Winter 2009 by San Joaquin Medical Society

New South Wing at Lodi Memorial Hospital Winter Issue 2009 WINTER 2009

SAN JOAQUIN PHYSICIAN

Open Wide...

With Confidence!

It’s Open Enrollment time for the San Joaquin Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the outof-pocket expense of regular dental care. This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers). • During Open Enrollment only, members may join as an individual or as a group with your employees. • Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families). • Pay no deductible on oral exams, x-rays and routine cleanings.

Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period that ends on December 31, 2009. Call a Client Service Representative at 800-842-3761 for more information, a brochure and application. Or visit www.MarshAffinity.com/cmadownload.html to download an enrollment kit.

Sponsored by:

Underwritten by:

Administered by:

Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the final arbiter of coverage.

42641 (11/09) © Seabury & Smith Insurance Program Management 2009 • CA Ins. Lic. #0633005

d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance@marsh.com • www.MarshAffinity.com Marsh is part of the family of MMC Companies, including Kroll, Guy Carpenter, Mercer and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

SAN JOAQUIN PHYSICIAN

SUMMER WINTER 2009

Volume 57, Number 4 • December 2009

36 48 55 62 WINTER 2009

{FeATUreS} lOdI MeMOrIAl HOSPITAl takes Wing

CMA HOUSe OF delegATeS Prescribes Policy

CMA NewS: CEO Report

CMA legISlATIve

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HeAlTH CAre reFOrM and Air Quality IN THe NewS New Faces and Announcements New SJCMS webSITe COMMUNITy HeAlTH FOrUM A gUIde FOr PHySICIANS: regarding Hospice Care MeMberSHIP beNeFITS: Your Ofﬁce Manager Advocate has the answers

Update

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Lawrence R. Frank, MD President James Halderman, MD President-Elect Robin Wong, MD Past-President

George Khoury, MD Secretary-Treasurer Board Members

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

Moses Elam, MD John Olowoyeye, MD Raissa Hill, MD Jerry Soung, MD

Trinh Vu, MD Anil K. Sain, MD Kristin M. Bennett, MD

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

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Committee Chairpersons MRAC F. Karl Gregorius, MD

Decision Medicine Kwabena Adubofour, MD

Ethics & Patient Relations to be appointed

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 to be appointed

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 Peter Gierke, MD

James R. Halderman, MD Peter Oliver, MD Robin Wong, MD

WINTER 2009

When was the last time a doctor came to YOU?

At California Pacific Medical Center’s Atrial Fibrillation and Arrhythmia Center we are committed to a comprehensive team approach in treating your patient. Whether a patient is having debilitating palpitations, recurrent syncope or severe heart failure, sensitive and difficult challenges await – for them and their family.

We are Andrea Natale, M.D., Steven Hao, M.D. and Richard Hongo, M.D., electrophysiologists who specialize in complex ablation procedures. In fact, we have the highest atrial fibrillation ablation volume on the West Coast; last year, we performed over 450 procedures. We would like

to make an appointment to see you in your office. Why?

We’d like the opportunity to acquaint you with our facilities, staff and equipment – including California Pacific’s new Stereotaxis lab. We’d also like to help familiarize you with referral indicators for your patients with arrhythmias, particularly atrial fibrillation.

The Atrial Fibrillation and Arrhythmia Center offers: s

"OARD CERTIFIED FELLOWSHIP TRAINED CARDIAC ELECTROPHYSIOLOGY SPECIALISTS

3TATE OF THE ART TECHNOLOGY AND FACILITIES FOR THE TREATMENT OF ARRHYTHMIAS

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)N (EALTH'RADES RANKED #ALIFORNIA 0ACIFIC h"EST IN THE 3AN &RANCISCO !REA FOR #ARDIOLOGY AND /VERALL #ARDIAC 3ERVICESv

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Let’s schedule an appointment for a visit to your ofﬁce: 415-600-7459

WINTER 2009

www.cpmc.org/services/heart

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MeSSAge > executive director

We Really Need a New Website! As 2009 comes to a close, it’s hard for me not to reflect on the past two years since I joined the medical society as your executive director. To say that these two years have flown by is an understatement. How quickly I remember that phone call from then President Javad “JJ” Jamshidi two years back as he attempted to explain to me what the medical society was and what they we’re looking for in a new executive director – someone with marketing and community relations experience. My name had been forwarded to him by a member who had seen my resume. We made the appointment to meet the executive board members and discuss the possibilities. Since I had a few days before that eventful meeting, I chose to do a little research on SJMS and look for some common ground. Finding the medical society’s website proved worthwhile but also frustrating. I learned that SJMS was actually a part of CMA and maintained a relationship with 37 other sister county societies located With our fingers-crossed, we plan to launch the throughout the state. I also learned that the society had new site this coming January 1st and see it as gone for a while without an our premier accomplishment for the past year. administrator, but appeared to have a capable support staff in place and was doing fine in many aspects despite not having an acting executive. But the website was clumsy, appeared outdated and difficult to navigate. My first thought – boy did they need a new website! So then the questions came. What do you think you can do to help us with membership? What are your feelings on publications? And can you help us create a new website? Get re-involved in the community and provide your members with the best service possible. That was my solution for attracting membership and I guess it’s worked. We’ve attracted 87 new members since and routinely enlist an average of 8 new members each month. Re-creating our Physician Magazine actually became our first staff project and I can still recall Moris Senegor’s delight when we met to discuss his vision for the publication. To say we’ve been successful is putting it mildly. You’re holding our 8th issue and all have been a financial and editorial success. So that leaves me with our website. The old website was difficult to maintain and lacked content. The physician locator hadn’t been updated in years and our hosting company had actually gone out of business. It’s been a long list of to-do’s since joining the society, but few projects have given us more excitement and greater satisfaction. With our fingerscrossed, we plan to launch the new site this coming January 1st and see it as our premier accomplishment for the past year. It will be feature-rich, content-driven and user-friendly. But most importantly, it will have been created for the best group of physicians in the state…. The members of the San Joaquin Medical Society. All the Best!

Moris Senegor, MD Editor Editorial Committee Shiraz Buhari, MD Kwabena Adubofour, MD Robin Wong, MD William West Managing Editor William@sjcms.org Michael Steenburgh Contributing Editor Sherry Roberts Creative Director/Graphic Designer sherry@sjcms.org 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

Mike Steenburgh Executive Director

SAN JOAQUIN PHYSICIAN

WINTER 2009

We invite you to . . .

Invest in Miracles.

ome investments offer miraculous returns. Take the Patient Pavilion at St. Joseph’s, for example. Planned in response to the needs of our growing community, this vital addition will save more lives, safely deliver more babies and provide private patient rooms. However, more than providing critical rooms and equipment, the new Patient Pavilion is an investment in the health and safety of every family who calls our community home. But to reach our $20 million fundraising goal and make this new Pavilion a reality, we need you to invest in us. Together, we’ll make miracles happen.

WINTER 2009

Give. 1800 N. California Street, Stockton, CA 95204 (209) 467-6347 • StJosephsCares.org

SAN JOAQUIN PHYSICIAN

Message > From The President

We live in Interesting Times I’d initially planned to write about current Health Care Reform legislation. Just this weekend, the House passed HR 3200 and 3962. Senate bills, S1679 and S1796, are pending as of this writing.

“The Senate bills include a work in progress regarding bonus pay for physicians in primary care, the section of our health care team in greatest need.”

ABOUT THE AUTHORLawrence Frank, MD is the 2009-2010 President of San Joaquin Medical Soceity.

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Once these emerge, a conference committee will work on combining the four for delivery to the White House for signing. Two issues important to us were not addressed, tort reform and permanent elimination of the SGR. The latter will be addressed in House Bill 3961 which would eliminate the annual SGR Medicare physician rate reductions, create a more stable payment system that increases physician reimbursement at rates greater than the growth of the economy. The Senate bills include a work in progress regarding bonus pay for physicians in primary care, the section of our health care team in greatest need. The public option, a source of lively discussion among us with some strongly in support and some strongly opposed, is on life support. Insurance issues addressed include limiting denial of insurance for pre-existing conditions and prohibiting rescissions without clear and convincing evidence of fraud. For unbiased summaries of the passed and pending health care reform bills, go to www.thomas.gov. But, as health care reform legislation remains a moving target and anything I write today may no longer obtain tomorrow, I’ll review some of the outcomes of this year’s CMA House of Delegates (HoD) meeting instead. We delved into concerns relevant to current political realities and some additional problems confronting California’s

physicians - including who could use the term “physician”. CMA physician members (including you) can send in resolutions for the HoD to review. Categories were: Medical Practice Issues; Health System Reform; CMA Membership, Finances and Governance; Insurance and Physician Reimbursement; Quality, Ethics and Legal Issues; Health Professions and Facilities; Science and Public Health. Deciding to promote legislation is expensive: ~$125,000 per issue. Herewith a summary of those issues given the highest priority by the delegates.

EMERGENCY SERVICES ISSUES PAYMENT FOR EMERGENCY SERVICES.

The CMA is to pursue legislation requiring health plans, not their subcontracted IPAs and MD groups, to pay ED physicians and ED on-call Sub-specialists for EMTALA required evaluation, treatment and stabilization of patients; health plans should create risk pools for their subcontracted groups for emergency care, thus incentivizing them to optimize health care access (i.e. increase drop-in

availability) thus minimizing the need for ED services.

WINTER 2009

EMERGENCY MEDICAL SYSTEM (MADDY) FUNDING.

—Increase training, discussion and access to palliative care and fight the scare tactics currently in vogue regarding palliative care. (A good source for refuting these is www. FactCheck.org.) —insure that preventive services, at a minimum those noted by the US Preventative Services Task Force & the Advisory Committee in Immunization Services, be appropriately reimbursed by all third party payers.

The CMA to support transparency in collection and disbursement of these funds derived from various fines and tickets. FEDERAL PAYMENT FOR EMERGENCY SERVICES FOR UNDOCUMENTED IMMIGRANTS

The CMA to support federal legislation to extend the Medicare Modernization Act which provides federal funds paid to states to care for (EMTALA mandated) Emergency care for undocumented immigrants.

MEDICAL ERRORS & “FAIR & JUST CULTURE”

All healthcare team members are responsible to report errors and “near misses” even if without adverse patient outcome, that investigations into these be not punitive but to correct systems & processes that contribute to patient risk,

E-PRESCRIBING OF CONTROLLED SUBSTANCES.

Urges the DEA to rapidly create reasonable requirements enabling e-prescribing of controlled substances. ONLINE AND TELEPHONE PATIENT MANAGEMENT REIMBURSEMENT.

Health plans should identify what services given on line or by telephone are reimbursable, that such reimbursements actually occur and that the CMA continue to support billing for such services currently not paid for by health plans. PAYMENT FOR CHILDHOOD VACCINES.

Referred to Board of Trustees for decision that the CMA pursue legislation requiring all childhood vaccines be covered by the Vaccines for Children Program regardless of insurance status and that all health plans be responsible to pay for all childhood vaccines. HEALTH CARE REFORM

—The CMA should continue to actively participate in any and all health care reform discussions & activities. Such reform should include helping the uninsured gaining insurance, tort reform (not in the House bill 3692 just passed), legislation allowing physicians and patients to make their own contracts.

WINTER 2009

But, as health care reform legislation remains a moving target and anything I write today may no longer obtain tomorrow, I’ll review some of the outcomes of this year’s CMA House of Delegates (HoD) meeting instead. - Lawrence Frank, MD

competency by either ABMS (re)certification in the same specialty as the referred physician or by practicing that specialty and being faculty at an accredited US Medical School. HEALTH CARE FACILITY PLANNING RELATED TO INFLUENZA OUTBREAK.

The CMA to support physician directed committees qualified & able to recommend staffing plan changes in response to an influenza outbreak and further, that the CMA oppose sanctions against health care facilities unable to meet mandated staffing ratios in the event of influenza like illness caused shortages. CALIFORNIA POISON CONTROL SYSTEM FUNDING.

The CMA to emphasize the public health importance of this system and take measures to assure protection of its funding. RECOVERY AUDIT CONTRACTORS (how

appropriate the acronym RAC) Inform physicians & the public of questionable practices including paying auditors on contingency vs. fee for service, improve appeals process to include review by an MD of similar specialty and geographic location, and that physicians be reimbursed for RAC associated expenses.

that members learn from their human errors, that Peer Review actions be based on relative risk and behavioral choices vs. outcomes and that continued non-adherence to safe policies and procedures or reckless behaviors result in disciplinary action.

CMA & others work to identify resources for assisting physicians with mental, physical and substance abuse issues with strict confidentiality.

CALIFORNIA CORPORATE MEDICINE BAR.

TRANSLATORS FOR THE HEARING IMPAIRED

The CMA is continue defending the bar on and educating physicians corporate practice of medicine and that alternative methods of recruiting physicians for underserved areas be pursued.

should be a health insurance benefit, not a cost burden to physicians..

QUALIFICATION REQUIREMENTS FOR MBC CONSULTANTS.

Consultants evaluating physicians referred for discipline by the Medical Board of California hold a valid California license, and demonstrate

PHYSICIAN WELLNESS:

EHR/CLAIMS BILLING/ TREATMENTS:

—Physicians should submit claims directly to payers, not via clearing houses used to downgrade claims —direct e-prescribing capability available without obligatory setup fees, service charges, proprietary software, charges for instructions/

SAN JOAQUIN PHYSICIAN

assistance. Must support patient privacy protection. —Physicians can have their own EHS via application neutral off the shelf software as opposed to vendor specific mandates; HIT vendors must disclose if their product meets requirements/stdds and is backwards compatible with legacy systems. CMA supports admin & financial assistance to Physicians in implementing required HIT and that the $ go directly to MD/groups, not an intermediary.

MEDICAL NECESSITY.

Referred to the Board of Trustees for a report back to the CMA HoD: The treating physician should be the one determining the medical necessity for diagnostic and therapeutic measures for patients as opposed to someone unfamiliar with the patient and without the responsibilities of a doctor-patient relationship, that it be recognized that all patients are different. Further, only a California licensed, actively practicing

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(209) 957-3888 Caring Support Guidance Choices

physician with demonstrated competency in the same field as the physician whose decisions are being questioned can deny or alter those requests. INCREASING MEDI-CAL PHYSICIAN REIMBURSEMENT.

Interesting concept of using a voluntary Medi-Cal Claim fee to a fund that would receive matching federal dollars. These monies would be put in a pool expressly to increase physician reimbursement for Medi-Cal patients and would increase physician willingness to see Medi-Cal patients. REMUNERATION FOR TIME SPENT COMMUNICATING WITH INSURERS.

Sure to be popular. The CMA support appropriate recompense for physicians and their staffs for time spend communicating with insurance company representatives to justify appropriate patient care. For a complete listing of all the actions at this year’s House of Delegates, log on to the CMA member website and choose your target in the House of Delegates column. Finally, as if there weren’t enough challenges for the medical community, the state has decided that Stockton should be California’s Gulag. If all of their proposals go forward, there may be one prisoner for every 100 Stocktonians. Not only might we have an influx of their families to live near their place of incarceration, we will have to clone most ancillary health care team members to replace our nurses, physicians assistants, nurse practitioners and possibly even physicians who will flock to an employer that pays very well and provides life-long health insurance for their employees and their families. There is a Chinese saying: “May you live in interesting times.” I’ve been told it is a curse... Live long and prosper.

WINTER 2009

SAN JOAQUIN PHYSICIAN

WINTER 2009

MeSSAge > From The editor

Magazine Production and Impressions of Spain In early October I met with our editorial team to plan this issue of the magazine.

“Since I spent most of October in no mood for medicine, why not write about Spain? After all that’s what I was preoccupied with. And so, here it goes….”

Photography of Spain by Moris Senegor, MD

WINTER 2009

Yes, you read it right. We now have an actual editorial team. For the past decade the “San Joaquin Physician” was assembled by me as Editor, and whoever was the Executive Director of the Medical Society as Managing Editor. A revolving door of secretaries often helped. For years I dreamed of a reporter to whom I could assign stories. A few prior Executive Directors took a crack at hiring one and never managed to come up with the right person. All of that changed when Mike Steenburgh came on board. He has, by far been the best Managing Editor of this magazine. The results are in your hands. The look of the magazine is more professional, and the articles more interesting. Mike hired a terrific writer-reporter who is putting feature stories together on short deadlines, and a graphic designer who has given the issues a “real magazine” look. In the meeting we set deadlines for submission of articles, and I realized that my own editorial was on a particularly difficult path since I was soon going away to Spain for two weeks; a biking trip in Southern Spain and a visit to Barcelona afterwards. I told the team I would come up with something while in Spain. Guess what? Bike riding through the Andalusian countryside and visiting historic monuments in its ancient cities, I found medicine and San Joaquin County farthest from my mind. What a surprise! I spent most of my “computer time”, in airports, busses and such, editing the countless photographs I took instead of writing my editorial. .

Upon return home, and back to the grind with a heavy call schedule, Mike’s e-mail requests for my editorial seemed downright disturbing. Ordinarily writing is an easy task for me. It all just pours out; but only when I have a subject that I am passionate about. Upon return from Spain I had none. I sat down nonetheless and produced a lofty essay inspired by a prominent story in local papers about an E.R. physician accused of stealing a watch from a patient who died while under his care. My thesis was to be that this shocking event was a symptom of the woeful inadequacy of not just E.R. physicians, but other hospital based specialists in our County, because of the undesirable patient populations our hospitals deliver to them. High workload and low pay cause tumult and turnover in such specialties, 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.

SAN JOAQUIN PHYSICIAN

Message > From The Editor most prominently in Emergency Medicine, and result in the entry of numerous itinerant physicians into our hospitals of variable quality, some with skeletons in their closets, and an occasional one with propensity for such outrageous behavior as theft from patients. As Mike kept desperately e-mailing me, now beyond the deadlines we set, I reviewed my serious article, and decided that it might be offensive to some. In the last second I decided to change my subject to something lighter. Since I spent most of October in no mood for medicine, why not write about Spain? After all that’s what I was preoccupied

with. And so, here it goes…. For a country that perfected “ethnic cleansing” half a millennium ago, modern Spain seems to value its ancient Moorish Muslim and Jewish heritage. Ferdinand and Isabella, revered in Spain as “Los Reyes Catolicos” (you will find a major boulevard so named in many Spanish cities), began cleansing Iberia of Muslims and Jews in 1492 by forced conversion and expulsion. The Inquisition which arose soon thereafter, finely polished the rough but efficient work these two began. Being a Sephardic Jew whose cultural ancestry goes back to that fateful expulsion, I went to Spain seeking some traces of my Ladino heritage and found none. Aside from a tiny synagogue in Cordoba, the size of a Brookside-mansion closet, there were no traces of Jews except neighborhoods in Seville

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WINTER 2009

churches of their Christian conquests to mosques. The greatest example is the Hagia Sophia, in Byzantine times the most magnificent edifice in the world aside from the Pyramids. Ottoman Turks placed 4 minarets around it and covered its rich indoor mosaics with Muslim art. Then they built an even more magnificent building, the Blue Mosque literally across the street from it with obvious intent to overshadow the infidel monument. No different than the disgusting bullring shaped Palace Charles V built next to the Alhambra which he never used. Desecration went both ways and was well balanced in those days. It is an ironic fate of history that the most visited monument in Spain nowadays is the Alhambra. With 7000 plus visitors per day, authorities have to issue timed advance reservations to prevent overcrowding. Ferdinand and Isabella must be turning over in their graves, located nearby, just below the hill from the Alhambra in the Cathedral of Granada. I wouldn’t know. I refused to visit them despite my well known propensity to honor famous dead people all over Europe. Their fine work has been upturned by a more open minded and liberal Spain, obviously ashamed of its heritage. Their progeny now proudly display the art of the Muslims so hated by their ancestors, and speak of them as a national treasure. This was obvious not only from the way Spanish tour guides recounted their history, but also the way these infidel monuments are displayed, advertised and marketed. I did detect a trace of shame for what they did to the Jews as well. But then they have so much more to be ashamed about, foremost for the rape of the and Cordoba named La Juderia, old Jewish quarters now completely occupied by Christian Spaniards for 500-plus years. I realized what efficient and thorough cleansers Ferdinand and Isabella were. As for Muslims, their traces were harder to eradicate. Some of the mosques they left behind were so magnificent that even the fanatically religious zealots of the times could not destroy them. So they converted mosques to churches, and minarets to splendid bell-towers such as La Giralda in Seville. In Cordoba they did something amazing. They plopped down a gaudy Renaissance style cathedral right in the middle of a wonderful mosque complex, creating a bizarre architectural look as though a UFO landed on this otherwise poignant and charming monument. In Granada, they subjected the Alhambra, that marvelous Moorish palace, to total neglect; Napoleon’s troops did some more damage in the 1800’s. The monument was saved by none other than an American diplomat who lived several weeks in the Alhambra in 1829, along with gypsies, the homeless, and criminals, and wrote about its charms. I strongly recommend Washington Irving’s “Tales of the Alhambra” as a must read if you intend to visit Granada. Being born and raised in Istanbul, I had already seen the other side of the fence. Muslims likewise converted

WINTER 2009

SAN JOAQUIN PHYSICIAN

Message > From The Editor Americas. This last subject didn’t come up much, except of course for Christopher Columbus. Despite his birth in Genoa, Italy, Columbus remains one of Spain’s favorite sons, a national hero almost as glorious as the Reyes Catolicos. His tomb in the Cathedral of Seville is quite a sight. Never mind that fellow Spaniards usurped this visionary captain and discarded him

in the end to a life of obscurity. He died while unsuccessfully suing the Crown for a share of the rich plunder he initiated, which catapulted Spain into a brief period of world domination, subsequently squandered under less capable kings. Now all is forgotten and Spain is grateful to the captain for his gift to the nation. You might ask if there was much about Spain that I liked. Plenty! Modern

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Spaniards were mostly cheerful and friendly. The unique fusion of Moorish and Christian culture gave Southern Spain an identity that one cannot find anywhere else in Europe, and this I found quite charming. I loved the Flamenco dancers, and especially the singers that accompanied them who created complex poly-rhythms by clapping their hands and stomping their feet. Their art sounded nothing but magical. I loved the Paris like boulevards of Barcelona and its unique modernist monuments mostly designed by Antonio Gaudi. While I generally came to dislike Spanish tapas, their appetizer size portions of food, I absolutely loved their grilled fish, Dorada a la plancha, which went well with cheap white wine from Rioja or Penedes. There was no greater pleasure than lunchtime at 3pm, in an outdoor Tirana restaurant by the river Guadalquivir, sipping that wine while observing La Giralda and Seville rooftops across the sleepy waterway intersected by various bridges. And then they served the fish. There was one moment in Spain when I was jolted out of my blissful neglect of medicine and San Joaquin County. It occurred in that closet sized Cordoba synagogue. There, between its narrow walls I encountered none other than Jim Pucelik, orthopedic surgeon at San Joaquin General Hospital. He was traveling with his wife and another Stockton couple who announced that they were my neighbors. We stared at each other, amazed. Then we sat at a sidewalk café and conversed for a bit. Soon I had to part with them and hurry for my date in a hamam, an Arab bath, and they had to move on with their excursion which eventually took them to Morocco. What a coincidence! Half way across the world, we walked into the same small monument, in the same historic town, at the same time. Just goes to show you how true that old cliché is about the world being too small. It was those same Spaniards that I now scorn who started the process of shrinking the world when they threw some money into a wild venture. I guess, maybe I shouldn’t be that hard about Ferdinand and Isabella. But then maybe not!

WINTER 2009

SAN JOAQUIN PHYSICIAN

managing > your practice

SAN JOAQUIN PHYSICIAN

WINTER 2009

Health Care Reform and Air Quality:

Connecting the Dots By: Michelle Garcia, Air Quality Director

Some say that reform is the secret to improving our health care system while others say it will not improve the health care system. This has been debated all summer long. What you may have not heard is how smart growth and healthy lifestyle choices can improve our health care system.

A recent article “Reform may not improve health care” by Dr. John Telles in the Fresno Bee laid out the connection very clearly. The article cites simple and cost free things that can help reduce the burden to the health care system and on your wallet. Choosing active transportation options such as walking and biking not only improve respiratory health by reducing air pollution but also promote general health and well-being through increased physical activity. Healthy lifestyle choices are important for so many reasons and can best be supported by smart growth policies that make these choices inviting and convenient.

Senate Bill 375 (Steinberg 2008) is landmark legislation that aligns regional land use, transportation, housing and greenhouse gas reduction planning efforts. It requires the Air Resource Board to set greenhouse gas emission reduction targets for passenger vehicles and light trucks for 2020 and 2035. The targets are for the 18 Metropolitan Planning Organizations (MPO’s) in California. These MPO’s are responsible for preparing Sustainable Community Strategies and, if needed, Alternative Planning Strategies, that will include the regions strategy for meeting the established targets. Ambitious targets are believed to be the key to California’s fight against air pollution and chronic disease. SB 375 will help champion smart growth with the planning of sustainable, mixed use communities around mass transit. Walking and cycling which will reduce greenhouse gases will also provide other harmful air pollutants and provide opportunities for improved health outcomes such as: • Reduced exposure to air pollutants such as ozone, particulate matter and toxic air contaminants • Increased walking and bicycling to everyday destination and therefore increased physical activity which can reduce obesity, diabetes, depression, and a range of other negative health outcomes • More equitable access to nutritious foods and health care services can help to reduce the prevalence of chronic illnesses • Reduced injury and death from traffic accidents and encouraged physical activities

For more information on the public health benefits of smart growth and how you can become involved to promote healthier, more livable communities, contact: Michelle Garcia, Air Quality Director at 559224-4224 ext 119 or airquality@fmms.org

WINTER 2009

SAN JOAQUIN PHYSICIAN

COMMUNITY > news

IN THE

NEWS

New Testing Capabilities

CMA Publishes Toolkit

Providing staff, physicians and patients with relevant & up to date information HealthCare Clinical Laboratories Announces New Testing Capabilities St. Joseph’s HealthCare Clinical Laboratories is pleased to announce the availability of the Novel H1N1 Influenza Virus and the HIV 1 RNA Quantitation Abbott RealTime PCR assay. The Influenza A H1N1 (2009) Test is a Real Time RT-PCR assay for human influenza A virus, and the differential detection of 2009 H1N1 influenza virus in nasopharyngeal swabs, nasal swabs, throat swabs and nasal aspirates only. The sample is to be placed in viral transport media. Stability is 48 hours at RT, 7 days refrigerated, and 30 days frozen. The assay provides two test results. One result is for the detection of the seasonal influenza A virus and the other result is for the Novel 2009 H1N1 influenza virus in the specimen. The kit is authorized by the FDA for emergency use, for the 2009 Influenza season only. Testing with the 2009 H1N1 kit should not be performed unless the patient meets clinical and epidemiologic criteria for testing suspect specimens. Based on several published studies, current molecular or PCR based diagnostic tests vary in their ability to detect and reliably quantify variant strains of HIV-1 and have been found to under-quantify them. As such, HCCL has adopted the Abbott RealTime HIV-1 assay because of this assays demonstrated ability to detect and measure diverse group M subtypes of HIV-1 including all known non-B subtypes, as well as group M, N and O isolates. (continued on next page)

requirement that physicians to Help You Understand the Impact sign new Blue Cross Changes Will Have on Your Practice contracts and accept Over the past several months, reduced rates Anthem Blue Cross has announced to continue treating Healthy Family several changes that will impact and AIM patients. physicians. The changes include To help physicians understand the fee schedule, payment policy, and impact these changes will have on claims editing software updates, a their practices, CMA has published switch to paperless EOBs, well as a this Blue Cross tool kit. The tool kit

SAN JOAQUIN PHYSICIAN

contains information on each of these changes, including important dates and links to important documents and sample letters. For a copy of this report, simply Call Gena Stoddart at 209-952-5299, San Joaquin Medical Society’s very own Membership Coordinator, or to learn more about other resources available to office managers from SJMS and CMA.

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news < COMMUNITY The Abbott RealTime HIV-1 Assay and Abbott m2000 System have also been recommended as a standard protocol for viral load testing in HIV/AIDS clinical trials sponsored by the National Institutes of Health (NIH). The recommendation applies to testing performed at adult and pediatric therapeutic HIV/AIDS clinical trial sites both in the United States and internationally, as well as the centralized network laboratories in the United States. The Abbott RealTime HIV-1 test is intended for use in conjunction with clinical presentation and other laboratory markers as an indicator of disease prognosis and for use as an aid in assessing viral response to antiretroviral treatment as measured by changes in plasma HIV-1 RNA levels. The assay is not intended to be used as a donor-screening test for HIV-1 or as a diagnostic test to confirm the presence of HIV-1 infection. For more information about HealthCare Clinical Laboratories, visit www.HCCL. com. Randeep Bajwa, M.D. Joins St. Joseph’s Medical Staff Specializing in Nephrology St. Joseph’s Medical Center is pleased to announce the addition of Randeep Bajwa, M.D., to the hospital medical staff. Dr. Bajwa comes to the Stockton area with experience as a Nephrology and Hypertension Fellow at Loyola University Medical Center in Chicago, IL. He obtained his medical degree at Govt. Medical College in Amritsar, Punjab, India. “My medical education and clinical training has given me experience in treating patients who require nephrology, transplant, and hypertension services in both inpatient and outpatient settings,” says Bajwa. “I hope to bring high quality, compassionate and comprehensive kidney care to the Stockton community.” Dr. Bajwa is board certified with the American Board of Internal Medicine and the American Board of Nephrology. He is a member of the American College of Physicians, the American Society of Transplant Renal Physician Association

WINTER 2009

(RPA), and the American Society of Nephrology. His special interests in the field include kidney dialysis (hemo and peritoneal), glomerulonephritis, renal transplants, kidney stones, and difficult to control hypertension. Dr. Bajwa has joined the practice of Dr. Jagjit Singh at 2350 North California Street in Stockton. To make an appointment, call (209) 943-0851.

Randeep Bajwa, M.D.

CMA Publishes H1N1 Billing Guide for Physicians To help physicians understand how to bill for H1N1 vaccine, CMA has reached out to all the major payors in California for clarification on their H1N1 billing policies. We have compiled this information into an easy to read chart available to members. You may also request a copy of the chart using the contact information below. For copies of either of these important resources, simply Call Gena Stoddart at 209-952-5299, San Joaquin Medical Society’s very own Membership Coordinator to receive a copy or to learn more about other resources available to office managers from SJMS and CMA. In the Spotlight: Retail health Clinics Retail health clinics are seeking an ever-increasing role in the health care system. But while the clinics hold themselves out as a cheap, convenient place to get

health care, they present real risks for both patients and the viability of primary care practices such as family physicians, pediatricians, and gynecologists, as former CMA President Dr. Dev GnanaDev recently explained at a panel discussion in Los Angeles broadcast on radio. The importance of a primary care physician to look after and coordinate a person’s health care is tough to overstate. These physicians monitor their patients’ health, encourage healthier lifestyles, and identify diseases or conditions early in order to provide treatment or coordinate care with specialists as quickly and effectively as possible. Steady access to a primary care physician improves people’s lives and health and help keeps health care costs down by ensuring the continuity of care necessary to catch problems early. Most retail clinics are staffed primarily by PAs/NPs and do not incorporate active and engaged primary care physicians. By encouraging episodic care – onetime visits for specific services like flu shots or for cough or cold symptoms – these clinics threaten to undermine the long term health of our communities. This episodic care may address a specific need of a patient, but can discourage patients from seeking the regular check-ups that are the optimal means of maintaining their health and treating illness or disease, thus avoiding the higher cost care required for advanced conditions or untreated disease. The relationship of retail clinics with pharmacies also poses concerns for quality patient care. Proposed business ventures between retail medical clinics and pharmaceutical chains create a strong potential for conflict of interest in prescribing, writing and filling based on the financial relationship. The potential for corporate profit-seeking to influence health care decisions is one of the reasons CMA fights every year to protect the ban on the corporate practice of medicine, successfully defeating three separate attempts to weaken or eliminate the corporate bar this year.

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COMMUNITY > news

IN THE

Commission and other agencies to develop regulations requiring “creditors” and “financial institutions” to address the risk of identity theft. The resulting Red Flags Rule requires all such entities that have “covered accounts” to develop and implement written identity theft prevention programs to help identify, detect, and respond to patterns, practices, or specific activities – known as “red flags” – that could indicate identity theft. The Commission previously delayed the enforcement of the Rule for entities under its jurisdiction until November 1, 2009. Jaspreet Kaur, M.D. The Commission staff has continued to provide guidance If done correctly, with a strong to entities within its jurisdiction, both relationship with primary care physicians through materials posted on the dedicated in the community, retail health clinics Red Flags Rule Web site (www.ftc. can play a safe and effective role in the gov/redflagsrule), and in speeches and health care system. Without physicians, participation in seminars, conferences retail clinics may create a false sense that and other training events to numerous patients are receiving all the primary care groups. The Commission also published they need, and the empty promise of a compliance guide for business, and cheaper care. created a template that enables low risk entities to create an identity theft program FTC Extends Enforcement with an easy-to-use online form. FTC Deadline for Identity Theft staff has published numerous general Red Flags Rule and industry-specific articles, released a At the request of Members of video explaining the Rule, and continues Congress, the Federal Trade Commission to respond to inquiries from the public. is delaying enforcement of the “Red Flags” To assist further with compliance, FTC Rule until June 1, 2010, for financial staff has worked with a number of trade institutions and creditors subject to associations that have chosen to develop enforcement by the FTC. model policies or specialized guidance for The Rule was promulgated under the their members. Fair and Accurate Credit Transactions On October 30, 2009, the U.S. District Act, in which Congress directed the

NEWS

SAN JOAQUIN PHYSICIAN

Court for the District of Columbia ruled that the FTC may not apply the Red Flags Rule to attorneys. Today’s announcement that the Commission will delay enforcement of the Rule until June 1, 2010, does not affect the separate timeline of that proceeding and any possible appeals. Nor does it affect other federal agencies’ ongoing enforcement for financial institutions and creditors subject to their oversight. The Federal Trade Commission works for consumers to prevent fraudulent, deceptive, and unfair business practices and to provide information to help spot, stop, and avoid them. To file a complaint in English or Spanish, visit the FTC’s online Complaint Assistant or call 1-877-FTC-HELP (1-877-3824357). The FTC enters complaints into Consumer Sentinel, a secure, online database available to more than 1,700 civil and criminal law enforcement agencies in the U.S. and abroad. The FTC’s Web site provides free information on a variety of consumer topics. Dr. Kaur Joins Millsbridge Clinic Lodi Memorial Community Clinic Millsbridge welcomes Jaspreet Kaur, MD. Dr. Kaur is board certified in internal medicine with an interest in women’shealth needs. She has been seeing patients in Lodi since July 2008. Dr. Kaur joins Drs. James Grady, Robert Kellar, Vijay Mirmira, Kenneth Mullen, Edmund Freund and Rajeev Shukla, and nurse practitioner Dani Bassett. The clinic is located at 1901 W. Kettleman Ln., Ste. 200, Lodi. Call 334-8540 to schedule an appointment. St. Joseph’s Medical Center Leads the Way in Environmental Excellence St. Joseph’s Medical Center has received the highest environmental achievement award presented by Practice Greenhealth, a national membership organization for health care facilities committed to environmentally responsible operations. The facility was named a member of the

FALL 2009

COMMUNITY > News

San Joaquin Medical Society Alliance – Halloween Party The Halloween Fall Festival was a great success with parents and kids leaving tired but happy. There were many outstanding costumes. The Bounce house, generously provided by the Medical Society, was one of the many activities for the children. Cookie decorating with the patient hands of Helen Ing and a really cool rope swing under the guidance of Vic Macko kept everyone busy. Alan Kawaguchi won the HUGE pumpkin as he guessed the correct weight of the pumpkin. Prizes were generously donated by Denise and Scott Bethune. The food by Touch of Mesquite was delicious! It was a beautiful afternoon for family & friends to relax and enjoy the warm fall day. Many thanks to Jeanne Siu, Helen Ing, Maria and Michael Rigdon, Marjo Ruhl, and Trisha & Vic Macko for opening up their beautiful home and backyard to us all.

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Environmental Leadership Circle, Practice Greenhealth’s most prestigious award. These competitive awards are given within the healthcare sector to institutions for outstanding programs to reduce the facility’s environmental footprint. “All of our members are committed to improving health care’s environmental performance, but there is an illustrious group of facilities setting the highest standards,” said Practice Greenhealth Executive Director Bob Jarboe. “They are the best of the best, the recipients of our top award. St. Joseph’s Medical Center has introduced extensive environmental strategies into health care and is committed to achieving further improvements.” The Environmental Leadership Circle recognizes healthcare facilities that exemplify environmental excellence and are setting the highest standards for environmental practices in health care. Award winners are chosen by the Practice Greenhealth award review team from the top Partner for Change applicants. To be considered, facilities must meet the criteria for the mercury-free award, recycle at least 25 percent of their total waste stream, have implemented numerous other innovative pollution prevention programs, and are leaders in their community. This is the fourth consecutive year in a row that St. Joseph’s Medical Center has attained the Environmental Leadership Status. St. Joseph’s has been part of the Environmental Leadership Circle since its inception in 2007. Each year, the hospital strives to achieve the highest level possible of environmental awareness and conservation integration. The many recycling programs ongoing at St. Joseph’s include green waste, batteries, cans, bottles, wood pallets, hospital products such as blue wrap and shrink wrap, baby bottles and energy efficient laundry washers.

Suasin, M.D. Radiation Oncologist Winlove Suasin, M.D. Joins ST. Joseph’s Regional Cancer Center St. Joseph’s Medical Center is pleased to announce the appointment of Winlove Suasin, M.D., to the hospital

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medical staff. Dr. Suasin is board certified in radiology and trained in radiation oncology. She joins the impressive roster of clinical experts on staff at St. Joseph’s Regional Cancer Center, including three board-certified radiation oncologists, nationally certified oncology nurses and clinical nurse specialists, and the area’s onlAmerican Board of Radiology Certified Dr. Suasin has practiced as a radiation oncologist at several hospitals and medical centers since 1994, including St. Francis Medical Center in Honolulu, HI; Doctors Medical Center in San Pablo, CA; AROS (Advanced Radiation Oncology Services) in Fresno, CA; and for Oncology Care Providers throughout Fresno, including California Cancer Center, Clovis Community Medical Center and Fresno Community Hospital. Dr. Suasin graduated with a Bachelor of Arts in Zoology from University of California at Davis in 1983. She received her Doctor of Medicine in 1990 from Creighton University School of Medicine, Omaha, Nebraska and completed her internship here in Stockton at San Joaquin County General Hospital. Dr. Suasin is a member of the American College of Radiology; American Medical Association; American Society of Therapeutic Radiology and Oncology; American College of Radiation Oncology; American Medical Women’s Association; Filipino Physicians of Northern California; Philippine American Physician Association; and a Board Member of the American Cancer Society. St. Joseph’s Medical group Welcomes New Pediatrician St. Joseph’s Medical Group is pleased to announce the appointment of Saadia Khan, M.D., to their team. Dr. Khan is Board eligible to the American Board of

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Saadia Khan, MD

Pediatrics, is fluent in Urdu and Hindi, and can understand and speak some Punjabi, Marvari, and Spanish. “Each day with children and their families gives me something new to smile about. It is humbling and a privilege to be able to care for a child,”” says Dr. Khan. “I look forward to establishing lasting relationships with my patients, their families and the Stockton community.” Dr. Khan graduated with her Medical Degree from Ross University in Dominica. She completed her Residency in Pediatrics through the Brody School of Medicine at East Carolina University at Pitt County Memorial Hospital in North Carolina. Saadia Khan, MD, is practiced in giving presentations, including one called “Finally, Family: International Adoption”, during Grand Rounds at Brody School of Medicine, East Carolina University in October 2008; and a study on “Hypertrophic Pyloric Stenosis” also at Brody School of Medicine, East Carolina University in June 2008. Dr. Khan is a member of the American College of Physicians, the American Medical Association and the American Academy of Pediatrics. Her hobbies and special interests include spending time with her daughter, reading, playing volleyball, traveling and photography.

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COMMUNITY > CHF2009

Community Health Forum 2009

Business leaders, educators, and local health professionals listened to presentations by Professor. Ed O’Neil, health economics expert from University of California San Francisco, and Ken Shachmut, executive vice president Safeway Health at the Community Health Forum in the De Rosa Student Center at UOP on Friday, November 13. By William West

“There never has been a truly free market in the health care arena, but where been introduced, they work to control costs and improve health.” - Ken Shachmut, Sr. Vice President

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The solution-oriented talks approached the health care conundrum on two tracks: a practical way to reduce costs under the current system and changes in the health care delivery system that must occur to head off a crash. Safeway has found a practical methodology that has held costs flat by incenting employees to lose weight, stop smoking, lower their blood pressure, and lower cholesterol. Achieving these improvements meant employees received rebates on their portion of their health insurance premiums. Safeway based their strategy on the analysis that 70 percent of health-care expenses came from personal behavior and chronic conditions that arise from smoking, obesity, lack of exercise and uncontrolled hypertension. They call their incentive program “Healthy Measures” and are now sharing their methods with other companies. Dr. O’Neil explained that the current paradigm for health care delivery needed to change and showed compelling examples that have worked in the real world. Dr. O’Neil used the story of a woman named Rose to illustrate a cost-saving paradigm shift. Rose was an older woman suffering congestive heart disease. She lived in England. She and 27 other women with the same affliction were followed for a period

of time and were admitted to the hospital 25 out of 28 times. They were following the traditional drug regimen and seeing the doctor periodically, unless they got very sick. When the women were empowered and trained to monitor their cholesterol, blood pressure, and weight, with computer check-ins via Skype, there were only 3 of 28 that were admitted to the hospital. The savings were huge and the health outcomes were significantly better. Dr. O’Neil posited that the U.S. health system, or “non-system”, was a paradigm that no longer worked and was akin to a car hurtling toward a brick wall. He told the true story of a masked bank robber armed with a shotgun who rounded up all the bank patrons until some ran into the women’s bathroom. The robber stopped and knocked on the door. He was following a paradigm that didn’t make any sense, but it was ingrained. Our health care world is following an equally outmoded paradigm. The reasons we continue on this ultimately bankrupt path are because it works lucratively for many components of the system—and like the bank robber—it’s the way we’ve always done things. Doctors are trained to have the patients come see them at their office and there he performs fee-for-service activities. The hospital execs are trained to keep their beds full

WINTER 2009

with the right kind of paying patients. Neither is incentivized to encourage a “Rose” paradigm. It is rational to do what brings in the money; hence the system keeps chugging along. Will physicians necessarily make less and less money as the system implodes? Or changes to a “Rose” paradigm?

“The answer is yes, if the same number of physicians exists with no changes to the system,” said Dr. O’Neil. “However, if they could manage 10,000 patients, or some such number, with a team that instituted a “Rose” paradigm, they could actually make more money. Considering projected

shortages of doctors, this may be a solution that solves a multitude of systemic problems.” Mr. Shachmut and Dr. O’Neil proclaimed their agreement on 90 percent of their strategies to reform the health care system. There was no disagreement that the current system would blow up financially in only a few years if nothing was done. “After spending some time with a local Congressman, who shall remain unnamed,” Business Council president and Community Health Forum board member, Ron Addington, asked, “he feels the Senate will change the current bill. Any hope that it will contain anything like what you all have discussed?” Both Mr. Shachmut and Dr. O’Neil stated that the current legislation before the Congress was riddled with bad ideas, but more good ideas than bad still remained. Thus, they both said they’d support passage of some sort of bill this year. It would be only the beginning of reforms but would be a framework to build upon. “No one wants their ox gored,” said Kaiser Physician-in-Chief, Moses Elam, “so do you think free markets can really work to solve the medical world’s problems?”

WINTER 2009

Dr. O’Neil replied that some free market practices, like price transparency, which Mr. Shachmut had outlined as part of Safeway’s effort, would work. Changing the paradigm to allow market forces and better practice modalities to ascend would require talented change agents and leaders. “There never has been a truly free market in the health care,” Mr. Shachmut added, “but where market elements have been introduced, they work to control costs and improve health.” “The California Medical Association has passed resolutions calling for more individual responsibility,” said Dr. Lawrence Frank, President of the SJCMS. “And as long as we’re talking about changing paradigms, perhaps having fruit instead of candy bars at the checkout stands might be helpful.” “I will take your idea back to Safeway,” Mr. Shachmut told Dr. Frank, “but I can’t make you any more of a promise than that.” Under direction of the San Joaquin County Board of Supervisors, the Community Health Forum is a collaborative of healthcare leaders in San Joaquin County, including representation of the Hospital Council of Northern and Central California, Health Plan of San Joaquin, Kaiser Permanente, San Joaquin Medical Society, San Joaquin County Health Care Services, San Joaquin County Office of Education, San Joaquin Delta College and University of the Pacific. The Community Health Forum convenes annual meetings and invites community healthcare leaders to collaborate as change agents to improve the quality and delivery of health care in San Joaquin County. The purpose and objectives of the Forum are to create tangible action steps to improve identified critical local healthcare issues.

Attendees listened closely to Professor Ed O’Neil, UCSF health care economist, shown in middle photo.

SAN JOAQUIN PHYSICIAN

WINTER 2009

Hospice Care < PRACTICE MANAGEMENT

Prognostication:

A Guide for Physicians regarding Hospice Care

The single greatest barrier to referral to hospice services is not discussing the goals of care as your patient’s terminal disease progresses.

At Hospice of San Joaquin we understand the difficulty physicians have when faced with prognosis for their terminally ill patients.

WINTER 2009

These goals may no longer be defined by cure rate as by what is important now for patients and their families. Defeating illness may not always be realistic. For patients and families, “prognostic information is often the single most important piece of information that patients need to make informed choices.”1 Broaching the subject, while difficult for physicians and patients alike, allows both to work together in defining realistic care goals. Goals are different for those patients in whom death is eminent because dying patients must choose between length of life (and perhaps futile attempts at cure) and quality of life. So, too, families may have a greater time accepting the fact of a terminal diagnosis than the patient. A recent article in JAMA attempts to lay out the “art of prognostic disclosure” in four steps: Preparation, Content, Patient’s Response, and Closing.2 Preparation: The physicians researches similar diagnoses for realistic survival rates, therapeutic interventions, and expected prognosis. By simply saying “we have discussed your goals for the time you have left, let’s now discuss the appropriate level of care . .” opens the conversation. Often it is helpful to suggest the patient bring a significant other to this meeting.

Content: Here is the prognostic disclosure— what you believe is the true prognosis to the best of your clinical ability. If you are uncertain, discuss the survival rates from estimates based on the patient’s diagnosis (es). Patient’s Response: Allow time and privacy for questions. Emphasize hope. There is always hope for pain management, hope for having symptoms controlled, and hope for a quality of life during these remaining months. Give feedback that reflects you will still be available to your patient, and he/she will not be abandoned. Know when to Close: Summarize your findings and what has been discussed for clarity. Patients who are facing life-limiting diseases should be treated with honesty regarding their disease trajectory. Should hospice care or comfort care be your recommendation or the patient’s choice, respect that choice, support that decision, and discuss what the patient still wishes to accomplish. At Hospice of San Joaquin we understand the difficulty physicians have when faced with prognosis for their terminally ill patients. We are here to guide you in that decision, and work together in providing a continuum of care where dignity, respect and quality of life is the focus; and, pain management and symptom control is the goal.

SAN JOAQUIN PHYSICIAN

WINTER 2009

SAN JOAQUIN PHYSICIAN

COver STOry > Lodi Memorial Hospital

New South Wing at

Lodi Memorial Hospital Beautiful new facility doubles size of Lodi’s important institution

By William West

A 36

fter a decade in planning and production, Lodi Memorial Hospital’s new South Wing is a welcome addition to a community hospital that touches the lives of almost everyone in Lodi. The opening comes during a diﬃcult economic climate for all hospitals.

SAN JOAQUIN PHYSICIAN

WINTER 2009

“The opening brings me a mixture of relief and fear,” said CEO Joe Harrington. Mr. Harrington’s trepidation comes because the new wing, which doubles the size of the hospital, has increased the debt load in the servicing of construction bonds used to finance the expansion, among other increased expenses. At the same time the hospital’s revenues have fallen as more and more patients are without insurance and are unable to pay for care. Employees at LMH, which is Lodi’s second largest employer with over 1300 on payroll, had some benefits frozen or deferred earlier in 2009 in an attempt to deal with lessened income. “Managing a hospital will always require adjustments in this economy,” said Mr. Harrington. “We are constantly analyzing our situation.” The relief is that the long road of planning, financing, and building is finally completed. The South Wing is beautiful, functional, and should serve well both patients and practitioners. “During the planning process the architect sat down with the medical-surgical staff spoke to them about how they did things now and how they might want to do things in the future,” said Carol Farron, Director of Community Development at LMH. “These discussions took place over two years. There were extensive discussions about the final design.” “We did spend a lot of time on the design and looking at other facilities,” said Mr. Harrington. “One of the outcomes was convenient access to computer systems for the physicians. There are terminals in the private rooms, and they are all private rooms, and also terminals outside the rooms and at the nurses’ stations. What this means for a doctor is that if they wish to add something they don’t have to gown back up to re-enter a room and input the computer.” Efficiency was one of the goals of the design. Keeping walking distances as short as possible was one design imperative, which adds to efficiency for the staff and physicians. The three different areas to chart and access terminals is part of that. >>

WINTER 2009

Members of the Lodi Memorial Board of Directors inside the new LMH Healing Garden : Back row, left to right: Ron Addington, Steve Crabtree, Robert McCaffrey, Bill Cummins, Jeff Kirst, Elizabeth Aguire, Dan Phelps, Taj Khan. Front row, left to right: Christeen Ferree, Joe Harrington, president and CEO, Cecil Dillon, board chair, Annette Murdaca, Debbie Olson.

SAN JOAQUIN PHYSICIAN

Fast Facts about the South Wing • 90 private patient rooms • 136,000 square feet • $185.5 million Financed by $150 million bond sale, $20 million fundraising, cash reserves for the rest • New central utility plant • In-patient pharmacy remodel • Morgue • New kitchen and dining room • Expanded information • Technology infrastructure • Relocated biomedical engineering and laundry • 110 local commissioned art pieces • 12 years from planning to completion • Construction began in May 2007 • Construction completion November 2009 • 0 lost-time accidents in 355,000 construction hours

Ms. Farron. “We wanted the Safety was also a primary goal. architecture and interior to aid One outcome of that policy was in healing or if appropriate, make to make all the rooms “same more comfortable and serene the handed.” dying.” “What that means,” said Ms. To meet the goal of a healing Farron, “is that all the rooms are environment they visited a identical in their layout. Think Seattle hospital that had a design about a hotel where the rooms ethos that seemed to work. are mirror images, with the bathrooms butted against each other. In that case you have a ‘right-handed’ room These centers are and a ‘left-handed room’. In the South example of shifting with the Wing these identical rooms will mean that tides and trying to adapt everything is always in the same relationship to medical practice as it is in the rooms. This just makes everything done today, - Ms. Farron. flow.” One of the goals for the new “What we saw in Highline wing was to be a Planetree Medical Center in Seattle is that environment. Planetree is an everything fit together. It was organization founded in 1978 to welcoming, professional, and promote the development and organic, “said Ms. Farron. “Going implementation of innovative to the hospital is a stressful models of healthcare that focus experience both for the patient on healing and nurturing body, and the family. We wanted to try mind and spirit. The name to ameliorate that in the design of comes from the roots of modern the building.” Western medicine -- the tree The four-story, 132,000that Hippocrates sat under as square-foot wing is an imposing he taught some of the earliest edifice. To ensure the structure medical students in ancient would complement the existing Greece. Lodian architectural themes, The Planetree mode of care architects were taken on a tour of is patient-centered, and holistic, the city. supporting mental, emotional, The results of all these efforts can spiritual, social, and physical be seen in the new South Wing’s healing. It encourages healing earthy yet rich exterior colors, partnerships with caregivers soothing interior features like and empowers patients and the atrium Healing Garden with families through the exchange water features, and the reassuring of information. Integrating and familiar mural of a Delta optimal medical therapies and landscape that greets visitors as incorporating art and nature they enter. into the healing environment “As much as we looked at colors is a core belief of the Planetree for a number of years, it was a philosophy. little nerve-wracking until it was “We wanted it to avoid finally on the building for real,” the typical hospital look,” said

“

”

Continued on page 40>>

SAN JOAQUIN PHYSICIAN

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COver STOry > Lodi Memorial Hospital said Mr. Harrington. â&#x20AC;&#x153;It looks great.â&#x20AC;? The South Wing isnâ&#x20AC;&#x2122;t the only new building in the LMH arsenal. Responding to the needs of the marketplace, and as part of a financial action plan that will build revenue, LMH now has six satellite clinics in Lodi and now in north Stockton in the Park West shopping zone. The Endoscopy Center of Lodi opened this year across the street from LMH and offers diagnostic and surgical capabilities that support physicians in gastrointestinal and other types of surgery. The Trinity Plaza Surgery Center at I-5 and Eight Mile Road also opened this year and is a 23-hour maximum recovery time ambulatory surgery center. Both centers offer physicians an opportunity to buy shares in the operation. Up to 49 percent of shares can be owned by physicians

and the remaining shares belong to Lodi Memorial Hospital. This financial strategy is part of LMHâ&#x20AC;&#x2122;s ongoing effort to create a medical and economic environment that attracts and retains physicians. â&#x20AC;&#x153;These centers are example of shifting with the tides and trying to adapt to medical practice as it is done today,â&#x20AC;? said Ms. Farron. â&#x20AC;&#x153;Another business that LMH engages in is practice management. Many physicians are becoming discouraged at the endless work and expense of practice management.â&#x20AC;? â&#x20AC;&#x153;We are very cognizant of the future shortage of physicians,â&#x20AC;? said Mr. Harrington. â&#x20AC;&#x153;Every center and everything we do is to make them happy practicing in San Joaquin County. How do you remove the obstacles while dealing with the fact that every physician could go somewhere else and make more money?â&#x20AC;?

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â&#x20AC;&#x153;We are very concerned about the prison hospital taking professional staff of all kinds,â&#x20AC;? Mr. Harrington said. This is really going to hurt us, particularly after doing a fairly good job with registered nurses. We helped support nurse training at Delta and it worked well to increase them. But that hospital is three years away and weâ&#x20AC;&#x2122;ll deal with it.â&#x20AC;? â&#x20AC;&#x153;There will always be an adjustment to be made in the way we operate and the offerings we build,â&#x20AC;? said Mr. Harrington. â&#x20AC;&#x153;Times have been very challenging but we still have an A-Plus rating with Standard and Poors. We are going to reinstate most of what was frozen for the coming year. We are basically sticking with our strategic plan. Things will move at a slower pace than before because of the economy but weâ&#x20AC;&#x2122;ll weather the storm. We think things will get better. Or weâ&#x20AC;&#x2122;ll figure out a new plan, whatever comes our way.â&#x20AC;?

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SAN JOAQUIN PHYSICIAN

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WINTER 2009

Trinity Plaza Surgery Center

Lodi Memorial Hospital’s Trinity Plaza Medical Center, located in the Park West shopping center at I-5 and Eight Mile Road, is a an ambulatory surgery center that offers physicians ownership shares. Five doctors -- Prithipal Sethi, Jeff Ing, Gordon Fahey and Kathleen Ligman, and Medical Director Phil Edington – have purchased share. More shares are available, up to a 49 percent total. LMH will own the remaining 51 percent. “This is a nice relationship for the physicians because it’s an investment opportunity,” said Amy Germann, the center’s administrator. “If the center is successful, they will receive distributions. It’s a chance to share in ownership on the ground floor.”

Current procedures include:

• Orthopedics and Sports Medicine, including arthroscopy of the knee, shoulder, ankle, and elbow; fracture and tendon repairs, and hand surgery including carpal tunnel release; Gynecology and Women’s Health, including D&C; cervical biopsy; breast biopsy and mastectomy; hysteroscopy; laparoscopy; and tubal ligation; General surgery, including hernia repair; biopsies, laparoscopic cholecystectomy; and varicose vein ligation; Ear, Nose and Throat, including endoscopic sinus surgery, tonsillectomy, septoplasty; and myringotomy (ear tube placement); Plastic Surgery, including rhino (nose), melo (face), blepharoplasty (eyelid); removal of skin lesions and skin grafts, breast augmentations/reductions, tummy tucks and other plastics procedures; Urology, including cystoscopy, lithotripsy, prostrate cancer surgery and other procedures; Podiatry, including general procedures, bunionectomy and hammertoe repair; Oral Surgery, including impacted wisdom teeth and dental restorations; Ophthalmology, including general ophthalmology surgeries such as cataract extractions with lens implant and corneal transplants. “We would encourage interested doctors to take a look at joining our facility,” said Ms. Germann. “We are a Limited

WINTER 2009

Liability Corporation that invites doctors to own up to four shares. For more information, please contact me.” • Free standing ambulatory surgery centers can better withstand potential changes in Medicare reimbursement. It is a venue for surgeries at a lower rate from the insurers’ perspective and lower co-pays for patients. Therefore, centers will attract business of that nature, even though they will certainly accept Medicare because they want to contribute to the community, according to Ms.Germann. “We have a lot of flexibility with block time, which is important to surgeons,” said Ms. Germann. “We have a lot of block time available in the mornings. Also, we have transfer agreements in place with all the local hospitals.” One advantage for physicians at this early stage is that Trinity is willing to buy equipment the physician recommends. “We are open to any physician to come here,” said Ms. Germann. “We currently have a lot of capacity and a lot of expertise. Our director of nursing had 22 years with Dameron in the ORs. We have many nurses with 20 years in specialties. We have done or are about to do plastic surgery, gynecology, pain management, ophthalmology, dentistry and urology.”

SAN JOAQUIN PHYSICIAN

GILL & GYNECOLOGY GILL OBSTETRICS OBSTETRICS & GYNECOLOGY .&%*$"- (3061 */$ .&%*$"- (3061 */$

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FALL 2009

Benefits < MeMberSHIP

yOUr OFFICe MANAger AdvOCATe

HAS THe ANSwerS

QUESTION: Can a corporation of physicians purchase

prescription drugs as a group and deduct the fees from each physician’s paycheck based on the amount each physician dispenses?

ANSWER: Drugs may be furnished by a physician only to his

or her own patients (Business & Professions Code §4170; Health & Safety Code §111500.) The Board of Pharmacy has interpreted the law to mean that physicians in group practice may not dispense drugs from a common stock unless a specific exception applies. The Board adopted 16 C.C.R. §1783, which it interprets to prohibit manufacturers or wholesalers from furnishing prescription drugs or devices to a medical group; rather they must be forwarded to “a physician.” Although many attorneys disagree with the interpretation of the Board of Pharmacy and find no statutory authority for the conclusion that physicians in group practice may not receive or dispense drugs from a common stock, physicians who fail to follow the Board of Pharmacy’s interpretation may be subject to referral to the Medical Board of California for investigation. For further information, consult CMA ONCALL document #0505, “Drug Dispensing (Not Schedule II-V Drugs),” available free to SJMS-CMA members at CMANet.org.

geNA STOddArT MeMberSHIP COOrdINATOr

(209) 952-5299 gena@sjcms.org

brIeFly NOTed grOUP PUrCHASe OF PreSCrIPTION drUgS Tracking Medical Record Releases Terminating Disorderly Patients

Continued on page 44>>

OFFICE MANAGERS FORUM: Join Gena Stoddart each month at Valley Brew for a lively seminar attended by dozens of other office managers who enjoy a complimentary lunch and some great networking as well. For more info or next month’s topic, call Gena at 952-5299 to be added to our guest list. Every second Wednesday from 11:00 - 1:00

WINTER 2009

SAN JOAQUIN PHYSICIAN

QUESTION: Should our

QUESTION: How do we

office track every time we release any medical records to a patient or third-party agency?

ANSWER: Yes. Among

terminate a disorderly patient who uses foul language to the staff and threatens to sue if he is unable to see the physician?

physician will provide the patient with a copy of the record or a detailed summary. In order to reduce the risk of liability, you should treat the patient until the patient has had a reasonable time to find an alternative source of care. The Medical Board of California advises that physicians must provide patients with at least 15 days of emergency treatment and prescriptions before the termination. For further information, consult CMA ON-CALL document #0805, “Termination of the PhysicianPatient Relationship,” available free to SJMS-CMA members at CMANet.org.

the requirements imposed ANSWER: The physician by the HIPAA Privacy Rules should send a written notice to is the requirement that the patient by certified mail, return physicians covered by HIPAA receipt requested. The letter provide patients or their legal should instruct the patient as to representatives on request an how to obtain the medical records “accounting” of certain types compiled during the patient’s care of disclosures of that patient’s (whom to contact, how, and where) protected health information and inform the patient that, upon (PHI) the physician has made. the patient’s written authorization, This obligation extends to the the physician will send a copy of the disclosures made by the physician’s patient’s medical record to the new “business associates,” that is, provider or that, alternatively, the outside contractors who act on the physician’s behalf with respect to a function St. Joseph’s Medical Center welcomes or activity involving the use or disclosure of PHI. To ensure compliance Radiation Oncologist with the accounting requirement, the HIPAA Dr. Suasin brings almost 25 years of experience in radiation oncology to Privacy Rules also require St. Joseph’s Regional Cancer Center. the maintenance of a She specializes in cutting-edge cancer disclosure accounting treatments, including: log that contains the · Three Dimensional Treatment mandatory elements Planning and Conformal Therapy that must be included · IMRT – Intensity Modulated in the accounting. A Radiation Therapy sample “Disclosure · Gamma Knife Stereotactic Accounting Log” and Winlove Suasin, MD Radiosurgery further information St. Joseph’s · MammoSite Breast Brachytherapy may be found in CMA Regional Cancer Center ON-CALL document 1800 N. California Street #1122, “Accounting of Stockton, CA 95204 To schedule an appointment, Disclosure,” available free please call (209) 467-6560. (209) 467-6560 to SJMS-CMA members at CMANet.org.

Winlove Suasin, MD

10-221 Dr. Suasin ad SJ Physician Magazine

SAN JOAQUIN PHYSICIAN

WINTER 2009

Law OямГces of

Michael J. KHOURI Michael J. Khouri

CRIMINAL DEFENSE

ATTORNEY AT LAW FORMER DEPUTY DISTRICT ATTORNEY OVER 29 YEARS EXPERIENCE ADMITTED IN ALL CALIFORNIA STATE AND FEDERAL COURTS

PROFESSIONAL BOARD DISCIPLINE DEFENSE MEDI-CARE AND MEDI-CAL AUDIT AND FRAUD DEFENSE

OFFICE: (949) 336-2433 CELL: (949) 680-6332 4040 BARRANCA PARKWAY SUITE 270 IRVINE, CALIFORNIA 92604 www.khourilaw.com WINTER 2009

SAN JOAQUIN PHYSICIAN

Not a Member of San Joaquin Medical Society or CMA?

Why Not! Here are just a few of the Benefits you’re missing ... Vast CMA Resources: Serving the counties of San Joaquin, Calaveras, Alpine, and Amador

Phone (209) 952-5299

• • • • • • •

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

San Joaquin Medical Society Resources: • • • • • • • • • •

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 Don’t Fight for You ... Who Will? 46

SAN JOAQUIN PHYSICIAN

WINTER 2009

Membership < MedICAl SOCIeTy

33 NeW

MEMBERS IN THE PAST 60 DAYS! ...and even more on the way. Teresita Amay, MD Psychiatry Kaiser Permanente 1305 Tommydon St Stockton, CA 95210 Office: (209)476-2000 Univ of the East Ramon Magsaysa: 1985 Randeep Bajwa, MD Nephrology 2350 N California St Stockton, CA 95204 Office: (209) 943-0851 Government Medical College Amritsar: 1998 Patricia Burke, MD Pediatrics Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-2080 University of Washington: 2001 Alfred Gaymon, MD Gastroenterology Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209)476-2000 Yale University: 1975 Andrew Giem, MD Urology Maple Street Urology 534 E Maple St Stockton, CA 95204 Office: (209) 941-0371 Loma Linda University: 2004 Carla Hunter-Galbraith, MD Family Medicine Perfected Care Family Practice 435 E Harding Way, Ste 2 Office: (209) 464-4832 Wayne State University: 2000 Sam Kokoris, MD Diagnostic Radiology Central Valley Imaging 1530 N Bessie Ave, Ste 108 Tracy, CA 95376 Office: (209) 833-2393 University of Southern California: 1991

WINTER 2009

Mark Lessner, MD Family Medicine Golden Valley Health Centers University of Arizona: 1975 Conway Lien, MD Diagnostic Radiology Central Valley Imaging 1530 N Bessie Ave, Ste 108 Tracy, CA 95376 Office: (209) 833-2393 Tufts University: 2000 Robert Lim, MD Radiology Central Valley Imaging 1530 N Bessie Ave, Ste 108 Tracy, CA 95376 Office: (209) 833-2393 State University of New York Syracuse: 2002 Craig Lovett, MD Orthopaedic Surgery 585 Stanislaus Ave, Ste A Angels Camp, CA 95221 Office: (209) 736-2030 University of Arizona: 1980 Bridget Norman, MD Obstetrics & Gynecology Kaiser Permanente 7373 West Lane Stockton, CA 95210 Office: (209) 476-2000 University of California - Davis: 1998 Alice Park, MD Psychiatry Kaiser Permanente 1305 Tommydon St Stockton, CA 95210 Office: (209) 476-2000 Yarbian Medical College: 1983 Jijibhoy Patel, MD Cardiovascular Disease 2320 N California St, Ste 1 Stockton, CA 95204 Office: (209) 466-4903 University of Mumbai: 1963

Richard Porzio, MD Diagnostic Radiology Central Valley Imaging 1530 N Bessie Ave, Ste 108 Tracy, CA 95376 Office: (209) 833-2393 Wayne State University: 1994 Ajithkumar Puthillath, MD Oncology 2626 N California St, Ste B Stockton, CA 95204 Office: (209) 466-2626 Aims Mysore University: 2001 Samina Qamar, MD Family Medicine Sutter Gould Medical Foundation 1300 W Lodi Ave, Ste P Lodi, CA 95242 Office: (209) 366-1990 University of Punjab: 1986 George Rishwain, MD Gastroenterology 1805 N California St, Ste 309 Stockton, CA 95204 Office: (209) 464-6000 Creighton University: 1977 Mario Sattah, MD Diagnostic Radiology Central Valley Imaging 1530 N Bessie Ave, Ste 108 Tracy, CA 95376 Office: (209) 833-2393 Emory University: 1994 Tiger Singh, MD Radiology Central Valley Imaging 1530 N Bessie Ave, Ste 108 Tracy, CA 95376 Office: (209) 833-2393 University of California – Davis: 1997 Kyle Yu, MD Diagnostic Radiology Central Valley Imaging 1530 N Bessie Ave, Ste 108 Tracy, CA 95376 Office: (209) 833-2393 University of California - San Diego: 1989 Ramiro Zuniga, MD Family Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6768 Pontifica University: 1989 RESIDENTS Dunni Adalumo, MD Family Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 University of Ibadan: 2004 Kavitha Bysani, MD Internal Medicine San Joaquin General Hospital 500 W Hospital Road

French Camp, CA 95231 Office: (209) 468-6000 Rangaraya Medical College: 2006 Krystin Cheung, DO Anesthesiology San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Touro University: 2009 William Knapp, DO Internal Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Touro University: 2009 Sam Moghtader, MD Family Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 St. George’s University: 2009 Behnaz Motlagh, MD Family Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 University of Utrecht: 2004 Priya Nand, MD Internal Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 St George’s University: 2009 Ravi Venkatesh, MD Radiology San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Case Western Reserve Univ: 2009 Nguyen Vo, MD Internal Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 St. George’s University: 2009 Yang Yang, MD Family Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Institute of Medicine Mymanar: 2001 Khaleedah Young, MD Family Medicine San Joaquin General Hospital 500 W Hospital Road French Camp, CA 95231 Office: (209) 468-6000 Western University: 2007

SAN JOAQUIN PHYSICIAN

CMA > 2009 House of Delegates

SAN JOAQUIN PHYSICIAN

WINTER 2009

CMA HOUSe OF delegATeS

PreSCrIbeS HeAlTH POlICIeS Politicians pay attention to California physicians

HUNDREDS OF DOCTORS IN A DISNEYLAND convention hall debated pocketbook and public policy issues during the House of Delegates of the California Medical Association in the latter part of October. Along with ways to handle the H1N1 pandemic and state reimbursement dilemmas, they grappled with projected outcomes from various aspects of national health reform. Then they voted on resolutions on these great issues of the day. The CMAâ&#x20AC;&#x2122;s lobbyists carried their decisions directly to the powerful players in health policy in Sacramento and Washington, D.C. >> By WILLIAM WEST

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SAN JOAQUIN PHYSICIAN

House of Delegates is a high-octane blend of study and debate during plenary sessions.

Dev A. GnanaDev, MD, President of the CMA; Assemblywoman Mary Hiyashi, Legislator of the Year winner; and Dustin Corcoran, CMA Senior Vice President

For first-time attendees the gathering was an epiphany because it gave a clear sense that physicians can play a vital role in wrestling the unwieldy monster of U.S. health care into some sort of workable system. The weight of California’s large medical constituency, influential because of its thousands of members and because key players in the House of Representatives are Californians, does move the ponderous mass of Congressional inertia. In fact, some facets of the House of Representatives health reform bill, HR3200, are there because of CMA, according to a presentation to the delegates by CMA’s Vice President for Federal Relations, Elizabeth McNeil. Nancy Pelosi, Speaker of the House of Representatives; Henry Waxman, Chairman of the Energy and Commerce Committee; Pete Stark, Chairman of the Health subcommittee of the House Ways and Means Committee; George Miller, Chairman of the Education and Labor Committee; and Nancy De Parle, Counselor to the President and head of the White House Office of Health Reform, listen closely to the decisions made by the CMA House of Delegates. “Uninvolved physicians can’t really comprehend the effectiveness of CMA unless they see it up close, like this convention,” said Dr. Peter Oliver, a general surgeon from San Andreas. Arriving at consensus among the delegates was predictably fraught with disagreements, but unanimity of goals was a guiding force during the sometimes impassioned debates. For example, some physicians found the idea of a public option to be abhorrent while others went so far as to propose a single payer system, yet both sides shared the goal of providing health care to all patients and fair payment to doctors. Joe Dunn, the outgoing CEO of CMA reminded the House of Delegates during a farewell speech that “physicians love to argue with other physicians.” “We must be wary of opponents who try to divide the House,” Mr. Dunn intoned. “Don’t let the issues of the day ever divide the House.” Mr. Dunn is returning to what he calls a “physicianfriendly legal practice” in Southern California. He wanted to remind the assemblage that “in the last three years, the plaintiff’s trial lawyer and Democrat that you hired as CEO kept all challenges to MICRA at bay.” The incoming CEO, Alfred Gilchrist, also commented on the proclivity for strong opinions from medical doctors. “In my 31 years in the service of organized medicine, I have found that doctors do not suffer from self-doubt.,” said Mr. Gilchrist, former head of the Colorado Medical Association. “I believe what

Dr. Lawrence Frank, President of the SJCMS, seated in blue shirt, working on resolutions

SAN JOAQUIN PHYSICIAN

WINTER 2009

Foreground left-to right: Jeremy Lazarus, MD, Vice President of the American Medical Association; Elizabeth McNeil, CMA Vice President, Federal Government Relations; and Robert Hertzka, MD, CMA Past President (Vice Speaker of the House, Luther Cobb, MD, is in the background)

you all do affects lives and my goal is to provide strategies based on core values that have measurable results.” Outgoing President Dr. Dev GnanaDev gave thanks for his opportunity to lead and asserted his dedication to patients and the profession of medicine that had taken him on a journey from a small village in India to a challenging practice in California. Incoming President, Dr.Brennan Cassidy, asked the hundreds of physician delegates to give “time, patience and persistence” to informing the public and lawmakers what it takes to provide comprehensive medical care. “As doctors, we take care of people 24/7,” said Dr. Cassidy. “It’s our mission to restore the health of our patients. As the national debate on health care reform moves forward, it’s crucial that physicians communicate clearly and loudly about what we need to do our jobs.”

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Dr. Cassidy is a past president of the Orange County Medical Association. He is a past Chairman of the CMA Board of Trustees. After several more opening speeches and formally establishing the rules for debate, the following three days were

“

It’s great to know any

physician can fashion a resolution and argue it’s worth before a study committee, a reference committee and then the entire House of

”

Delegates,

- Dr. James Scillian

filled with morning to night committee meetings and general meetings of the entire House of Delegates. The heart of the House of Delegates is found in the creation and

consideration of resolutions. “It’s great to know any physician can fashion a resolution and argue it’s worth before a study committee, a reference committee and then the entire House of Delegates,” said Dr. James Scillian, Kaiser Permanente Chief Pathologist for their Stockton, Manteca, and Modesto locations. Here is a simplified version of the way the legislative process works: • The House of Delegates votes on resolutions created by individual physicians and vetted through committees of local doctors in the weeks and months prior to the convention. Groups known as “reference committees” then discuss the resolutions during openmicrophone sessions where supporters and opponents argue their cases. The reference committees work all night to finalize recommendations on the various resolutions. The

SAN JOAQUIN PHYSICIAN

CMA > 2009 House of Delegates

Health Care Reform was the hotly debated issue in this committee meeting

recommendations and their rationale are presented to every delegate and then the House of Delegates votes to accept, reject, or refer the resolution to the Board of Trustees for a decision. • The House of Delegates runs under strict parliamentary rules. When doctors meander off course during debate, the Speaker of the House of Delegates pulls them back on subject with gentle but ruthless attention to the germane. Though the discussion is deadly serious, they are not bereft of humorous moments. For example, one naturally slow-talking physician drawled, that a rule change shortening time for speeches from two minutes to ninety seconds “won’t give me enough time to even get my name out.” This hyperbole was met with widespread laughter and good-natured jibes. • “When you see the breadth of involvement in issues across the

SAN JOAQUIN PHYSICIAN

Dr. Richard Pan, candidate for the 5th Assembly District, was endorsed by the CMA

board by all these physicians, it is truly remarkable,” said Dr. Lawrence Frank, President of the San Joaquin County Medical Society.

“

When you see the breadth

of involvement in issues across the board by all these physicians,

”

it is truly remarkable

- Dr.

Lawrence Frank, President of the San Joaquin Medical Society

“The efforts of all these physicians as a group is inspiring,” said Dr. Oliver. “And the money for the CMA is very effective,” said Dr. Scillian. “The state and national executives are absolutely

first class professionals. The health of the general medical community is of great importance and the efforts here are incisive and telling.” “This is truly a way to be part of the community of physicians and citizens,” said Dr. Frank. State legislators and candidates recognized by the 138th House of Delegates of the CMA Knowledgeable legislators who support physicians’ issues are invaluable in crafting public policy that is beneficial to the practice of medicine. Listed below are two CMA allies, one a sophomore legislator and one a candidate who happens to be a doctor and member of the CMA. Support for these politicians is important for safeguarding the medical profession. California Medical Association

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Honors Assembly member Hayashi with Legislator of the Year Award Assemblywoman Mary Hiyashi, Assembly District Eighteen, is the Chair of the Business and Professions Committee in the California State Assembly. When physical therapists pushed for a bill that said that no referrals from physicians were needed, she told legislators this would not get through her committee and if they brought it up she would block it and also any appeal. Appealing the decision of the committee chairperson is a standard procedure in the Assembly. Committee chairpersons have the right to veto such a request, but it is rarely used. They brought up the bill, she denied a hearing for the bill and when they appealed she exercised her veto. “CMA is pleased to recognize Assemblywoman Hayashi’s strong commitment to protecting the integrity of the doctorpatient relationship, and to ensuring that Californians have access to high quality care from their doctors,” stated CMA President Dr. Dev GnanaDev. “For her public service on behalf of patients and doctors in California, we are pleased to name her the CMA Legislator of the Year.” “I am honored to receive this award, and I would like to thank CMA for this incredible recognition,” stated Assembly member Hayashi. “Ever since I came to the Legislature, health care has been my top priority. CMA is deeply committed to

WINTER 2009

protecting the values and practices that make up safe, ethical, and quality medical care, and I feel very privileged to be able to work with such a dedicated group of advocates.” Richard Pan a pediatrician and democratic candidate for the assembly was endorsed by the CMA The California Medical Association has endorsed Sacramento pediatrician Dr. Richard Pan for the 5th Assembly District. As a long-time pediatrician and educator in the Sacramento community, Dr. Pan has been a tireless advocate for providing health care for children and families in California. “As a pediatrician serving many of the neediest families in the Sacramento region, Dr. Pan understands the importance of ensuring access to health care,” said Brennan Cassidy, MD, President of the CMA. “His experience and knowledge on health care issues will be incredibly valuable in the legislature to his community and the people of California.” In addition to his service as a pediatrician, Dr. Pan has worked to pass along to the next generation of physicians the importance of giving back to the community, founding Communities and Physicians Together. His service on the Sacramento First 5 Commission, as a Board member of Blood Source, and the United Way are further evidence of the strong commitment to his community which will make Dr. Pan such an effective legislator.

SAN JOAQUIN PHYSICIAN

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FALL 2009

CMA < CEO REPORT

California Medical Association CEO Report with Joe Dunn

As I look back on the last year, I am amazed at the breadth and scope of the challenges that California physicians and the practice of medicine faced.

A dysfunctional state budget threatened funding for nearly every state health program.

Insurers continued their steady onslaught on physicians and the doctor-patient relationship. State lawmakers sought to expand scope of practice for nonphysicians and to weaken the bar on the corporate practice of medicine. State regulators sought to impose new fees and new requirements on physicians. While federal health reform efforts presented an opportunity to fix much of what is broken in our health care system, some proposals posed a significant threat to the viability of the practice of medicine for many physicians. And that’s just a partial list. As amazed as I am at the challenges to the medical profession, I am equally amazed at the ability of CMA and our county partners to meet those challenges. In the state legislature, in Congress, in the courts, with the medical board, with state regulators, with insurers, with the public: CMA fought to protect the interests of physicians and their ability to provide care to their patients. As I think back on the battles we have taken on, the victories we have won, and how much remains yet to accomplish,

WINTER 2009

one thing will stand out: the critical role that organized medicine plays in protecting the interests of doctors and patients. As many of you have heard me say, the world is increasingly complicated and fraught with risk for physicians. Everywhere you turn, there is some interest group or corporation seeking to usurp the sacred authority of physicians, usually in the name of making an extra buck. The multifaceted and integrated advocacy that the changing world requires can come only from organized medicine. As you read the following pages about CMA’s accomplishments over the past year, I hope that you do so with a mixture of pride and even hope – pride that as a member of organized medicine you are fighting to protect what is important, and hope that our strength, vigilance, and dedication will continue to protect the ability of doctors to practice your noble profession. Protecting Access to Doctors

At the heart of much of CMA advocacy is our efforts to ensure patients have access to doctors. This takes on many forms, including working to improve reimbursement, fighting against onerous regulations, protecting patients from unlawful rescissions of their insurance, and health reform. In the last year, CMA: • successfully defended its injunction

against Medi-Cal provider cuts, saving doctors more than $100 million and helping Medi-Cal patients keep their doctors; • won enhanced physician network adequacy requirements for insurers and reduced administrative burdens for physicians in the Department of Managed Health Care’s “timely access” regulations; • filed an amicus brief defending the ability and flexibility of state and local governments to pursue health reform without federal pre-emption; • for the second year, put a bill on Governor Schwarzenegger’s desk that would protect patients from unlawful rescissions of their health insurance; • when physician licensing faced monthslong delays due to furloughs of Medical Board employees, filed a lawsuit to exempt the Medical Board from any state furloughs; and • with LACMA jointly submitted an amicus brief in support of a lawsuit filed against Blue Cross for illegally cancelling patients’ health insurance policies Protecting the Quality of Care

Physicians are not just on the front lines of providing health care; they are on the front lines of ensuring that the quality of health care meets the incredibly high standards of care where they practice. While nearly all peer review done in California is done efficiently, timely, and in a manner that protects patients from quality of care deficiencies, the current peer review system can be enhanced. CMA sponsored a bill to prevent the use of improper or biased review to remove physicians for non-quality of care concerns and to correct those rare circumstances where peer review is delayed to the point that patients are placed in danger by the

SAN JOAQUIN PHYSICIAN

CEO REPORT > CMA inability to promptly remove a physician who is providing substandard care. CMA also filed an amicus brief in a case defending physicians’ right to a hearing before their peers. Protecting MICRA CMA has continued its staunch defense against attacks by personal injury lawyers on MICRA, California’s landmark medical malpractice reform law that keeps doctors medical liability premiums and thus health care costs in check, helping ensure patients have access to their doctors. This year, CMA defended the constitutionality of MICRA in court, filing an amicus brief and testifying before the appellate court in the case, which ultimately upheld the constitutionality of MICRA. CMA is also working to ensure that federal health reform efforts do not undermine MICRA. Personal injury lawyers ramped up their attacks on MICRA in the press this year, very likely in an attempt to set the stage for an assault on MICRA in the next 1-2 years. CMA is engaged on all levels in preparation for the expected attack, working with our coalition and county partners to educate physicians, lawmakers, and the public about the importance of preserving this law. Protecting the Profession of Medicine Government bureaucrats, insurance companies, hospitals, optometrists, psychologists, nurses, physical therapists, and others all want to practice medicine or tell physicians how to do so. These incursions threaten the profession and risk undermining the quality of care provided to patients. This year, CMA:

• successfully waged an extensive lobbying and grassroots advocacy campaign to defeat three separate legislative attempts by hospitals and labor unions to erode California’s bar on the corporate practice of medicine; • counseled the Attorney General on the corporate bar, ultimately obtaining an AG opinion reinforcing the ban and preventing corporate interests from unduly influencing physicians’ professional judgment; and

SAN JOAQUIN PHYSICIAN

• defeated a number of legislative attempts to expand the scope of practice of allied health professionals, including: - a bill allowing pharmacists to independently initiate and provide immunizations to children and adults; - a bill allowing physical therapists to evaluate and treat patients without a previous diagnosis or referral from a licensed physician; and - efforts by nurse practitioners to gain admitting privileges CMA is also working with the American Academy of Ophthalmologists to prevent the Board of Optometry from promulgating unsafe regulations that would lower the standards for the training required to treat glaucoma, and is fighting an effort by the Schwarzenegger Administration to expand the scope of practice of nurse anesthetists. The efforts by other professions to practice medicine will continue next year, as nurses, optometrists, and others are planning further attacks on medicine. Membership

A growing and active membership is the foundation for the success of organized medicine. This year, we are working on new ways to educate non-member physicians about the value of CMA and to connect member physicians to the services and benefits that CMA offers. These initiatives include: • the Membership Ambassador program, designed to give physicians the tools they need to more easily recruit their colleagues; • a Member Help Center to address any questions physicians have, or to steer them to the right CMA resource to get the help or information they need; • a revamped package of services and benefits to give physicians a greater monetary return on their investment in CMA membership; and • providing physicians with HIT support, as discussed on page 4. These initiatives and efforts by our county partners have helped CMA maintain relatively stable membership levels during the economic downturn of the last year, as other member-based organizations have suffered large setbacks.

Practice Management Tools

Particularly for physicians who practice in solo or small group settings, the challenges of managing a practice are greater with every passing year. Public and private payors alike squeeze your bottom line, interfere with your ability to treat your patients, and require ungodly amounts of paperwork. And these are on top of the everyday issues of running a business. To help physicians meet these challenges over the last year, CMA:

• published the Best Practices manual, providing physicians with information and tools to improve the efficiency and quality of their practices; • produced the Red Flags Rule Toolkit and webinars, helping physicians understand and comply with new identity theft regulations promulgated by the Federal Trade Commission; and • updated, as we do every year, CMA ONCALL, an online library available free to members that contains over 4,500 pages of legal, regulatory, and reimbursement information for physicians. Health Information Technology

The federal stimulus package passed earlier this year included billions of dollars for physicians to help them purchase and transition to electronic health records (EHRs). For the first time, there was recognition of the need to provide resources to help physicians transition to EHRs. EHRs may not be for all physicians and all practices, but for those for whom it makes sense, CMA is providing them with the information and assistance they need to make the transition successfully. To help physicians navigate their way through the decision whether to adopt EHRs and how to obtain federal funding, CMA created an HIT Resource Center on our website. We are also leading a coalition that recently made the shortlist to be named one or both HIT Regional Extension Centers (REC) for California. Being named a REC would put us in the perfect position to give physicians the information and assistance they need to transition successfully to EHRs. And

WINTER 2009

SAN JOAQUIN PHYSICIAN

CEO REPORT > CMA finally, CMA is in the process of vetting EHR vendors, so that physicians have a credible source of information to help them select which vendor and which EHR works best for their practice. No other organization in California has been able to provide physicians with the resources that CMA has to help physicians adopt new health information echnology. CALPAC

CALPAC continues to play a vital role in our advocacy efforts, helping to identify and elect candidates that share CMA’s vision for medicine and health care. This election cycle is particularly exciting for physicians, as two physicians are viable candidates for open Assembly seats. CALPAC’s continued investment in Independent Expenditures is meeting the demands of a changing political landscape and helping to make sure that true physician champions get elected to the state legislature. CALPAC is also playing a major role in raising the visibility of our grassroots advocacy, to ensure that the physician voice is heard on important issues impacting health care in the legislature and in Congress. Payor Advocacy

Physicians and their practices are frequently plagued by payor issues, particularly with insurers and government. Whether caused by greed, bureaucratic incompetence, or both, payment issues pose a very real threat to the viability of many physician practices. CMA’s Economic Services team is your advocate with payors in three critical ways:

• They work with public and private payors to prevent onerous provisions from getting into contracts; • They give physicians the tools to figure out whether to get into contracts in the first place; and • They help physicians with payment issues with private and public payors.

SAN JOAQUIN PHYSICIAN

These services paid off for CMA member physicians big-time in the last year, when the Medicare transition to Palmetto created numerous payment delays. CMA’s Economic Services team helped recover more than $100 million in delayed payments for California physicians. Another big concern with payors are increasing efforts by insurers and government alike to use massive databases to pay physicians less, usually dressed up as efforts to improve quality or lower costs. The California Physician Performance Initiative (CPPI), a collaborative of insurance companies and other payors, is seeking to use physician performance “grades” to economically profile physicians. CMA fought to get physicians the right to review the data used to grade their performance, which helped to uncover serious flaws in the CPPI methodology. CMA also filed a lawsuit against health insurance giant WellPoint, alleging that they colluded with Ingenix, a unit of United Health Group, on a price-fixing scheme to set artificially low reimbursement rates for out-of-network care. Health Reform

And last, but certainly not least, health reform. Physician passions run high on health care reform, and they should. Doctors care deeply about their profession and their patients, and want to make sure that any reform helps to address the problems they face, not create new ones. While many physicians have differing views on how to do so, nearly all physicians agree on the need to expand the access that people have to their doctors. This belief is at the core of CMA’s longtime tradition and policy of fighting to expand access to care. This year, we carried the spirit of that tradition into the federal health reform debate. Even though it sometimes appeared that the folks in Washington weren’t listening to health care providers, Congressional leadership

was listening to CMA. Thanks to the hard work of our Executive Committee and staff, House leaders rebased the Medicare sustainable growth rate (SGR) formula in HR 3200, the primary House reform legislation. This is a vital step towards preventing future cuts to Medicare physicians. Also as a direct result of CMA advocacy, House leaders increased primary care rates for Medicaid providers, an important step for strengthening the safety net. Not everything on the table is good for physicians and their patients though. Particularly in the Senate bill, there are serious landmines for health care that CMA is working to defeat. These proposals include: • an independent commission (IMAC) with the authority to set Medicare policy and rates; • a Value Index program, which would shift funding from California and other states where the underlying costs of providing health care are higher to places like Minnesota and Iowa, where the population is wealthier, less diverse, and the underlying costs are cheaper; and • the Physician Outlier Feedback program, which would reduce payment by 5% for physicians who are “outliers,” above 90th percentile in national utilization rates. The Senate bill also fails to fix the SGR, setting the stage for a 25% cut to Medicare physician payments in 2011. CMA continues to work with both the House and Senate to support the positive aspects of health reform and defeat the proposals that would harm physicians and their ability to care for their patients. As many of you know, this is my last House of Delegates as the CEO of the California Medical Association, but I am leaving you in good hands. Alfred Gilchrist, a passionate and skilled advocate for doctors, will take over as CEO in November. From his time as CEO of the Colorado Medical Society and his many years as director of federal and state government relations for the Texas Medical Association,

WINTER 2009

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WINTER 2009

SAN JOAQUIN PHYSICIAN

CeO rePOrT > CMA

Alfred brings a wealth of experience to the position. Please join me in extending a warm welcome to Alfred and his wife, Robin. As was I, Alfred will be blessed with an incredible staff. The talent assembled at CMA is a roster of all-stars who could go work anywhere in corporate America. Instead, they have dedicated themselves and even their lives to fighting on your behalf. Working with them has been an incredible honor. While I will no longer be the CEO, I look forward to continuing to fight on behalf of the doctors of this state. Medicine is a noble profession that deserves the respect and protection of our society. While I have learned much during my time at CMA, there is one thing that I remain convinced of that hasn’t changed one bit: the only way

to protect the interests of doctors and patients is a strong, unified house of medicine. I’d like to offer one last thought: there will always be issues that threaten to divide doctors. We all know the list, as do our opponents, who will seek to use those differences of opinion to divide and conquer. As issues rise and fall in their profile and importance, the one constant must be a unified house of medicine. There will not be a time when medicine is not under attack, when the forces of greed and self-interest threaten the profession of medicine and the ability of doctors to take care of their patients. A house of medicine weakened by the infighting of today’s battles will be ill-equipped and unable to fight the battles of tomorrow.

I shudder to think of what health care would look like without organized medicine. Your patients, the people of California, need you to be strong, need you to be unified, need you to speak up on their behalf with one, powerful voice. We can debate policy or disagree about politics amongst ourselves, but when the time comes to act, we must stay unified. If we let our differences become discord, we will lose everything for which we have fought. I want to thank you for the privilege of serving as your CEO. Together with our county partners and a great staff, we have accomplished much over the last three years of which I am very proud. I look forward to our continued friendship, and to continuing to fight on behalf of you and your patients.

With Heartfelt Gratitude, the medical society would like to thank the following retired members for graciously paying a voluntary dues amount of $25 in 2010 which will support our new Decision Medicine Jr. Program at Hamiltion Elementary School. Richard Balch, MD George Barr, MD Harold Berkman, MD J. David Bernard, MD William Brock, MD Glen Grown, MD Paul Brown, MD Darrell Burns, MD Edward Caul, MD George Chen, MD Thomas Chen, MD Robert Evert, MD Ernest Fujimoto, MD Stephen Gaal, MD Jack Gilliland, MD Romulo Gonzales, MD William Gorham, MD William Hambley, MD Raymond Henry, MD

SAN JOAQUIN PHYSICIAN

Robert Hermann, MD Lawrence Hildebrand, MD Dusan Hutak, MD John Irish, MD Leonid Kamenetsky, MD Masanobu Kamigaki, MD Michel Khoury, MD Norman King, MD William Latham, MD Robert Lawrence, MD Chen Liem, MD Robert Lilienstein, MD Andrew Lin, MD Bill Maduros, MD Rene Marasigan, MD Guey Mark, MD Richard Nickerson, MD Marvin Primack, MD Walter Reiss, MD

Robert Salter, MD Robert Sankus, MD Robert Schmitt, MD Robert Talley, MD Walter Tim, MD Warren Wass, MD Calvin Wegner, MD Orest Wesely, MD Richard Yee, MD Sheldon Yucht, MD Henry Zeiter, MD

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CMA > 2009 Legislative Wrap-up

CMA’s 2009 Legislative Wrap-Up “I’ll gladly pay you Tuesday for a hamburger today” J. Wellington Wimpy or the Great State of California

By Dustin Corcoran, Senior Vice-President

California has perhaps replaced Wimpy as the most famous example of borrowing against the future to address today’s appetite. This year marked another significant erosion of California’s financial situation, forcing the Governor and legislature to grapple with a multibillion dollar budget deficit. Political observers surely felt that Sacramento had fallen into a time-warp as partisan bickering over-shadowed problem solving leaving Californians to endure another historically late budget. Other pressing matters including prison reform, water shortages, and California’s ever increasing number of uninsured took a back seat to the budget deficit.

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In 2008 the Governor signed two separate budget accords that were supposed to solve California’s budget woes. Those deals proved to be badly out of balance almost immediately after they were signed. Facing a $40 billion budget deficit, legislators were forced to reconvene in early 2009 and pass a new budget that supposedly would keep California solvent through 2010. That budget contained $15 billion in cuts, $12.5 billion in new taxes, $7.8 billion in federal stimulus money, and $5.4 billion in borrowing. That budget also fell short, causing the state to face a $21 billion deficit by July 2009. The continual focus on the budget and the ongoing need to make massive cuts or find new revenues paralyzed lawmakers for months. Democrats refused to consider any additional cuts and Republicans were equally adamant that they would not support any new taxes. The partisan stalemate forced California to start the new fiscal year on July 1st without a balanced budget in place. Many thousands of state workers and businesses that contract with state went unpaid, hospitals were left without reimbursement and some patients lost their state-provided health insurance while the Governor and legislators continued to feud over a solution. Finally, on July 28th, Governor Schwarzenegger signed a new “balanced budget” that primarily relied on massive cuts and billions in borrowing to fill the deficit. But even that budget is now $4 billion in the red as California’s economy continues to struggle and next year’s

budget deficit may exceed $10 billion based on current estimates. It is very likely that the legislature will once again have to take mid-year action to address the deficit now and in the future. To make matters worse the Governor continued his well worn pattern of veiled threats toward legislators for their failure to act on issues such as the budget, water and prisons. The Governor used a variety of methods to try to force legislators to act. At one point the Governor sent Senate President Pro Tem Darrell Steinberg (D-Sacramento) a bronzed sculpture of bull testicles insinuating that the legislature needed a pair. Not surprisingly Steinberg and other legislators were not amused. By the end of the legislative session the Governor threatened to veto all legislation sent to him until lawmakers sent him a water deal he found acceptable. That threat caused considerable consternation among Republicans and Democrats alike. Ultimately the Governor backed off from his threat and acted on the bills before him. The continuing strain between the legislature and the Governor does not bode well as major problems facing the state continue to loom. Is it any wonder that the Field Poll recently found that both the Governor and legislature suffer from historically low approval ratings of 27% and 13% respectively? The only Governor with lower approval ratings than Schwarzenegger was Gray Davis, the man that Schwarzenegger replaced through a recall election in 2003. For CMA it was another busy year. State budget cuts consumed many

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hours of hard work as we worked to defend the already abysmally low MediCal reimbursement rates. Ultimately CMA’s Center for Legal Affairs was forced to sue the state to block the Governor’s attempts to reduce rates by ten percent. Fortunately the court found in favor of physicians and ordered an injunction against the state prohibiting implementation of the cuts. In the Legislature we faced fights difficult and sometimes ugly – fights over scope of practice, peer review, the bar on the corporate practice of medicine and rescission of insurance policies. Fortunately, CMA was able to defeat every bill that we opposed. Not a single bill we opposed made it to the Governor and every scope bill was defeated in their first committee. The pharmacists, nurse practitioners, and physical therapists all pursued scope of practice expansions this year. Pharmacists attempted to get legislative approval to administer vaccines directly to patients without a physician protocol. That bill was overwhelmingly defeated. The nurse practitioners finally abandoned their efforts to establish independent practice and worked proactively with CMA to provide greater clarity to their practice protocols. The physical therapist legislation proved to be the most contentious scope bill of the year with their legislative staff asserting that physical therapists were more qualified to diagnose patients than physicians. Needless to say that argument did not carry the day and the bill was soundly rejected. This year the fight to preserve the prohibition on the corporate practice of medicine was difficult to say the least. Three bills were introduced to destroy or undermine the corporate bar and allow for the direct employment of physicians by hospitals. Both the California Hospital Association and the American Federation of State, County and Municipal Employees union sponsored measures to take direct control of physicians through employment. The bills were passed out of the Assembly but were defeated in the State Senate. Both organizations have made it clear that they intend to pursue

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their efforts next year so the fight will continue. CMA sponsored several bills and ultimately three made it through the legislative process and to the Governor. The first bill, AB 2, would have prohibited insurance companies from rescinding a patients insurance policy without proving that the patient intentionally misled the company when they sought coverage. Unfortunately this bill was vetoed by the Governor. Our second sponsored bill which would have made needed changes to the peer review system was also vetoed. The Governor did sign our third sponsored bill, SB 606, to expand the Steven M. Thompson medical school loan repayment program to provide additional funding to physicians willing to practice in underserved areas. Overall it was another year that was lost to the budget morass that the State continues to find itself in. It is likely that the final year of Gov. Schwarzenegger’s term will again be dominated by budget deficits. The projected $10 billion shortfall will be extremely difficult to address since the state is out of easy or politically acceptable means of bridging the gap. Perhaps Wimpy will take Minerva’s place on the Seal of the Great State of California. CMA Sponsored Legislation AB 2 (De La Torre) UNLAWFUL RECISSION: INDEPENDENT REVIEW

This bill would have provided protection to patients by requiring a health care service plan or health insurer to obtain final approval from an independent review organization prior to rescinding a health plan contract or insurance policy. This review would have used a clear legal framework to determine whether the rescission was appropriate while protecting the enrollee’s rights during the review process. The bill would also have improved the process at the front-end by requiring plans and insurers to complete medical underwriting prior to issuing a policy and made applications easier to fill

out accurately and completely. This was a reintroduction of AB 1945, which was vetoed in 2008. Vetoed by Governor on 10/11/09 AB 120 (Hayashi) PEER REVIEW

Nearly all peer review done in California is done efficiently, timely, and in a manner that protects patients from quality of care deficiencies. However, the current peer review system could have been strengthened. For example, improper or biased review could be utilized to remove physicians for non-quality of care concerns. In rare circumstances peer review can be delayed to the point that patients are placed in danger by the inability to promptly remove a physician that is providing substandard care. AB 120 would have improved an already robust system to make it even more effective in ensuring high quality care in CA hospitals. Vetoed by Governor on 10/11/09 AB 497 (Block) HIGH OCCUPANCY VEHICLE LANE ACCESS FOR PHYSICIANS

This bill would have allowed physicians to use the high occupancy vehicle (carpool) lanes on the freeway when responding to an emergency. This bill would have expanded current law which allows physicians, with the appropriate decal on their car, to exceed speed limits when responding to an emergency. Failed in Senate Transportation & Housing Committee, reconsideration granted AB 526 (Fuentes) PUBLIC PROTECTION AND PHYSICIAN HEALTH PROGRAM ACT OF 2009

This bill would have created the Patient Protection and Physician Health Program in California. The bill would have allowed physicians with mental health or addiction problems to seek help leading to appropriate treatment and monitoring prior to harming a patient. With the closure of the Medical Board Diversion

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CMA > 2009 Legislative Wrap-up Program there is not a sufficient program available for physicians seeking help. This was a reintroduction of AB 214 of last year. Held on the Senate Appropriations Committee Suspense File AB 583 (Hayashi) HEALTH CARE PRACTITIONERS: DISCLOSURE OF EDUCATION

CMA co-sponsored this bill with the California Society of Plastic Surgeons. It has become increasingly difficult for the public to identify the license, education, and training of health care professionals who practice in the state and many are unable to distinguish between physicians and non-physicians. To protect the public’s health and safety, this “truth in advertising” legislation would have required a health care professional to disclose information in various health care settings to help patients understand who will be helping them with their health care, such as information about their license, education, and recognized board certification. Two-year bill, on the Senate Floor AB 1201 (M. Perez) ADEQUATE REIMBURSEMENT FOR VACCINES

CMA co-sponsored this bill with the American Academy of Pediatrics and the California Academy of Family Physicians. The bill required plans/ insurers to adequately reimburse for both the acquisition and administrative costs of giving shots, such as purchasing the vaccine, storage, inventory, staff time, supplies, etc. This bill also would have prohibited plans from applying co-pays, deductibles and other cost-sharing mechanisms to immunizations. Held on Assembly Appropriations Committee Suspense File SB 606 (Ducheny) STEVEN M. THOMPSON LOAN REPAYMENT PROGRAM: OSTEOPATHIC PHYSICIANS

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CMA co-sponsored this bill with the Osteopathic Physicians and Surgeons of California to allow Osteopathic Physicians (DOs) to access the Steve Thompson Loan Repayment Program (STLRP). The STLRP is currently available to MDs, but not to DOs, who tend to focus on primary care and would be good candidates for the program. This legislation makes DOs eligible for the STLRP and requires them to pay an additional $25 fee toward the program, as MDs are now required to do. Signed by the Governor, Effective 1/1/10 CMA Opposed Legislation SB 726 (Ashburn) HOSPITALS: EMPLOYMENT OF PHYSICIANS AND SURGEONS

This bill, as amended in Assembly Health Committee, would have allowed virtually all Healthcare Districts and Rural Hospitals to directly employ up to 5 physicians in a pilot program. The CEO of a facility would have had to show they had been unsuccessful in recruiting a physician for 12 months, that no currently contracted physician or physician with privileges would be supplanted, and the physician was not recruited from an FQHC. Employment contracts could have been be up to 10 years but would be renewed if signed prior to December 31, 2017. The Medical Board of California would have been responsible for an interim report on the success of the pilot program due in 2013 with a final report due in 2016. Placed on Assembly Inactive File AB 646 (Swanson) PHYSICIANS AND SURGEONS: EMPLOYMENT

This bill was amended in Assembly Health Committee to establish a pilot program to allow Healthcare Districts located in an underserved area to directly employ and charge for physician services. Districts would have been allowed to hire up to 5 physicians with an ability to request up to 5 additional contracts and to limit the pilot to 10 years.

Failed in Senate Business & Professions Committee AB 648 (Chesbro) RURAL HOSPITALS: PHYSICIAN SERVICES

This bill, as amended in Assembly Health, would have allowed a rural hospital that served an underserved area or population to directly employ and charge for physician services. The demonstration project would have lasted up to 10 years and allowed the hospital to employ up to 10 physicians. To be eligible, the hospital had to demonstrate that it could document that it had been unsuccessful in recruiting a physician for 12 months and the CEO certified to the MBC that there was a critical unmet need in the community. Failed in Senate Business & Professions Committee, reconsideration granted AB 721 (Nava) PHYSICAL THERAPY DIRECT ACCESS

This bill would have substantially expanded the scope of practice for physical therapists in California by allowing them to evaluate and treat patients without a previous diagnosis or referral from a licensed physician. Current law does not specifically address physical therapy treatment without referral, but the law does prohibit therapists from making medical diagnoses. Failed in Assembly Business & Professions, reconsideration denied AB 1126 (Hernandez) THE PUBLIC EMPLOYEES’ HEALTH CARE ACT: BILLING DISPUTES

This bill would have prohibited a health care provider giving emergency services and care from seeking reimbursement or attempting to obtain payment for any covered services provided to an employee or annuitant enrolled under the Public Employees’ Health Care Act (PEMHCA). This bill specifically noted that the affected emergency services providers included but were not limited to

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hospitals and hospital-based physicians such as radiologists, pathologists, anesthesiologists, and on-call specialists. 2-year bill, in Assembly PERS Committee

acknowledgment from the patient or the patient’ s legal representative confirming that the patient received this information. The failure of a physician and surgeon to comply with this requirement would have constituted unprofessional conduct.

AB 1218 (Jones) HEALTH INSURANCE RATE REGULATION

2-year bill, in Assembly Business & Professions Committee

This bill would have required the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to approve any increase in the amount of the premium, copayment, coinsurance obligation, deductible, and other charges under the health care service plan or health insurance policy. CMA opposed similar legislation in 2005 (SB 26) and 2006 (SB 425) because of concern that such rate regulation could lead to rate regulation of provider reimbursement. Failed in Assembly Health, reconsideration granted AB 1458 (Davis) DRUGS: ADVERSE EFFECTS REPORTING

This bill would have required health care professionals to report “suspected serious adverse drug events that are spontaneously discovered or observed” to MedWatch, a drug safety and adverse event reporting system operated by the federal FDA. This bill would have placed an unnecessary mandate on the practice of medicine. Held on Assembly Assembly Appropriations Committee Suspense File AB 1478 (Ammiano) WRITTEN ACKNOWLEDGEMENT: MEDICAL NUTRITION THERAPY

This bill would have required that a physician, prior to providing care for diabetes or heart disease, must inform the patient or the patient’s legal representative of the option of “medical nutrition therapy” treatment for diabetes or heart disease, including a description of the potential risks, consequences, and benefits; and obtain written

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SB 700 (Negrete McLeod) PEER REVIEW

As amended April 13th, this bill would have required an 805 report to be filed with the MBC prior to the 809 hearing process. The bill would have circumvented the fair hearing process and not allowed a physician to test the validity of charges prior to an 805 report being filed. Further it would have required peer review at individual physician offices even though many are covered by medical staff membership, participation with groups of 25 or more physicians, or through contracts with insurers. The bill also called for more 805 reports for alleged misconduct. Placed Senate Inactive File SB 810 (Leno) SINGLE PAYER HEALTH CARE

This bill was a reintroduction of SB 840 (Kuehl) from last session. The bill would have created a single-payer system of health care in California. Specifically, SB 810 created a single payer purchasing pool and would have prohibited most private health insurance from being sold. Held on Senate Appropriations Committee Suspense File Bills of Interest AB 1422 (Bass) HEALTH CARE PROGRAMS: CALIFORNIA CHILDREN AND FAMILIES ACT OF 1998

This bill, supported by CMA, contains a 2.35% tax upon the total operating revenue of Medi-Cal managed care plans until January 1, 2011 in order to draw down federal funds that will help

fund the Healthy Families Program (HFP). Approximately 1/3 of the revenue resulting from this tax will be returned to the plans through higher reimbursement rates and the remaining 2/3 of the revenue will be directed to the HFP. The bill also increases premiums in the HFP. The bill also allows the Managed Risk Medical Insurance Board, during the 2009-10 and 2010-11 fiscal years, to adopt regulations to modify benefits, program requirements and operations on an emergency basis. The bill also allows the state Children and Families First Commission (created by Proposition 10) to direct “unneeded revenue” from specific accounts into their Unallocated Account. This carefully crafted bill is a “win-win” that contains a temporary approach to restore desperately needed funding to the HFP and protect access to health care for uninsured children while a long-term solution can be identified. Signed by the Governor, took effect 9/22/09 AB 542 (Feuer) NON-PAYMENT FOR ADVERSE EVENTS (Watch)

In the face of strong CMA opposition, this bill was dramatically narrowed by the author before its first committee hearing. The bill now would apply only to hospitals and merely requires the state to adopt regulations establishing uniform policies and practices governing the nonpayment to hospitals for hospital acquired conditions by public and private payers, consistent with those developed by the federal Centers for Medicare and Medicaid Services (CMS). The original problematic language creating a state Patient Safety Committee that would substantiate a broader list of adverse events and determine nonpayment policies for all providers was removed. CMA will continue to provide suggestions to further improve this bill and will stay engaged in the discussion. 2- year bill, in Senate Health Committee

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CMA > 2009 Legislative Wrap-up AB 613 (Beall) MEDI-CAL TAR REFORM (Support)

This bill would have required the Department of Health Care Services (DHCS) to improve and streamline the treatment authorization request process by, among other things, performing a cost-benefit analysis for each TAR and reducing the number of TARs required, developing alternative approaches for fraud and abuse detection, developing an alternative to the requirement that a patient obtain a TAR for each individual day of his or her stay in the hospital and consider adopting a single TAR for the entire length of a patient’s hospital stay, and make publicly available the rules and criteria for determining medical necessity. Held on Assembly Appropriations Committee Suspense File AB 832 (Jones) SURGICAL CLINIC LICENSING (Watch)

In the face of strong CMA opposition, this bill was completely gutted by the author before its first committee hearing. The original problematic and unnecessary language that would have required all physician-owned surgical clinics to be licensed by the state was removed and replaced with language requiring the Department of Public Health to convene a workgroup to discuss the licensing of ambulatory surgical centers. CMA will have a representative on the workgroup, as will other impacted physician specialty organizations, and we will continue to make the case that the existing accreditation process is more than adequate and protects patient safety. Held on Assembly Appropriations Committee Suspense File AB 834 (Solorio) PEER REVIEW (Watch/Refer)

As amended April 14th, this bill would have established an alternative to the 805 process when a physician and

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surgeon accepts remediation in lieu of the filing of a report. The bill would have allowed a peer review body to impose, if the physician accepts, remediation in the form of mandatory proctoring, consultation, education or retraining. The peer review body could place limits on the physician’s privileges during remediation. A report would be submitted to the MBC upon commencement and conclusion of the remediation or if the remediation was not successfully completed. This bill was referred to policy for development of this “805 lite” program. 2-year bill, in Assembly Business & Professions Committee AB 877 (Emmerson) SCOPE OF PRACTICE REVIEW COMMITTEE (Support)

This bill was amended from an “intent” bill, to having substantive language creating a scope of practice committee to perform an occupational analysis on any bills seeking to substantively expand the scope of a healing arts practice. The American Medical Association (AMA) has sample language for this issue and has been supportive of state efforts to create scope review committees. The author took language from AMA, and worked with our office for suggestions on making the review committee one that does not recommend but rather gives a review as to education and training, current law of other states and evaluate the quality and cost of health for proposed scope expansions. Held on Assembly Appropriations Committee Suspense File AB 977 (Skinner) PHARMACISTS: IMMUNIZATION ADMINISTRATION (Watch)

The author gutted her bill after it failed in committee in the face of strong CMA opposition. The bill would have allowed pharmacists to independently initiate and administer immunizations

to children and adults and now only contains uncodified language requesting the California Pharmacists Association to provide information to the chairpersons of Business and Professions and Health Committees on the status of immunization protocols between independent pharmacists and physicians. CMA monitored the bill closely to ensure that any study conducted was unbiased and narrowly focused and ensured that objectionable language was not inserted at a later date. 2-year bill, in Assembly Health Committee SB 58 (Aanestad) PEER REVIEW (Watch)

This bill was amended to require a peer review body to administer an Early Detection and Resolution Program to allow physicians to complete additional training, while privileges were limited, prior to the filing of a disciplinary quality report. The bill would also have allowed a physician to submit explanatory or exculpatory information when an 805 report was filed and required the MBC to remove expunged reports from a physicians file. This bill was heavily negotiated with peer review reforms. Held on Senate Appropriations Committee Suspense File SB 196 (Corbett) EMERGENCY MEDICAL SERVICES (Support)

The transparency provisions previously contained in the bill were eliminated by amendments taken on 6/18/2009. The bill would have required a hospital to provide 180 days notice and hold public hearings prior to the elimination of emergency services. Vetoed by the Governor on 10/11/09 For the full list please visit: cmanet.org

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