Summer 2009

Dr. Guey Mark

2009 Lifetime Achievement Recipient Summer Issue 2009 SUMMER 2009

SAN JOAQUIN PHYSICIAN

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Did you know—The number of charges filed with the EEOC from 2005–2008 was up 26 percent.2 And the total amount of money awarded nearly tripled, to $102.2 million.3 Did you know—Workers’ compensation, general and professional liability insurance generally do not cover the vast majority of complaints filed against employers —discrimination, harassment, and many others.

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SUMMER 2009

Volume 57, Number 2 • Summer 2009

32 52 46 16 SUMMER 2009

{FEATURES} Dr. Guey Mark

{DEPARTMENTS}

2009 Lifetime Achievement Recipient

21 Managing Your Practice

A Bitter Pill

24 In The News

How health plans hinder physicians’ drug prescribing preferences—and harm patients

Passing the presidential baton Electronic Health Record

The Daily Life of HER by Eric Hill

New Faces and Announcements

38 Public Health Update

Swine Flu Update by Wendi Dick, MD

40 Community Service – Off the Chart

Dr. Barbara Rankin and St. Mary’s Medical Clinic

44 Hospital Technology

St. Joseph’s Introduces new cancer treatment

60 Legislative Update

SJMS members meet with representatives

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Helping doctors treat and patients heal.

The Advanced Imaging Center at Lodi Memorial Hospital offers Board certified radiologists, comprehensive diagnostic services, and a convenient location for patients.

Robin Wong, MD President Lawrence R. Frank, MD President-Elect Javad Jamshidi, MD Past-President James Halderman, MD Secretary-Treasurer

High Field MRI Breast MRI Digital X-ray (walk-in’s welcome)

Board Members Shiraz Buhari, MD Thomas McKenzie, MD Javad Jamshidi, MD

Moses Elam, MD John Olowoyeye, MD George Khoury, MD

Ashok V. Daftary, MD Anil K. Sain, MD Kristin M. Bennett, MD

Medical Society Staff Michael Steenburgh Executive Director Debbie Pope Office Coordinator Gena Stoddart Membership Coordinator

(209) 333-7422

Committee Chairpersons MRAC F. Karl Gregorius, MD

Decision Medicine Kwabena Adubofour, MD

Ethics & Patient Relations Arudra Bodepudi, MD

Communications Morris Senegor, MD

Legislative Patricia Hatton, MD

Community Relations Joseph Serra, MD

Audit & Finance Marvin Primack, MD

Member Benefits Jasbir Gill, MD

Nominating Hosahalli Padmesh, MD

Membership Ashok Daftary, MD

Public Health Karen Furst, MD

Scholarship Loan Fund Eric Chapa, MD

NORCAP Council Sandon Saffier, MD CMA House of Delegates Representatives Shiraz Buhari, MD Patricia Hatton, MD James J. Scillian, MD

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Lawrence R. Frank, MD Francis Isidoro, MD Gabriel K. Tanson, MD

James R. Halderman, MD Javad Jamshidi, MD Robin Wong, MD

SUMMER 2009

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SAN JOAQUIN PHYSICIAN

MESSAGE > executive director

How will you spend the money?

This question must be on every doctor’s mind with all the promises contained in the Presidents stimulus Plan relating to electronic Health records (eHr) and all of the hype we’re hearing from so many sources. Well, we don’t want you to feel uninformed so we have chosen to feature several well-written pieces from different perspectives. On one hand, you can read first-hand how local family physicians raissa Hill and san tso implemented their propriety-system from Hill Physicians two years ago and how it’s working today. and on the other-hand, we have included a more cautionary styled story which outline some of the pitfalls to be avoided as many rush to capitalize on this windfall. additionally, we have partnered with Health Plan of san Joaquin to offer several unique educational opportunities relating to eHr. The first of these will be an evening dinner presentation on July 8th (see page 19 for details) and we even have a special presentation for our Office managers Forum which will be the same day only during the lunch hour and held at Valley Brew restaurant.

Later in the year we are planning a unique eHr “trunk show” which will feature 8 or more of the most prominent eHr suppliers and an opportunity “as every July signifies the changing of our to actually try out these society leadership, it also brings with it a new systems “hands on” so to Lifetime achievement recipient” speak. as every July signifies the changing of our society leadership, it also brings with it a new Lifetime achievement recipient. This year’s winner is dr. Guey mark – a well-deserving physician who has given back so much to his community. Be sure to read his fascinating story beginning on page 32. in closing, you may notice a few changes to the magazine debuting with this issue. in addition to a graceful redesign by our new creative director sherry roberts, we are focusing more of our space on what interests our physician membership. new medical technology, interesting articles on running your practice, timely legal and legislative updates from cma and of course some interesting tidbits on our friends and partners around town.

With that said, i welcome you to enjoy our newest issue and feel free to submit your ideas, recommendations and story ideas since after-all – it is your magazine! all the Best.

mike steenburgh executive director

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Moris Senegor, MD editor Editorial Committee shiraz Buhari, md kwabena adubofour, md robin Wong, md Michael Steenburgh managing editor Sherry Roberts creative director/Graphic designer sherry.lavone@gmail.com William West contributing Writer Contributing Sources california medical association Los angeles county medical association san diego county medical society The san Joaquin Physician magazine is published quarterly by the san Joaquin medical society suggestions, story ideas or completed stories written by current san Joaquin medical society members are welcome and will be reviewed by the editorial committee.

Please direct all inquiries and submissions to: San Joaquin Physician Magazine 3031 W. march Lane, suite 222W stockton, ca 95219 Phone: 209-952-5299 Fax: 209-952-5298 email address: gena@sjcms.org medical society Office Hours: monday through Friday 8:00 am to 5:00 Pm

SUMMER 2009

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Message > from the President

Physicians and the “HIT” Parade EHR’s, EMR’s, RHIO’s and the ARRA

“It has been reported that less than 20% of office based physicians use some form of EHR system and only 4% have a comprehensive EHR system as recommended by the federal government capable of sending prescriptions directly to a pharmacy and allowing for clinical decision support.”

ABOUT THE AUTHORRobin Wong, MD is the 2008-2009 President of San Joaquin Medical Soceity.

President Barack Obama has signed the American Recovery and Reinvestment Act (ARRA) in February setting aside at least $17 billion or more of the $787 billion economic stimulus package for incentive payments to physicians and hospitals that implement electronic health records (EHR) or EMRs , electronic medical records. With the adopting of EHRs comes the need for establishing of a health information exchange (HIE), which is a system that allows EHR systems to communicate and exchange information, usually using an internet-based portal. There also exists a need for regional health information exchanges (RHIO’s) which are formed by regional stakeholder groups to facilitate the exchange of information among local providers of care. Therefore, multiple systems need to be in place and interoperable for the HIT parade to begin to be effective.

Washington and state lawmakers, heath policy advocates, and many health care leaders justifiably support the adoption of EHRs, and thus the sharing of clinical information as a significant means to better quality of patient care and dramatically lower health care costs related to duplication of tests, services, and treatment. Congress is so enthused with HIT that it has penalties built into the bill for Medicare providers who do not implement a qualified EHR over the allotted number of

years.

Naturally soft ware vendors have spotted a potential financial bonanza and are using all sorts of ways to get physicians to buy their product. One example is eClinicalWorks partnering with Dell and Wal-Mart to offer a packaged deal including hardware, software, instillation, training, and first year support through Sam’s Club stores nationwide.

It has been reported that less than 20% of office based physicians use some form of EHR system and only 4% have a comprehensive EHR system as recommended by the federal government capable of sending prescriptions directly to a pharmacy and allowing for clinical decision support. This information comes from a study that was published in the New England Journal of Medicine, July 3, 2008. Other health agencies see overall adoption rates as high as 40%, but less than 5% of physicians use comprehensive EHRs. Medical leaders are very hopeful that the Medicare and Medicaid financial incentives of the ARRA will spur on and help physicians buy and implement EHRs realizing that cost is one major barrier. It has been estimated by HIT consultants that 5 year costs, not including hardware, for a comprehensive EHR system can surpass $40,000 per physician.

The provider incentives as generally outlined by ARRA are available through two

pathways: the Medicare program or the Medicaid program. You chose one depending on you type of practice. Each is described below briefly as summed up by the CMA Health IT Campaign Plan.

The EHR that a physician selects to implement must be able to communicate to systems from other vendors, and it must contain features like clinical decision support, be able to electronically prescribe, exchange data with other providers, and be able to report on yet to be determined clinical quality measures. The EHR system must be certified most likely by the Certification Commission on Healthcare Information Technology (CCHIT). It is advised that be besides getting a CCHIT certified program that also the contract require the vendor to meet all the standards as they finalize.

For the near future this physician is waiting and not joining

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Medicare: Generally, almost all Medicare provider physicians will qualify for EHR grants of up to $44,000 paid out over five years starting 2011or 2012.

Physicians practicing in a Federally-designated Health Professions Shortage Area will qualify for a 10% bonus. The bonus payments will be made based on physicians demonstrating to the Medicare program meaningful usage of a qualified system.

Waiting until 2013 or 2014 reduces your bonus period. All payments will cease after 2016. If you wait to qualify until 2015, you receive nothing. Also by 2015 Medicare providers who treat Medicare patients without an EHR will see reimbursements decrease 1% that year. The pay cut grows to 2% in 2016 and 3% in 2017 and every year afterwards.

Medicaid: The payments for Medicaid are higher, up to $65,000, but they are more targeted to safety net physicians. In order to receive Medicaid payments a physician must either: 1) have 30% of their patient volume covered by Medicaid, or 2) be a pediatrician, and have 20% of their patient volume be Medicaid, or 3) work in an FQHC and have 30% of their patient volume be “needy individuals” (Medicaid, CHIP, sliding scale or uncompensated care).

These payments may be made available to physicians to assist physicians with implementation of an EHR system before meaningful use is established.

Possibly the most important consideration with regards to the Medicaid provider incentives is that they are optional for states to implement

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the electronic HIT parade yet.

I am certainly keeping up with developments through the CMA, which is already creating and implementing a Health IT campaign plan. The CMA goals are to help member physicians assess whether making the transition to EHR is right for their practice, assist physicians in selecting and implementing the proper EHR system, help members understand and access the available Medicare and Medicaid incentive programs, and create policies on the Federal and State government levels that will make the transition to EHR workable for California physicians.

I am concerned as are many other physicians about the unknowns of selecting an appropriate EHR system since the standards are not fully identified.

I certainly do not want a system that will “slow down” the office and take away time spent directly with the patient. As a patient I would be annoyed and disturbed to observe my doctor paying more attention to his tablet pc than to me during the office visit.

I share negative thoughts like others that financial incentives would be ill spent on EHR systems that cannot right now exchange data will each other or with personal health records controlled by patients.

Presently, I feel active surveillance is the right choice along with planning for entry into the HIT parade in the near future.

Finally, my term as president of the San Joaquin Medical Society is at an end. I have been honored to serve and benefited from this experience as a physician leader. I thank the membership for allowing me the opportunity to have served as your president.

SUMMER 2009

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Message > from the Editor

SURGERY AND WAR How can well trained, experienced individuals, highly accomplished in their fields blunder?

“The lesson from Bernard Fall was that sometimes a given battle is already won or lost before the armies actually take the field and engage.”

SUMMER 2009

In his book “Hell in a Very Small Place”, historian Bernard Fall, writing about the French defeat in Vietnam at Dien Bien Phu points out that the battle was “lost during the brief fortnight between November 25 and December 7 1953. It was not lost in the little valley in Vietnam’s highland jungles but in the air conditioned map room of the French commander in chief.” The battle was actually fought between March and May 1954, several months after the French Commander General Navarre made his fateful plans that previous autumn. His choice of a remote outpost supplied only by air as the focus of a set piece battle with the Communist Viet-Minh turned out to be a fatal mistake. A significant underestimation of the enemy’s manpower and firepower also contributed to the most humiliating defeat of the French in the 20th century, even worse than the Nazi invasion of 1940.

The lesson from Bernard Fall was that sometimes a given battle is already won or lost before the armies actually take the field and engage. Poor planning pre-determines the outcome. This lesson is well known to any seasoned surgeon. Once a surgeon masters the technical skills required for a given operation, execution of the procedure

is usually uneventful. Naturally there are a number of statistically obligatory complications that occur no matter what, such as post-op infections or bleeds. Putting those aside, most seriously bad outcomes of surgery occur from poor planning, not poor execution. Common mistakes include misunderstanding of the pathology to be treated, attempts to fit “off the shelf” square peg operations into round hole patients, overly aggressive risks taken for fragile bodies, and the converse, overly conservative surgery ABOUT THE AUTHORMoris Senegor, MD serves as the Chairperson of the Publications Committee for the San Joaquin Medical Society and Editor of its flagship publication the San Joaquin Physician.

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Message > from the Editor for conditions that require a more aggressive approach.

How can well trained, experienced individuals, highly accomplished in their fields blunder? Let’s take another example from war. In 1950 the famed General Douglas Mac Arthur finished his career with a colossal gaffe when he sent his troops in Korea across the 38th parallel. What began as a defensive war after the North Koreans invaded the South, suddenly turned into an offensive one as U.N. troops raced across the North towards the Chinese border. The move invited Chinese entry into the war in a surprise attack that routed the Americans who were caught hopelessly spread out at the shores of the Yalu River in harsh winter conditions.

The casualties were enormous and eventually it took a Herculean effort, and a different commander, General Ridgeway, to avert a complete annihilation of the American forces, as in what happened a decade later to the French at Dien Bien Phu. The historian David Halberstam, in his book “The Coldest Winter” doesn’t mince his words about Mac Arthur. After various Communist leaders on the other side, he paints the legendary American General as the greatest villain of the Korean War. And his sin?

Vainglory! He unilaterally decided to reunite the two Koreas and achieve a huge victory to top off his career; in so doing he ignored the perilous, poorly supported position he was placing his troops in hostile topography and weather. The accolades to be gained from total victory were foremost in his mind, without regard to the practical impossibility of it all if the Chinese entered the war. And thus depraved motivation in planning, subjugated military considerations to an inferior status.

The end result was a horrific sacrifice of thousands in both sides of the war.

Aberrant motivation abounds in the retrospective review of failed surgery just as it does in war. The most common is financial: procedures are selected over others solely because they pay better. Unindicated ones are performed mainly for reimbursement. Vanity also enters the picture: procedures are performed by those lacking necessary training or experience because others are doing them, or because surgeons seek bragging rights for doing “glitzy” procedures. Ultimately the mistakes are psychological, and reflect either personality weaknesses of individual surgeons or external stresses of the time that weaken resistance to a poorly selected choice, true in war as in surgery.

I first realized the commonalities between surgery and war when in 2003 President Bush was setting the stage for the second Iraq war. His administration’s collective effort to convince the nation of the necessity for this war seemed like that of a surgeon attempting to convince a patient about a scary operation, albeit greatly extrapolated to the political spectrum. I

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empathized with his administration, knowing full well how difficult it is to “sell” something – in my case surgery – to someone reluctant to “buy” it. Then the war was under way and initially it seemed to be going well; the surgery was a success. But when complications set in, and there were plenty, we ended up with a patient hospitalized for months, left partially crippled, requiring treatment after treatment. Looting, Abu Graib, insurgency, the first and second Fallujah operations, and more, each seemed like more surgery to correct the complications of the original one. How well did I know

SUMMER 2009

the feeling!

Once complications set in, the surgeon faces an angry, bewildered, despondent family. And my-oh-my, did the Bush people face that! For years to come. They also have to answer to second guessing colleagues as to what went wrong, what they could have done better. Some surgeons are forthright with such difficult queries, others exhibit denial, defensive behavior, or they fight back, figuring the best defense is a good offense. We saw a bit of all that in the Administration’s handling of the fallout as they faced Congress, the press, families of casualties,

disgruntled military officers, and even some in their own administration.

When I see a survivor of multiple complications in follow-up, after the dust has settled, I always ask them the following question: “looking back at your experience, was the surgery worth it? Did it do you any good?” By this time some patients have come through all- right, others have residual problems.

Some say yes, some say no; they are usually quite honest. They have minimal regard for my feelings after all they have been through. For the Bush folks that question is still premature.

By the time it is asked and answered Bush and his people may long be dead and gone. That’s the way history works; the feedback loop is slow, longer than a lifetime, and in this it differs from surgery.

One thing is for sure: both war and surgery are actions of last resort, radical solutions to problems not solved by conservative therapy, otherwise known as diplomacy in political parlance.

Once engaged, these actions can be hazardous, their outcomes sometimes unpredictable. Overconfidence in one’s ability to manage the action can lead to dangerous ground. But underestimation of the enemy, whether it is a disease or an army, is a substantially deadlier mistake. When viewed in retrospect the predestined outcomes of failed surgery or war are as clear as in a Greek tragedy. In the fog of the original decision making however, uncertainty abounds. But it is oh-so obvious when the dust settles.

Thus Bernard Fall writes, some 10 years after the defeat at Dien Bien Phu, with convincing lucidity that the French were misguided in their military adventure, in the same way a surgeon reflects upon his failures, usually in a more quiet, introspective setting. One can only hope that both military commanders and surgeons learn from their mistakes and not repeat them. I am glad that as a surgeon my bad decisions affect individual lives, when as a General or President similar actions result in disaster for thousands, sometimes millions.

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Electronic Health Record beware

In a recent open letter to President Obama, David Kibbe, a senior adviser to the American Academy of Family Physicians and expert on health information technology (HIT), described the current electronic health records (EHRs) as costly, difficult to use, and unable to allow hospitals, physician offices, or pharmacies to easily share information about patients’ medical histories and treatments.

By Stephen H. Carson, MD

He wrote, “If America’s physician practices suddenly rushed to year, productivity rarely surpasses what it was with paper records install the systems of their choice, it would only dramatically for PCPs. intensify the (tower of) Babel that already exists.”

Interoperability: Physicians who buy an independent e-pre The following points should help physician buyers understand scribing tool or EHR that is not fully integrated with their practice why physicians should approach EHRs and e-precribing tools management system for demographic data, billing, and collecwith extreme caution: tions will be frustrated with the ongoing costs and headaches Affordability. Most standalone EHRs cost a minimum of of making the two systems work seamlessly. Anytime there are $10,000 per physician for purchase, installation, and staff trainupgrades to one system, there are unanticipated costs and glitches ing. Maintenance and upgrades can with the second system. There are also easily run up to $2,000 per year per major interoperability issues between physician. Subscriptions for EHRs physicians and their hospitals, labs, and typically cost $400 per month per radiology vendors. This connectivity is “If America’s physician physician. necessary to eliminate the errors and practices suddenly Return on Investment: Although the time associated with having to rerushed to install the the government and health plans key patient data into your EHR. systems of their choice, it reap 90 percent of the financial ben Unexpected Downtime: Solo and would only dramatically efit of EHRs, physicians are expected small practices cannot afford dedicated intensify the (tower to pay for the efforts in time and technicians to solve problems inherof) Babel that already money. For example, the current ent with electrical outages, computer incentive dollars for e-prescribing glitches, and server crashes. exists.” - David Kibbe and pay-for-performance may not Changing Requirements: EHRs will amount to more than $3,500 per need to incorporate ever-changing physician per year — hardly enough requirements for clinical decision to offset the costs, let alone the headsupport, order entry, data capture and aches. Many of the incentives are not guaranteed for more than information exchange between stakeholders. Physicians will four years. be regularly forced to spend additional dollars to modify their Reduction in Productivity: The average primary care physician information systems. will experience a 20 percent reduction in productivity and collec Based upon the current incentive timetables, it is my recomtions in the first year of using a full-blown EHR. Beyond the first mendation that physicians should NOT start shopping for hard-

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technology > EHR ware or software until the fall of 2010, with the goal of launching FDA Barriers: The FDA still prohibits the use of e-prescribing in January 2011. Although some physicians may want to proceed modules to submit prescriptions for controlled substances. This sooner, my rationale for waiting is as follows: explains why fewer than 5 percent of all prescriptions in the Cost of both hardware and software will continue to drop over United States have been filed electronically over the last year. the next two years.

What about the HITECH Act in the American Economic Functionality of fully integrated practice management and Recovery and Reinvestment Act? It is estimated that $17.2 bilEHR systems is dramatically improving from month to month. lion of the $20 billion dollars set aside to stimulate IT adoption EHRs of the next decade will need to include modules for will be in the form of incentive programs under Medicare and population health improvement, clinical decision support, eligiMedicaid. As currently written, ambulatory physicians participatbility verification, charge capture, claims adjudication, HEDIS ing in Medicare will be eligible if they can demonstrate that they reporting, and interoperability. Although there are some excellent are “meaningful users” of certified EHR technology (standards products on the market today, none are to be established before Dec. of the products is ready to meet 31, 2009). “Meaningful use” is the requirements that are expected defined as being connected in to be in place within two years. a way that improves the quality Standards: Under the MicroSoft Windows 7 is likely using measures selected by the stimulus act, the Office of to replace Windows Vista in early ONC. Incentives will be limited to the National Coordinator 2010.

75 percent of Medicare-allowed (ONC) for Health Open source platforms are charges in any year and up to Information Technology likely to heat up the competition $44,000 over five years. Physicians will require EHRs to adopt among vendors and drive the price practicing in health professional new sets of standards, of EHRs downward. New adaptashortage areas can receive and specifications, and tions of Vista for the ambulatory additional 10 percent. Physicians certification criteria by physician will stimulate disruptive who start after 2014 will not Dec. 31, 2009. These new innovation. receive any incentives. standards will result in Inexpensive and energyFor Medicare-covered services unanticipated upgrade efficient thin client hardware will rendered during 2015 or after by a costs for those who have become an attractive option for professional who cannot demonalready purchased an EHR. physician offices. strate meaningful EHR use, the Incentives for innovative programs Medicare physician fee schedule run by state, federal, regional, will be reduced by 1 percent for health plan, and independent 2015, 2 percent for 2016, and 3 practice associations will continue to percent for 2017. There is an escape evolve. clause for professionals who can demonstrate significant hard Standardized patient ID cards and card-readers that interface ship, but that clause will apply to a professional for a maximum of with practice management systems is a priority for the Medical five years.

Group Management Association (MGMA). MGMA estimates Unfortunately, the money from the Medicare and Medicaid that machine-readable patient ID cards could save physician programs will be paid out over four or five years and won’t be offices, health plans, and hospitals as much as $1 billion a year by available until 2010 or 2011. The Act provides for comparable eliminating unnecessary administrative efforts and denied claims. incentives and disincentives for professionals providing substanReal-time claims adjudication through the EHR will allow physitial services through Medicare Advantage plans. cian offices to determine eligibility, deductible thresholds, and The Act also provides for payments to those states that have CPT codes for immediate adjudication and reimbursement of approved Medicaid plans and programs to encourage the adopthe office visit. This feature is where the real long-term financial tion and use of certified EHR technology. Specifically, these states reward is for physicians. will receive 100 percent of the payment outlays of their programs Standards: Under the stimulus act, the Office of the National and 90 percent of their costs of administering such programs.

Coordinator (ONC) for Health Information Technology will Payments to physicians cannot exceed 85 percent of average require EHRs to adopt new sets of standards, specifications, and allowable costs for certified EHR technology and are capped at certification criteria by Dec. 31, 2009. These new standards will $25,000 for the first year and $10,000 for subsequent years. These result in unanticipated upgrade costs for those who have already amounts will be reduced by two-thirds of that amount for pediapurchased an EHR. tricians. Eligible providers must have at least a 30 percent Medic ICD-10 code sets are likely to be required by October 2013 aid patient load, and pediatricians must have at least a 20 percent and require tighter integration between clinical and billing funcMedicaid patient load. Federally qualified health center or rural tions. health clinics must see at least a 30 percent load of patients classi-

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TEchNOlOGy > EhR

fied as “needy,” which is broader than medicaid beneficiaries.

For those of you who are ready to make the leap despite the challenges, i would offer the following advice: Purchase a fully integrated practice management system and eHr. do not buy separate systems in the hope that they will always work well together. make sure the integrated system supports the full set of HiPaa transaction standards, appointment scheduling, patient reminders, electronic eligibility verification, advanced claims editing (including health savings accounts), automated payment posting with electronic remittance advice, integrated credit card processing, configurable reporting, the icd-10 code sets, and, if necessary, specialized medi-cal claims processing that addresses medical home requirements. in addition, do not forget to research the ability of the system to interface with health plans and clearinghouses. do not waste your time on standalone e-prescribing — you are only going to have to dump it later for an eHr. remember, the incentives from medicare for e-prescribing drop to 1 percent in 2012, to 0.5 percent in 2013, and then they disappear.

Pick an eHr suited to your specialty. Get advice from your colleagues and your specialty society. For example, voice recognition in the eHr is often a big plus for surgeons and enables savings

on transcription costs. Look for software that automatically flags common tasks that are unique for your specialty (e.g., cancer screenings for internists and family practitioners).

Vendor reputation: Pay attention to the vendor’s track record for service and support. interoperability: if possible, find an eHr that can receive data from your preferred lab and hospital and deliver patient-specific data into the correct field in each of your patient’s electronic chart. application service providers using a subscription model for maintaining and servicing your office is the best approach for physicians in small- and medium-sized practices.

Workflow Planning, staff training, and implementation: an experienced vendor will work with physicians and their staff to map out the ideal workflow for the office and develop a carefully planned out schedule for training and implementation.

Physicians should not underestimate the time or importance of these efforts. check the 2008 Best in kLas awards based on customer satisfaction with healthcare information technology vendors and consultants.

Our firm devotes its practice to civil litigation with decades of experience representing health care professionals in:

A Professional Law Corporation DONALD M. RIGGIO MICHAEL R. MORDAUNT PETER J. KELLY NEAL C. LUTTERMAN • CORINNE K. REYNOLDS STEPHANIE ROUNDY JESSICA TOMLINSON

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• MEDICAL MALPRACTICE ACTIONS • MEDICAL BOARD INVESTIGATION • HOSPITAL CREDENTIALING PROCEEDINGS • PERSONAL INJURY PROSECUTION • EMPLOYMENT LITIGATION AND COUNSELING • FAMILY LAW MATTERS

2509 West March Lane, Ste. 200 Stockton, California 95207 Phone (209) 473-8732 Fax (209) 957-9165

SUMMER 2009

Health Plan of San Joaquin and the San Joaquin Medical Society Board present:

AN EVENING OF DISCUSSION ON ELECTRONIC HEALTH RECORDS (EHR) We understand the importance of keeping our Physician Partners at the forefront of technology and innovation to better serve our community.

The 2009 federal economic stimulus package includes $19 billion for health information technology (HIT), the vast majority of which will be directed to physicians to subsidize the purchase and usage of Electronic Health Records

Date: July 8, 2009 (dinner will be served) Time: 6:30pm Location: Health Plan of San Joaquin

7751 S. Manthey Road, French Camp (Community Room)

Our Providers will learn about: - Current technology updates - Criteria for Medi-Cal and Medicare providers to receive incentive payments - What type of incentive payments are available for implementation - How EHR can impact and enhance your practice

(EHR) systems. Beginning in 2011, qualifying Medicare providers stand to receive up to $44,000 under the program; qualifying Medi-Cal providers stand to receive as much as $65,000. These funds are predicated on physicians using EHRs, so practices and groups that already have purchased EHR systems can also qualify for funds.

To learn more or to register for this event call: 209.461.2302 or 209.461.2254 SUMMER 2009

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Independent But Not Alone.

Rahul Patel, M.D. )JMM 1IZTJDJBOT QSPWJEFS TJODF Uses Ascender preventive care reminders, 3FMBZ)FBMUI POMJOF DPNNVOJDBUJPO UPPMT BOE )JMM T &)3 GPS B DPNQSFIFOTJWF TPMVUJPO UP QBUJFOU DBSF practice management and ePrescribing.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. r 'BTU BDDVSBUF DMBJNT QBZNFOUT r 'SFF FMFDUSPOJD DPNNVOJDBUJPO DBQBCJMJUJFT WJB 3FMBZ)FBMUI

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That’s why Hill Physicians Medical Group is one of the country’s leading Independent Physician Associations. It’s a smart choice for providing better healthcare.

Your health. It’s our mission.

Learn more about Hill Physicians at www.HillPhysicians.com/Providers or contact: Sacramento area: %PVH 3PCFSUTPO SFHJPOBM EJSFDUPS %PVH 3PCFSUTPO!IQNH DPN San Joaquin: 1BVMB 4DINJU SFHJPOBM EJSFDUPS 1BVMB 4DINJU!IQNH DPN Bay area: +FOOJGFS 8JMMTPO SFHJPOBM EJSFDUPS +FOOJGFS 8JMMTPO!IQNH DPN Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.

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SUMMER 2009

MANAGING > your practice

ThE DAIly lIFE OF EhR Does the sound of EMR, EPM, or even EHR make you wish you were MIA? Well, you are not alone…yet!

Whatever you call them, Electronic Medical Records (EMR’s), Enterprise Practice Management systems (EPM’s), or Electronic Health Records (EHR’s), these systems serve the same purpose; they convert data normally recorded on paper into an electronic format. Then they leverage that format to do all the data-crunching and communicating in a manner far superior to previous paper-versions.

By Eric Hill

does this spell the end for the profession of medicine? in a single word, nO! Without physician input, an eHr is paralyzed.

However, if an eHr is fed the identical information contained within a written progress note, it will more efficiently convert that data into improved clinical quality and, yes, increased business returns.

This is my experience as the practice manager for a twophysician Family medicine group. in early 2007 we began using the nextGen emr/ePm in collaboration with Hill Physicians medical Group’s esolutions unit. now commonly known as the “Hill eHr”, this system is an asP model, meaning that all the data is stored off-site and retrieved via a dedicated t1 line with point-to-point access from the practice to the hosting site. all practice management functions (e.g. demographics, scheduling, billing, collections, etc.) and medical management tasks (e.g. charting, prescription refills, referrals, record management, etc.) are completed by all staff (including physicians) using our eHr. This transformation was gradual and did not always come easy. However, knowledgeable and accessible support eased the transition and has made the return to paper an unimaginable option. We have pressed on and it has now been over two years

SUMMER 2009

since that memorable “Go Live” date. When i reflect on the changes our office has seen on a day-to-day basis, some striking before and after images immediately come to mind. calmer Office environment. The days of what seemed like nothing short of controlled chaos are gone. The patients and staff have not changed, but how we interact with them has become much more focused and organized. it has fostered a calmer environment in which we work, translating to a better patient experience.

Less Paper clutter. We still use paper but much less than we once had, and now, what we do use is shredded and recycled. The sticky notes of past have been replaced with electronic messaging, and medical records are received or scanned electronically into our eHr. Our files and cabinets are far less crowded.

Less running around. staff no longer runs around the office searching for a chart or form. doctors do not have to track down an m.a. to personally explain their orders. all this is contained and communicated within the eHr. most importantly, patients seem to sense that things flow more smoothly, putting them at ease while visiting the office.

Quicker turnaround. centralized organization and improved

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communication has enabled us to more quickly respond to patients’ needs, whether it be a request for a prescription refill (ePrescribing) or a call back from the physician. “To Do” lists do not get lost in an EHR; when completed, they get documented and communicated better. We feel more organized.

Increased Staff & Patient Confidence. The increased accessibility to timely information by all requisite staff has had the effect of boosting both staff and patient confidence in the work that we do. Staff can now immediately and confidently summarize precisely what has occurred in response to a particular patient request or concern. Everything is documented on the screen before them; there is no need to leave their seats.

Better Accountability. Audit trails and task-tracking capabilities give both management and staff reassurance that one employee’s performance will not be compromised by a second employee’s shortcomings. EHR’s do not lie, and when employees are aware of this power, finger-pointing is alleviated, and accountability and performance actually increase.

Remote Access. The ability to access the EHR securely from

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anywhere you can obtain an internet connection is very powerful.

Recently, while on vacation in the Philippines, both my wife and I accessed our EHR from the island of Boracay through our laptop’s Virtual Private Network software (VPN). Whether accessing the EHR from home or a tropical paradise, the mere fact that you can is nothing short of amazing. Whether such access is advisable while on vacation is a whole other question!

In the medical profession, an EHR is often described as simply a more efficient means for maintaining medical records. Now, I have come to realize that it also produces a better environment in which to work and, in turn, provides patients with a calmer, more orderly visit. To my fellow practice managers who have been hesitant to champion EHR because they worry it may change what they are used to, I say, “You should be so lucky.” That’s been my experience and, in retrospect, I can hardly imagine our office without an EHR. Take my advice and don’t go MIA on EHR! Have I sparked your imagination?

SUMMER 2009

Upcoming Complimentary Dinner / Seminars for San Joaquin Medical Society Members with...

Presented By :

G. James Avery II, M.D. Topic: Strategies in the Surgical Treatment

of Advanced Heart Failure

Thursday, September 10th, 2009 Cocktail Reception 6:30pm Dinner Presentation 7:00pm

Papapavlo’s Bistro Stockton, California in conjunction with :

Steven C. Hao, M.D. Topic: State of the Art Management Reservations are Required!

Please call the medical society office at (209) 952-5299 to reserve your seat.

of Atrial Fibrillation

Thursday, November 5th, 2009 Restaurant location: to be announced

Business Records Storage Media/Vital Records Vault Certified Document Destruction Document Imaging Services

Mike Long, Director of Marketing

209-320-6618

email: mlong@pacificstorage.com www.pacific-records.com

SUMMER 2009

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COMMUNITY > news

IN THE

NEWS

Providing staff, physicians and patients with relevant & up to date information

Sutter Gould Medical Foundation Opens New Surgery Center in Stockton Sutter Gould Medical Foundation (SGMF) recently opened a new Surgery Center at their Stockton Medical Plaza at Hammer Lane and Don Avenue.

The 12,000 square foot facility will provide space for specialists in orthopedics, gynecology, pain management, urology, and general and

vascular surgery. Features include three operating rooms, two procedure rooms, a 6-bed pre-op area and a 14-bed post-op recovery area. There is a private checkin area and a waiting area with wireless internet service and a flat-screen television for patients and their families.

“This project has created an efficiently sized and modern design for ambulatory (outpatient) surgery procedures, and includes the latest technology and equipment,” said Katrina Holmes, Central Valley Regional Administrator for Sutter Gould Medical Foundation’s Surgery Center. “We are extremely pleased with

LMH PRU makes national top 10

ranking of rehabilitation facilities by the Uniform Data System for Medical Rehabilitation (UDSMR).

That organization makes its determination by assessing functionalindependent measurement (FIM) scores. The FIM system is a an outcomes-management program for skilled-nursing facilities, subacute facilities long-term-care hospitals, veterans administration programs, inpatient-rehabilitation hospitals and

other related venues of care. FIM scores enable providers and programs to document the severity of patient disability and the results of medical rehabilitation. They establish a common measure for the comparison of rehabilitation outcomes. FIM scores provide an established means of collecting rehabilitation data in a consistent manner and allow clinicians to follow changes in the

The LMH Physical Rehabilitation Unit at the hospital's west campus was notified that its positive patientoutcomes are among the top 10 percent of rehabilitation hospitals nationally. The determination was made by the Program Evaluations Model Score Card (PEM), a national 24

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SUMMER 2009

news < COMMUNITY the way the project turned out.”

The staff at the SGMF Surgery center comes with over 20 years of years of experience. “We feel very fortunate to have hired professional, experienced, compassionate staff for the Sutter Gould Surgery Center,” added Holmes, who herself has over 10 years in surgery center operations and 20 in OR operations.

“Our staff is dedicated to providing the best surgical experience to all of our patients.

Gould radiologists to share digital images and diagnoses instead of shipping X-ray film between locations.

Commitment to Northern California health care The Surgery Center is one

example, Sutter Gould has completely moved into the replacement clinic at their 600 Coffee Road site, after 54 years in the existing building. An additional medical office building, designed to house Gould Medical Group specialists, will soon open at the Stockton Medical Plaza site on Hammer Lane.

Sutter Gould Medical Foundation has care centers in Stockton, Lodi and Tracy in San Joaquin County, as well as Modesto and many communities throughout Stanislaus County. SGMF is part of Sutter Health, a family of not-for-profit hospitals and physician organizations that share resources and expertise to advance health care quality. Providing personalized care in more than 100 communities throughout Northern California, the Sutter Health network is a regional leader in cardiac care, cancer treatment, orthopedics, obstetrics, and newborn intensive care, and is a pioneer in advanced patient safety technology.

Technology a part of the equation – including a paperless medical record

As with all of SGMF’s projects, the surgery center is equipped with the latest health technology features.

EPIC, Sutter Gould’s electronic medical record system, allows Gould physicians San Joaquin General Hospital Residents and teaching staff enjoyed to access a patient’s an Appreciation BBQ Lunch this past month as a way to introduce medical record instantly them to the benefits of membership in both our local county society to review lab results, and the CMA. SJMS and CMA staff served the Residents and visited prior physician visits, with them while they completed their applications. and prescription histories. The computer resources at the physician’s fingertips also part of the Sutter Gould’s commitment include PACS, a filmless picture archiving to improve, replace or build care centers Employment Practices and communications system that allows in the Central Valley. In Modesto, for Lawsuits: Are You at Risk?

functional status of their patients from the start of rehabilitative care through discharge and follow-up.

Long regarded as the gold standard for measuring function, the FIM instrument is widely recognized by, and familiar to, most rehabilitative staff. This familiarity, coupled with minimal administrative burden, makes implementation easy, and providers can produce meaningful reports soon after.

SUMMER 2009

Nationally about 800 rehabilitation facilities are evaluated by this process. This LMH inpatient unit has been operational since 1990 and treats stroke, motor-vehicleaccident, brain-injury and spinalcord-injury patients along with neuro/muscular-disorder patients, like Guillian-Barre Syndrome and multiple sclerosis. Congratulations to the PRU staff and medical director Ramnik Clair, MD.

Open any newspaper or look on any news Web site and you’re bound to notice an article about another business being sued by an employee or former employee alleging discrimination or wrongful termination.

These stories always make headlines.

But are businesses truly being sued more often? Is your practice at risk? If it is, how much could you be forced to pay in such a situation?

When an employee brings a complaint against a business, or a suit involves misadventure by a key employee, the

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COMMUNITY > news

IN THE

filed with the U.S Equal Employment Opportunities Commission (EEOC) rose 26 percent from fiscal years 2006– 2008.4 And the total amount of money awarded in those complaints during that span nearly tripled, from $44.3 million to $102.2 million.5 Even if a case goes to EEOC mediation, the average period it takes for it to be settled is 84 days—almost four business months.6

NEWS trend is unmistakable: the businesses pays more.

The number of resolved lawsuits alleging breach of the Fair Labor Standards Act more than doubled in 2005 (the last year that statistics are available) to almost 3,600 compared with the 1,596 cases in 2000.1 A survey found that complaints from disgruntled employees in 2007 cost businesses an average $63,114, including judgments, settlements, fines and legal fees.2 The survey also reported that two out of three U.S. private companies experienced some type of event related to management liability within the past five years, costing an average $393,017. The number of incidents ballooned more than 25 percent from 2005.3 The survey results mirrored government statistics. The total number of charges

The question a responsible business owner should ask is: Am I covered for this increasing eventuality?

Workers’ compensation, general and professional liability insurance policies generally do not cover the vast majority of complaints filed against employers.

For this reason, Employment Practices Liability insurance (EPLI) has grown in popularity. “Generally, purchasing EPLI insurance is a wise investment,” write lawyers Robert Hoffer and Kelly Schoening in the Business Courier of Cincinnati, “but not all plans are created equal.”

Decision Medicine Alumni from 2008 were invited to attend the UC Merced Commencement Program featuring First Lady Michelle Obama as the key-note speaker. Nine students were selected from last year’s 24 participants and attended as VIP guests with seating in the front section.

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When considering EPLI insurance, they recommend asking the same questions as you would about any insurance: what is covered; what is the deductible; which attorneys can you engage; and how are claims settled.

The San Joaquin Medical Society offers its members EPLI insurance. This coverage also includes risk-management tools that can lower your risk, as well as access to a legal information hotline staffed by employment practices attorneys. And if you never had coverage before, ask about the simplified First Time Buyers program. You can contact a Marsh client service representative toll-free at 800-842-3761 today for more details and a no obligation premium indication.

The Dameron Hospital Foundation honored Dr. Joseph and Sylvia Spracher as the 2008 Heart of Gold recipients.

The dinner held at the Stockton Golf and Country Club honored the Spracher’s for their lifetime devotion to Dameron Hospital. Dr. Spracher’s affiliation with Dameron Hospital stretches back to the 1940s when as a playful boy growing up on nearby Oak Street the nurses would shoo him off the hospital lawn.

Dr. Joseph Gordon Spracher began his practice in Stockton. A native of Idaho, he graduated from Stockton High School. He received his bachelor’s degree from College of the Pacific and his doctor of medicine degree from Tulane University, New Orleans, Louisiana in 1964.

Sylvia Weezner was born at Dameron Hospital where her mother Hazel graduated from Nursing School. Sylvia joined the Dameron Auxiliary in 1970. She is the “flower lady” preparing fresh bouquets every week for the hospital lobby and creating centerpieces for the Auxiliary luncheons. Sylvia followed in her mother’s footsteps by receiving the coveted “Connie Connolly” award in 1990.

Dr. Spracher served as hospital

SUMMER 2009

COMMUNITY > news Chief of Staff (1992-1993) and continues to serve on physician committees. He served as team physician for Lincoln High School football for16 years. After leaving Lincoln, he joined the University of the Pacific as team physician for three years and was instrumental in the formation of the university’s sports medicine program. He has donated his time and skill to Su Salud and Kaiser Permanente’s Neighbors in Health.

Sylvia and Dr. Joe’s proudest accomplishments are their four Dameron born children, Kristen, Stacey, Suzanne, and Joe and seven grandchildren.

Stockton Lymphedema Clinic Opens

St. Joseph’s Promotes Literacy with Books From Birth

Books for Babes Program ensures each new baby born receives his first book

­­Most healthcare workers enter the field because they have an innate desire to serve humanity. Virtu Arora is one of these individuals. She has been a physical therapist for over ten years, working in various fields of therapy, including acute care, outpatient clinics, and nursing. She recently completed her doctorate degree in physical therapy, and was compelled to open her own clinic.

Recently opened by Virtu is Stockton Physical Therapy and Lymphedema Clinic. The clinic specializes in Lymphedema management, physical rehabilitation, and kinesiotaping. Lymphedema is a condition in which fluid abnormally accumulates in the tissues of the arms, legs, and other body parts. Stockton PT and Lymphedema clinic offers Complete Decongestive Therapy for Lymphedema.

They provide custom, individual care for each patient, including orthopedic, incontinent, and neurological patients.

“Stockton is fortunate to have many physicians and clinicians with good understanding of lymphedema and incontinence issues. But more awareness is needed”, Says Virtu. The clinic attempts to make treatment of the simple variety, one stop for all the patient’s needs. The clinic hopes to have a website up and running in the very near future.

The Stockton Physical Therapy and Lymphedema Clinic is located at 221 Tuxedo Ct, Suite B, in Stockton, just down the street from UOP. For more information on their customized care and therapy offerings, call (209) 464-0200.

SUMMER 2009

Reading to newborns is the basis for developing literacy in children, and enhances their reading abilities as they grow older. Babies associate books with the closeness they experience as their parents hold them.

They hear the sound of the words long before they know their meaning, but listening peaks an interest in language and they start to love books.

As a result of their teaching experience the members of Tau Chapter of Delta Kappa Gamma, an international society of educators, have developed a program called Books for Babes which provides "baby's first book" to each baby born at St. Joseph's Medical Center. Since October 2002, St. Joseph's Auxiliary volunteers have presented over 10,000 books to the newborns of St. Joseph's. The project has been supported by many generous donations as well as substantial grants from Rotary Club, Junior Aid, St. Joseph's SPIRIT Club, St. Joseph's Auxiliary, and the United Way. If you would like to contribute to Books for Babes or become a volunteer at St. Joseph’s, please contact the Volunteer Services Department at (209) 467-6527.

About St. Joseph’s Medical Center St. Joseph’s Medical Center is a not-for-profit, fully accredited, regional hospital with 294 beds, a physician staff of over 400, and more than 2,400 employees. St. Joseph's specializes in cardiovascular care, comprehensive cancer services, and women and children’s services including neonatal intensive care (NICU). St. Joseph’s Medical Center is the largest hospital, as well as the largest private employer in Stockton and San Joaquin County. In addition to being nationally recognized as a quality leader, St. Joseph’s is consistently chosen as the “most preferred hospital” by local consumers. Founded in 1899 by Fr. William O’Connor and administered by the Dominican Sisters of San Rafael, St. Joseph's continues to lead the region in medical innovation as well as ongoing clinical research, developing tomorrow's advancements, today.

In 2008, St. Joseph’s provided over $45 million in charity care, community benefits, and unreimbursed patient care. St. Joseph’s Medical Center is a member of Catholic Healthcare West (CHW), a system of 42 hospitals and medical centers in California, Arizona and Nevada. For more information, please visit our website at www.StJosephsCares.org.

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SUMMER 2009

Technology > the future

Cloud Computing and Healthcare Bad Weather or Sunny Forecast?

The fact that Google and Microsoft are heavily invested “in the cloud” extends to their new offerings for medical records services, such as Microsoft’s HealthVault and Google Health. While still in beta testing, these software giants have partnered with large healthcare providers for their programs: Microsoft with Kaiser Permanente and Google with The Cleveland Clinic.

SUMMER 2009

What Is Cloud Computing?

In current IT circles, the Internet is often referred to as The Cloud. Think of multiple computers in a giant mesh all inter-working together. Now think of many such meshes and step back … see The Cloud?

Although you may not physically see it, The Cloud is there for all sorts of signals: data, telephony, digital, etc. The term “Cloud Computing” denotes the use of cloud-, or Internet-, based computers for a variety of services. In its historically short life span, its usage is still evolving as we speak.

The expression “The Cloud” has its roots in telephony applications in the early 1990s.

In other words, telephone utilities were leveraging The Cloud for their switching and routing in order to deliver the proper connections for phone calls, faxes, live feeds, signals, etc.

The Internet in its infancy, right around that same time, leveraged those connections to allow users to “dial up” and reach their intended Internet forum or tech support area. We now fondly look back at those times and wonder how business was conducted at “dial-up” speeds.

By the turn of the millennium, the Internet was moving at much faster speeds — referred to as broadband — and all the computing equipment to make that happen was up “there” somewhere, and the term “in the cloud” became all the rage.

Then, around the middle of the decade, “Cloud Computing” was firmly in the lexicon as a way to define what the user was doing: accessing computing services in the cloud.

As definitions evolved and got refined, Cloud Computing now implies the user experience moving away from personal computers and into a “cloud” of computers.

Users of The Cloud are not concerned with the inner workings of the remote application and only “see” and “use” the services being requested, without control of the technology infrastructure to make it happen.

Keep that in mind when we traverse healthcare.

Who Uses Cloud Computing?

Almost everyone in this day and age with an electronic communications device uses one form or another of Cloud Computing — it is everywhere.

Whether you are banking online with your computer, viewing GPS-aware restaurant reviews on your mobile device, or sending live digital media through your webcam, you are using services in The Cloud, i.e., not installed or contained within your local device.

A case can be made that anytime you used dial-up in the early days of the Internet, you were leveraging The Cloud, but were you?

Your computer was local, your software application was local, your data was local, and you were viewing it on your CRT

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monitor locally. Back then, all you were using the Internet for was to transmit and

receive data that, once the transmission was complete, ended up locally.

In the early part of the decade, companies like Amazon began architecting their websites in such a way that you could utilize their services simply through the use of a browser like Netscape or Internet Explorer.

Soon after, other companies got into the fray, and, through the use of more robust technologies, “in the cloud” applications became more and more commonplace. By the middle of the decade, most major corporations with a large Web presence had working and mature renditions of their services completely “in the cloud.”

Fast forward to now when companies like Google and Microsoft offer “in the cloud” services that do not require hardly any additional software on your local computer, beyond the operating system of the computer or device and a browser.

Some services are offered for free by merely signing up, while others are offered as a recurring, monthly, per-seat subscription; schemes include Software-As-A-Service (SaaS) and Application Service Providers (ASP).

It is a trend and a pattern that is quickly gathering steam.

What Is Cloud Computing As It Applies to Healthcare?

The trend appears to be irreversible. Many software applications, services, and data once in the realm of a local computer or local server safely secure in your building are now in the domain of the public Internet. Private health information once confined to these local networks is migrating, wholesale, onto the Internet.

Patients voluntarily grant access to their health records every time they sign a waiver to the health insurer that then decides on the payment disposition to the doctor, pharmacy, or hospital. For the most part, the collection and organization of this data is completely legal.

It then follows that companies want to automate and accelerate access to these records in order to then offer “in the cloud” products and services to both patients, doctors, and institutions.

The fact that Google and Microsoft are heavily invested “in the cloud” extends to their new offerings for medical records services, such as Microsoft’s

HealthVault and Google Health. While still in beta testing, these software giants have partnered with large healthcare providers for their programs: Microsoft with Kaiser Permanente and Google with The Cleveland Clinic.

Microsoft and Google are two prominent examples of many other company offerings that are following the accelerating trend of placing previously local and private health records “in the cloud.” This coming explosion of information will be stored in massive data centers around the world and will provide access to healthcare records for patients, insurers, doctors, pharmacies, and institutions.

Interesting timing and fascinating convergence of events if you consider the new Obama administration initiatives like “Transforming Healthcare Through IT” and “Enabling Healthcare Reform Using Information Technology” — recommendations by the Healthcare Information and Management Systems Society (HIMSS) to the Obama administration and the 111th Congress.

How Will Cloud Computing Affect Your Practice?

In the coming months and years several factors are converging into a “perfect storm” of opportunity and challenges.

For most solo, small, and medium practices, Cloud Computing represents a juncture of significance. Do you invest up front and build your local computing infrastructure and keep your data local or do you amortize your investment over recurring monthly charges and keep everything “in the cloud,” including your data.

Either choice presents additional challenges: What about backups, disaster recovery and 99.999 percent uptime to the Internet? What about HIPAA compliance of

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medical society alliance > update! these services and applications offered both as local and “in the cloud”? What about hybrid applications that leverage both local infrastructure and the “cloud”?

Carefully analyzing the options and acting prudently could mean the difference between bad weather or sunny forecast when it comes to implementation time. By utilizing the SWOT analysis approach — strengths, weaknesses, opportunities, and threats — each practice could analyze the adoption of a unique computing infrastructure commensurate with their needs.

The convergence of the technologies associated with Cloud Computing and the pronouncements laid out by the newly passed American Recovery and Reinvestment Act of 2009 (ARRA) will propel practices of all sizes to carefully consider their approach to their selection of the right electronic medical record application.

According to the Certification Commission for Healthcare Information Technology (CCHIT), there are over 300 vendors that currently offer some variance of Electronic Medical Records — some “in the cloud,” some locally, and some in both.

They include: Electronic Health Records (EHRs) Electronic Medical Records (EMRs) Personal Health Records (PHRs) Payor-based Health Records (PBHRs) Electronic Prescribing (E-prescribing) Financial/Billing/Administrative System Computerized Practitioner Order Entry (CPOE) Systems The Bottom Line As part of your SWOT analysis, determine first which path your practice will take: local, “in the cloud,” or a hybrid of both. Then and only then procure your IT infrastructure to meet the software, hardware, and network requisites for that application, in that order.

Correctly implementing and utilizing information technology will offer your practice enormous benefits, local, cloud computing, or a hybrid of the two.

Your practice will have better access to healthcare services and information that would subsequently result in improved outcomes, fewer errors, and increased cost savings — a sunny forecast to be sure.

SUMMER 2009

Alliance Member of the Year:

Laurie Eager!

L

aurie Eager has been named the 2009 Medical Alliance Member of the Year. She has been active with the Medical Alliance for the past 17 years, serving on the Board in a variety of positions. Her dazzling smile, creative mind, enthusiasm, and resourcefulness has been a huge asset to the positions of fundraising, membership, hospitality, sharing card, nominating and of course, presidency. During her presidency it was her idea to have a “small, hands on project”. It became known as “Soap for Hope”. This simple project recycles travel soap and shampoo. They are collected and with a note of encouragement are delivered to local shelters.

Laurie’s talents, effort and generosity have touched many organizations throughout the Stockton area, including, Presentation Church, Junior Aide, and as co-director for the spring theatre at Claudia Landeen School. Her natural giving spirit extends to the many lives she has brought joy and hope to beyond the boundaries of any organizations.

Congratulations Laurie!

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cover story > Dr. Guey Mark

Dr. Guey Mark

2009 Lifetime Achievement Recipient

by William West l photos by Mike Steenburgh

Dr. Guey Mark, the San Joaquin Medical Society’s 2009 Lifetime Achievement Award winner, was born in 1928 in a village in the southern Chinese province of Guangdong.

Though it is now one of the most productive parts of China, at that time poverty was the rule in the fertile sub-tropical province. Most survived by subsistence farming.

“If you could get out of China, at that time, you went,” said Dr. Mark. “Ninety percent of the immigrants from China came from the four provinces near where I grew up.”

In the early 1930s, his father went to Canada and then to Chicago, eventually bringing Guey’s older brothers to South Bend, Indiana, where they opened a popular Cantonese

SUMMER 2009

restaurant. Canton is the former name of Guangdong Province. There were severe restrictions on immigration from China but Chinese already in the Western Hemisphere received legal exceptions. Hence the route through Canada.

His father, who had been a well-known Taoist priest in China, would return periodically from America to bring a son back to the West. During those years women weren’t allowed to immigrate.

In 1938, at age ten, Guey Mark boarded a ship with his father for the journey across the Pacific. He was seasick every day. >>

SAN JOAQUIN PHYSICIANS

33

assimilating into the english-based life of south Bend was a very new experience. ”i was ten years old and the biggest kid in the first grade,” dr. mark laughed. “But i didn’t experience any overt hostility to chinese. i then learned the language fairly well, skipped two grades and graduated high school when i was nineteen.” in the ninth grade, his class was assigned to write a paper about their career goals. He wrote that he wanted to become a physician as a way to help people. dr. mark followed through on the dream that he formulated in that middle-school paper. He went to University of michigan, University of notre dame, and received his m.d. from indiana University.

He returned to asia with the U.s. army medical corps in korea.

“This happened after the korean War,” dr. mark said. “But living there was still rough. i lived in a tent for many months.” after his military service he and his wife, clara, whom he married in 1953, visited a distant relative in stockton named Bing mark. Bing owned a restaurant on the corner of Weber and california. Guey and clara were looking for a place to start a practice and stockton was about the right size town. “it was just about the same size as south Bend,” dr. mark said. “There were plenty of delta waterways to fish and we were interested in that. also, you could get to the snow in a few hours but you didn’t have to live in it.” intrigued with the climate, he also learned that there was a large chinese community in stockton. at the time there were more than I was blindly groping along to create an office.

5000 chinese residents.

But I didn’t make any major mistakes. The medical “in south Bend there had been about four or community was cordial and friendly. There were no five chinese families, total,” said dr. mark.

He visited the administrators of st. Joseph’s cliques. The doctors used both hospitals.

Hospital and dameron Hospital. He felt - Dr. Mark comfortable with each of them and in 1958 opened an office in the 540 north california “i had motion sickness and don’t remember a single Building. He moved his office twice, comfortable day on board,” dr. mark said. “But i wasn’t eventually residing in the 2800 california street Building scared because i was with my father, even though i didn’t before he retired in 2008. know him very well.” “in 1958, i didn’t know anything about forming an office,” The departure was fortunate because during this period said dr. mark. “i was blindly groping along to create an Japan was attacking china. shipping lanes were becoming office. But i didn’t make any major mistakes. The medical more and more dangerous. community was cordial and friendly. There were no cliques.

“

”

The doctors used both hospitals.”

He and Clara raised three children; together built his practice when Clara stayed to manage the office after initially helping part-time; and became involved in the Chinese and greater Stockton communities. An unforeseen boon was Dr. Mark’s ability to speak Chinese. There were many that didn’t speak English in the large Chinese population and what had been a youthful barrier became an asset.

One of his notable associations was Dr. Dora Lee and her family, which included young Robin Wong, who grew up to become a physician and is the outgoing President of the S.J. Medical Society. Dora Lee was a well-respected Chinese community leader and physician, much beloved by many in Stockton.

“Robin Wong used to call me ‘Uncle Guey’,” Dr. Mark said.

Dr. Henry Wong, a Radiation Oncologist, thinks Dr. Mark is long overdue for the Lifetime Achievement Award.

“I am very happy for him and he deserves it very much,” Dr. Wong said. “He served his profession for more than 50 years. That is a great endurance record. He is very competent and was always working. Several years ago the local Chinese community voted him Citizen of the Year.”

Dr. Wong first met Dr. Mark in 1977 when he was recruited out of UCLA to come to St. Joseph’s.

SUMMER 2009

“Dr. Mark was very active in the S.J. Medical Society and was also Chief of Staff at St. Joseph’s. His wife, Clara, is a very great lady,” Dr. Wong said. “They have both done so much.”

Dr. Mark began his practice as a family practitioner, which in those days also meant delivering babies. He had to stop delivering because he wasn’t getting enough sleep to take care of his office practice during the day. His original plan was to practice for a few years, then go back to school for training in cosmetic surgery or orthopedics.

“But I got into the family practice, and it was pleasurable, and the dollar sign wasn’t all-important,” said Dr. Mark. “I enjoyed family practice and stuck with it. When I went to medical school I wasn’t looking for a big windfall. I didn’t really know much about the financial end. I just wanted to help people.”

Dr. Mark’s desire to help people spurred him to contribute to many community organizations, such as the Jene Wah multipurpose center, the Senior Service Agency and the Chinese Benevolent Association. He was named Chinese Citizen of the Year in 2002 by the Chinese Cultural Society of Stockton.

“Guey is one of the most generous contributors to anything we’ve ever done here in the Chinese community” said Gladys Ikeda, Vice-President of the Chinese Cultural

SAN JOAQUIN PHYSICIANS

35

Society. â&#x20AC;&#x153;He has contributed thousands of dollars to Jen Clara plan one big trip per year and he loves to play golf. His Wah. He had a large Chinese practice because he was one favorite golfer is Phil Mickelson, the big left-handed shortof the few Chinese speaking doctors in the early days. He game wizard. contributed the largest amount toward the construction of â&#x20AC;&#x201A; â&#x20AC;&#x153;I like him because I am left-handed,â&#x20AC;? Dr. Mark said. â&#x20AC;&#x153;The the gate at the Weber Point event center. He was Chairman problem with golf and age is that now the par-fours have of the Stockton Sports Commission, also.â&#x20AC;? become par-fives and sixes.â&#x20AC;? â&#x20AC;&#x201A; His ties to Indiana are still strong, including his son â&#x20AC;&#x201A; The lifestyle of the harried physician has definitely changed Nelson, who is an for the retired family economics professor practitioner. at Notre Dame. Dr. â&#x20AC;&#x201A; â&#x20AC;&#x153;I got rid of the alarm Guey is one of the most generous Mark and his wife clock,â&#x20AC;? said Dr. Mark. â&#x20AC;&#x153;I like contributors to anything weâ&#x20AC;&#x2122;ve ever done established the Mark to stay up late and wake up here in the Chinese community Brothers Lectureship when I want to.â&#x20AC;? at Indiana Universityâ&#x20AC;&#x2122;s â&#x20AC;&#x201A; When asked to reflect School of Medicine, on the economic state of to recognize nationally the American health care and internationally renowned medical scientists of Asian system, Dr. Mark humbly stated that he didnâ&#x20AC;&#x2122;t really wish to descent. The recipient presents two lectures and spends comment. two days on campus, during which one or two additional â&#x20AC;&#x153;I am not a deep thinker,â&#x20AC;? Dr. Mark said. â&#x20AC;&#x153;I am a plodder.â&#x20AC;? lectures to smaller groups are given. Guey wanted to honor â&#x20AC;&#x201A; â&#x20AC;&#x153;I would tell new physicians today not to be so money his older brothers through the endowment. hungry,â&#x20AC;? Dr. Mark said. â&#x20AC;&#x153;They have big debt from college.

After the long journey of his career, Dr. Mark says that he But if they help people it will work out. They will make doesnâ&#x20AC;&#x2122;t miss the practice, but he misses the people. He and plenty of money.â&#x20AC;?

â&#x20AC;&#x153;

- Gladys Ikeda

â&#x20AC;?

Please join us for the annual

Lifetime Achievement Dinner SAN JOAQUIN MEDICAL SOCIETY

Dr. Guey Mark honoring our 2009 Lifetime Award Recipent

Tuesday, June 23, 2009

Dinner $60.00 per person &RFNWDLO 5HFHSWLRQ DW SP Â&#x2021; 'LQQHU DW SP

Stockton Country Club

&RXQWU\ &OXE %RXOHYDUG Â&#x2021; 6WRFNWRQ &DOLIRUQLD Additionally, we will honor the passing of the gavel from President Robin Wong, MD to President-Elect Lawrence Frank, MD

5693 E\ -XQH WR WKH 0HGLFDO 6RFLHW\ 2IĂ&#x20AC;FH DW

36

SAN JOAQUIN PHYSICIAN

SUMMER 2009

Not a Member of San Joaquin Medical Society or CMA?

Why Not! Here are just a few of the Benefits youâ&#x20AC;&#x2122;re missing ...

Vast CMA Resources: Serving the counties of San Joaquin, Calaveras, Alpine, and Amador

Phone (209) 952-5299

r r r r r r r

Contract Analysis Reimbursement Hotline Legal Hotline Legislative Hotline HIPPA Compliance Seminars and Conferences Extensive Online Resources including over 200 letters, agreements, forms, etc. r Plus - Free Legal Advice with CMA ON-CALL Documents!

San Joaquin Medical Society Resources: r r r r r r r r r r

Annual Directory Member Seminars Cost Saving Benefits Quarterly Publication Classified Advertising Insurance Savings Alliance Membership Annual Social Events Patient Referrals Office Manager Forum and Practice Resources

Federal, State, and Local Advocacy: Your Dues are an Investment which Supports our Efforts in Protecting Your Rights.

If we Donâ&#x20AC;&#x2122;t Fight for You ... Who Will?

SUMMER 2009

SAN JOAQUIN PHYSICIAN

37

PUBlIc hEAlTh > swine flu

PUBlIc hEAlTh cORNER

NOvEL H1N1 INFLUENzA (SWINE FLU) UPDATE as of may 18, 2009 in san Joaquin county (sJc) nine cases of probable or confirmed novel H1n1 influenza (swine flu) have been reported. These cases have been scattered throughout the county and there have been no fatalities. since most people with influenza like illness are not tested, the true number of novel H1n1 infections is likely much larger.

Of note, in general there is an unusual amount of respiratory illness around for this time of year. in the first 3 weeks of the outbreak sJc Public Health services Laboratory received 437 specimens for patients with influenza-like-illness. about 10% (46) tested positive for influenza a. Of these, about 80% tested positive for seasonal influenza a, subtypes H3 or H1. Only 20% have been novel H1n1. statewide and nationally about half of the influenza tests are positive for novel H1n1. most people in the Us with novel H1n1 influenza have had mild or moderate illness, with more severe disease in those with underlying medical conditions. caution is needed though since it is still very early in this outbreak, and the average age of those with novel H1n1 is much younger (about 16 yrs. old) than is usual with seasonal influenza. also, influenza pandemics historically come in waves with the second wave being more severe.

The cdc is watching the virus closely to evaluate for mutations that may make it more virulent or resistant to antiviral drugs. also, the flu season is just beginning in the southern Hemisphere and will be watched carefully to get an idea of what may be in store for the northern Hemisphere in the fall. The public health community is planning for the possibility of increased number and severity of cases in the fall. This includes planning for mass vaccination clinics, patient surge in hospitals and outpatient settings, and distribution of antiviral medications from the strategic national stockpile. current recommendations for testing people with influenza-like-illness (fever > 100° F, plus cough or sore throat) are limited to those who are hospitalized, pregnant women or health care workers. The sJc Public Health Laboratory can be contacted for testing information (468-3460). if an outbreak is suspected please notify Public Health services immediately at 468-3822 (after hour call 468-6000). recent novel H1n1 influenza Health alerts can be viewed on the sJc Public Health services website at www.sjcphs.org. Other websites with information for health professionals include www.cdc.gov/l1n1flu/guidance, and www.cdph.ca.gov/ Healthinfo/discond/pages/swineinfluenza.aspx.

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SAN JOAQUIN PHYSICIAN

Job Opening: Assistant Health Officer at Public Health Services san Joaquin county Public Health services is recruiting for the position of assistant Health Officer. a physician with a background in Pediatrics or Family Practice is preferred. This is a management level position working with the director of the Family Health division and the manager of the children’s medical services program.

The work primarily involves providing medical consultation to the california children’s services program. time will also be spent providing medical consultation to other programs in the Family Health division. These include cHdP, maternal child and adolescent Health, child death review, Fetal infant mortality review, childhood Lead Poisoning, and Black infant Health.

For more information see the san Joaquin county Human resources website at: http://www.jobaps.com/sj. For questions about the position call debra sanders at 468-2283.

SUMMER 2009

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39

COMMUNITY service > off the charts

Physicians Wanted Helping neighbors in need

off the charts Dr. Barbara Rankin

Dr. Barbara Rankin has volunteered at St. Mary’s Interfaith Community Services’ Virgil Gianelli M.D. Medical Clinic for the past 20 years. The Medical Clinic provides care to uninsured clients who are chronically ill homeless and working poor residents, five days a week. All of the doctors and nurses volunteer their time, working half day shifts between one and four times a month. Medications and supplies are purchased; however, pharmaceutical sample meds are often used.

For Dr. Rankin treating these patients that otherwise would “go without,” is both intellectually and psychologically rewarding. It is these patients who are grateful for the kindness and respect they are shown in the Clinic. Dr. Rankin recalls, “…in my current office-based family practice, I rarely see the ”interesting cases” that present at St. Mary’s, the textbook cases of chronically ignored conditions, such as late-stage skin cancers, orthopedic deformities, end stage or previously undiagnosed cardiac, pulmonary, rheumatologic and psychiatric diseases.” Practicing medicine as stated by Dr. Rankin “continues to be the optimal marriage between intellectual stimulation and interpersonal gratification, engaging both my scientific curiosity and empathy for my fellow man.”

If you would like to volunteer your time, expertise, ideas and/or sample meds and supplies, please contact Edward Figueroa, CEO at 209.467.0703.

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SAN JOAQUIN PHYSICIAN

We are constantly reminded of the heavy toll the economic downturn is taking on people in Northern California’s Central Valley. With unemployment affecting nearly one of every five people here, the resulting lack of health care coverage for those affected has essentially eliminated their access to health services and preventive care.

That’s why the United Way in Stanislaus and San Joaquin counties, in cooperation with Kaiser Permanente, is presenting the 13th annual Neighbors in Health event on August 16, 2009.

Doctors, nurses and other volunteers are needed to staff this safety net event for uninsured and lowincome adults and children. Free health care services and screenings will be offered at Kaiser Permanente medical offices in Stockton and Modesto.

Free services will include immunizations as well as cholesterol, dermatology, diabetes, blood pressure, body fat, prostate, STD, dental and vision screenings.

Women will also be able to obtain mammograms and Pap smears. All services are provided confidentially and regardless of health insurance status.

Numerous agencies, organizations and private practice physicians participate in Neighbors in Health.

“Neighbors in Health was founded upon the idea of our community coming together to provide health care services to those in need,” said Michael Wong, MD, Assistant Physician-In-Chief for Quality at Kaiser. “Our providers have always been willing and eager to donate their time and talents for worthy community causes, and Neighbors in Health is one that’s near and dear to the Central Valley.”

Neighbors in Health has humble beginnings in 1987 as a local neighborhood response to health care needs. Dr. Wong helped establish the event in partnership with a local community health program, Su Salud.

“As the need for health care grows among the uninsured and underinsured in our communities, events like this become more and more vital,” he said.

FOR MORE INFORMATION Physicians who are interested in volunteering with Neighbors in Health can call the Kaiser Permanente Health & Wellness Department at (209) 476-5145 for more information.

SUMMER 2009

Introducing the

Ambassador Preview Membership An exclusive opportunity from Brookside Country Club

Preview Brookside Country Club for 1 year with no initiation Full Golf Equity Full access to all golf, tennis, dining and social amenities Full Golf Non-Resident Full access to all golf, tennis, dining and social amenities Reserved for members who live outside San Joaquin County.

Sport Social Weekday access to all golf amenities, full access to all tennis, dining and social amenities Junior Sport Social Full access to all golf, tennis, dining and social amenities Reseved for members under the age of 40.

Social Annual golf amenities allowance, full access to all tennis, dining and social amenities Contact Us Today!

(209) 956.6200 www.brooksidegolf.net SUMMER 2009

SAN JOAQUIN PHYSICIAN

41

COMMUNITY > partners

HEALTH PLAN OF SAN JOAQUIN

HONORS LOCAL HEALTH CAREERS SCHOLARSHIP AWARDEES Health Plan of San Joaquin honors graduating high school seniors who received academic scholarships from the Health Careers Scholarship Program. Twenty local high school students from San Joaquin County were awarded scholarships for $2,500 and $1,000 for a total of $35,000 in awards.

Health Plan of San Joaquin’s Health Careers Scholarship Program was established to provide scholarships to students based upon their interest in pursing a career in the healthcare industry. The 2009 cycle is the first academic year that the scholarships were awarded, and over 40 applications were received. ”San Joaquin County, and the Central Valley as a whole, is particularly challenged by physician shortages both in primary care and in key specialty areas. HPSJ’s academic scholarships are a proactive strategy to encourage and support a new generation of medical professionals,” said Dale Bishop, M.D., Medical Director for Health Plan of San Joaquin. The goal is to create a channel that can bring future healthcare providers back to practice in San Joaquin County.

The scholarships will be used to assist students who have shown promise and interest in pursuing higher education in the healthcare industry.

Health Careers Scholarship 2, 2 The students who received scholarships in 2009 are: Neda Dastgheyb, Merrill F. West High School, Tracy Deanna Dawson, Weston Ranch High School, Stockton

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SAN JOAQUIN PHYSICIAN

$2,500 $2,500

Valleri Gammon, Manteca High School, Manteca Gurwinder Kaur, Manteca High School, Manteca Amanpreet Arora, Middle College High School, Stockton Zakir Safdar, Ronald McNair High School, Stockton Maria Yepez, Lodi High School, Lodi Kamiko Agari, St. Mary’s High School, Stockton Diana Furukawa, St. Mary’s High School, Stockton Hansel Poerwanto, St. Mary’s High School, Stockton Cynthia Cienfuegos, Edison High School, Stockton Miguel Serrato, Edison High School, Stockton Jordan Lippincott, Escalon High School, Escalon Danielle Rivera, Merrill F. West High School, Stockton Chelsea Cochran, East Union School, Manteca Jeannine Halleck, Sierra High School, Manteca Mayra Padilla, East Union High School, Manteca Allen Chang, Tokay High School, Lodi Karina Luzada, Ronald McNair High School, Stockton Jordan Guidice, St. Mary’s High School, Stockton

$2,500 $2,500 $2,500 $2,500 $2,500 $2,500 $2,500 $2,500 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000

Many of the students who received the scholarships are first generation college students. In addition, the majority of the students will be attending colleges throughout California including; UOP, Cal Berkley, UCLA, Cal State Stanislaus and UC Santa Cruz to name a few. Because many the students come from local families and plan to study at California-based colleges and university, HPSJ leadership is hopeful that students will be more likely to return to San Joaquin County upon graduation.

DeAnna Dawson, a Weston Ranch High School senior who received a $2,500 award, states “I have always loved working

SUMMER 2009

with children. When I was nine years old, a pediatrician spoke to my class and from that day on, I began looking more at being a pediatrician as a career, and now everything has fallen into place.”

Ms. Dawson will be studying at the University of California Santa Cruz as a Pre-Med Health Sciences student.

The scholarship Dawson received from HPSJ will support books and study materials, and will complement additional academic scholarships that will assist with her tuition.

Health Plan of San Joaquin established an outreach campaign in conjunction with the San Joaquin County Office of Education to notify the high schools and their counselors.

A panel of medical professionals and administrators who work throughout the community reviewed the applications.

The scholarships were competitive and based upon academics, test scores and personal written statements. Additionally, many families showed a financial need especially with the slumping economy.

The Health Careers Scholarship Program serves as an additional community-based strategy to develop future healthcare leaders in the region and will assist potential students attending an accredited junior/ community college or four-year College or university.

To learn more about the Health Careers Scholarship Program, contact Shani Adams, Community and Legislative Affairs Manager at (209) 461-2284 or sadams@hpsj.com.

SUMMER 2009

A PROGRAM OF THE SAN JOAQUIN MEDICAL SOCIETY

DOCTOR - We Need Your Involvement!

Decision Medicine impacts the lives of 24 students each summer and it could never happen without the support of our member Physicians.

Join with your peers and mentor one of our students for one morning in your practice. Let them see first-hand what practicing medicine is all about from your perspective and then join them for a one-hour complimentary lunch at Valley Brew.

You may just enjoy it as much as they will!

Call the medical society office now to be added to the list.

SAN JOAQUIN PHYSICIAN

43

Hospital > technology

STEREOTACTIC RADIOSURGERY / RADIOTHERAPY COMES TO ST. JOSEPH’S MEDICAL CENTER A new Varian Trilogy linear accelerator recently installed at St. Joseph’s Regional Cancer Center brings Stereotactic Radiosurgery (SRS) and Stereotactic Radiotherapy (SRT) capability to San Joaquin County for the first time. Previously patients who needed such technology had to be sent out of the area to tertiary care facilities for intracranial or extra cranial treatments.

by Moris Senegor M.D., Surgery, Neurological Henry Y. Wong, M.D., Oncology, Radiation

The Trilogy treatments are noninvasive radiotherapy procedures. They are either a single session, singlefraction, high dose to a very small volume of tissues, called stereotactic radiosurgery (SRS); or fractionated to 2-5 or more sessions, at lower dose each session, to extend treatments to larger volumes, which is called Stereotactic Radiotherapy (SRT). SRT has greater applicability to include disease sites in many different parts of the body.

Stereotactic Radiosurgery (SRS) is a technique that delivers highly focused, high dose radiation to a specific target usually within the brain, with the aim of obliterating specific pathology within the target.

The Leksell Gamma Knife is another variation on this theme, but is limited to intracranial lesions. Unlike the Gamma Knife, the Trilogy Stereotactic system can also be used for properly selected extra cranial cases.

The goal of treatment is to non-invasively remove susceptible pathology from the brain (or other internal cavity) without resorting to open surgery.

This is especially useful in surgically inaccessible areas such as the skull base or brainstem, and offers another option for patients who refuse open surgery for personal or medical reasons.

A diverse group of pathology cancer can be treated using Stereotactic Radiosurgery. The technique was initially developed in Scandinavia for treatment of Arteriovenous Malformations of the brain, and this remains one of the main indications for the procedure. The most common treatment however is that of metastatic brain tumors. Other tumors now commonly treated include acoustic neuromas and skull base meningiomas. The technique has

44

SAN JOAQUIN PHYSICIANS PHYSICIAN

SUMMER 2009

recently become popular for non-ablative treatment of trigeminal neuralgia. While Microvascular Decompression â&#x20AC;&#x201C; open surgery â&#x20AC;&#x201C; remains superior in its results, most trigeminal neuralgia patients are elderly and infirm and therefore poor candidates for invasive procedures. Thus, stereotactic radiosurgery has supplanted more traditional invasive treatments. â&#x20AC;&#x201A; The procedure involves highaccuracy image fusion with high-resolution imaging of CT and other image modalities (MRI study being the most common one) that demonstrate patient anatomy in a sophisticated specialized treatment planning software. Reference frames have to be used to keep the data consistent.

These are either traditional stereotactic frames applied to the head, or mouth-based frames that patients wear using a bite-block.

Treating physicians, usually a team of neurosurgeons, radiation oncologists, and radiologists, then perform a complicated process of target selection fed into the computer. Generally a specific area of treatment has to be carefully outlined since everything within this area is subject to obliteration by the high dose of radiation delivered, as though it were surgically removed.

Once completed, the computer then will generate a customized plan that delivers the radiation to the patient using the optimal technique.

SUMMER 2009

The treatments are either a single session, single-fraction, or fractionated to 2-5 sessions. â&#x20AC;&#x201A;Stereotactic Radiotherapy (SRT) can give higher doses in fewer sessions than conventional radiotherapy and can benefit properly selected patients. It has been used to cure medically inoperable Stage I lung cancers, spinal cord tumors, or cancers

that come close to critical structures. It has benefited inoperable hepatocellular carcinoma, metastases to the liver or to the lung. It can be used in conjunction with chemotherapy or as a â&#x20AC;&#x153;boostâ&#x20AC;? (i.e., higher dose) to conventional radiotherapy. There are exciting SRT studies conducted all over the world for cancer in the kidney, prostate, and pancreas, to name a few. It brings new hope to patients for disease processes where traditional therapy has been less effective. â&#x20AC;&#x201A; The advent of Stereotactic Radiosurgery/ Radiotherapy within our county represents an important milestone in our history of medicine. It brings our area in line with advanced 21st century technology, and provides convenience for patients who no longer have to travel long distances to receive such treatment.

Note to physicians: To learn more about the Trilogy or arrange for a private demonstration, please contact St. Josephâ&#x20AC;&#x2122;s Cancer Center at (209) 467-6560.

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medical society > update

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Passing the presidential baton by william west

Messages from the Presidents Passing the presidential baton from Robin Wong to Lawrence Frank provides an apt moment to reflect on past accomplishments and outline new goals. Following are the thoughts of the outgoing and incoming society presidents, offered to you in a question and answer format.

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Dr. Robin Wong 2008-2009 San Joaquin Medical Society President What is the greatest challenge facing San Joaquin Physicians today and what can the medical society do to help with it?

Implementing HIT into the practices of members is the greatest challenge facing the San Joaquin Physician today. Establishing the appropriate electronic health record system and health information exchange will have significant costs not only up front but also for ongoing support. Also, the use of these new systems will most likely slow the practice down, especially during the initial stages of learning. I believe the Medical Society along with the CMA can do a lot to help physician members by keeping up-to-date with what will be required and provide sound advice on the most cost effective, the most adaptable, and the most userfriendly systems on the market for physician practices.

Solo physicians are having difficulty making it in the central valley – do you see any positive change coming?

The solo primary care physician practice is most certainly on the decline throughout the state, not only in the Central Valley. However, solo practice is thriving and is successful in many locations. I am hopeful that positive change in the reimbursement for the primary care physician will soon come as I feel principal members of Congress are aware of the plight of primary care throughout this nation. They are willing to pay for quality care and not quantity of care. Attracting new primary care physicians to the Stockton area is not that difficult. The real challenge is retention of physicians, as after a few years they seem to move on to other positions and sites.

What excites you about the future of the San Joaquin Medical Society?

What excites me as a Medical Society leader is a growing active membership that includes many of the new young physicians practicing in our area. Their involvement in Decision Medicine and participation in Medical Society committees is crucial to our mission and to our professional identity as leaders in the healthcare field. I am very excited to have two young energetic physicians serving on the Board of Directors.

What is the best thing you have learned from serving as president this past year?

The single best fact that I have learned from serving as this year’s Medical Society president is that physicians of the Medical Society have before them a unique opportunity to influence health reform in this area under President Obama’s American Recovery and Reinvestment Act which calls for some form of health care reform this year.

If you could spend one minute with every physician practicing in the San Joaquin County area, what would you say?

I would tell every practicing physician to remain positive during this stressful, burdensome and difficult time for the practice of medicine. I would strongly encourage each physician to keep up to date as our nation’s healthcare system is reformed locally, state-wide, and nationally. I would encourage the physician to be vocal and speak out for what is right for medicine and for the patients we serve whether they are insured or not insured.

Are you satisfied with the medical society’s stepped up membership growth and retention efforts?

Yes, I am pleased with the membership gains that have been achieved. Michael Steenburgh and his staff have been very instrumental in increasing the Medical Society’s membership.

Nevertheless, we need to continue to recruit new physicians and retain those who are current members. As we all know there is strength in numbers.

Following the sale of the medical society’s phone exchange service last year, what is the society’s financial status?

The Medical Society has certainly cleaned up its financial morass under the leadership of its immediate part president Dr. Jamshidi.

The budget for the society is being met and closely monitored by the Board of Directors. The sale of the physician exchange service has relieved the Medical Society of a significant financial burden. The financial status of the Medical Society is now clear and unencumbered.

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Dr. Lawrence R. Frank 2009-2010 San Joaquin Medical Society President How are conditions at San Joaquin General Hospital?

San Joaquin General Hospital is managing; as all public and many private hospitals, SJGH is faced with increasing challenges due to the current economic situation. San Joaquin County’s unemployment rate of 16.4% is at the highest it’s been for several years. Those who lose their jobs, lose their medical insurance.

When faced with financial distress, many will defer medical expenses such as medications and follow-up physician visits until their condition becomes extreme. At that point, many will turn to SJGH, the provider of last resort, very ill and in need of costly medical care.

SUMMER 2009

Our Medical Assistance Program (MAP) does offer some help for unfunded patients to get out-patient care while we assist them in applying for other third-party assistance. There is increasing concern regarding cuts in medical funding (Medi-Cal, Children’s Health care) for the medically indigent. To what extent, if any, impending Federal funding will help is not yet clear.

San Joaquin General Hospital is fortunate to have strong support from the County Board of Supervisors. Two attend the hospital’s monthly Medical Executive Committee meetings where they are apprised of our continuing operational challenges. They continue to support/have extended the contract with The Camden Group, currently charged with hospital management.

between area hospitals to see which could convince the greatest percentage of its employees to join the American Cancer Society’s Great American Smoke Out by pledging not to smoke for one day - the third Thursday of November.

San Joaquin County has one of the lowest percentages of attracting new physicians to establish their practice here — what can we do to change that?

Attracting new physicians to underserved areas is an ongoing struggle, not only in Stockton. Some regions offer varying degrees of loan forgiveness to attract young physicians, many of whom leave their training programs burdened with loans for hundreds Many San Joaquin Medical Society members are aware of thousands of dollars. In the current contracting economy, this of SJGH’s trials and realize that loss of the hospital would may prove difficult but definitely worth exploring. The Medical overburden the private sector in Society should help potential caring for the medically under new physicians to apply for the “I hope to increase the San Joaquin Medical insured/uninsured.

CMA’s Steven M. Thompson Loan Society’s profile with our community to Repayment Program. improve the overall health of our citizens, for As the incoming President, whom rates of obesity, diabetes, hypertension, have you set goals for the San Many young physicians remain and smoking are unacceptably high. San Joaquin in the area where they trained. A Joaquin Medical Society?

Medical Society’s promotion of healthier life significant number of our physicians styles may elevate the standing of physician The solo and small-group trained at San Joaquin General members in the eyes of San Joaquin County.” practitioners, particularly in Hospital and remained to provide primary care, are being squeezed exemplary medical care to our on the one hand by unfunded mandates that increase the cost (to citizens. The SJMS has worked actively with the San Joaquin the practitioner) of providing care and on the other hand by static County Health Care Services and others to encourage the new or diminishing reimbursement for services rendered. I will bring University of California, Merced, Medical School to send its these issues to the CMA which, unfortunately, some feel has lost medical students to SJGH for their clinical rotations; many touch with practitioners “on the ground.” medical students from other medical schools who have rotated The current buzz words are “Health care reform,” a nebulous through our training programs successfully applied for residency term; details are sketchy but goals are clear. Whether a staff positions here. Of these, a number have gone on to practice in physician at a public hospital or a private practitioner, most our county. physicians are stymied by a byzantine “system” of health care that does not always result in the best outcome for our patients and As a Delegate to the CMA’s House of Delegates from yet is extremely expensive. Terms such as “universal health care” San Joaquin County, what bills or resolutions do you see and “single payor” are bandied about interchangeably causing coming along? confusion and consternation. As representative of our county’s physicians, the Medical Society will make every effort to see that The CMA currently has a number of legislative issues on its front our concerns and issues are seriously considered and addressed burner. Among these are protecting patients from Health Plans as the state and the nation move forward changing the way health and Insurance companies unlawfully terminating their contract care is provided to our patients. for provision of health care (AB 2), further improving Peer Review in California to assure patients continue to receive the I hope to increase the San Joaquin Medical Society’s profile with highest quality of health care (AB 21), Adequate Reimbursement our community to improve the overall health of our citizens, for for Vaccines (AB 1201), and improving and streamlining the whom rates of obesity, diabetes, hypertension, and smoking are Medi-Cal Treatment Authorization Request process (AB 613). unacceptably high. San Joaquin Medical Society’s promotion of healthier life styles may elevate the standing of physician The 2009 House of Delegates list of resolutions has not yet been members in the eyes of San Joaquin County. sent to Delegates. Any CMA member can submit a resolution for consideration; Mike Steenburgh, the society’s Executive By way of example, the SJMC could promote a contest Director, can help with this process.

SUMMER 2009

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guest opinion > prescribing practices

A Bitter Pill

By Cheryl England with Additional Research by Chris Womakc

How health plans hinder physicians’ drug prescribing preferences—and harm patients Plus, you’ll receive a FREE tablet splitter just for participating in the Half Tablet Program.”

Substitute “set of FREE ginsu knives” for “tablet splitter” and you have a marketing line straight out of the cheesiest come-on ever. Not exactly what you’d expect from a company with revenues last year of $61 billion, much less when that company has a heavy say in patient healthcare. After all, we’re talking healthcare here, not timeshare programs or egg slicers.

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Yet, that was just the line that Anthem Blue Cross used in a letter to patients encouraging them to ask their doctors to prescribe higher-strength tablets that they would then cut in half to reach their prescribed daily dose—and thus save “up to $360 per year on out-of-pocket costs.” Well, unless, as the footnote says “Personal savings may vary.”

In little and big ways, health insurers, pharmacy benefit managers and health maintenance organizations use their “power of the purse” to interfere in the doctor-patient relationship. It can take any number of forms: there is the practice of substitution, in which a health plan stops covering a patient’s current medication in favor of others, whether generic or therapeutic; there are ever-changing formularies and fail-first policies, where a patient must take one or more drugs that don’t help before insurance will pay for higher-end therapy; there are prior authorization requirements, under which doctors must first get an insurer’s permission before it will cover a particular drug for a patient; there are attempts to incent physicians financially; and there are attempts to get the patient to ask their doctor for certain drugs beneficial to the insurers’ bottom line.

Certainly, this list is incomplete, but it does comprise the main issues that physicians battle with every day on behalf of their patients. In addition, the individual actions are less important than their common thread—these measures get in the way of important therapy for some patients. While insurers and HMOs point out that as the ultimate payers, they have a stake in the cost of treatments, and a responsibility to seek cost-effective care for their patients, it’s clear that they sometimes go too far. How often they overstep the line is a matter of debate, and it’s not something that’s easy to define with statistics. But it’s becoming more and more clear that red tape and the insurers’ drive to be ever-more profitable is hurting more and more

SUMMER 2009

patients, especially the most vulnerable patients—those with serious illnesses and low-income Medi-Cal beneficiaries.

By the Numbers

It’s a daunting task to figure out how much health plans interfere with drug prescribing, but doctors treating diseases such as multiple sclerosis can provide a glimpse into what’s going on throughout the system. Drug insurers structure their coverage to provide cost-effective treatment for broadest cross-section of patients, but it’s when a patient deviates from the average that drug insurers most often seem to interfere. Formularies requiring patients to try cheap drug X before expensive drug Y don’t take into account individual drug responses, comorbidities, or rare or difficult-to-treat diseases, such as MS. The glimpse MS provides is bracing.

Nearly two-thirds of neurologists and MS specialists reported that insurance barriers interfere with their ability to diagnose and treat MS patients, according to a 2007 study by the National Multiple Sclerosis Society and the drug company Teva Neuroscience.

About 70 percent of these doctors said insurers try to restrict the use of infused disease-modifying drugs at least some of the time, with only 10 percent saying it never happens. Compare that to what happens with less expensive infused corticosteroids: 24 percent of the doctors said insurers sometimes interfere, and 37 percent said they never do.

Among MS patients taking an immunomodulatory drug, 22 percent said they’d had trouble with insurance plan reimbursement. Of patients reporting such difficulties, more than one-third reported high co-payments or deductibles, nearly one-quarter said prior authorization had been a problem, while 8 percent said they’d been denied drug coverage. Thirty percent of patients reported one of several other difficulties.

The Rules

As long as these conditions have been met, plans can’t limit or deny coverage for a drug because a doctor plans to use it for an off-label indication: the drug is FDA-approved for another indication; the drug is being prescribed by a contracting physician for treating a life-threatening condition or a chronic and seriously debilitating condition; the drug is recognized as treatment for this indication by the American Medical Association Drug Evaluations, the American Hospital Formulary Service Drug Information, the U.S. Pharmacopoeia Dispensing Information, or two articles in a major peerreviewed journal showing data on the offlabel use as safe and effective. See Health and Safety Code section 1367.21.

Plans must have an expeditious process for physicians to get non-formulary, medically necessary drugs authorized, except as otherwise provided by law or where the state Department of Managed Health Care has approved an exclusion of the drug from the benefit plan. See Health and Safety Code sections 1363 and 1367.24.

Plans cannot limit or exclude coverage for a drug meeting four conditions: The drug was previously covered; the contracted physician continues to prescribe the drug; the prescription is for an FDA-approved use; and the drug is considered safe and effective for treating the enrollee. Generic substitutions are allowed. See Health and Safety Code section 1367.22.

Each plan must provide to physicians a written description of their expedited process for authorization of non-formulary drugs, as well as timelines. See Health and Safety Code sections 1363 and 1367.24.

Plans that will not authorize or pay for a drug that is more appropriate than a formulary medication may be exposed to malpractice liability. Physicians encountering this situation should appeal the coverage decision in writing and involve a plan official familiar with medical issues. See CMA On-Call document 104.

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guest opinion > prescribing practices The Dangers of Substitution

The simple fact is that sometimes formularies and other insurer barriers to specific medications do harm patient care. James Roach, MD, practices urology in Imperial County, and for this 78-year-old, being second-guessed by insurers is nothing new, except that those questions now often come from companies administering Medicare’s drug coverage program, Part D. “If I want to give a patient testosterone, I get the same answer every time—‘Erectile Dysfunction is not covered’,” he explains while rustling through his desk. “I have to write a long letter telling them the reason you give testosterone to an older man, if he has a low level, is that it’s good for his mental health.” In fact, he says three or four of his patients no longer use county mental health services as a result of the treatment. In addition to depression, low levels of the hormone cause weak muscles and can lead to osteoporosis and prostate cancer, he continues.

Probably the biggest area of concern for physicians and patients, however, is drug substitution, either generic and therapeutic.

Generic substitutions—at least until recently—have been generally considered less harmful than therapeutic since the U.S. Food and Drug Administration requires that a generic drug have the same amount of the active ingredient as the name brand drug.

Yet, the FDA allows a generic drug to differ from a brand-name drug by up to 20 percent of its composition; these differences can include the way the drug is released into a patient’s system or the addition of flavors and preservatives. Sometimes these differences can affect how a patient reacts to the drug.

Nick LaRocca, vice president of MS Society healthcare delivery and policy, states the problems bluntly: “Are there excesses on the part of insurers? Are there arbitrary decisions? Are there decisions that are being made by people who don’t have medical training? Are there instances where the choice of a preferred drug is contingent more on economic considerations than scientific considerations? Yes to all of those.”

He has a more nuanced explanation of why these things happen.

“Depending on who you are, you’re going to look at this a bit differently—from the standpoint of insurance companies, these MS drugs are expensive,” he points out. In fact, medications of all kinds are getting more expensive to research and develop, a trend driven partly by a move toward biologics, such as lab-grown protein therapeutics. Drugs for MS and other immunologic disorders are among the phenomenon’s leaders. At the same time, the predominance of employer-based insurance gives serious heft to employers’ pressure for cheaper rates. “The insurers are worried about this, and this is the reason why they throwing up all these barriers, and there are more barriers to come,” such as an initial moratorium on new drugs of perhaps six months, he says.

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One study on “Effects of Generic-Only Drug Coverage in a Medicare HMO” by J. Christian-Herman, M. Emons, and D. George, found that requiring patients to take generic drugs has been associated with, among other things, increased overall hospital admissions and a negative impact for quality metrics for certain conditions. Another 2007 study published in the British Journal of Cardiology reported that patients who switched from Lipitor to the generic simvastatin showed a 30-percent increase in risk for major cardiac events or deaths from all causes among patients who switched from Lipitor to the generic simvastatin.

Fortunately, in California, pharmacies can generally only switch a patient to a generic drug if the physician has not indicated that the prescription be filled as written. Even then, the patient must be informed that the switch is being made according to the state’s Health & Safety Code Section 1348.6.

Therapeutic substitutions—in which less expensive drugs that are not chemically equivalent are suddenly covered instead of current therapies—are definitely cause for alarm. Dr. Roach, the Imperial County urologist, consistently finds that prescribing the prostateshrinking drug Avodart causes therapeutic substitution problems with insurers. “There are all kinds of studies on the tremendous savings in money, mortality and morbidity by not having to do prostate operations,” but some companies will suddenly stop

SUMMER 2009

covering the drug, he says. Others will switch their coverage to Finasteride, a drug from the 1950s, which he calls “similar, but not as good.” Instead of Flomax or Uroxatral, insurer formularies favor cheaper drugs Hytrin or Cardura, which were originally high blood pressure drugs. That’s a big problem if your patients are elderly. “Very often you’ll put men on these and they’ll get very dizzy and fall down—I know of a case where a man fractured a hip,” he says. “These drugs are not safe.”

as drug formularies can be a rat’s nest of traps. First, just because a drug is on an insurance companies’ formulary, it doesn’t mean that the company will necessarily pay for it. Certain drugs require prior authorization before they can be prescribed—and sometimes authorizations can take months, even if it ends in a denial. Worse, insurers can remove drugs from the list for no particular rhyme or reason and they can change policies on how they pay—or do not pay—for the drugs.

With therapeutic substitutions, it’s not the pharmacy at Take the case of patient we’ll call “Mary.” Mary is a 74-year-old fault—most states do not allow pharmacies to make this sort widow with multiple conditions including hypertension, sleep of substitution. The power here lies with insurance plans and apnea, spinal stenosis, Felty Syndrome and more. Her secondary pharmacy benefit managers or PBMs, who buy and sell drugs insurance is a Blue Cross-Blue Shield plan issued through the in bulk to eventually distribute them to patients at the other end of the chain. The way internal medicine specialist Uberto Muzzarelli sees it, the policies degrade SINCE 1954, WHEN YOU the kind of care he can provide. “Basically, HAVE NEEDED US . . . you’re going backward, in terms of treating WE HAVE BEEN HERE. patients with 1990s or 1980s medications, and it’s not often in the best interest of THE ATTORNEYS OF the patient,” he says. What’s more, in his THE MCNAMARA LAW FIRM specialty, the system leaves an opening for ARE PROUD TO SERVE less thorough physicians to make mistakes MEMBERS OF THE or cause harm through laziness. “There are MEDICAL COMMUNITY many patients who you can change from IN ALL AREAS OF: an ARB to an ACE inhibitor if you do it THE MCNAMARA right—you have to counsel the patient about potential risks and you have to reLAW FIRM • BUSINESS check them,” he says.

Oxnard urologist Max Stearns, MD, finds insurer therapeutic substitution specially counterproductive when he’s trying to get specific antibiotics for a patient. Some insurers’ faxes and other communications objecting to a drug are well-meaning, by pointing out a particular drug’s possible interactions with other compounds, for example. “But sometimes what we’re giving the patient, we understand, is just the only medicine that works in this particular patient’s situation, and we have to go round and round with the companies for a while before the patients can actually get that medication approved,” he says. “Sometimes it’s resolved when the insurance company just refuses to pay for it, period.”

Mary and the Formulary

Drug substitutions aren’t the only onerous practice that insurers and PBMs use to lower their costs for medicines. Even something as seemingly straightforward

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guest opinion > prescribing practices government that she receives as a benefit after the death of her husband. Mary was doing fine and living a healthy life as long as she received her medications.

Then the worst occurred. Mary received a letter from Medco, a PBM, stating that as of January 1, her medication plan had changed. The company had eliminated formularies altogether— instead every brand name drug would cost $65 per prescription for the first 30 prescriptions and free thereafter. The first four generics were free and $10 per prescription thereafter. Mary, who lives at the poverty level and who takes seven brand-name drugs—many of which have no generic equivalent—and six generics, simply could not afford the nearly $500 that a 3-month supply of her medications would cost. So, embarrassed about her lack of money, she simply stopped taking her medications.

In mid-February, Mary was admitted to the hospital in critical condition. She was immediately put back on her medications and released 24 hours later. Mary’s physician, Marcy Zwelling, MD, asked Medco to fax her the new rules. Medco refused. “Some patients can choose to move to a different health plan, but she can’t,” says Zwelling. “This plan pays for her medications. It’s a single-payer take it or die system—or how about take it and die?”

And Mary’s not alone. Because of cost concerns resulting from insurance company out-of-pocket requirements, working age adults are increasingly unable to access medically necessary prescriptions for their chronic medical conditions, according to a study from the Center for Studying Health System Change.

African Americans were found to be twice as likely to have problems affording their drugs.

On the subject of formularies many insurers impose fail-first or step-therapy polices. Under these practices, patients must try certain less-expensive drugs before they will cover the doctor-recommended drug. And even if you have gone through step-therapy previously, changing insurers often means having to repeat the process. Sometimes your physician can get an exception to the rules, but sometimes not.

Whether an insurer covers the physician-recommended therapy is often left to a medical reviewer in the employ of the insurer— one that has no personal knowledge of the patient’s particular case. One patient received a letter from BlueCross of California denying his physician’s requested coverage worded thusly: “Our Peer Clinical Reviewer, HARRY WEISMAN, MD, has determined: Based on the information provided, the request for the Non-preferred sedative hypnotic (sleeping medication) Rozerem cannot be authorized because there is no documentation that the short acting from of Ambien, Ambien IR, and the hypnotic medication, Lunesta, have not been tried in the past 180 days, or that patient has a history of substance abuse. As a result, it is not covered by your health benefit plan.”

The letter goes on to explain how a committee of physicians and pharmacists has determined “which medications are sound, therapeutic and cost-effective choices” and that “medical studies demonstrate that all of the medications were equally effective in their ability to induce or sustain sleep.” The company makes darn sure the patient understands that an MD made this recommendation—note the doctor’s name in all capital letters—and stresses the fact that a committee of physicians

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SUMMER 2009

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guest opinion > prescribing practices and pharmacists armed with medical studies helped make this determination. How can a patient not be expected to question his or her doctor?

More recently, a new bit of jargon has entered the medical professionâ&#x20AC;&#x2122;s vocabularyâ&#x20AC;&#x201D;forced off-label prescribing. In certain

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cases, health plans require that physicians prescribe drugs that are FDA approved, but not for the condition that the patient has.

As an example, with the difficult-to-treat condition fibromyalgia, insurers contracting with Medicare Part D required patients to fail off-label therapy on gabapentin before beginning on-label treatment with more-expensive Lyrica. Both drugs are approved by the FDA, but only Lyrica is approved for treating fibromyalgia.

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Butâ&#x20AC;&#x201D;and hereâ&#x20AC;&#x2122;s the catchâ&#x20AC;&#x201D;there are also times when health plans will not approve drugs for the conditions for which they are FDA approved. In the end, it makes you wonder whether FDA approval is waning in relevance.

Money Talks

As a group, physicians are an ethical bunch. Most have had the mantra â&#x20AC;&#x153;whatâ&#x20AC;&#x2122;s best for the patient comes firstâ&#x20AC;? drilled into their heads enough so that by the time they finish residency they probably mumble it in their sleep. But that hasnâ&#x20AC;&#x2122;t stopped the health plans from trying to incent physicians financially to prescribe the medications they deem most cost effectiveâ&#x20AC;&#x201D;er, appropriate.

Granted, in California it is illegal for health plans to give physicians financial incentives to prescribe certain brands of drugs over others, or for prescribing generics rather than brand name drugs. Yet the everclever health plans are finding ways to beat the system. In one example, health plans are starting to encourage physicians to prescribe generic drugs via pay-for-performance plans.

In P4P, physiciansâ&#x20AC;&#x2122; practices are paid more if they meet

SUMMER 2009

certain criteria designed to improve care and efficiency, such as prescribing more drugs electronically or reducing patient cholesterol levels. And we’re not talking pocket change here on the extra pay—between 2003 and 2006, health plans distributed over $212 million in payments to physician groups across the country as a result of meeting P4P quality measures. And that was without the incentive for prescribing generic drugs.

Even more insidiously, pharmaceuticals have now begun hitting patients with incentives. Most of these incentives make the offer sound quite reasonable and scientifically valid. Our friends at Anthem Blue Cross, when pitching the “FREE tablet splitter” offer gave this explanation: “How does the Half Tablet Program work? If you take one of the eligible medications (see below list), you’d split a higher-strength tablet in half to reach your prescribed daily dose. This means you would need only half the number of tablets. If you have a co-pay for prescription drugs, the Half Tablet Program can cut that co-pay in half. If you have coinsurance, your out-of-pocket costs will be less, as you’ll need only half as many tablets.” The letter goes on to give an exact example.

While this may seem innocuous, there are good reasons doctors prescribe certain dosages for patients. And, elderly people are most at risk for being susceptible to these offers. This is especially dangerous since these are the people most likely to be taking numerous medications and who could be most easily confused by which pills they are supposed to split and which they are not.

Other offers include a discount coupon for the drug that the insurer prefers. In a recent letter, Blue Shield of California offered one patient a $25 coupon for Enablex, a drug they were recommending as a less-expensive medication that was “as safe and effective” as the patient’s current drug for an overactive bladder, Detrol LA. We asked Department of Managed Health Care spokesperson Lynne Randolph if the DMHC would follow up on this type of offer, especially given the assertion that the replacement drug was as safe and effective as the current drug.

She would not answer our questions on the telephone but did send a reply via email stating “The DMHC has the authority to examine treatment decisions under the existing grievance process, including the use of the Independent Medical Review.

The DMHC also has an obligation to the rate-paying public to promote both access to care but also seek ways to keep down the costs of care. Therefore, it is not appropriate for the DMHC to make broad comment on these types of issues unless the certain circumstances and conditions are examined.” She continues to make the point that prescription drug benefits are not mandated by law saying “Also because the prescription drug benefit is not mandated, the DMHC looks at any changes proposed by health plans very closely to make sure that the patient has as much access to medically necessary drugs as possible.”

Still, the fact remains that these examples are not isolated instances. Any doctor can offer numerous tales of patients

SUMMER 2009

requesting particular drugs based on come-ons by pharmaceutical companies. And many states are ahead of California in offering prescribing incentives within P4P plans.

There Oughta Be a Law

With all of the dangers the various barriers pose, you’d think that we’d have strong laws in place to protect doctor-patient rights.

Yet, while California has some of the best patient protections in the country, they are not enough. First, even where legislation has been enacted, regulatory enforcement has been minimal.

Indeed, one of the core tenets of the Knox-Keene Act—the body of law that regulates HMOs and some Blue Cross and Blue Shield PPOs—is that enrollees receive accessible care through an adequate network of physicians. But despite evidence that this is not happening, there has not been one single enforcement action by the Department of Managed Health Care against a plan for failure to meet this core requirement.

Worse, the laws we do have are a confusing tangle of jargon and red tape that both physicians and patients find nearly impossible to navigate. Indeed, a handful of physicians have started hiring a full-time staff member just to handle prescriptions. Others spend precious time writing letters to insurers requesting exemptions, often to no avail. (You can find sample letters at the CMA OnCall library).

Asked how well it works to write letters to the Medicare Part D-affiliated insurance companies explaining why certain drugs are the best option for a patient, Dr. Stearns, the Oxnard urologist says with some resignation: “Sometimes they’ll give authorization, sometimes they won’t.” But out on the border where he practices medicine, the unemployment rate is sky-high—nearing 30 percent by his telling—and that means without drug coverage, many of his patients would choose between medicine and food. “I think these insurance companies are ripping people off,” he adds.

The Condition My Condition Is In

the barriers we’ve listed, however, only show a small portion of the problem. Insurer tactics, rules and formularies change constantly; new and better drugs are always coming onto market; state laws are rewritten as new issues come to light; and patients’ needs continually change as their conditions improve or become worse, or as they develop new ones. It’s no wonder physicians can feel like they’ve fallen into the rabbit-hole leading to Alice’s Wonderland.

The real problem boils down to one simple fact—there are tremendous conflicts at all levels of the drug prescribing system.

At the root is the corporate health plans’, PBMs’ and HMOs’ need to make a profit. “We have care following financing,” says Dr. Zwelling. “It’s what’s paid, not what works. And that’s dangerous.”

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legislative > update

Congressman McNerney Conducts Round-table with SJ County Physicians Congressman Jerry McNerney chose to spend a Saturday morning with representatives from our Legislative Committee and Society Board to discuss various healthcare issues.

In addition to this timely meeting over breakfast, the Congressman appointed three of our members to his standing Healthcare Advisory Board which meets quarterly with him to discuss current and future healthcare legislation. Our representatives are: Javad Jamshidi, MD, Moses Elam, MD and Jasbir Gill, MD who will join with other physicians and healthcare leaders from throughout the 11th District which is represented by Congressman McNerney. These are the first appointees from the central valley to be made to this prestigious board.

Another breakfast meeting is being scheduled with Representative McNerney over the 4th of July Congressional recess. Please contact the medical society office if you wish to attend. Space is limited.

CMA Legislative Day 2009 This past April CMA held their annual Legislative Day at the Capitol and a number of San Joaquin Medical Society members and Alliance members took part. In addition to a lively morning session hearing from various CMA executives and lobbyists, the session featured a fascinating overview of upcoming legislation and several break-out sessions with topics like: Peer Review, Scope of Practice, Ethnic Physicians Organization and a session for medical students.

Following the morning sessions and luncheon held in the Convention Center, it was time to walk across the Capitol lawn and pay a few visits to our legislators. Fewer of our legislators had the time to meet with us personally this year due to a large number of committee meetings scheduled at the same time, but we did manage to meet with their senior staff members or healthcare policy directors. One exception to the this rule was freshman Assembly member Bill Berryhill who made time to break away from a previous meeting and spend 20 minutes with us in person. Berryhill represents District 26 which was Greg Agharizianâ&#x20AC;&#x2122;s old seat.

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SUMMER 2009

medical society > membership

19 New Members in the Past 60 Days! ...and even more on the way.

Vijaya Bansal, MD Obstetrics & Gynecology P. Gill OB/GYN Medical Group 1617 N. California St, Ste 2A Stockton, CA 95204 Office: (209) 466-8546 University of Delhi: 1981 Kishore S. Bhende, MD Anesthesiology Sutter Gould Medical Foundation 600 Coffee Road Modesto, CA 95355 Office: (209) 524-1211 University of Bombay: 1976 Dave D. Robinson, DO Geriatric Psychiatry Inland Psychiatry 2522 Grand Canal Blvd, Ste 1 Stockton, CA 95207 Office: (209) 951-4666 KS Univ of Medicine: 1996 Meenal A. Shah, MD Nephrology 1530 Bessie Ave, Ste 102 Tracy, CA 95376 Office: (209) 836-1627 N.H.L. Municipal Medical Coll: 1999 Bruce Stump, MD Anesthesiology 2626 N. California St, Ste G Stockton, CA 95204 Office: (209) 464-9846 Loma Linda University: 1981 Vu Ngo, MD Family Medicine Kaiser Permanente 1721 W. Yosemite Ave Manteca, CA 95337 Office: (209) 824-6258 St. Louis University: 1991 Jerome McDonald, MD Cardiothoracic Surgery Stockton Cardiothoracic Surgical 1617 N. California St, Ste 1D

SUMMER 2009

Stockton, CA 95204 Office: (209) 948-1234 Univ of Pennsylvania Sch of Med: 1994 RESIDENTS Ghada Abdelwahed, MD Family Medicine San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Ross University: 2004 Ye Aung, MD Internal Medicine San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6373 Institute of Medicine: 2001 Sangita Batish, DO Internal Medicine San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Touro University: 2006 Catherine Fontecha, MD Surgery San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 St. George's University: 2008 Pourya Ghazi, MD Internal Medicine San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Besheshti Medical School: 2001 Sricharitha Krishnamoorthy, MD Family Medicine San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231

Office: (209) 468-6000 VMKVM College: 2003 Kelly Savage, DO Internal Medicine San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Touro University: 2008 Dushyant Viswanathan, MD Internal Medicine San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 St. Georgeâ&#x20AC;&#x2122;s University: 2006 Robert Yavrouian, MD Internal Medicine San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Drexel University: 2004 Mohammad Yusufzai, MD Internal Medicine San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 St. George's University: 2008 Ussama Zaid, MD Surgery San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 UC Davis: 2007 Mark Schoch, MD Surgery San Joaquin General Hospital 500 W. Hospital Road French Camp, CA 95231 Office: (209) 468-6000 New York Medical College: 2004

SAN JOAQUIN PHYSICIAN

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