and others as a necessarily negotiable issue. CMA’s diverse delegates wrestled with this and crafted some compromise policy ABUSE (David Smith, MD) 3. PHYSICIAN AID IN DYING: STUDIED NEUTRALITY (Robert to guide advocacy with the insurance industry and politicians. On other important fronts, CMA elected its first East Indian-American president, Liner, MD) 4. MODERN CHEMICALS POLICY FOR CALIFORNIA (Lucy Crain, Anmol Mahol, MD, of Alameda County. The CMA’s active public foundation, cofounded by our own Rolland Lowe, MD, hosted an annual MD) 5. TORTURE AND MILITARY PHYSICIANS (Ann Myers, MD, and dinner for more than seven hundred people, which raised substantial funds for good work.

Marcus Conant, MD) 6. EMERGENCY CONTRACEPTION OTC FOR MINORS (Rachel Continued on Opposing Page...

26 San Francisco Medicine december 2006

www.sfms.org

in memoriam Nancy Thomson, MD, SFM Obituarist

John P. McCann, MD John P. McCann, MD, passed away at age 82 following a myocardial infarction at his summer home in Bidderford, Maine, on October 11, 2006.

He was born to John and Rose McCann, June 9, 1924, in Flint, Michigan.

Dr. McCann attended the University of Michigan and Notre Dame as a pre-med, Marquette University School of Medicine for his MD, and Harvard University for his MPH, as well as the Armed Forces Staff College.

He was licensed to practice medicine and surgery in California, Idaho, and New York. He was a visiting lecturer at USAF School of Aerospace Medicine, Brooks AFB, Texas, Harvard University School of Public Health, and Ohio State University and an associate clinical professor at UCSF. During WWII, he began pilot training in 1944 in the U.S. Army Air Force and served in England as a B-17 bomber pilot with the 8th Air Force.

Following the end of the war he continued medical school until returning to active duty in March 1949 as an intern. In 1953, he returned to flight status as a pilot and flight surgeon for the rest of his Air Force career. He flew more than forty different military and civilian aircraft with more than 3,400 hours of rated flight time since 1944 as a military and civilian pilot.

He was designated an FAA Aviation Medical Examiner and a senior medical member of a number of major military and civilian aircraft rescue and investigating teams. This included the bombing of Pan American Flight

#103 over Lockerbie, Scotland, in 1988.

He had been a member of the San Francisco Medical Society and the California Medical Association since 1982 and served on the Residency Review Committee for the American Medical Association as well as the boards of several corporations. He authored various papers for military and scientific journals and was a member of the World Medical Association, the American College of Preventive Medicine, the Aerospace Medical Association, the New York Academy of Medicine, the New York Academy of Science, the Academy of Occupational Medicine, the Alpha Omega Alpha Honor Medical Society, and he was also a Fellow in the American College of Physicians. He was particularly active in Federation Aeronautique International, serving as a delegate.

His friends and associates knew him as a man of great compassion, understanding, and encouragement and were surprised to learn he did so many things and accomplished so much so quietly.

He is survived by his wife of sixty-two years, Elizabeth; his sister Martha; sons Michael, John, Timothy, Dennis, Christopher, Kevin, and Daniel; and daughters Kathleen, Maureen, and Colleen; ten grandsons; eight granddaughters; four great-grandsons; and one great-granddaughter.

His sister Mary and son Joseph preceded him in death.

2007 CMA Meeting Continued from Opposing Page ...

“Major Surgery” Continued from Page 16 ...

The CMA House of Delegates is one of the few places left where physicians (and future physicians) of all ages, specialties, locales, and political leanings can come together and hammer out common ground.

We return from the meeting each year both energized and exhausted, if that makes any sense.

Some of our delegates have been re-upping for election by the SFMS membership for well over a decade, and returning each year to play their important roles. Some of our delegates have gone on to join the CMA board, to become CMA’s representative to the AMA, and to serve as CMA President.

There must be some reward in all this service, and we invite others who might be interested to get in touch to know more about what it’s all about and how you might join us.

to our state’s health care problems,” he said in a statement, adding that the proposed system would be “a serious and expensive mistake.”

UCSF’s Kahn countered that the governor has it wrong.

“SB840 is not about socialized medicine,” he said. “You would still have public and private health care providers. What this is really about is simplifying the finances of health care.”

According to researchers at Harvard Medical School, about a third of all health care spending nationwide is squandered on bureaucratic overhead—the result of a vast array of insurance forms and procedures. “All the evidence suggests that the current system doesn’t work,” Kahn said. And gradually, business leaders are reaching the same conclusion.

“The (health care) system is out of control, it’s unstable, it’s basically bankrupt, it gets worse each year, and all we do is tinker around the edges when what we need are major fixes,” Craig Barrett, chairman of chip-maker Intel Corporation, said in a speech last week. He didn’t call specifically for universal coverage, but he said that employers should demand that hospitals use standardized record systems to keep costs under control.

“The current health care system is economically unsustainable and negatively impacting our nation’s ability to compete globally,” Barrett said.

“It’s time for a systemic transformation, and U.S. employers must lead.”

Unless, that is, our politicians can find the courage to do so.

Editor’s Note: This column was reprinted from the San Francisco Chronicle, with permission. David Lazarus’ column appears Wednesdays, Fridays, and Sundays. He can be contacted at dlazarus@sfchronicle.com.

SFMS Annual Dinner January 25, 2007 This year’s dinner will be held at the Concordia-Argonaut.

Please watch your mailbox an for invitation. www.sfms.org

december 2006 San Francisco Medicine 27

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