September 2015

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

FORTY-NINE SQUARE MILES OF INNOVATION LOCAL BREAKTHROUGHS IN MEDICINE AND PUBLIC HEALTH

VOL.88 NO.7 September 2015

MIEC Belongs to Our Policyholders! “ As your MIEC Claims Representative, I will serve your professional liability needs with both steadfast advocacy and compassionate support.”

Senior Claims Representative Michael Anderson

Toni Brayer, MD

Board of Governors, Internal Medicine

Service and Value MIEC takes pride in both. For over 35 years, MIEC has been Keeping true to our mission steadfast in our protection of California physicians. With conscientious MIEC has neverexcellent lost sightClaims of its original mission, and always putting Loss Underwriting, management hands-on policyholders (doctors like you) first. For 40 years, MIEC has been steadfast Prevention services, we’ve partnered with policyholders to keep in our protection of California physicians with conscientious Underwriting, premiums low. excellent Claims management and hands-on Loss Prevention services; we’ve partnered with policyholders to keep premiums low.

Added value: Added value: carrier with low overhead n Zero-profit n No profit motive and low overhead n Dividends with an average savings on 2011 premiums of 40.4%* Dividends for an average savings of 25% on 2015 premiums for California Forphysicians* more information or to apply:

n

For more information or to apply: n www.miec.com n n www.miec.com Call 800.227.4527 n Call 800.227.4527 n Email questions to underwriting@miec.com n Email questions to underwriting@miec.com * (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

* On premiums at $1/3 million limits. Future dividends cannot be guaranteed.

MIEC 6250 Claremont Avenue, Oakland, California 94618 800-227-4527 • www.miec.com

SFmedSoc_ad_02.13.15

MIEC Owned by the policyholders we protect.

IN THIS ISSUE

SAN FRANCISCO MEDICINE

September 2015 Volume 88, Number 7

FORTY-NINE SQUARE MILES OF INNOVATION FEATURE ARTICLES

MONTHLY COLUMNS

9 Identifying HIV: The First Step to Hope in the AIDS Crisis

Paul Volberding, MD

4

Membership Matters

9

Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH

11 Linking HIV with AIDS: A Breakthrough in Understanding

Stephen E. Follansbee, MD

13

15

One Medical: Redefining the Primary Care Model Thomas Lee, MD

San Francisco Values: Health Care Is a Right, Not a Privilege David E. Smith, MD, and Steve Heilig, MPH

17 Universal Health Coverage: Healthy San Francisco Provided

Access to Residents

Steve Heilig, MPH 18 Optogenetics: Taking Neuroscience by Storm

Bruce Goldman

20 A Neurological First: A Piece of San Francisco Medical History Arthur E. Lyons, MD 21 A Cardiovascular First: Catheter Ablation of the AV Junction

Melvin Scheinman, MD

16 Welcome New Members

28 Medical Community News 30 Upcoming Events 29 Classified Ad

OF INTEREST 24 CMS Update

Ashby Wolfe, MD, MPP, MPH 26

Public Health Update: Mandatory Influenza Vaccination or Masking of Health Care Workers During Influenza Season Tomás J. Aragón, MD, DrPH

27 Health Policy Perspective—Physician-Assisted

Dying: Honest Choices

Donald Abrams, MD, and Steve Heilig, MPH

ADVOCACY UPDATE

23 September SFMS Advocacy Update

John Maa, MD, FACS

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 Web: www.sfms.org

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members 2015–2016 Membership Desktop Reference

other key contacts. SFMS members can download the profiles for free as part of their member benefits at http://bit.ly/1JRuj4d.

SFDPH Releases Health Advisory on Opioid Overdose

The San Francisco Department of Public Health has issued an advisory after noting an increase in opioid overdose cases reported to the SF Drug Overdose Prevention and Education (DOPE) Project, with more than 75 cases in July 2015 (versus 25 in July 2014). Most have occurred in the Civic Center area and involved a fine white powder found to be pure fentanyl. Multiple doses of naloxone have often been required to reverse the overdose. There has not been a corresponding rise in overdose-related ambulance calls or deaths from opioid overdose, suggesting that programs designed to avert mortality by supplying naloxone to users and their close contacts have so far been effective. Health care providers should continue to promote appropriate provision of naloxone.

Naloxone can be distributed and prescribed to lay persons in San Francisco who may experience or witness an opioid overdose.

It is covered by Medi-Cal, Healthy SF, and most health plans and can also be furnished by pharmacists registered to do so without a prescription. Naloxone is also available at no cost from the DOPE Project, targeting drug users and their friends and family via syringe exchange sites. These means of naloxone provision and use are protected by California law (AB635 and AB1535). Visit http://bit. ly/1PnXr3h for additional resources for substance use treatment and naloxone.

CDC Vaccine Schedule App for Clinicians and Other Immunization Providers

The 2015–2016 SFMS Membership Directory and Physician Desk Reference has been mailed out to all active physician members. The annual Directory is one of the most valued benefits of membership and is the only pictorial directory of physicians in San Francisco. This resource is complimentary to all SFMS physician members currently practicing medicine and is used throughout the year by physicians and their staff. For questions or information about the Directory, please contact Ariel Young at (415) 561-0850 extension 200 or ayoung@sfms.org.

SFMS Members Receive Complimentary Access to Payor Profiles

The California Medical Association has published updated profiles on each of the major payors in California, including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, United Healthcare, Medicare/Noridian, and Medi-Cal. Each profile includes key information on health plan market penetration, a description of the plan’s dispute resolution process, and the name and contact numbers for medical directors, provider relations, and 4

The Centers for Disease Control and Prevention (CDC) has launched a vaccine schedule app for clinicians’ use on smartphone and tablets. Health care professionals who recommend or administer vaccines can immediately access all CDC-recommended immunization schedules and footnotes using the CDC Vaccine Schedules app. Optimized for tablets and useful on smartphones, the app shows the child, adolescent, and adult vaccines recommended by the Advisory Committee on Immunization Practices.

The app visually mimics the printed schedules, which are reviewed and published annually. Users can identify correct vaccine, dosage, and timing with two or three clicks. Any changes in the schedules will be released through app updates. For more information, visit http://bit.ly/1UzvSqo.

Covered California Health Plan Network Directory Accuracy

Last November, the California Department of Managed Health Care (DMHC) released the results of an audit of the Anthem Blue Cross and Blue Shield Covered California networks.

Among other things, the audit found that 12.8% of the physicians listed on Anthem’s network were not accepting Covered

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

California patients, while 12.5% were not in practice at the location listed in Anthem’s directory. The audit also found that only 56.7% of the physicians listed in Blue Shield’s Covered California directory could be verified as accepting Covered California patients.

DMHC will be conducting a follow-up of its audit this fall to determine whether the health plans have resolved their inaccurate network directories.

SFMS physicians who are misidentified as participating in a network by Anthem or Blue Shield when in fact they are not, or whose information in a network directory is inaccurate, are urged to contact CMA’s Center for Economic Services at (888) 401-5911 or economicservices@cmanet.org.

JAMA Study Shows E-Cigarettes Could Serve as Gateway to Traditional Tobacco Products; SFMS and CMA Participate in Save Lives CA Lobby Day and Endorsement of Tobacco Legislation Package

The Journal of the American Medical Association published a new study that showed that high school students who use electronic cigarettes are more than twice as likely to progress to smoking conventional tobacco products.

Students who used e-cigarettes were about twice as likely over the course of the study to report smoking cigarettes, three times as likely to report smoking hookah, and five times as likely to report smoking cigars.

The study comes as lawmakers, during a special session, reintroduced SB 151, which would raise the smoking age in the state to twenty-one years old, and SB 140, which would regulate e-cigarettes in the same way as other tobacco products.

SFMS and CMA join our Save Lives California coalition partners to applaud California legislators spearheading legislation to keep tobacco out of the hands of our youth and to increase the overall health and wellness of Californians.

Several San Francisco physicians participated in the August 26 coalition lobby day (coverage on p. 25). The passage of this package of bills will have an immediate, life-saving impact by reducing the number-one preventable cause of premature death and disability.

Noridian Announces New Audits

Noridian, California’s Medicare administrative contractor, has announced that it will be conducting service-specific targeted audits of procedure codes 99205 and 99233 when rendered by providers with specific specialties (99205 performed by cardiology and pulmonary; 99233 performed by internal medicine and hematology/oncology).

These reviews are conducted on a pre-payment basis, meaning Noridian will notify physicians selected for claim audits through the additional documentation request (ADR) process before payment is made. Upon receipt of a request for information, practices must submit all applicable documentation for each claim with a copy of the ADR as a cover sheet. Records should be mailed (hard copy or CD) or faxed to Noridian within 45 days of receipt, or a claim denial will result. More information on the ADR process can be found at https:// med.noridianmedicare.com/web/jeb/cert-reviews/mr/ads-submissions.

CMS Clarifies ICD-10 Grace Period Guidance

In early July, the Centers for Medicare & Medicaid Services (CMS) announced that for a period of one year, it will allow for flexibility in claims payment, auditing, and quality reporting processes. CMS specifically clarified its statement that during the 12 months after ICD-10 implementation, contractors would not deny claims based solely on the specificity of the ICD-10 diagnosis code. However, claims will be rejected if they do not contain a valid ICD-10 code.

CMS further defined a “valid code” as one that is coded to the maximum level of specificity. Claims will not, however, be rejected or audited simply because they contain the wrong code—as long as it is a valid code from the right family. The ICD-10 implementation date of October 1, 2015, has not changed.

WWW.SFMS.ORG

September 2015 Volume 88, Number 7 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD

SFMS OFFICERS President Roger S. Eng, MD President-Elect Richard A. Podolin, MD Secretary Kimberly L. Newell, MD Treasurer Man-Kit Leung, MD Immediate Past President Lawrence Cheung, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD John Maa, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD

Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

Term: Jan 2014-Dec 2016 William J. Black, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

5

Success.

It’s what California’s finest physicians strive for... and what CAP can help you achieve.

Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT).

As a physician-directed organization, we understand the realities of running a medical practice, and are committed to supporting you with a range of value-added programs and services. These include a 24-hour adverse outcomes hotline, HR support, EHR consultation, a group purchasing program, and payment and reimbursement education and support, to name a few.

Protect Your Online Reputation With CAP’s Free Physician’s Action Guide!

The Physician’s Online Reputation Action Guide can help you build a strong and positive reputation.

Learn how to: • Encourage patients to post positive reviews.

• Appropriately respond to negative reviews.

• Optimize social media to establish your credibility.

Request your free electronic or hard copy today!

800-356-5672 | CAPphysicians.com/ReputationPro

EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH

Forty-Nine Square Miles of Innovation “I cannot pretend I am without fear, but my predominant feeling is one of gratitude. I have loved and been loved; I have been given much and I have given something in return; I have read and traveled and thought and written. I have had an intercourse with the world, the special intercourse of writers and readers.”

-Oliver Sacks, MD, 1933-2015, a few months before dying of cancer in August San Francisco has been called many things: the most beautiful city in the nation; the place where all the brightest, craziest, most desperate, and/or most good-looking people end up; “49 square miles, surrounded by reality”; and much more. Many trends start here, like them or not—“San Francisco Values” has been a slogan of either pride or revulsion, depending upon one’s perspective. Many people pass through our transient city, many of them changed forever for the experience.

One such visitor was the late Oliver Sacks, MD, whom the New York Times named “the poet laureate of medicine,” who died at press time after a long career as a neurologist and best-selling author. On his very long and impressive CV is this: Mt. Zion Hospital, San Francisco, 1960-1961: Research Assistant, Parkinsonism Unit; 1961-1962: rotating internship.

Sacks later noted that he was drawn here not only by top-notch medical training but by San Francisco’s reputation as a hotbed of poetry and nascent “countercultural” elements—such as beatniks—and that this is where he began writing in earnest, not only about science and medicine but about “colorful” local characters and scenes. True to form, he hitchhiked to get here for his internship as well, and for a time rode motorcycles with the local Hell’s Angels (and survived). His books such as Awakenings and The Man Who Mistook His Wife for a Hat, among many others, remain classics of medical literature.

Nowadays the most dominant “rebels” in the Bay Area might be said to be the technologically-inclined denizens of Silicon Valley (and now of our city as well). They are seeking to reinvent much of our economy and society (and, it should be acknowledged, seeking to get rich in the process).

In medicine, most of this new biotech innovation remains one of vast potential with practical applications still in the future. But, barring some huge disaster or the dreaded severe economic “correction”, it can be wagered that striking innovations centered here will continue and accelerate. What manner of diagnostic tools, treatment options, devices, and preventative strategies are already in the pipeline? What new care delivery options? What innovations we cannot yet even categorize?

In this issue of our journal we feature just a few from our recent and distant past.

The most “vintage” breakthrough is a neurological disWWW.SFMS.ORG

covery dating from the 1800s and is chronicled by our editorial board member, SFMS past-president, and local medical historian and neurosurgeon Arthur Lyons, MD. The devastation of the early HIV epidemic with San Francisco as a ground zero resulted in some of the most rapid medical science progress in history. It’s explored in pieces by two of the leaders in that response—Paul Volberding, MD, and Stephen Follansbee, MD. The “free clinic” movement dates from 1960s San Francisco and is told here by Haight-Ashbury Clinic founder David Smith, MD, with the more recent effort to move towards universal coverage (Healthy San Francisco) also described. Melvin Scheinman, MD, describes a cardiological first.

If space were unlimited we could cover the abundance of other advances made locally—with the presence of major teaching hospitals, UCSF, and the biotech industry there are many. Genentech, the discovery of prions, the discovery of telomeres, the discovery of oncogene viruses, the first fetal surgery, the development of precise recombinant DNA techniques that led to the Hepatitis B vaccine, and so on have all been written about extensively. And again, there are many more to come.

Despite what breakthroughs may occur in the future, the human element of medicine will remain paramount. Regardless of what some believe or dream, “tech” will never fully replace a thinking, feeling, trained physician. In fact, Dr. Oliver Sacks seemed to feel this way regarding his own practice and even his writing. When asked what he might like to be most known for a century from now Sacks replied, “I would like it to be thought that I had listened carefully to what patients and others have told me,” he said, “that I’ve tried to imagine what it was like for them, and that I tried to convey this.”

No one taught me more about how to be a doctor than Oliver Sacks,” reflected another renowned physician/author, Atul Gawande, MD, in The New Yorker, “He wanted to see humanity in its many variants—face to face, over time, away from our burgeoning apparatus of computers and algorithms. He captured both the medical and the human drama of illness, and the task of the clinician observing it.”

We like to think he learned at least some of that during his relatively brief stay in here in San Francisco, but regardless, it’s one more reminder that, despite whatever progress comes from the concentration of innovation in our area and beyond, medicine will always be more about people than procedures.

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

7

RECEIVE MORE THAN $6,000 A YEAR IN SAVINGS AND SERVICES, INCLUDING:

FOR $3 A DAY, SFMS/CMA MEMBERS

SFMS/CMA Member Benefit

Value

Patient referral service via SFMS’ phone referral line and online physician finder tool . . . . . . . . . . . . . . . . . . . . . . . . . $200 Access to exclusive physician networking events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150 Personal physician webpage for practice promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 Subscriptions to San Francisco Medicine and SFMS Membership Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 One-on-one assistance with practice management experts from Center for Economic Services on . . . . . . . . . . . . . *$150 reimbursement and practice operation issues . *value hourly rate with a practice management consultant Access to objective written analyses of major health plan contracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 Discounted employment contract review service with a contract attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Special member rate for AAPC’s ICD-10 training seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200/session Discounted registration for the Western Leadership Academy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300 CME tracking and credentialing service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20 HIPAA-compliant communication via DocBookMD, enabling physicians to instantly exchange patient information . . . . $100 with other physicians at the point of care 15% off temper-resistant security prescription pads and printer paper with Rx Security . . . . . . . . . . . . . . . . . . . . $162 .75 30% off your current bill for medical waste management and disposal services through EnviroMerica . . . . . . . . . .*$1,000 *based on average savings

30% off on Epocrates products, including Epocrates Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50 Up to 10% discount on life insurance through Mercer Health & Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 Member-only savings on office supplies and magazine subscriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Access to webinars and seminars ranging from business essentials for physicians, EHR adoption best practices, . . . $400 and effective coding/billing strategies, including our exclusive value-based payment model workshop with CMS Region IX Administrator in May 2015 .

For a list of full member benefits, visit http://www.sfms.org/membership/membership-benefits/full-member-benefits.aspx.

8

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

FORTY-NINE SQUARE MILES OF INNOVATION

IDENTIFYING HIV The First Step to Hope in the AIDS Crisis Paul Volberding, MD The early wave of HIV infection in San Francisco was swift but unrecognized. In 1980 I was working part-

time in the walk-in side of the San Francisco General Hospital Emergency Room and recall many gay men presenting with severe “flu.” I have no way to prove it, but I believe many were quite likely suffering from acute primary HIV infection. My wife, Molly Cooke, was a medicine chief resident at SFGH during the same time and began to note gay men being admitted with very unusual infections seldom before seen in young and “healthy” adults. Following the first publications about what soon was called AIDS, San Francisco saw a horrifying, rapid increase in cases and, soon, deaths from this utterly mysterious new disease.

With Art Ammann’s report of AIDS in an infant following blood transfusion in 1982, the reality of AIDS as an infectious disease became inescapable. The public’s anxiety (and that of my own, as a caregiver) climbed quickly, as we knew nothing about either the transmissibility of whatever was causing AIDS or its natural history. And, of course, we had no therapy to prevent certain death for everyone with advanced AIDS. In retrospect, of course, while we were asking all those questions, the virus was continuing to spread, infecting tens of thousands before we had any tools to confront the epidemic.

The first step to hope required the identification of this new infection. Fortunately, the scientific community became mobilized. After a delay, the NIH made research funding available for AIDS. My own first grant was submitted in 1982 and funded in 1983, and during 1983 and 1984, only several years after the first recognition of AIDS, the cause was revealed. Although much is made of the dispute between Luc Montanier in Paris and Bob Gallo in the United States, fewer than should do so actually appreciate that here at UCSF Jay Levy also discovered the virus and was undoubtedly independent in doing so.

As a side note, Jay’s discovery was a personal one for me, as I had moved to San Francisco in 1978 specifically to work in his laboratory, leaving the day before seeing my first Kaposi’s sarcoma patient as I started a position at SFGH. The early reaction to the recognition that a human retrovirus was the cause of AIDS is well chronicled in Randy Shilts’s pivotal book And the Band Played On. Personalities of the cast of characters in HIV discovery were large, and competition was fierce and less than polite. I recall first hearing of the French discovery at a scientific meeting in Park City, probably in 1983.

Reaction from the Americans at the meeting was dismissive, and the fight over assigning credit for the discovery continued for years. Even the name of the virus generated discord, which continued until HIV was chosen as a neutral term, not favoring any of the independent discoverers.

WWW.SFMS.ORG

Once the virus was identified, scientists including Jay Levy found antibodies in the blood that could be used to identify those who had been exposed. I recall volunteering for one of the first tests of Jay’s HIV detection assay and was hugely relieved to be negative. By then I’d cared for hundreds of AIDS patients, many before the concept of “body substance precautions” came into vogue, and I was privately terrified that I had been infected. Knowing that I was not was of course good news to me, but, more important, it allowed me to be fully assured in reassuring the public that HIV was clearly not easily transmitted by nonsexual means.

Having identified the virus and an antibody assay allowed us to clarify HIV transmission, but we more gradually learned a shocking lesson. With essentially all other viruses, a positive antibody test means that one has been exposed to the virus and typically that one has overcome that brief infection and become immune. With the HIV antibody test, we found a great number of persons testing positive. Some had AIDS, but many more were either completely asymptomatic (“healthy seropositive” was a popular term) or complaining of a variety of signs and symptoms less striking than AIDS. We began to worry that these “milder” cases might be at risk of progressing to AIDS. A leader in this research, Donald Abrams, published a key paper asking whether this condition was an endpoint or a prodrome to AIDS. Unfortunately it certainly was, but as we followed all this, it gradually became clear that all the seropositives were progressing and that none had developed immunity, and that the untreated mortality of HIV infection was close to 100 percent.

HIV is now a chronic disease. Treatments can suppress the virus in the vast majority of individuals able to take the drugs regularly, and new regimens of combination therapy are contained in a single daily pill, most with few side effects. Treatment may well allow a normal life span and also prevents transmission. Efforts here and elsewhere aimed at “Getting to Zero” are moving us toward community-wide HIV control, while others are working to find a cure or an effective vaccine. But none of this amazing progress could have started without first finding the virus itself. The San Francisco medical community has contributed mightily to success in the HIV epidemic, but at its heart it is all based on finding the agent that has changed our world.

Dr. Volberding is an oncologist by training who has specialized in HIV since the epidemic was first recognized in 1981. He is now the director of the UCSF AIDS Research Institute, codirector of the UCSF-Gladstone Center for AIDS Research and director of research for UCSF Global Health Sciences. He lives in San Francisco with his wife, Molly Cooke, also an academic physician at UCSF. He is a longtime member of the SFMS. SEPTEMBER 2015 SAN FRANCISCO MEDICINE

9

L RS o actic A C YE ncisc al Pr O L LO n FraMedic Sa nd P g a n EMFeatusripitals

es

a re

Ho

yA

Ba

Morrissey Hall, St. Mary’s Medical Center 2250 Hayes Street, San Francisco Refreshments and hors d’oeuvres provided by the SFMS

For detailed event information, including a list of confirmed exhibitors, please visit http://www.sfms.org/Membership/StudentResidents.aspx

EVENT OPEN TO ALL UCSF, CPMC, ST. MARY’S, AND KAISER PERMANENTE SF RESIDENTS AND FELLOWS

FORTY-NINE SQUARE MILES OF INNOVATION

LINKING HIV AND AIDS A Breakthrough in Understanding Stephen E. Follansbee, MD What was the discovery? AIDS is the end product of infection due to HIV, a retrovirus. In the spring of 1981, unexplained clusters of an unusual malignancy called Kaposi’s sarcoma and lung infection caused by Pneumocystis carinii (now P. jiroveci) were noted. San Francisco, along with New York City and Los Angeles, was identified quickly as an epicenter for this new syndrome, associated with severe immune deficiency and death. By July 1982 there were more than 414 cases in the U.S. and 155 deaths reported. Theories as to causality were plentiful. Evidence that AIDS was due to an infectious agent was presented at a meeting sponsored by the New York City Department of Health in June 1982. However, a virus causing lymphadenopathy syndrome (LAN) was not presented until June 1983. HTLV-3 (to become HIV) was announced as the cause of AIDS in April 1984.

How was this news first received, with hesitation or enthusiasm? For many of us, the identification of a virus causing AIDS was expected, and accepted. Although less than thirtysix months seems like a rapid time to identification of a viral etiology, health care systems and providers had to react more quickly to the possibility of other causes and modes of transmission. In retrospect, we were seeing patients admitted with the acute retroviral syndrome in 1977. The first inpatients with AIDS in San Francisco hospitals occurred during the summer of 1981, when there were no specific infection prevention precautions for AIDS in place. The epidemiology rapidly pointed to an infectious agent, even before the June 1982 meeting. In April 1982, UCSF initiated precautions based on guidelines for cytomegalovirus infection. CDC guidelines in November 1982 suggested infection prevention precautions should follow those for preventing hepatitis B transmission in the workplace. Identification of HIV as the cause validated the infection prevention plans that had been implemented in Bay Area hospitals more than a year before.

At the initial NIH press conference in April 1984, when HTLV-3 (HIV) was presented to the public as the cause of AIDS, it was suggested there would be a blood test for HIV. After the first blood test was licensed in early 1985, blood banks quickly adopted the screening test. At the same time WWW.SFMS.ORG

they instituted a policy of not releasing the result to donors for a waiting period of several weeks, to discourage people at risk for HIV from donating blood just to access the test. By the end of 1985, there were more than 800 publicly funded HIV test sites and nearly 80,000 people had been tested in the U.S. Over the next several years, additional tests, such as the Western Blot (1987), p24 antigen test (1989), and HIV viral load test (1999) became available. At the same time, the HIV denialists were still arguing that HIV was an innocuous virus, that the tests monitoring infection and the state of viral replication were useless.

Even in 2014 there were articles offering alternative explanations for the cause of AIDS, denying that this is a viral infection. Arguments for other causes of AIDS include speculation that AIDS is a U.S. government experiment at genocide gone awry, is related to immune overload from other concurrent infections, is the toxic result of recreational drug use or chemicals, is due to malnutrition, is related to the wrath of a God, is an accidental lab event allowing a fairly innocuous infection in other primates to enter the human species, or is due to contaminated vaccine against polio, just to name a few.

Fueled by these unfounded speculations of other causes, in San Francisco and elsewhere, there was a minority of people with HIV who refused antiretroviral treatment when the first medication became available in 1987. This minority has continued to decline, now twenty-eight years since the introduction of the first antiviral medication against HIV and nearly twenty years since the introduction of combination medication therapy that has radically changed the course of HIV disease.

What has the long-term impact been?

In 2015, some of the tests monitoring the status of HIV infection, particularly plasma HIV viral load testing, as well as genotypic and phenotypic assays of HIV to assess for the emergence of drug resistance, have become the standard of care in HIV medicine.

These tests have been used to shorten the time course of introduction of new anti-HIV medications in North America and Europe. They have also been used to help guide patient management using the increasing number of medications licensed to treat HIV in the U.S. This finding has also enhanced

Continued on the following page . . .

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

11

Linking HIV and AIDS Continued from the previous page . . . the evaluation of strategies to prevent HIV. A blood test now allows fairly rapid assessment of prevention strategies, including the use of chemoprophylaxis (so-called PrEP) for vulnerable individuals. While there are still important questions to be answered, such as what aspects of human immunity are necessary for effective control of this virus, as well as how to develop a vaccine for prevention of HIV, for many the identification of HIV as the cause of AIDS has removed the stigma and fear of HIV as being the consequence of other causes.

How did it impact you and your practice? I made the decision to enter the subspeciality of infectious diseases in 1980 because I naively thought that this offered me an unusual opportunity within internal medicine to cure patients. For several years, patients presenting with AIDS lived an average of nine months, despite our best efforts to treat the opportunistic conditions and support nutrition and healthy lifestyles. The identification of HIV as the cause of AIDS allowed for the rapid testing and availability of newer medications. It allowed for more complete assessment of strategies of HIV management, leading to the current recommendation to test and treat at even the earliest stage of infection. It allowed for development of successful yet still imperfect strategies for prevention of HIV infection. It has moved this infection from its nearly universally fatal course to one that is manageable for people who have access to testing, treatment, and monitoring. Lastly, this discovery still holds the promise of new findings to come, including advances that will provide a vaccine for prevention and a cure for those infected.

There is a lot to be learned from questions that are seemingly well answered scientifically yet continue to generate controversy.

The current paranoid, unscientific public opposition to accepting the benefits and efficacy of routine preventive vaccination for common childhood viral and bacterial infections is an example. It is simplistic to think there is one explanation to understand the motivation of individuals or groups who deny that HIV is the cause of AIDS, or deny the tremendous benefits that have occurred as a result of this important scientific finding.

Our responsibility to ourselves as scientists and healers, to our patients and to our communities, is to continue to understand the truths of what is known and to strive for better answers and solutions to legitimate questions that remain. The science and medicine of HIV treatment and prevention is no exception.

Stephen E. Follansbee, MD, is a retired HIV and infectious diseases specialist in San Francisco. Since completing his postgraduate training at UCSF, he practiced for sixteen years with the Infectious Diseases Associates Medical Group and then another sixteen years with Kaiser Permanente in San Francisco. He is a clinical professor of medicine at UCSF and longtime member and pastpresident of the SFMS. Since retirement his main activities have been to say “no” to most requests for new responsibilities and to say “yes” to becoming certified in scuba diving.

12

Tracy Zweig Associates INC.

A

REGISTRY

&

PLACEMENT

FIRM

~ Physicians ~ Nurse Practitioners Physician Assistants

Voi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1- 9141 FA X: 8 0 5 - 6 4 1 - 9 1 4 3 t z w e i g @t r a c y z w e i g . c o m w w w. t r a c y z w e i g . c o m

Attorneys representing doctors, their patients, families, and friends to obtain their disability insurance and other insurance coverage benefits.

LAW OFFICES OF S.F. Medicine MANN LAWRENCE 02-20-14 (855) 592-7664

LarryMann@TheDisabilityInsuranceSite.com

Contact us for a free attorney consultation

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

FORTY-NINE SQUARE MILES OF INNOVATION

ONE MEDICAL Redefining the Primary Care Model Thomas Lee, MD During my years of medical training, I was lucky enough to practice in a wide variety of clinical environments, from small, rural family practice and communi-

ty health centers to large, urban academic medical centers and staff-model HMOs. And no matter the environment in which I cared for patients, the common thread among them was that good people were frustrated and demoralized from working in a broken delivery system—a system that was more than past due for an overhaul.

Physicians and patients alike shared my frustration with what seemed to be an irrational delivery model.

For all the talk about quality patient care, the system appeared to prevent (if not suppress) thoughtful, patient-centered medical care. It was this disconnect that sparked a personal mission for me to explore and ultimately start a radically new model of primary care—one that would eventually become One Medical.

I decided to focus on primary care because I felt it was one of the most undervalued and broken parts of the delivery model. Poor reimbursement, complex work flow, high overhead, and declining morale were just some of the problems that primary care physicians faced.

Primary care, if done well, can offer a more holistic perspective for patients (rather than being just the sum of several organ systems). In an era of hyper-specialization and micronization, I felt that an integrated primary care model could provide unique insight and guidance to patients as complete individuals. Lastly, I felt that a strengthened primary care model would help reduce downstream specialty and hospital costs, resulting in more affordable and accessible health care for all.

When starting One Medical, we were able to look at what was happening in San Francisco and Silicon Valley as inspiration for what was possible in health care. Iterative prototyping was a common design methodology used by many high-growth tech companies; could the same be applied to health care?

In that spirit, we opened a small, single prototype office in downtown San Francisco in early 2003 with just one doctor— me. We started without any preconceived notions about what “needed” to be done. Thinking expansively around the patient, we designed a model that could care for patients thoughtfully at both small and large scales. We reorganized work flow and used technology to support new processes. Instead of asking for more from payors, we looked internally to see how we could improve our administrative overhead. Much of what we did wasn’t necessarily new or unknown per se. We just applied solid organization management against some well-known and important principles.

WWW.SFMS.ORG

One of the key learnings from our rapid prototyping was that lots of small changes can really add up. As an example, by using email instead of phone for many simple administrative tasks, we could more effectively respond to and document patient needs on a consistent basis, saving time and money. Though email may seem trivial, it was (and still is) uncommon for medical offices to incorporate email on a broad-scale basis.

Of course, we hit a variety of obstacles along the way, and progress wasn’t always a straight line forward.

We had to grapple with the complexity of varying health care regulations, particularly as we grew and began operating in multiple states. We also had to learn how to serve differing demographics from a variety of neighborhoods. What appealed to patients in the Financial District did not necessarily appeal equally in Noe Valley, often due to differing demographic and clinical needs.

Initially, we didn’t know if our higher-quality, higher-touch model could garner enough efficiency to be economically sustainable. But after iterating on multiple ideas in our first prototype, it became pretty clear that we were able to deliver higher-quality care and service while also operating at much lower overhead than a traditional primary care practice. We knew we were headed down the right track.

Today, One Medical includes about forty offices in seven markets. We care for prenatal mothers, kids, adults, and seniors in a wide variety of neighborhoods and communities. Employers now sponsor One Medical as a benefit. And we’re starting to make some investments in 24/7 video and phone-based services. Though we’re always iterating and improving the model, the fundamental pillars of our practice remain strong: a commitment to delivering high-quality primary care in an affordable manner for all.

My hope is that this practice style—using thoughtful design and technology to operate more effectively and efficiently—will become more the norm than the exception. Our model enables primary care providers to spend more time with patients and engage in thoughtful decision making rather than managing paperwork. This is the kind of environment that attracts medical students and residents into careers in primary care.

Amazingly enough, it’s still very early days for what’s possible in primary care and at One Medical. We’re excited about what the future may hold.

Thomas Lee, MD, is the founder and CEO of One Medical Group. He has served on the SFMS board of directors.

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

13

Confidence The feeling you have when you are affiliated with Hill Physicians.

Ofelia Maristela, M.D.

Hill Physicians provider since 2009.

Uses Ascender preventive care reminders and Hill inSite to review eClaims and eligibility.

At Hill Physicians, we continue to improve upon coordinated care, with remarkable results.

We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include: • Fast, accurate claims payments • Free eReferrals and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,800 independent primary care physicians, specialists and healthcare professionals have joined Hill. Feel confident in the future of your practice and your patients by affiliating with Hill Physicians Medical Group.

For more about the advantages of affiliating, visit HillPhysicians.com/JoinUs.

14

Hill Physicians’ 3,800 healthcare providers accept HMOs and many PPOs from Aetna, Anthem Blue Cross, Blue Shield, CIGNA, Easy Choice, Health Net, Humana, SCAN, San Francisco Health Plan, United Healthcare WEST and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

FORTY-NINE SQUARE MILES OF INNOVATION

SAN FRANCISCO VALUES Health Care Is a Right, Not a Privilege David E. Smith, MD, and Steve Heilig, MPH

When the Supreme Court ruled in favor of the Affordable Care Act, or “Obamacare,” in June, top White

House and federal health officials held a meeting to reflect on what that meant. One striking thing they noted was that this decision confirmed that “health care is a right, not a privilege.”

And why was this so notable? That was the founding slogan of the Haight-Ashbury Free Medical Clinic in June 1967.

That fabled “summer of love” was a long time ago, but some of the values of that era do not seem so radical now as they did then. Health care should not be available only to those who can pay for it. The environment needs protection from us.

Women are equal to men and should have control over their reproductive and other health needs. Racism is an outdated scourge. Our diets matter, and the less meat we eat, the better for all concerned. Drug abuse is and should be addressed as a public health and medical issue more than a legal one.

Marijuana in particular is not something that should lead to prison. Some illegal drugs might even, if judiciously used, help people. War is bad, meaning peace is good. Communal living may yet be a necessary movement as our population ages. And while “All You Need Is Love” might be stretching things, as the second momentous Supreme Court decision regarding marriage equality showed, real love should not be prohibited but encouraged. As even the Pope has noted, who are we to judge?

We are not blind ’60s apologists—there were many problems then. But the mainstreaming of worthy ideas from that era continues.

The free clinic movement was ignited here and spread nationwide.

The ACA is far from perfect, but “the perfect is the enemy of the good.” Getting it adopted involved many compromises. But millions of Americans now have access to care, and there are many good new ACA elements—mandated contraception, constraints on discriminatory and predatory practices, expanded addiction treatment and preventive services, and more. Overall health costs appear to be less than they would be without the ACA. Implementing and fine-tuning it is a hugely complex, ongoing task—as has been true with Medicare and Medicaid, health programs established in the ’60s out of the spirit of solidarity with those most in need.

A mentor to us both, Dr. Philip R. Lee, served as U.S. assistant secretary of health and chancellor of U.C. San Francisco in the 1960s. Bullets were fired through his window at UCSF while he was seeking to desegregate that campus, then often called “the plantation” by local African-Americans. He WWW.SFMS.ORG

Dr Smith, center, with co-author Heilig and other associates of the Haight-Ashbury Free Medical Clinic and Rock Medicine.

has repeatedly reminded us that progress often takes decades, even lifetimes. Phil is now in his nineties, but he recently reflected, “We may not always be listened to, or be as influential as we might wish, but we just keep on trying.”

“San Francisco values” have been both lauded and reviled through the years. Some people will never agree with them. But compassion and equality are timeless goals enshrined in the founding documents of our nation, revived in many ways in the “City of Saint Francis” a half-century ago. And when even the United States Supreme Court endorses such movements, to us it seems that, yes, in many ways, the hippies indeed got it right.

David E. Smith, MD, is a graduate of UCSF Medical School, founder of the Haight-Ashbury Free Medical Clinic, past president of the American Society of Addiction Medicine, recipient of the U.C. Berkeley Haas Public Service Award, and a lifetime SFMS member.

Steve Heilig, MPH, is a longtime staff member of the SFMS, coeditor of The Cambridge Quarterly of Healthcare Ethics, and recipient of the California Medical Association’s Sparks Award for contributions to public health. An earlier version of this piece appeared in the San Francisco Examiner.

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

15

WELCOME NEW MEMBERS Latoya Comer Frolov, MD | Psychiatry Jin Ge, MD | Internal Medicine Boris Getman, MD | Pathology Elizabeth Patricia Griffiths, MD | Internal Medicine Sasha Gupta, MD | Neurology Andrew Hall, MD | Anesthesiology Fatemat Hassan, MD | Pediatric Cardiology Aaron Hayson, MD | General Surgery Matthew Hickey, MD | Internal Medicine Gillian Lee Hsieh, MD | Gynecologic Oncology HOUSE OFFICERS Kevin Hwang, MD | Orthopaedic Sports Medicine Audrey Arai, MD | Family Medicine Monica Elizabeth Kaitz, MD | Occupational Medicine Rahmat Balogun, DO |Internal Medicine Andrew Allen Kao, MD | Ophthalmology Geoffrey Buckle, MD | Internal Medicine Bridget Keenan, MD | Internal Medicine Laura Kay Byerly, MD | Geriatric Medicine Nicole Kim, MD | Internal Medicine Mauro Caffarelli, MD | Child Neurology Hannah Kirsch, MD | Neurology Emily Cedarbaum, MD | Internal Medicine Yilun Koethe, MD | Radiology Angela Lin Chang, MD | Pediatric Allergy Justin Krogue, MD | Orthopaedic Surgery Molly Chapman, MD | Radiology Courtney Lawhn Heath, MD | Radiology David Chen, MD | Pediatrics Lauren Lederle, MD | Internal Medicine Daniel Chow, MD | Radiology Esther J. Lee, MD | Anesthesiology Adam Coy, MD | Radiology Julieann Lee, MD | Pathology Bryan Darger, MD | Emergency Medicine Janet Y. Lee, MD | Endocrinology, Diabetes and Sarah Schaffer DeRoo, MD | Pediatrics Metabolism Michael Do, MD | Anesthesiology Rebecca Anne Dumont Walter, MD | Neuroradiology Justin Libaw, MD | Anesthesiology Jenny Lu, MD | Radiology Fanny Mojdeh Elahi, MD | Neurology Harjot Maan, MD | Dermatology Robert ElDabaje, MD | Internal Medicine Daiva Mattis, MD | Pathology Camila Fabersunne, MD | Pediatrics Kareem Mawad, MD | Radiology Joline Fan, MD | Neurology SoYoun Min, MD | Oral and Maxillofacial Surgery Emily Frank, MD | Pediatrics PHYSICIANS Kelly Ann Fung, MD | Internal Medicine Thomas Sean Halligan, MD | Family Medicine Meaghan Margaret Lynch, MD | Physical Medicine and Rehabilitation Curtis Paul Ross, DO | Urology Sarita Satpathy, MD | Internal Medicine Denise Stella Zusman, MD | Psychiatry

Alicia Morehead-Gee, MD | Internal Medicine Tyler Edwards Morrison, MD | Psychiatry Kanae Mukai, MD | Cardiovascular Disease Vicky Thi Nguyen, MD | Radiology Arvind Nishtala, MD | Internal Medicine Marci Pepper, MD | Anesthesiology Kenny Pettersen, MD | Internal Medicine Yujie Qiao, MD | Radiology Sandeep Sabhlok, MD | Anesthesiology Shayan Salim, MD | Oral and Maxillofacial Surgery Brian Sauer, MD | Neurology Joshua Shak, MD | Internal Medicine Jun Shoji, MD | Nephrology Elif Sozmen, MD | Neurology Nichole Starr, MD | General Surgery Kenji Taylor, MD | Family Medicine Diana Thiara, MD | Internal Medicine Christina Toutoungi, MD | Psychiatry Kent Truong, MD | Pathology Diana Tsen, MD | Pediatrics Richard Wang, MD | Pulmonary Disease Mia Williams, MD | Internal Medicine Jason Yoo, MD| General Surgery Haining Yu, MD | Psychiatry Sean Dustin Ziegler, MD | Psychiatry STUDENTS Lisa Deng Maya Ragini Overland Sheila Rhandi Rugnao

THE CALIFORNIA MEDICAL ASSOCIATION AND T H E C A L I F O R N I A M E D I C A L A S S O C I A T I O N F O U N D A T I O N P R E S E N T T H E 19 TH A N N U A L

Presidents’ Reception & Awards Gala

10.17.2015

DISNEY’S GRAND C A L I F O R N I A N H O T E L & S PA ANAHEIM, CA

6-7PM – RECEPTION

7 - 9 P M – D I N N E R , AWA R D S P R E S E N T A T I O N & L I V E A U C T I O N 9PM-MIDNIGHT – DANCING I N D I V I D U A L T I C K E T S A N D T A B L E S O F 1 0 A R E AV A I L A B L E FOR PURCHASE THROUGH OCTOBER 9!

FOR MORE INFORMATION, P L E A S E V I S I T W W W. C M A N E T. O R G / G A L A .

16

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

FORTY-NINE SQUARE MILES OF INNOVATION

UNIVERSAL HEALTH COVERAGE Healthy San Francisco Provided Access to Residents Steve Heilig, MPH What was the discovery? The “discovery” was that San

Francisco could truly reach universal health care access via a program designed to fill in any gap, funded via mandated employer contributions. A commission, which I served on, was chaired by former San Francisco Public Health Directors Drs. Sandra Hernandez and Mitch Katz to help design it. We called it “Healthy San Francisco” (HSF).

How was it first received, with hesitation or enthusiasm? Patients loved it, once they sorted out the concept,

eligibility, and registration. The medical community had mixed but generally supportive responses once the admittedly limited reimbursements started arriving for services previously donated. Certain segments of the business sector were not so impressed, and a restaurant association even sued all the way to the Supreme Court to stop it. They lost. A few folks, mostly tourists, objected to the small surcharge at restaurants, but as the owner of one popular eatery in my neighborhood put it, “That’s not the type of person we want to serve anyway.”

What has the long-term impact been? First, access to

care for upwards of 70,000 San Francisco residents. Then, with the advent of the ACA and enrollment of many of those into Medi-Cal, continued access for approximately 20,000 who did/

WWW.SFMS.ORG

do not qualify for any other coverage—mostly undocumented immigrants.

How did it impact you and your practice? My “practice” in this regard was to help design and advocate for HSF and monitor it. Many media questions came in from around the nation, asking how it worked and was working and if it was replicable elsewhere (usually not). I, along with SFMS Past-President Gordon Fung, served on the commission charged with revising a downsized HSF to fit into the ACA era.

But mostly, I recall this: walking down Divisadero Street, hearing my name called, seeing an old friend for the first time in years. He told me he had just had a knee replacement at SFGH after years of severe pain; that he had considered killing himself at one point due to that unresolved suffering. He said HSF made the surgery possible, and he hugged me and started to cry when I told him I had been part of the program’s start. I’ll never forget that.

Steve Heilig, MPH, is a longtime staff member of the SFMS, coeditor of The Cambridge Quarterly of Healthcare Ethics, and recipient of the California Medical Association’s Sparks Award for contributions to public health. An earlier version of this piece appeared in The San Francisco Examiner.

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

17

FORTY-NINE SQUARE MILES OF INNOVATION

OPTOGENETICS Taking Neuroscience by Storm Bruce Goldman A most marvelous instrument, the brain, comprises about 100 billion nerve cells, or neurons, each of

which may connect to 10,000 other neurons. Pulses of information in the form of electrical signals race along nerve fibers like sports cars on a speedway. Yet what do you see when you look at a brain? Inscrutability. A shimmering, gelatinous mass of fatty fibers, snaking and threading to who knows where.

What if you could install traffic signals along the neurons threading through a living brain, so that you could start or stop traffic on them and observe the effects?

Karl Deisseroth, MD, PhD, an associate professor of bioengineering and of psychiatry and behavioral sciences at the Stanford University School of Medicine, and his colleagues have created just such a system. The technology, called optogenetics, mixes optics, genetic engineering, and several other disciplines.

It literally uses lights to control the messages zinging along our nerves: The go signal is blue, and the stop signal is yellow. Both are photosensitive proteins called opsins, originally discovered in microbes.

Optogenetics has taken neuroscience by storm. Since Deisseroth published the first paper describing how it works in 2005, thousands of researchers around the world have started using it to define the deficits behind schizophrenia, autism, addiction, Parkinson’s disease, and more. And in December 2010, the peer-reviewed Nature Methods named optogenetics the journal’s “method of the year.”

“Optogenetics is the solution to our long-standing problem of lack of precision,” says Anatol Kreitzer, PhD, a UCSF neuroscientist who recently collaborated with Deisseroth on a study of Parkinson’s disease. “It lets us selectively inhibit or activate exactly the cells we’re interested in. Karl’s work is really revolutionary.”

Until now, most brain studies have relied on electrodes or drugs. Electrodes work fast. But they stimulate in a nonpredictable way, igniting many different nerve-cell types in many different circuits. Plus, even though the stimulation is local, nerve fibers innocently passing through can get stimulated and trigger consequences far away. And while electrodes can activate neurons, they can’t inhibit them, which is just as critical to studying brain function.

Drugs can selectively activate or inhibit neurons, but not always just the ones you want (that’s one reason they produce side effects). Plus, they ooze everywhere and can’t be mopped up quickly, making them lousy on/off switches. Without precise techniques, how are you ever going to make sense out of 100 18

billion sentient spaghetti strands winding to and fro like midday traffic in some 3-D Manhattan?

Deisseroth is a practicing psychiatrist as well as a researcher. In 2004, as a new assistant professor at Stanford, he was eager to improve the lives of patients with psychiatric disorders and dissatisfied with brain scientists’ inability to map the malfunctioning nervous circuitry behind those disorders.

“Psychiatry has a long way to go,” he says. “That’s not because psychiatrists are anything but thoughtful, well-trained, and observant. It’s because we’ve lacked the tools to tease apart the component circuits that make up a working brain and examine their functions, one by one.”

So he conjured up a work-around: Neurons transmit electrically coded information down long, skinny fibers that project to other neurons near and far. What if you could coat their surfaces with photosensitive molecules so that when light hit those fibers, it would make them propagate—or resist propagating— impulses on demand? Suppose you could also control which set of neurons would carry those molecules on their surfaces, and you could direct the light to just the place you wanted. Then, at the flick of a switch, you’d be able to turn on or turn off the flow of impulses in the neurons of interest and learn a huge amount about what they’re doing.

Deisseroth knew that photosensitive molecules called op-

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

sins had been isolated from microbes such as Chlamydomonas reinhardtii, aka pond scum. Opsins are pore-like proteins that open in response to particular wavelengths of light, allowing currents consisting of electrically charged particles to flow either in or out (depending on the particular type of opsin) across cell surfaces.

In theory, opsins were made to order for Deisseroth’s approach. In practice, few had tried it and nobody had pulled it off, for plenty of reasons. For one, the opsin molecules would have to show up not just anywhere inside of neurons but on their surfaces, where all the electronic impulse-passing action is. Proteins go where myriad biochemical imperatives direct them. Whether microbial opsins would really wind up on the surfaces of mammals’ neurons—the only place where they could do any good— would be a bit of a crapshoot.

On top of that, proteins are complex and finicky, working well only under the right conditions (heat, acidity, and the company of chemicals called cofactors). Would an opsin molecule work as well in a mammalian neuron as it does in a pond-scum cell? Another nail-biter: Microbial proteins on mammalian cell surfaces are sitting ducks. If the immune system, which abhors foreign substances, sees them, it just might chew the neurons they’re sitting on into shreds, or at least produce profound inflammation.

It added up to one risky proposal. But Deisseroth wanted to take a shot at it. He recruited two grad students, Feng Zhang and Ed Boyden. Zhang knew chemistry, molecular biology, and virology.

Boyden was adept at electrophysiology. They plunged in.

A researcher at the Max Planck Institute had recently found an algae-derived gene coding for an opsin that, when stimulated by blue light, passed electrical current in a way that, in principle, could cause neurons to fire. Deisseroth got hold of the gene and suggested that Zhang try to fit it into some kind of system that could shuttle it into living mammalian neurons.

Zhang eventually settled on using a defanged virus. Viruses are good at breaking into cells and commandeering their genetic machinery. To use a virus as a genetic-engineering tool, you take away its disease-causing weapons and replace them with a gene or genes you’ve taken from somewhere else. Then you inject your customized gene shuttle into an experimental animal.

When the virus gets inside a cell’s nucleus, it delivers the alien gene into that cell’s own genome.

To ensure that just the right cells would produce the protein, Zhang affixed a kind of bar code to the opsin gene. Typically, genes have short “come hither” sequences of DNA right in front of them that tell cells’ gene-reading machines which genes to perch on and when to make the proteins they specify. These little DNA tags are called promoters, and gene-readers in different cell types are attracted to different promoters. A gene—say for hemoglobin—with a particular promoter sequence may get hit on all the time by the gene-reading machines in a red blood cell, but never in a skin cell.

Deisseroth’s team surmounted every hurdle.

They succeeded in virally delivering opsinencoding genes into rodents’ nervous tissue.

They were able to restrict opsins’ production to neurons, or even just a select type of neuron. The protein popped up on nerve-cell WWW.SFMS.ORG

surfaces as hoped, and they bioengineered it further so it would do so more readily. Blue light made selected neurons fire. To test this in live, freely moving, opsin-injected rodents, Deisseroth’s group inserted a customized tube, or cannula, into the rodents’ brains. During experiments, they threaded an ultra-thin optical fiber (outer diameter one-tenth of a millimeter) through the cannula. This way they could, at will, send pulses of laser light through the fiber to exactly the desired brain area. It worked like a charm, eventually.

As for the immune-reaction heebie-jeebies, a tight seal called the blood-brain barrier appeared to exempt experimental animals’ brains from patrol by bulky antibodies and cellular cops. The suspicious molecules apparently went undetected.

The Deisseroth group published their results with the excitatory blue-light opsin in 2005 in Nature Neuroscience.

Not long afterward, they got an inhibitory, yellow-light-sensitive opsin, isolated from yet another one-celled organism, to work.

Labs around the world are now routinely using both of them.

While the new methodology has terrific potential in psychiatric research, it has obvious limitations. Experiments that introduce foreign genes for light-responsive, nerve-impulsetriggering proteins into human beings aren’t safe just yet. That’s where experimental mice come in. But when you’re watching a mouse, it’s a whole lot easier to observe its movements than its mental state. So a nice way to check out optogenetics’ potential for brain research is to examine the animal equivalent of Parkinson’s disease, a movement disorder.

While Parkinson’s ultimate causes are unknown, the disease clearly involves the loss of a set of neurons located in a structure deep within the brain, whose signals feed directly into two separate circuits crucial to controlling voluntary movement.

Recently Deisseroth, along with UCSF’s Kreitzer and colleagues, optogenetically unraveled the workings of those two nerve-cell circuits and proved that one of the two facilitates normal movement, while the other inhibits it. Using both the blue-light-responsive, nerve-revving opsin and the yellow-lightresponsive, nerve-blocking one, the researchers showed that imbalances in these two circuits’ function can produce Parkinson’s-like symptoms in mice—and that optogenetic interventions can exacerbate or alleviate those symptoms. By stimulating one of the two opposing circuits, they could restore normal movement in mice even after destroying the upstream nervous circuit that normally drives this activity and whose loss is the hallmark of Parkinson’s disease. The results were published last year in Nature.

The finding implies that Parkinson’s patients’ conditions could someday benefit from new drugs that might be able, unlike current treatments, to stimulate the circuit that facilitates movement but not the circuit that inhibits it.

Bruce Goldman covers immunology, infectious disease, neurosciences, cellular and molecular physiology, and biochemistry for the Stanford University School of Medicine. This article was reprinted courtesy of Stanford University.

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

19

FORTY-NINE SQUARE MILES OF INNOVATION

A NEUROSURGICAL FIRST A Piece of San Francisco Medical History Arthur E. Lyons, MD In the fall of 1884, the news here was that Grover Cleveland, a Democrat from New York, won the first of

what would turn out to be his two elections as president of the United States. But in Britain there was a major medical event to be reported. To the consternation of vocal and often violent English antivivisectionists, a neurologically diagnosed brain tumor was successfully diagnosed and operated upon for the first time in history. It was removed from a twenty-five-yearold farmer at the Maida Vale Hospital, London. The case was diagnosed and the tumor localized in the brain based primarily on experimental work on dogs and monkeys carried out over the previous decade by Dr. David Ferrier (1843–1928), augmented by the clinical investigations of epileptic seizures by Dr. John Hughlings Jackson (1835–1911).

Although the man’s tumor was highly malignant and the patient did not survive more than a few months, it was hailed as a remarkable achievement and widely reported in the medical as well as the popular press. Cerebral localization was still being argued and prominent investigators continued to hold that the brain acted as a whole and that localization of the various brain functions was largely a myth. The patient’s physician was Alexander Hughes Bennett, MD (1848–1901), whose father, also a prominent doctor, had died of a potentially removable brain tumor. It was he who made the clinical diagnosis and urged surgery. The reputation of the surgeon, Rickman Godlee (1849–1928), lent legitimacy to the case. He was nephew of the famous Joseph Lister, his office partner, future president of the Royal College of Surgeons, and ultimately knighted by King George. The significance of the Godlee-Bennett case was well appreciated. Beside being an example of the then-recent remarkable advances in surgical technique, it was tangible evidence of the concept of brain localization, and it particularly dramatized the value of animal experimentation.

In San Francisco in early 1886, a young man was admitted to the Lane Hospital on Clay and Webster Streets, suffering from severe headache and focal epileptic seizures. Joseph Oakland Hirschfelder, MD (1850–1922), the admitting physician, made the diagnosis of brain tumor near the contralateral motor strip. All the tools that we now consider routine in such cases lay far in the future. X-rays, for example, had to wait another ten years before Wilhelm Roentgen made their discovery.

Hirschfelder had to depend on clinical signs alone. Like Bennett in London, he relied on the character of his poor patient’s seizure disorder and his post-ictal palsy. The San Francisco surgeon involved was Hirschfelder’s colleague John F. Morse, MD (1856–1898). The finding of the tumor in their case, after opening the intact skull, again helped vindicate the still-controversial concept of cerebral localization. The description of the tumor, soft and infiltrating, was consistent with a glioblas20

toma as fatal now as it was then. Their patient died after three weeks of postoperative infection, a not uncommon outcome at the time in spite of the stifling carbolic acid mist of antiseptic surgery. The Hirschfelder-Morse case was the second successful attempt at removal of a nonapparent tumor from the brain, and the first in the United States. It was to become the forerunner of many such cases in this country.

Joseph O. Hirschfelder, born in Oakland, was a well-known and highly trained San Francisco doctor. A U.C. graduate, he took his medical training in Germany and was professor of Clinical Medicine at the Cooper Medical College (ultimately to become Stanford after the 1906 earthquake). Among other things, he was one of many investigators who carried out early laboratory experimentation on tuberculin in hopes of finding a cure for the scourge of tuberculosis. He was the first of at least three generations of men who became prominent in American science. He was also a president of the San Francisco Medical Society.

John F. Morse was born in San Francisco, the son of a pioneer physician. He graduated from the Medical College of the Pacific and from the Friedrich Wilhelm University in Berlin, and he subsequently spent a year in Heidelberg. With that extensive training behind him, he established his surgical practice in San Francisco in 1882. Beside his pioneering brain tumor surgery, he carried out many of the earliest appendectomies here and was the first in this country to successfully operate on abdominal aortic aneurism using copper wire. He was active in medical politics and he too was a president of the San Francisco Medical Society. Surgery lost a giant when he died suddenly of apoplexy at age forty-one.

Although far from what was considered the medical centers of the world at the time—Philadelphia, New York, London, Paris, and Berlin—San Francisco had a remarkably sophisticated medical community in the late nineteenth century. In spite of the presence of many quacks and unlicensed practitioners, most doctors had a good education for the time, and many of the physicians had extensive European training. The Hirschfelder-Morse case is a good early example of pioneering skilled medical and surgical practice in San Francisco. The groundbreaking step in the practice of neurosurgery carried out here in 1886 is a case in point.

Arthur E. Lyons MD, is a retired neurosurgeon, medical history buff, and longtime member of the SFMS and the San Francisco Medicine editorial board. He is also a past-president of the SFMS.

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

FORTY-NINE SQUARE MILES OF INNOVATION

A CARDIOVASCULAR FIRST Catheter Ablation of the AV Junction Melvin Scheinman, MD Prior to the 1980s, patients with very symptomatic, drug refractory supraventricular arrhythmias were treated with open heart surgery with direct destruction

of the AV junction, followed by permanent pacemaker insertion.

In March of 1981, after three years of work in the animal laboratory, I conceived the idea of using a catheter technique for AV junctional ablation using direct-current energy.

Before applying this approach to people, we studied the effects of direct shocks using canines. These dogs underwent extensive physiologic testing as well as postmortem studies to be certain that the delivered energy was safe in terms of not disrupting valve function or producing damage to the myocardium or coronary vessels.

The technique was first applied in March of 1981 to a gentleman with atrial fibrillation, heart failure, and severe comorbidities, who was judged to be too high-risk for surgery.

The procedure turned out to be successful and was followed by insertion of a permanent pacemaker. We subsequently used a similar technique for catheter ablation of a posterior-septal accessory pathway in 1984.

The initial discovery received mixed reviews, as some cardiologists felt it would be used for no more than a very small, select patient group. Others opined that it merely traded one disease (drug-refractory tachycardia) for another (pacemakerdependent state).

WWW.SFMS.ORG

In the late 1980s, radiofrequency energy was substituted for direct current shocks, and this technique rapidly became the treatment of choice for patients with supraventricular tachycardia. The technique of a catheter ablation for control or cure of virtually all cardiac arrhythmia is now well accepted throughout the world.

The effect on my life was largely gratification that I have in some small way contributed to the betterment of patients’ lives.

It continues to give me great gratification that patients whom I have treated are totally restored to normal lives.

Dr. Melvin Scheinman received his undergraduate degree at Johns Hopkins and his medical degree at the Albert Einstein College of Medicine. He received his post graduate training in cardiology at UCSF and established the Cardiac Electrophysiology section at UCSF in 1979. He was the first to apply catheter ablation in humans and was instrumental in in defining mechanisms of arrhythmias as well as ablative procedures for complex arrhythmias. He currently holds the Shorenstein Chair in Cardiology and is director of the Comprehensive Genetic Arrhythmia section at UCSF. He has received a number of pioneer and out standing teaching awards from the American College of Cardiology, Heart Rhythm Society, as well as UCSF. In 2014 he was awarded the outstanding scientist award (clinical domain) from the ACC.

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

21

M E D I C A L

PR OF E SS I O N A L

L I A B I L I TY

I N S U RA N C E

GUIDE GUARD ADVOCATE

MEDICAL PROFESSIONAL LIABILITY INSURANCE

CALIFORNIA PHYSICIANS DESERVE Your Guide: Awarding more than 35,000 CME certificates in 2014* Your Guard: Resolving 89%* of claims without indemnity payments Your Advocate: Largest contributor to the No On 46 coalition

Our heart beats in California ... and has for almost 4 decades.

Talk to a NORCAL Mutual agent/broker today. Š 2015 NORCAL Mutual Insurance Company. * Based on 2014 data.

844.4NORCAL | CA.NORCALMUTUAL.COM

LOCAL ADVOCACY John Maa, MD, FACS

September SFMS Advocacy Update August was an active month in advocacy for SFMS. Tobacco Regulation On August 26, 2015, three SFMS members joined more than a hundred physicians, health care workers, and patient advocates at a daylong rally at the Capitol in Sacramento in support of the six tobacco control bills heard during the special extraordinary session on health care convened by Governor Brown. Local physicians Drs. Laura Davies, Renee Fogelberg, and John Maa represented SFMS at the press conference and legislative meetings coordinated by Save Lives California, a coalition with the CMA, American Heart Association, American Lung Association, Planned Parenthood, American Academy of Pediatrics, California Dental Association, SEIU, and more. Along with several UCSF medical students, they spoke to members of the Legislature and their staff about the package of bills to regulate electronic cigarettes, raise the legal age to buy cigarettes to twenty-one years old, and create new tobacco taxes. SFMS and CMA have endorsed all six bills. The bills had previously won support from the Senate health committee and, with the success of the Legislative Day, are swiftly moving through the Senate and Assembly before the 2015 legislative session concludes in mid-September.

SB X2-5 by State Senator Leno (D-San Francisco) would set up statewide rules for e-cigarettes similar to those governing tobacco cigarettes, including that they be labeled accurately and not be marketed to children. Other bills in the package include: SB X2-6 would close loopholes in smoke-free workplace laws by prohibiting smoking in certain environments, such as covered parking lots, gaming clubs, bars, and tobacco shops.

SB X2-7 would raise the minimum legal age to purchase and consume tobacco products from 18 to 21.

SBX2-8 would extend funding eligibility for tobacco education programs in school districts and require all schools to be tobacco free.

SB X2-9 would authorize local jurisdictions to impose a tax on the distribution of cigarettes and other “tobacco products.”

SBX2-10 would establish an annual Board of Equalization tobacco licensing fee program, which is estimated to raise $12 million.

A separate measure first introduced by Senator Richard Pan at the press conference seeks to impose a $2-per-pack tax hike on cigarettes and is backed by Save Lives California. The tax is projected to raise $1.1 to $1.4 billion annually. The revenues would help support state health care and smoking prevention entities including the Department of Health Care Services to fund Medi-Cal, the Department of Education to assist school programs for tobacco education, and the University of California to support physician training and its Tobacco-Related Disease Research Program. The coalition has also submitted a ballot initiative for the tax increase in the event that the Legislature WWW.SFMS.ORG

fails to institute the tax and will begin collecting signatures if this occurs. A Field Poll released the day of the press conference revealed that 67 percent of California voters would support the $2 tobacco tax.

After the Legislative Day, Dr. Fogelberg reflected, ”As a primary care physician or subspecialty clinician this is the most important work we can do. Our patients’ lives matter.” Dr. Davies noted, “It was great to be part of an event with such broad support focusing on the health of all Californians.”

End-of-Life Care/POLST

In another win for SFMS advocacy efforts, on August 18, Governor Jerry Brown signed AB 637 by Nora Campos (D-San Jose), which authorizes nurse practitioners and physician assistants, under the direction of a physician and within their scope of practice, to sign Physician Orders for Life-Sustaining Treatment (POLST) forms and make them actionable medical orders.

This new law had been championed to the CMA by SFMS delegation efforts for three consecutive years before the CMA sponsored a bill that Governor Brown has now signed, and it

Continued on page 25 . . .

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

23

CMS UPDATE Ashby Wolfe, MD, MPP, MPH

Proposed Rule Released Update to Physician Fee Schedule (Changes to compensation and reimbursement rules) In July, CMS released the first update to the Physician Fee Schedule since the repeal of the Sustainable Growth Rate through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal includes a number of provisions focused on person-centered care and continues the Administration’s commitment to transform the Medicare program to a system based on quality and healthy outcomes.

In the proposed CY 2016 Physician Fee Schedule rule, CMS is also seeking comment from the public on implementation of certain provisions of the MACRA, including the new Merit-based Incentive payment system (MIPS). This is part of a broader effort at the department to move the Medicare program to a health care system focused on the delivery of quality care and value.

The proposed rule includes updates to payment policies, proposals to implement statutory adjustments to physician payments based on misvalued codes, updates to the Physician Quality Reporting System (PQRS), which measures the quality performance of physicians participating in Medicare, and updates to the Physician Value-Based Payment Modifier (VM), which ties a portion of physician payments to performance on measures of quality and cost. CMS is also seeking comment on the potential expansion of the Comprehensive Primary Care Initiative, a CMS Innovation Center initiative designed to improve the coordination of care for Medicare beneficiaries. The proposed rule also seeks comment on a proposal that supports patient- and family-centered care for seniors and other Medicare beneficiaries by enabling them to discuss advance care planning with their providers. The proposal follows the American Medical Association’s recommendation to make advance care planning services a separately payable service under Medicare.

CMS is accepting public comments on the CY 2016 PFSproposed rule until September 8, 2015, and will issue the final rule by November 1. More information about the proposed rule can be found at https://s3.amazonaws.com/public-inspection. federalregister.gov/2015-16875.pdf.

Maximum Penalties before MACRA 2015 2016 2017 2018 2019 2020 2021 2022 and beyond 24

The Medicare Access and CHIP Reauthorization Act (MACRA) MACRA repeals the SGR Medicare payment update formula and updates the Physician Fee Schedule payment for 2015 onward. MACRA sunsets existing programs (PQRS, VM, and Meaningful Use) by December 31, 2018. In their place, MACRA creates a new Merit-Based Incentive Payment System (MIPS) to measure performance on Quality, Resource Utilization, Clinical Improvement, and Electronic Health Records as a way to score eligible providers. MIPS eligible providers get a composite score based on four domains (Quality, Resource Utilization, Clinical Improvement, and Electronic Health Records). While the statute establishes the weights for the different domains, CMS is developing the specifics for what measures will be included in each domain. MACRA emphasizes using outcome measures when possible.

Depending on how many measures are available for the certain domains, the statute allows the Secretary to re-weight the domains. The MIPS composite score will determine the MIPS program payment adjustment factor. The MIPS adjustment factor will be 4% in 2019, 5% in 2020, 7% in 2021, and 9% for 2022 onward. MIPS requires the lowest 25% tile (below the performance threshold) to receive the maximum negative payment adjustment. MIPS also allows an extra payment for exceptional performance; the threshold for exceptional performance is yet to be determined by the Secretary. A scaling factor is applied to the MIPS adjustment factor to ensure that MIPS is budget neutral.

Clinicians who chose to continue to participate in straight fee-for-service Medicare, billing under Part B and the Physician Fee Schedule, will be subject to MIPS. Clinicians who choose to become involved with, or are already participating in, Alternative Payment Models, will be exempt from the MIPS requirements. Alternative Payment Models (APMs) include participants in CMMI models, MSSPs, ACOs, and CMS demonstrations, including Patient Centered Medical Homes. Entities can become APMs if they use certified EHR technology, use measures in the MIPS program, and the entity bears significant financial risk. APM guidelines will be developed by a Payment Model Technical Advisory Committee. Eligible Professionals in APMs will have requirements specifying that a percentage of their Part B payments will be furnished

Maximum Penalties and Bonuses After MACRA

4.5% 6% 9%

10%

11% or more

Maximum penalties and bonuses are 4% Maximum penalties and bonuses are 5% Maximum penalties and bonuses are 7% Maximum penalties and bonuses are 9%

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

Advocacy Update Continued from page 23 . . . by the APM (25% in 2019 and 2020; 50% 2012 and 2022; 75% 2023 onward).

The timeline for MIPS and APM development is directed by the statute, and CMS is working to meet the statutory milestones. MACRA funds CMS to develop quality measures for MIPS. MACRA emphasizes using measures with evidence support and the use of outcome measures. CMS plans to seek stakeholder input for the development of MIPS, APMs, and new measures.

Please consider signing up for the Health Care Payment Learning and Action Network, which is an open listserv, from which members of various workgroups will be solicited for the purposes of implementing the new MACRA legislation. Information about the network can be found at http://innovation.cms. gov/initiatives/Health-Care-Payment-Learning-and-Action-Network/. Register for the listserv at http://innovationgov.force. com/hcplan.

Ashby Wolfe, MD, MPP, MPH, is chief medical officer at Centers for Medicare & Medicaid Services Region IX.

NEW ANTIBIOTIC RESISTANCE RESOURCES The CMA Foundation’s AWARE (Alliance Working for Antibiotic Resistance Education) offers a free new mobile application providing clinical guidelines for optimal use of antibiotics. It is available for both Android and iOS devices and found in the Google Play or iTunes stores by searching “AWARE Toolkit.” This tool is already being used by clinicians worldwide.

And if you truly want to see trends in resistance illustrated, by pathogen (Campylobacter, E. coli O157, Salmonella, and Shigella) and state, check this new CDC National Antimicrobial Resistance Monitoring System (NARMS) tool as well: http://wwwn.cdc.gov/narmsnow/ It provides a quick and alarming graphic portrayal of resistance trends.

goes into effect on January 1, 2016. This victory demonstrates that the CMA is open to scope of practice expansions that enhance the safety and timeliness of patient care, and ensure that patient end-of-life treatment preferences are honored.

The POLST form was introduced in California in 2008 and indicates the types of medical treatment patients desire toward the end of their lives. Signed by both a doctor and patient, POLST forms give the seriously-ill patient more control over the care they receive, documenting their wishes in advance should they become unable to further communicate their desires. Sixteen other states allow nurse practitioners and physician assistants to sign POLST forms.

Under current law, a POLST form did not become valid until signed by 1) the patient or their decision-maker and 2) the treating physician. In situations in which access to a physician is limited, several days might pass between the time a patient or decision-maker completed a POLST form, and the physician reviewed and signed. During such a delay, patients may receive unwanted care or treatment because their POLST is not yet valid. At SFMS’s urging, CMA collaborated with palliative care specialists and geriatricians to co-sponsor this bill, recognizing the importance of POLST to document end-of-life care preferences with the hope that this new bill could result in increased use of POLST orders.

Sugar-Sweetened Beverage Ordinances Update

Finally, the American Beverage Association filed opposition in federal court against two of the sugar-sweetened-beverage bills supported by SFMS and signed by Mayor Lee in July. The City Attorney chose not to oppose the injunction against the ban of soda advertising on city property, but appears poised to defend the warning labels on billboards, buses, transit shelters, sports stadiums and posters that was advanced by Supervisor Scott Wiener. A response from the City Attorney’s office is anticipated in early September.

John Maa, MD, FACS, is a past president of the Northern California Chapter of the American College of Surgeons, and chair of the University of California Office of the President Tobacco Related Disease Research Program. He is on the medical staff of Marin General Hospital and is a member of the San Francisco Medical Society board of directors and the editorial board for San Francisco Medicine.

WWW.SFMS.ORG

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

25

PUBLIC HEALTH UPDATE Tomás J. Aragón, MD, DrPH

Mandatory Influenza Vaccination or Masking of Health Care Workers During Influenza Season As in previous years, I am issuing

Duration of Order

a Health Officer order mandating that all hospitals, skilled nursing, and other long term care facilities in the City and County of San Francisco require their health care workers (HCWs) to receive an annual influenza vaccination or, if they decline, to wear a mask in patient care areas during the influenza season.

For other clinical facilities and ambulatory care centers, we strongly recommend implementation of a similar policy.

This order is ongoing and applies to each influenza season unless the order is rescinded. The influenza season is defined as December 15 to March 31 of the following year. In any given year, if influenza surveillance data demonstrate unusually early and/or late peaks, I may extend the period during which the masking program shall apply for that year.

Influenza infection affects 5 to 20 percent of the US population every year, leading to an estimated 3.1 million days of hospitalization and 31.4 million outpatient visits. HCWs are both at risk for influenza and can transmit the virus to their patients and coworkers. Patients in our health care facilities, especially young children, pregnant women, the elderly, and those with chronic health conditions, are at greater risk for influenza-related hospitalization and death. Healthy People 2020 objectives target a 90 percent seasonal influenza vaccination rate for all health care personnel.

State law requires that general acute care hospitals and certain employers, including skilled nursing and other long term care facilities, offer influenza vaccinations to employees. (Cal. Health & Saf. Code, §1288.7, subd. (a); 8 Cal. Code Regs., § 5199, subd. (c)(6)(D) and (h)(10).) If hospital employees decline vaccination, they are required to sign a declination statement in lieu of vaccination. (Cal. Health & Saf. Code, §1288.7, subd. (a); 8 Cal. Code Regs., § 5199, subd. (c)(6)(D) and (h)(10).) This order enhances patient protection by requiring unvaccinated HCWs to wear a face mask in patient care areas during the influenza season. Comprehensive mandatory vaccination programs, that include masking for unvaccinated HCWs, have been associated with high HCW vaccination rates (>95%).

Our goal is to protect both health care workers and patients from influenza disease by increasing rates of influenza vaccination of HCWs. We expect this policy to reduce employee absenteeism during influenza season, and reduce HCW-to-patient transmission of influenza.

For the purposes of this order, “health care workers” or “HCWs” are persons, paid and unpaid, working in health care settings who have direct patient contact or who work in patient care areas.

I appreciate your help and support in protecting the residents of the City and County of San Francisco. For any additional questions, please contact the SFDPH Immunization Program at 415-554-2955.

Rationale

Facilities Subject to the Order

This order applies to hospitals, skilled nursing, and other long term care facilities.

Definition of HCWs

Tomás J. Aragón, MD, DrPH, is Health Officer of the City and County of San Francisco, and Director of the Population Health Division at the Department of Public Health. He is a member of the SFMS.

Order: I, as the Health Officer of the City and County of San Francisco, am requiring that each and every hospital, skilled nursing, and long term care facility in San Francisco implement a program requiring its health care workers to receive an annual influenza vaccination or, if they decline, to wear a mask for the duration of the influenza season while working in patient care areas.

26

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

HEALTH POLICY PERSPECTIVE Donald Abrams, MD, and Steve Heilig, MPH

Physician-Assisted Dying: Honest Choices The California End-of-Life Options Act (SB128), which would have legalized physician-assisted dying (PAD), was front-page news and stirred much controver-

sy. The bill is now in limbo due to religious opposition, although the multidenominational California Council of Churches supported it. Lawsuits to legalize the practice of PAD (not “suicide,” a term that is not truly relevant here) seem to be failing as well, and a ballot initiative—expensive and even messier than legislation—might be the next step.

One casualty of such emotional debates can be basic truths about the personal, clinical, and policy decisions surrounding this issue. Both of us have much experience in these arenas and hope to shed some light here.

Approaching the end of their lives, patients most want two things from their doctors: that they have clinical competence and know everything that might be done to help a patient not suffer, and that they will be there for the patient no matter what.

Rarely—not often, but not never—that can include hastening the end to some degree, and always at the patient’s own choice.

Most of the time such requests are not carried out, but just knowing that one has some added control and choice at the end can actually extend life in some cases—ironic, but true.

The California Medical Association (CMA) opposed PAD for many decades, until this year. This change in position initially was spurred by the SFMS delegation, which three times in recent years attempted to get the CMA to reexamine its opposition, for the following reasons: First, accumulating surveys of doctors’ opinions on this topic (more than 30,000 physicians in published surveys thus far) indicate that at least half, and likely more, physicians now support some legal options for PAD. Second, experience in states that have legalized PAD for years shows that the many fears about abuses have not been realized and that, again, the practice is uncommon, and legalizing it can actually lead to improvements in general care at the end of life.

Finally, the hallowed medical dictum “Do no harm” is now seen to include the possible harm of keeping patients alive and suffering longer than nature or their God intended, or, first and foremost, longer than they might want for themselves.

After the SFMS wrote to CMA leadership stressing these facts, the CMA conducted a survey of its leadership and found that a substantial majority supported legalizing PAD, or at least not opposing it. While still working to ensure that all reasonable safeguards against abuse are in any PAD policy, the CMA then changed to a “neutral” position. This is how a democratic organization, which purports to represent the profession, should work.

The one vocal medical group against SB128, the Association of Northern California Oncologists, also conducted a survey of members on this topic. Their survey also came back with a majority supporting PAD legality. But the executive leadership WWW.SFMS.ORG

of the Association felt otherwise and discounted the members’ vote in deciding to continue to oppose SB128. We wish they had had the integrity of the CMA in this regard and, as a result, Dr. Abrams has terminated his membership with the Association.

For those who care for patients coping with end-stage disease, support of PAD, or at least neutrality, increasingly seems a humane option. The PAD issue comes down to an issue of patient choice and control toward the end of life, when we are very vulnerable. Many if not most of us will be such patients at some point, and we hope that by that time, we and our doctors will be empowered to make ultimate these choices without outside interference. And that our medical associations will also respect those choices and majority opinion.

Dr. Donald Abrams is chief of oncology at San Francisco General Hospital and a professor of medicine at the University of California, San Francisco. He was a pioneer in the response to the AIDS epidemic and is a longtime SFMS member. Steve Heilig is coeditor of The Cambridge Quarterly of Healthcare Ethics, health policy director for the San Francisco Medical Society, and a former hospice worker and director. He drafted the original resolution urging the California Medical Association to take a neutral stance on physician-assisted dying.

SFMS ADVOCATES FOR CHINESE COMMUNITY PHYSICIANS In a recent, unfortunate conflict between a local health plan and a physician association, SFMS and CMA sent a strong letter of support for physician and patient interests.

The Chinese Community Health Care Association (CCHCA) includes many SFMS-member physicians, serving the local community. CCHCA leaders asked for support in a contracting conflict with the local health plan, and SFMS responded that “CCHCA is a pillar of the San Francisco community, having been organized as a nonprofit independent physician organization more than three decades ago to promote social welfare by making health services more accessible to the Chinese community . . . CMA and SFMS are greatly concerned that the Health Plan’s actions interfere with physicians’ ability to serve their patients, while also diminishing the long, proud history of the Chinese Hospital and the close relationship generations of physicians and patients in San Francisco have enjoyed.” The conflict is currently unresolved, but the letter concludes, “CMA and SFMS are prepared to support CCHCA and its physicians to continue to achieve their charitable purposes.”

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

27

MEDICAL COMMUNITY NEWS SPMF

Bill Black, MD, PhD

SPMF physicians advance medical knowledge through research and education.

Research increases their awareness—and their colleagues’ awareness—of cutting-edge treatments that can improve patients’ lives.

Here are some “breakthroughs” from our physicians and patients: Historic six-way and nine-way donor and recipient kidney transplant matches took place this year at California Pacific Medical Center (CPMC) and UCSF Medical Center thanks to Matchgrid, an algorithmic program enabling incompatible pairs to be matched.

The software was developed by David Jacobs, who came up with the idea after he had a kidney transplant at CPMC. Mohammed Kashani-Sabet, MD, director of CPMC’s Center for Melanoma Research and Treatment, participated in research with colleagues that sparked FDA approval of nivolumab, a breakthrough drug for melanoma. Checkpoint inhibitors including nivolumab have emerged as promising therapies in slowing and preventing tumor growth.

David King-Stephens, MD, Kenneth Laxer, M.D. and Peter Weber, MD, pioneered new research that was key to FDA approval of the RNS® System (NeuroPace)—a brain stimulator—in treating epileptic seizures.

The effectiveness of NeuroPace was shown in a randomized controlled trial at multiple centers in the U.S. Robert Miller, MD, Jonathan Katz, MD, and colleagues at CPMC’s Forbes Norris MDA/ALS Research and Treatment Center are studying new ways to reduce neuroinflammation suspected to contribute to the progression of amyotrophic lateral sclerosis (ALS). They are leading a national clinical trial of a drug that shows promise in halting ALS progression. They are also leading a national multicenter effort to standardize electronic health records in ALS so basic clinical data can be stored in a single data system.

28

Kaiser

Maria Ansari, MD

Recent advances in technology have led to the development of applications that have expanded the diagnostic and therapeutic roles of endoscopy. Endoscopic ultrasound (EUS) is primarily a diagnostic imaging technique in which an ultrasound probe is built into the tip of the endoscope. EUS allows for the structural evaluation of abnormalities of the gastrointestinal tract, such as esophageal, gastric, and rectal tumors.

Ultrasound imaging can also image structures and organs immediately adjacent to the gastrointestinal tract, such as the pancreas, common bile duct, gallbladder, and liver. By advancing a small needle via the endoscope and directing a fine needle aspirate, we can perform a minimally invasive cytology. EUS has become a standard diagnostic evaluation for the staging of gastrointestinal tract and pancreatic cancers.

By providing access to areas deep within the abdominal cavity, EUS offers therapeutic interventions that would otherwise require surgical or percutaneous radiologic treatment. EUS-guided drainage of pancreatic pseudocysts and debridement of pancreatic necrosis has improved the management of highly morbid complications from pancreatitis. Additionally, EUS-guided celiac plexus nerve block offers an alternate approach to delivering analgesia for cancer patients, and EUS placement of fiducial markers into tumors enables focused radiation treatment of pancreatic cancers.

Over the past three years, we expanded our endoscopic mucosal resection (EMR) service. EMR is the curative removal of large precancerous growths from the gastrointestinal tract that historically required surgical resection. As a result of EMR, hundreds of patients have benefited. Most recently, we have begun to develop services in endoscopic submucosal dissection (ESD). ESD is an advancement of EMR practices with the goal of curative treatment of stage IA cancers of the gastrointestinal tract. Indications for endoscopy have rapidly increased, and as technology evolves, endoscopy will remain at the forefront.

CPMC

Edward Eisler, MD

Dr. Robert Miller, director of the Forbes Norris MDA/ALS Research and Treatment Center at CPMC, received new funding from the ALS Association and Neuraltus to lead a novel phase II clinical study of the drug NP001, an immune system regulator that has shown promise in halting the progression of amyotrophic lateral sclerosis (ALS). Dr. Miller will lead a placebo-controlled, six-month treatment trial to confirm results observed in a previous study of NP001, the results of which were published in the April 2015 issue of Neurology: Neuroimmunology & Neuroinflammation, an official journal of the American Academy of Neurology.

In early May, CPMC launched a collective effort to become a high-reliability organization. Sepsis is the first of five focus areas targeted for improvements in 2015. Subsequent areas of focus will be the Universal Protocol Time Out, handwashing, alarm fatigue reduction, and hand-offs. The Leapfrog Group, which ranks hospital quality and safety nationally, recently released its Hospital Safety Score grades for the last six months. The Pacific, California, and St. Luke’s campuses received “A” ratings from this organization, while the Davies Campus received a “B” rating.

CPMC was recognized as being among the best hospitals in California for 2015–2016 by U.S. News & World Report. The annual rankings rate top hospitals in the state and in major metropolitan regions, according to their performance in sixteen adult specialties. Of the 430 hospitals reviewed in California, CPMC was recognized among the best, ranking fifth in the San Francisco metro area and fifteenth in the state. In addition, CPMC received “high performer” recognitions in three specialties: heart bypass surgery, hip replacement, and knee replacement. CPMC also ranked as a “top50 hospital in the nation” for gynecology. Only 137 of the nearly 5,000 U.S. hospitals evaluated received a national ranking in at least one specialty.

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

SFVAMC

Saint Francis and St. Mary’s

C. Dianna Nicoll, MD, PhD, MPA

Transcatheter aortic valve replacement (TAVR) has become groundbreaking therapy for treating severe symptomatic aortic stenosis (AS) in patients that are high risk or inoperable for surgical aortic valve replacement (SAVR). AS affects 16.5 million Americans over age sixty-five and becomes progressively severe with age. When patients develop symptoms, half will die within two years without treatment. In the past, 40 percent of patients were not offered SAVR due to comorbidities, but now TAVR allows them life-saving therapy.

TAVR involves using a catheter to implant a new valve attached to a stent within the patient’s diseased valve. In the majority of cases, TAVR can be performed percutaneously from the groin. TAVR requires specialized, multidisciplinary expertise in interventional cardiology, cardiac surgery, echocardiography, electrophysiology, anesthesia, radiology, and nursing, among others, for patient-centered care. TAVRs are performed in state-of-the-art, hybrid operating rooms designed to meet the needs of both the operating room and catheterization laboratory.

SFVA is one of the leaders in TAVR, being among a handful of nationally approved VA centers. Since 2013, our program has completed more than fifty cases with excellent outcomes. We offer valve-in-valve TAVR for patients with degenerated surgical bioprostheses. We offer both currently available FDA-approved devices from Edwards and Medtronic, with their balloon-expandable and self-expanding valves, respectively. These options increase patient eligibility, decrease morbidity, and increase eligibility for percutaneous treatment, since access size requirements are significantly decreased. SFVA team leaders Drs. Elaine Tseng (cardiac surgery) and Kendrick Shunk (interventional cardiology) are nationally and internationally recognized in clinical and basic science research in TAVR, with continuous funding since 2005. SFVA research predicted crucial valve-in-valve outcomes using benchtop research prior to global registry results.

WWW.SFMS.ORG

Robert Harvey, MD, MBA and Robert Weber, MD

Medical advancements are an opportunity to improve the processes and tools used in treating and caring for patients. Dignity Health Saint Francis Memorial Hospital and Dignity Health St. Mary’s Medical Center are proud to offer the CyberKnife® Robotic Radiosurgery System, an advanced radiation therapy option for patients.

The service is available at San Francisco CyberKnife, a new world-class outpatient cancer treatment center that opened at Saint Francis this summer to serve patients from Saint Francis, St. Mary’s, and Dignity Health Sequoia Hospital in Redwood City. San Francisco CyberKnife is a joint venture between Dignity Health, independent San Franciscobased physicians, and Alliance HealthCare Services, Inc., a national provider of outsourced health care services.

CyberKnife is a state-of-the-art, noninvasive alternative to surgery for the treatment of both cancerous and noncancerous tumors, such as those located in the lung, brain, spine, liver, pancreas, and kidney. The treatment delivers beams of high-dose radiation to tumors with extreme accuracy in five or fewer outpatient procedures. Compared to tradi-

tional surgical procedures, CyberKnife may also be a more ideal option for patients with inoperable or surgically complex tumors.

CyberKnife’s modern mechanism of treating tumors has several benefits for patients, including no anesthesia or hospitalization, minimal radiation exposure to healthy tissue, little to no recovery time, and immediate return to daily activities.

Led by John Meyer, MD, medical director of Radiation Oncology at Saint Francis, and Sara M. Huang, MD, medical director of the Cancer Center at St. Mary’s, San Francisco CyberKnife offers a dedicated CyberKnife nurse navigator, numerous locations for patient consultation and follow-up care, and a nurse and three physicians on staff who speak Cantonese and Mandarin. The medical staff also includes Lisa Boohar, MD; Barry Chauser, MD; Alexander B. Geng, MD; Meiwen Wu, MD; and C. Dale Young, MD. The addition of CybeKnife to the Saint Francis and St. Mary’s oncology programs means that patients have an innovative, painless alternative to the challenges of traditional surgery.

Classified Ad

Family Medical Practice for sale. East San Francisco Bay, CA – Multi-discipline practice serving the Asian community. Revenue over $1 million. Multi-language staff; buyer doctor must be fluent in one Chinese dialect. EMR; high profit margin; seller will train buyer in proprietary systems. $682,000. Real estate also available. info@PracticeConsultants.com. 800-576-6935. www.PracticeConsultants.com.

Save the Date! January 29, 2016 is the SFMS Annual Gala January 29, 6:30 pm to 9:00 pm | Legion of Honor | Celebrate SFMS’ 148 years of physician advocacy and camaraderie with many of San Francisco’s most influential stakeholders in the medical community! The 2016 Annual Gala will be held at the iconic Legion of Honor. Guests are treated to an exquisite reception with elegant hors d’oeuvres and libations. Richard Podolin, MD will be installed as the SFMS President.

Network with colleagues, meet SFMS leaders, and enjoy a private viewing of the Legion of Honor’s collection galleries. Please note this is a member-only event. Gala tickets will go on sale November 2015.

SEPTEMBER 2015 SAN FRANCISCO MEDICINE

29

UPCOMING EVENTS 9/19: Zero Prostate Cancer Run/Walk | 9:30 a.m., Lake Merced (Skyline and Harding Rd.) | Join SFMS physician members from Golden Gate Urology for the annual Zero Prostate Cancer Run/Walk. This tight-knit community activity brings together athletes, doctors, cancer survivors, and those who care about them to end prostate cancer. Visit http://bit.ly/1EknsZh for more information on how to get involved.

9/22: CMS Webinar on Physician Compare Website and Quality Data | The Centers for Medicare and Medicaid Services (CMS) will host a series of one-hour webinars about public quality reporting and the Physician Compare website. The Physician Compare website was launched on in 2010 as mandated by the Affordable Care Act. It provides contact information, specialties and clinical training, hospital affiliations, and group practice information. Each webinar will offer physicians and other stakeholders an opportunity to ask questions about public reporting on Physician Compare and this year’s thirty-day measure preview period. Webinars will be conducted via WebEx on 9/22 at 10 a.m., 9/23 at 1 p.m., and 9/24 at 8 a.m. All sessions will present the same information. Visit http://bit.ly/1IRwiBf to register for the webinar.

9/25: Special Hope Foundation Conference—Effective Health Care for Adults with Developmental Disabilities | 8:00 a.m.– 4:00 p.m., California Endowment Oakland, 1111 Broadway, Oakland | Is California on the right track to provide effective and accessible health care for adults with developmental disabilities?

Health care providers, funders, researchers, advocates, policy makers, and other thought leaders will collaboratively look at managed health care for adults with developmental and intellectual disabilities at this one-day, information-sharing symposium.

For more information or to RSVP, please contact Kathy Bradley at (515) 480-6858 or kathybradley53@gmail.com.

10/4-7: 2015 Health 2.0 Annual Fall Conference | Santa Clara Convention Center | SFMS members may be eligible to receive complimentary access to the 9th Annual Health 2.0 Fall Conference. This 3-day event will showcase new technologies in health care, examining what has changed in the past year and giving participants a sneak peek at what’s next. Attendees can look forward to live product demos, engaging panel discussions with expert speakers, and days of networking opportunities. Visit http://bit.ly/1LGnWj6 for more information.

10/17: CMA President’s Reception and Awards Gala | 6:00 p.m.–12:00 a.m., Disney’s Grand Californian Hotel & Spa, Anaheim | The California Medical Association and the CMA Foundation invite you to the Nineteenth Annual President’s Reception and Awards Gala. Entertainment for this year’s Gala includes Power Mix, a fifteen-piece band featuring a team of male and female vocalists covering the best-loved songs and dance hits from yesterday and today. Each year, CMA and the CMA Foundation celebrate the extraordinary leadership of individuals and orga30

nizations making a difference in the health of Californians. Festivities include a cocktail reception, dinner, an inspiring awards presentation, a live auction, and exciting entertainment. Mark your calendars, as this will be a whimsical night to remember.

Additional event information, including ticket sales and RSVP details, is available at www.cmanet.org/gala.

10/29: IMQ Medical Staff Conference | 8:30 a.m.–4:40 p.m., Embassy Suites LAX Hotel, Los Angeles | Effective medical staff leadership is not easy. Patient-care problems can require thoughtful and sometimes difficult communications with colleagues. Join other medical staff leaders in a one-day learning opportunity that provides a foundation of knowledge, techniques, and best practices to help you succeed. In one day, attendees will gain insights to assist them in successfully leading a medical staff and, in doing so, to comply with key accreditation, licensure, and legal requirements. For more information, visit http://bit.ly/1fseILN or contact Leslie Anne Iacopi at (415) 882-5167 or liacopi@imq.org.

10/30–31: 2015 Latino Health Conference | Oakland Marriott City Center | The 2015 Latino Health Conference seeks to address health disparities in the Latino/Hispanic community by sharing evidence-based practices and clinical research, promoting diversity in the health care workforce and creating linkages between community health organizations and health care providers. Conference participants will receive evidence-based strategies, practice tips, tools, and patient education resources to improve their clinical practice and patient care. Visit http:// latinohealthconference.com/lhc/ for program and registration details.

11/5: SFMS Career Fair for Residents/Fellows/Physician Members | November 17, 5:00 p.m. to 8:00 p.m. | Morrissey Hall at St. Mary’s Medical Center, 2250 Hayes Street SFMS will be hosting our fifth annual Career Fair on November 17 at Morrissey Hall located on the St. Mary’s Medical Center campus. The event runs from 5:00 p.m. until 8:00 p.m. and is complimentary to residents and fellows from the four San Francisco-based residency programs. This is an excellent opportunity for physicians looking to practice in the Bay Area to network with representatives from a variety of practice types and settings, and for employers to connect with physician job seekers.

For event details or to inquire about exhibiting, contact the Membership Department at (415) 561-0850 extension 200 or membership@sfms.org.

11/9–10: Transforming Health Care—Statewide Stakeholder Summit | Sacramento Convention Center | The California Office of Health Information Integrity (CalOHII) is hosting a two-day conference focusing on the impact of personalized medicine on the future of health care. Presenters include national, state, and local health care leaders and innovators, as well as people on the front lines who will share their challenges and progress. Visit http://bit.ly/1fsh3WN for event and registration details.

SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

YOU WORK TO PROTECT YOUR PATIENTS. We work to protect you.

AS A PHYSICIAN, you probably know better than anyone else how quickly a disability can strike and not only delay your dreams, but also leave you unable to provide for your family. Whether it is a heart attack, stroke, car accident or fall off a ladder, any of these things can affect your ability to perform your medical specialty.

That’s why the SFMS/CMA sponsors a Group Long-Term Disability program underwritten by New York Life Insurance Company: • Benefits not tied to a practice, giving you more flexibility with potential career changes • Benefit payments that are 100% TAX FREE — when you pay premiums yourself • High monthly benefits up to $10,000

LEARN MORE ABOUT THIS VALUABLE PLAN TODAY! ——————————————————

Call Mercer for free information, including features, costs, eligibility, renewability, limitations and exclusions at: 800.842.3761 ——————————————————

• Protection in your medical specialty for the first 10 years of disability With this critical protection, you’ll have one less thing to worry about until your return.

SPONSORED BY:

UNDERWRITTEN BY:

New York Life Insurance Company New York, NY 10010 on Policy Form GMR

69963, 70830 Copyright 2015 Mercer LLC. All rights reserved.

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com

OR SCAN TO LEARN MORE!

Advancing cancer research and care.

Our physicians and researchers are making new discoveries to help in the fight against cancer. With nationally recognized cancer experts and dozens of clinical trials, we provide access to promising new cancer therapies. Comprehensive cancer care at Sutter Health CPMC. It’s another way we plus you.

cpmc.org/cancer