Fall 2013

BARNONE

These Correctional Health Care Leaders Are Locking in a New Era of Health Care

Fall 2013

E

Decision Medicine: Turning dreams into realities

BE XCL NE US FI IVE TS

PLUS: Fraud & Abuse: What physicians need to know to comply with state and federal laws

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VOLUME 61, NUMBER 3 • SEPTEMBER 2013

Decision Medicine 2014 Students

{FEATURES}

12 18 46 60 FALL 2013

{DEPARTMENTS} 23 MICRA

FRAUD & ABUSE

What Physcians Need To Know

UNSAFE DRIVERS

Know Your Obligations

BAR NONE

These Correctional Health Care Leaders Are Locking in a New Era of Health Care

DECISION MEDICINE

Turning Dreams Into Reality

Trial Lawyers’ Money Grab Threatens to Overturn MICRA

24 IN THE NEWS

New Faces and Announcements

33 DOCBOOK MD CASE STUDY 36 MEMBER-ONLY BENEFITS

Get the most from your membership

42 PUBLIC HEALTH 65 NEW MEMBERS 69 IN MEMORIAM

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PRESIDENT Thomas McKenzie, MD PRESIDENT-ELECT Ramin Manshadi, MD PAST-PRESIDENT Raissa Hill, DO SECRETARY-TREASURER James J. Scillian, MD BOARD MEMBERS Lawrence R. Frank, MD, Moses Elam, MD, Peter Drummond, DO, Dan Vongtama, MD, Karen Furst, MD, Kwabena Adubofour, MD, Kristin M. Bennett, MD, Clyde Wong, MD, George Savage, MD

MEDICAL SOCIETY STAFF EXECUTIVE DIRECTOR LIsa Richmond COMMUNITY PROJECT MANAGER Vanessa Armendariz MEMBERSHIP COORDINATOR Jessica Peluso

SAN JOAQUIN PHYSICIAN MAGAZINE EDITOR LIsa Richmond EDITORIAL COMMITTEE Tom McKenzie, MD Lisa Richmond, Mike Steenburgh Vanessa Armendariz

COMMITTEE CHAIRPERSONS MRAC F. Karl F. Karl Gregorius, MD DECISION MEDICINE Kwabena Adubofour, MD ETHICS & PATIENT RELATIONS to be appointed

MANAGING EDITOR Mike Steenburgh CREATIVE DIRECTOR Sherry Roberts CONTRIBUTING WRITERS Lita Wallach, Vanessa Armendariz, James Noonan,

LEGISLATIVE Jasbir Gill, MD COMMUNITY RELATIONS Joseph Serra, MD PUBLIC HEALTH Karen Furst, MD

THE SAN JOAQUIN PHYSICIAN MAGAZINE is produced by the San Joaquin Medical Society

SCHOLARSHIP LOAN FUND Janqyn Funamara, MD NORCAP COUNCIL Thomas McKenzie, MD

SUGGESTIONS, story ideas or completed stories written by current San Joaquin Medical Society

CMA HOUSE OF DELEGATES REPRESENTATIVES Robin Wong, MD, Lawrence R. Frank, MD,

members are welcome and will be reviewed by the Editorial Committee.

James R. Halderman, MD, Patricia Hatton, MD, James J. Scillian, MD, Peter Oliver, MD, Roland Hart, MD

PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO:

Kwabena Adubofour, MD,

San Joaquin Physician Magazine

Gabriel K. Tanson, MD, Ramin Manshadi, MD

3031 W. March Lane, Suite 222W

Stockton, CA 95219 Phone: 209-952-5299 Fax: 209-952-5298 Email Address: lisa@sjcms.org MEDICAL SOCIETY OFFICE HOURS: Monday through Friday 9:00 AM to 5:00 PM

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A message from our President > Thomas McKenzie, MD

United We Stand Thank you for allowing me the privilege to lead the San Joaquin Medical Society this year.

From the start, it promises to be a very disorganized, counterproductive year for physicians, patients, insurance companies, bureaucrats and politicians in trying to figure out how to implement the sweeping legislation known as the Affordable Care Act on January 1, 2014. The challenge to all of us is how to provide professional, quality healthcare to our patients without bankrupting our practices, hospitals, medical systems, outpatient clinics and surgery centers while we include care for an estimated 5.8 million enrollees in the new Covered California exchange. It doesn’t matter if you are an employed physician

or in independent private practice, this is a tidal wave coming at us.

How each of us comes to grips with this reality will be different. I would submit a “head in the sand” response is not going to cut it.

We need to effectively communicate to each other what works, and what doesn’t.

Use the San Joaquin Medical Society to help effectively communicate to those in Sacramento. SJMS is an organization of dedicated physicians who advocate quality healthcare for all patients and serve the professional needs of its members. That is our mission. United We Stand.

Unfortunately, there is another whale in the room, which needs to be addressed head on. Ever since I moved back to California, I have heard numerous concerns by CMA that the trial lawyers were challenging the 1975 MICRA law and specifically the cap on non-economic damages. Every legislative session seems to have a variation of this same theme, and the CMA very skillfully communicates the physician point of view with consistent outstanding success. It is

ABOUT THE AUTHOR ­ Dr. Thomas McKenzie is President of the San Joaquin Medical Society and is an Orthopedic Surgeon practicing in Lodi.

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Param K. Gill, M.D.

Vincent P. Pennisi, M.D.

Jennifer Phung, M.D.

Jasbir S. Gill, M.D.

David L. Eibling M.D.

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Kimberly McLaughlin, M.D.

Darrell R. Burns, M.D.

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Tonja Harris-Stansil, M.D.

Catherine Mathis, M.D.

Kevin E. Rine, M.D.

Jacqualin Miller, D.O.

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YOU DON’T PROFIT FROM SICK EMPLOYEES. WHY DOES YOUR HEALTH PROVIDER? In an industry built on fee-for-service care, Kaiser Permanente succeeds because we’re built around prevention and the highest quality care. One Harvard Business Review article described our care as “untainted by any economic conflict of interest.” * And in an industry report by The Economist, Kaiser Permanente’s care was described as promoting economy and quality care with “no financial motive to order unnecessary procedures.”†

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FALL 2013

A message from our President > Thomas McKenzie, MD

FALL 2013

increase health care costs in California by $9.5 billion annually. Read the study yourself at the following link: http://www.micra.org/studies-research/ documents/HammReport2011_000.pdf Which way do you think premiums will go? Roughly multiply your current premiums by a factor of 4 to reflect the $250,000 to $1.1 million increase, and you have a ballpark increase of what this will do

“

Along comes

Attorney General to repeal California’s Medical Injury Compensation Reform Act(MICRA).

If you don’t think they are serious, check out their websites. Or go to Sacramento, San Francisco, or the Southland to listen to their commercials already blanketing the airwaves.

If successful, the trial attorney’s efforts will cause malpractice rates to skyrocket, and

MICRA challenge version

“

our great luck to have such an effective CMA lobbying organization to get our common sense point of view through to some legislators who have minimal understanding of the practice of medicine, the enormous financial pressures we are all under while trying to deliver quality care to our patients.

My sense is that a lot of physicians have heard this cry of wolf year after year, and have become somewhat complacent about the fact that MICRA repeal can easily destroy their practices literally overnight.

Growing up on a ranch on Woodbridge Road outside of Lodi, surrounded by grapevines, hoe or shovel in hand most of the summer, I heard a common statement from my mother. “Give them an inch…… they’ll take a mile.” It is an understatement to say that my mother was pretty strict with her three sons. I have no doubt what she would say about the trial lawyers.

I applied another saying as a company commander in the Army while stationed in Germany. “There are three types of people in this world……those who make things happen, those who watch things happen, and those who wonder what the ****** happened.” (Fill in your own asterisks, the Army ones are not repeatable.)

Along comes MICRA challenge version 2013…a proposed ballot measure to increase the speculative, non-economic damages from the current $250,000 to $1.1 million, reflecting an “inflationary adjustment” of the cap since the enactment of MICRA in 1976.

Also included are mandatory unannounced urine tests for physicians.

Seems appropriate to the casual observer trial lawyer, cost-of-living goes up every year, shouldn’t the cap? Shouldn’t physicians be tested like professional athletes? (Who is doing performance enhancing drugs in medicine, and what am I missing out on?)

Can’t we just trust trial lawyers when they say their efforts to rewrite the California Injury Compensation Reform Act are for the best interests of California patients? Well… maybe not. A recent study by California’s former independent non-partisan Legislative Analyst found that doubling MICRA’s noneconomic damages cap to $500,000 would

2013…a proposed ballot measure to increase

the speculative, non-economic damages from the current $250,000 to

$1.1 million ,

reflecting an “inflationary adjustment” of the cap since the enactment of MICRA in 1976.

to your practice bottom line in the first year.

We all become part of a mass extinction.

Looking at recent year premiums, I have enjoyed slowly decreasing premiums over the last several years. I’ll bet most of you have too. It is the bright spot of my annual review of practice expenses. A brief look at 2012 NORCAL premiums is instructive.

General Surgeons in San Joaquin County average a $28,147 annual premium. NonInvasive Internists average a $7,976 annual premium. Obstetrician/Gynecologists average a $38,865 premium. In contrast, the average of medical malpractice hell-holes to include Florida, New York, Michigan are significantly higher-$146,214 for General Surgeons, $38,514 for Internists, $171,504 for OB/Gyns.

On May 2, 2013, a coalition—including the Consumer Attorneys of California and the trial lawyer-funded Consumer Watchdog group—announced intentions to seek to overturn California’s landmark Medical Injury Compensation Reform Act (MICRA) through a ballot initiative. On July 24, 2013, language was submitted to the California

recreate the same conditions that threatened to throw California’s health care system into crisis during the early 1970s. Prior to MICRA, out-of-control medical liability costs were forcing community clinics, health centers, physicians and other health care providers out of practice. It can easily happen again. Give them an inch…they’ll take a mile.

California’s MICRA has been a national success story with broad public support and has safeguarded both patients and our health care delivery system for decades. It is a model for numerous other states trying to achieve medical malpractice reform. The alternative proposed by the trial lawyers would severely impede our county and state’s ability to provide health care to our patients. United We Stand. There are three types of people in this world……….

Oh, by the way, did I mention that I’m an optimist?

SAN JOAQUIN PHYSICIAN

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Letter From The Executive Director

STAFF REPORT

SUMMER OF “FIRSTS”

T

here have been so many eventful “firsts” for me this summer at SJMS! We kicked off the summer with our annual membership dinner to honor Lifetime Achievement Award recipient, Dr. Marvin Primack. It was wonderful to have so many of you in attendance as we celebrated his many accomplishments!

LISA RICHMOND

I would have to say the highlight of my summer was facilitating my first Decision Medicine Program. What an inspiring group of young people! This is an outstanding program and a great example of how SJMS is making a positive impact on the community in which we work and live. We are always looking to further the involvement of our physician members. Please call us if you are interested in participating in next year’s program. I invite you to read more about the 2013 Decision Medicine Class on page 60.

{

I AM EXCITED TO WORK ALONGSIDE OUR NEW PRESIDENT, DR. THOMAS MCKENZIE AS WE TACKLE IMPORTANT ISSUES THAT WILL IMPACT THE WAY YOU PRACTICE MEDICINE IN SAN JOAQUIN COUNTY, SUCH AS THE AFFORDABLE CARE ACT AND THE RECENT ATTACKS ON MICRA. I am excited to work alongside our new President, Dr. Thomas McKenzie as we tackle important issues that will impact the way you practice medicine in San Joaquin County, such as the Affordable Care Act and the recent attacks on MICRA. Your membership is more important than ever as we stand united to weather the storms that are inevitably coming our way soon. You will find more details in the message from your President on page 6.

As we enter fall, the season for change, we want you to know we are here to help!

Look for Jessica Peluso, Membership Coordinator in your office soon. She will be visiting offices to inform you and your staff about the many resources available at SJMS and CMA. Aloha,

Lisa Richmond

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FALL 2013

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FRAUD

&ABUSE WHAT PHYSICIANS NEED TO KNOW TO COMPLY WITH STATE AND FEDERAL LAWS

M

ost physicians strive to work ethically, providing highquality medical care to their patients and submitting proper claims for payment. Unfortunately, the presence of some dishonest individuals has created the need for laws that combat fraud and abuse in the health care system. This trend has intensified with the passage of federal health reform legislation in 2010.

The laws covering “fraud and abuse” have proliferated and broadly prohibit activities, some of which physicians may have in the past undertaken in good faith. Depending on the law, violations may be punishable by criminal and civil penalties, civil monetary penalties, payment suspensions, mandatory or discretionary exclusion from state and federally funded health programs, including Medicare, and other sanctions such as licensure actions or asset forfeitures.

This article examines the most important fraud and abuse laws that apply to physicians.

kickback statute prohibits knowingly and willfully offering, soliciting, paying or receiving remuneration (essentially anything of value), directly or indirectly, in exchange for or to induce patient referrals for which payment can be made under a federal health program, or to induce recommending or arranging for the purchase of items or services covered by a federal health program.

The statute has been interpreted broadly to include any kind of compensation, and to apply so long as one purpose of the compensation is to induce referrals. Violation of the statute is punishable by a $25,000 fine and up to five years imprisonment and is grounds for exclusion from the Medicaid and Medicare programs.

Violation of the statute also exposes the violator to civil monetary penalties. The statute and accompanying regulations, however, provide safe harbor provisions that, if met, guarantee compliance with the law.

_________________________________________________________________________

CMA On-Call

_________________________________________________________________________

Throughout this article, you will find references to “CMA On-Call” documents. On-Call is the California Medical Association’s online health law library. On-Call documents are available free to members at www.cmanet.org/cma-on-call. Nonmembers can purchase documents for $2 per page. _________________________________________________________________________

Anti-kickback laws

_________________________________________________________________________

Both California and federal law prohibit kickbacks and fee splitting by physicians and other health care providers. The federal anti-

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CMA > Fraud & Abuse

has a financial relationship with the entity, offering, accepting or accepting receiving consideration (in offering, or receiving consideration (in the arrangement fits within an exception. the form of money or otherwise) as compensation the form of money or otherunless wise) as compensation If the self-referral prohibition or inducement to refer patients, clients or or inducement to refer patients, clients or applies and an exception is not applicable, the physician customers.

Unlike the federal statute, which only customers.

Unlike the federal statute, which onlymay not make a referral to the entity for designated applies to referrals of patients whose medical applies to referrals of patients whose medical health serviceshealth covered by Medicare services are paid by aare government health services paid bycare a government care and the entity may not, directly or indirectly, bill for program such as Medicare, the California statute program such as Medicare, the California statute any designated healthpayor services resulting from a applies to referrals irrespective of the payor applies to referrals irrespective of the prohibited referral. (including commercial payors). (including commercial payors).

has a financial relationship with t unless the arrangement fits within If the self-referral prohibition app exception is not applicable, the ph not make a referral to the entity fo health services covered by Medic entity may not, directly or indirec any designated health services res prohibited referral.

California alsonot broadly prohibits WhileW thehile California statute does not includestatute the California does include physician self-referral of patients regulatory safe harbors, itsafe includesharbors, broad regulatory it includes broad pursuant to the Physician statutory exemptions, such as the payment of fair statutory exemptions, such as the payment of fair Ownership and Referral other market value compensation services other market valueforcompensation for services of 1993, which is also than than the referral of patients.

Violation of patients. the law is Act Violation the referral of of the law is known as the Speierby Act.up The to one a criminal offense that is offense punishable by that up to oneis punishable a criminal California statute applies year in prison in or fines up to $50,000. year prison or fines up to $50,000. to all patients regardless For more For information moreon information anti-kickback laws, see on anti-kickback of who pays for the laws, health see California California Medical Association Medical (CMA) On-Call Association (CM A) On-Call care services. California’s document document #1151, “Prohibitions #1151, Against “Prohibitions Kickbacks Against Kickbacks statute also provides a and Fee-Splitting.” and Fee-Splitting.”

On-Call documents are On-Call available documents are available broad exception allowing free tofree members toinmembers CMA’s online resource in CM libraryA’s at online resource library at physicians to refer http://www.cmanet.org/cma-on-call. http://www.cmanet.org/cma-on-call.

Nonmembers Nonmembers patients to a hospital can purchase can purchase documents for $2documents per page. for $2 with per which page. they have ______________________________________________________ ______________________________________________________ a financial relationship, so long as the hospital Self-Referr al eferr Laws Self-R al L aws does not pay the physician ______________________________________________________ ______________________________________________________ for the referral and any equipment Both Both state and federal lawand prohibit physicians law prohibit physicians state federal lease between the parties satisfies certain from from referring patients for goodspatients or services in for goods or services in referring requirements. whichwhich the physician or physician’s immediate the physician or physician’s immediate family has a financial interest, with some family has a financial interest, with some For more information on self-referral laws, exceptions. exceptions. see CMA On-Call document #1156,

California also broadly prohibits physician self-referral of patients pursuant to the Physician Ownership and Referral Act of 1993, which is also known as the Speier Act. The California statute applies to all patients regardless of who pays for the health care services. California’s statute also provides a broad exception allowing physicians to refer patients to a hospital with which they have a financial relationship, so long as the hospital does not pay the physician for the referral and any equipmen lease between the parties satisfies requirements.

“Self-Referral Prohibitions (Federal and

In general, federal self-referral laws (known as the In general, federal self-referral laws (known as the California).”

“Stark” laws) prohibit a physician from makinga physician from making “Stark ” laws) prohibit a referral to an entity for thean provision of certain a referral to entity for the provision of certain “designated health services”health (including hospital “designated services” (including hospital inpatient and outpatient services) if the physician services) if the physician inpatient and outpatient

For more information on self-referra see CM A On-Call document #1156, “Self-Referral Prohibitions (Federal California).”

OIG clarifies to disclose health caredisclose fr aud voluntarily OIG clhow arifies how to heal The OIG document also details how toof disclose certain types of fraud The U.S. The Department U.S. Department of Health and Human Services of Health Office of Inspector and Human Ser v ices Office Inspector andSelf-Disclosure abuse, such as false billing, employing an individual the OIG General General (OIG) has updated (OIG) its “Provider has updated Self-Disclosure its Protocol,” “Prov in an ider Protocol,” in on an exclusions listreturning and potential anti-kickback and physician self-referral attempt attempt to make reporting to make potentialreporting fraud and returning potential overpayments fraud and overpayments less painful less for painful practices and for facilities. practices and facilities. violations.

The OIG and abu exclusio v iolatio

uncovering of potential fraud can achievePhysicia a In 15In years, 15 more years, than $280more million has than been returned $280 to federal million health hasPhysician beenpractices returned toinstances federal health more favorable outcome when disclosing systemic programs programs through a self-disclosure through process, a self-disclosure where physicians and process, where physicians and problems voluntarily,more fav thanMedicare having them discovered by the government hospitals hospitals voluntarily report voluntarily instances of falsereport Medicare billing, instances antiofrather false billing, anti- or brought to rather th the government’s attention by a whistleblower.

Practices face tougher the gove kickback k ickback violations or v theiolations like. In the new or publication, the like.

OIG hasIn provided the new publication, OIG has prov ided penalties when the OIG initiates a fraud finding.from penaltie moremore transparency transparency about the process, including about whatthe is expected process, from including what is expected physicians physicians and how to have and a successful howresolution. to have a successful resolution.

The OIG Provider Self-Disclosure Protocol is available at https://oig.hhs.gov/The OIG compliance/self-disclosure-info/files/Provider-Self-Disclosure-Protocol.pdf. complian

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A new threat from an old fr aud law ____________________________________________________________________

Civil Monetary Penalty Law

____________________________________________________________________

The federal civil monetary penalty law prohibits hospitals from knowingly paying, directly or indirectly, physicians to “reduce or limit services” provided to Medicare and Medicaid beneficiaries who are under the direct care of the physician.

According to the U.S. Department of Health and Human Services Office of the Inspector General (OIG), which enforces the law, whether the services are medically necessary or prudent, is irrelevant under the civil monetary penalty statute. The OIG also believes that payments to incentivize use of comparable, but less expensive items (i.e., product substitution) violate the law, because it limits choices.

Violations are punishable by fines of up to $2000 per patient, which can be assessed against both the hospital and the physician.

While there are guidelines, exceptions and safe harbors to the civil monetary penalty law, anti-kickback and self-referral laws, this area of law is ripe for government enforcement. As such, it is critical that physicians obtain counsel with respect to any physician-hospital alignment arrangement. For more information, see CMA On-Call document #1103, “Fraud and Abuse (Federal and California Law),” and #0317, “Physician Alignment Models” ____________________________________________________________________

Antitrust Laws

The Affordable Care Act (ACA) gives the government more power and dedicates more money to improving federal efforts against health care fraud, waste and abuse. The ACA expands an old law, the False Claims Act (FCA), and places physicians’ business practices under the microscope like never before.

The statute, enacted in 1863 during the Civil War, protects against the submission of fraudulent claims by government contractors and enforces strict penalties for such violations. The ACA expanded the reach of the law and made it easier for federal investigators to launch FCA cases against alleged violators.

Of 2,309 civil and criminal cases — including FCA cases — opened in 2012 by the U.S. Department of Health and Human Services Office of Inspector General (OIG), 21 percent involved physicians, compared with about 15 percent in 2010, according to OIG data.

Under the FCA, a violation occurs when a person knowingly presents, or causes to be presented, a false or fraudulent claim for payment; knowingly creates, uses or causes a false record; or conspires with others to issue such a record or claim.

For physicians, a broad range of scenarios put them afoul of the FCA, including filing false codes for payment, making improper referrals and participating in Medicare kickback schemes. Physicians can face treble damages (i.e., three times the amount of collections received as a result of the false claims) and civil fines for violating the FCA, a percentage of which might go to compensate whistle-blowers who first alerted the government to the alleged fraud.

Violations also can bring increased monitoring going forward or exclusion from government programs.

While criminal health fraud enforcement has targeted hot spots such as California, Florida, New York and Texas, FCA investigations have not been as geographically focused.

____________________________________________________________________

Antitrust laws prohibit conduct that has unreasonable anticompetitive effects. These laws generally prohibit conduct by or among two or more competitors, such as contracts, combinations and conspiracies that unreasonably restrain trade, or by single entities that become so large that they become a monopoly. The basic objective of antitrust laws is to eliminate practices that unreasonably interfere with free competition, so that each business has a fair opportunity to compete on the basis of price, quality and service. These laws should be considered when physicians, hospitals, payors and other providers integrate, collaborate or otherwise coordinate their activities.

Because of the important economic underpinnings reflected in antitrust laws, penalties for violating them are significant.

Criminal violations of the Sherman Act, for example, are felonies punishable by imprisonment for up to three years and/ or fines of up to $350,000 for individuals and $10 million for corporations per violation. A criminal conviction virtually assures civil liability. Judgments for civil violations often run in the millions, particularly since a private party can recover FALL 2013

The first step to complying with FCA requirements is to know what the rules are and how they apply to individual physician practices. The OIG provides general compliance guidance to all health professionals, but particular risk areas vary depending on industry circumstances.

Physicians should implement written policies, procedures and standards of conduct related to compliance expectations. Such documentation should identify how compliance issues are investigated and resolved in your practice, and it should include policies of non-intimidation and non-retaliation for employees who report potential violations.

Promoting overall transparency and a culture of compliance also is important.

Physicians should maintain detailed records and report any potential violations to authorities immediately, as and when appropriate. All levels of employees, from senior management to entry-level workers, should receive regular compliance training.

For more information on avoiding fraud and abuse in the Medicare and Medicaid programs, visit the OIG website at https://oig.hhs.gov/compliance/physician-education.

SAN JOAQUIN PHYSICIAN 15

CMA > Fraud & Abuse

Internet Inter coupon net sitescoupon may put physicians sites in violation m ay ofput state state and feder aal nd kickback feder laws al k ick back l aw In an effort Intoan boosteffort a medical practice, to boost a medical practice, three times the amount of damages actually sustained and recover a number a of number physicians haveof begun physicians have beg un other costs and attorneys’ fees incurred in prosecuting the action— fees offeringoffering discounts for their discounts medical for their medical which often exceed a million dollars. servicesser through v ices internet-based through coupon internet-based coupon Antitrusteach violations can arise, for example, if a physician-hospital companies companies (e.g., Groupon). While (e.g., each Groupon). W hile alignmentagrees arrangement becomes so large that it is exercising substantial deal varies, deal typically varies, the physician t yagrees pically the physician market power in the relevant area. Similarly, to the extent a hospital to give the tocoupon give company the acoupon percentage company a percentage physician organization are otherwise competing organizations, an of the revenue of the obtained revenue by the physician obtained by the and physician between them could conceivably be challenged as a restraint from patients from using patients the coupon (reports using the couponalignment (reports of trade unless they for are sufficiently integrated for purposes of the suggestsuggest as high as 50 percent) as high in returnas for 50 percent) in return antitrust laws. the company’s the company’s promotion of the practice promotion of the practice throughthrough various types of various coupons or “daily t y pes of coupons or “daily For more information on antitrust laws, see CMA On-Call document #1000, deals.” deals.”

“The Antitrust Laws: What Physicians Can Do.” For more information on

antitrust laws such as they relate to Accountable Care Organizations, see CMA The primary The riskprimar to physiciansy using risk such to physicians using On-Call document #0300, “Legal and Practical Considerations Concerning third-party third-part coupon programs yiscoupon that they programs is that they Accountable Care Organizations (ACOs).” may runmay afoul of run state andafoul federal antiof state and federal antikickback klaws ickback that provide,laws among other that prov ide, among other _____________________________________________________________________________ things, things, that it is unlawful that for a physician it is unlaw to f ul for a physician to Tax Exempt Status offer any offer discountany or otherdiscount consideration or other consideration _____________________________________________________________________________ as compensation as compensation or inducement for or inducement for Tax laws are implicated when a hospital, or a 1206(ℓ) medical referring referring patients, or to split patients, professional or to split professional is tax exempt pursuant to Internal Revenue Code §501(c) fees with fees a partyw who ith procures a part patientsy who procures foundation, patients (3). Health care issues have received priority by Internal Revenue for, or refers for, patients or refers to the physician. patients to the physician.

Service (IRS) enforcers for a number of years. In general, in order to qualify for tax exemption under Section 501(c)(3), an entity must Even if Even the patientsif obtaining the patients the benefits obtaining the benefits organizednonand operated exclusively for charitable purposes, with of such of coupons such are cash-based coupons and non-are cash-basedbeand no part of its earnings going to the benefit of a private shareholder or insured,insured, the activity may the raise significant activ it y may raise significant individual. The IRS looks to a number of factors when evaluating the legal issues legal for physicians. issues Accordingly, for physicians. Accordingly, qualifications of a health care organization for tax exemption. physicians physicians should act with great should caution act w ith great caution in this area in and this only after area obtaining and theonly after obtaining the While the of maintaining tax-exempt status, and liabilities advice of adv an attorney ice experienced of an attorney in health ex perienced inburdens health for failing to do so, generally rest with the tax-exempt organization, care fraud care and abuse fraud laws. and abuse laws. penalties can also be imposed on private parties (which could include physicians ifhas they are in a position of influence at a tax-exempt The California The Medical California Association has Medical A ssociation organization) confirmed confirmed that the Medical Board that of the Medical Board of who receive “excess benefits” in a transaction with a taxexempt organization.

Accordingly, physicians who exercise influence California California is looking at this issue is with look ing at this issue w ith with a tax-exempt organization should be scrupulous in conducting respect respect to its legality under to California’s its legalit y under California’s business with that organization.

MedicalMedical Practice Act. Practice Act. For more information, see CMA On-Call document #0305, “Legal and For more, For see CMA more On-Call , see document C M A On- Call document Practical Considerations #0104 “Practice #010Promotion 4 “P rac Through tice ThirdP romotion Through Third- Concerning Medical Foundations.” Physicians are strongly urged to consult with qualified legal counsel because the Party Coupons.”

Par t y ForCoupon general information s .” For general infor mation for qualification and maintenance of Section 501(c)(3) taxon physician on advertising, physician see CMAadver Ontising , see C Mrequirements A Onexempt status Call document Call#0102, document “Advertising by#0102 , “Adve r tising by are extremely detailed and complex.

Physicians.”

Physician For more information s .” For on the more infor mation on the state and state federal kickback and prohibition, federal k ickback prohibition , see CMA see On-Call CM document A On#1151,Call document #1151, “Prohibitions “P rohibition Against Kickbacks s andAgain Feest K ickback s and Fee Splitting.”

Splitt ing.”

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FALL 2013

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Karen K. Davis, MA, CPHRM l Risk Management NORCAL Mutual Insurance Company

REPORTING

UNSAFE DRIVERS KNOW YOUR OBLIGATIONS!

CASE

Consider the following case scenario: A physician had a 42-year-old male patient who was a diabetic on insulin. This patient lost consciousness while he was driving, and his car struck two pedestrians, a woman and her 10-year-old son. Both pedestrians suffered severe injuries as a result of the accident. The woman later sued the driver’s physician, alleging that the physician was liable for the actions of his patient, which resulted in the injuries to her and her son. She asserted that the patient’s diabetes caused him to suffer a temporary loss of consciousness with loss of control of his vehicle, ultimately resulting in the crash. She claimed that the physician had neglected his duty to report the patient as an unsafe driver to the state’s department of transportation and was therefore responsible for the injuries to the third-party victims (her and her son).

CASE DISCUSSION

At trial, this case was decided in favor of the defendant physician. Attorneys for both sides acknowledged that physicians in that particular state have a responsibility to report to the department of transportation when a patient is unable to drive in a safe manner. The patient in this case, however, was not an unstable diabetic, and he had never before experienced a loss of consciousness as a result of his diabetes. Therefore, the jury ultimately decided the physician had properly evaluated the patient’s ability to drive and did not owe a duty to the accident victims.

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Risk Management > Unsafe Drivers

LIABILITY RISK REDUCTION

Although the physician in this case was not held liable, there is a possibility that physicians across the United States could be answerable for injuries or property losses affecting third-party victims but caused by patients. Therefore, if you are in medical practice, you should know what conditions are reportable to your specific transportation department (or local health officers or other officials or agencies working in cooperation with the transportation department), and you should report as required when, in your clinical judgment, a patient meets the criteria.

Most states set forth a list of what is reportable, and the lists often include conditions such as epilepsy, unstable diabetes, cerebral vascular insufficiency, neuromuscular diseases, loss or impairment of a limb, mental or emotional disorders, visual impairment, substance abuse, and other conditions that could hinder safe driving. Physicians are generally required to report when they diagnose a person with a disease or disorder that would interfere with a patient’s safe operation of a motor vehicle. Generally, the physician is responsible for reporting, but the transportation department makes the decision about whether to retest the driver and/or to revoke a patient’s privilege to operate a motor vehicle.

WHAT DOES MY STATE REQUIRE?

Each state has its own laws governing reporting procedures and obligations. To find information about your state’s department of transportation reporting requirements, you can consult an American Medical Association resource “State Licensing and Reporting Laws” (a chapter of the Physician’s Guide to Assessing and Counseling Older Drivers) at www.ama-assn.org/ama1/pub/upload/mm/433/older-drivers-chapter8.pdf. This publication summarizes transportation department reporting laws for all states and the District of Columbia. As the publication notes, however, this information is subject to change, and therefore you may want to verify the data by searching for current medical reporting requirements on your particular state’s department of transportation website. The AMA publication lists the web address for each state’s transportation department, which may make your search easier. The decision about whether or not to report can be very fact-specific. You may want to consult your attorney to advise you in complicated situations.

REPORTING AND CONFIDENTIALITY

In some states, information about a patient’s condition may be released to the transportation department without the patient’s consent, and no civil or criminal action may be brought against a physician for providing the information required under the state’s system.

The federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules require physicians and other covered entities to protect the confidentiality of patient’s health information. However, HIPAA does not prevent physicians and other healthcare providers from disclosing patient information that is required by law.1 Therefore, if your state has mandatory reporting of medical conditions that impede safe driving, you should submit the information your state calls for to identify the person and describe the problem limiting driving ability.

If your state allows or authorizes (but does not mandate) reporting of patients whose conditions create driving hazards, your report will be affected by the HIPAA “minimum necessary” rule. To comply with the rule, you will need to consider the situation and then release only the minimum necessary patient information required to make a reasonable and comprehensible report.2 Before making a report, you should discuss with the patient your examination and your conclusion that the patient’s driving ability is impaired. You should advise the patient that you will be reporting the circumstances to the appropriate state department or agency. After recommending that a patient stop driving, having a conversation to get the patient’s feedback and to explore the patient’s ideas for alternate transportation can help the patient anticipate and adjust to coming changes.

Discussion can contribute to the patient’s acceptance of a non-driving status. You should document in the patient’s medical record about the substance of your discussion.

CONCLUSION

In the case that opened this article, the diabetic patient’s situation did not match the reporting criteria established by his state’s law. Although the physician was sued, he was able to show he was in compliance with his state’s requirements. As a physician, you should be aware that if you have a patient who, in your clinical opinion, meets the state’s reporting threshold, you have a duty to notify the transportation department about that patient. Two potential consequences, depending on the laws of your state, might result from neglecting your reporting duty: you could be held responsible as a proximate cause of a patient’s motor vehicle accident and/or you could face a challenge to your medical license. Both possibilities are best avoided through knowledge of and compliance with your state’s statutes on transportationdepartment reporting.

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HOW TO REPORT:

VISUAL STANDARDS: A patient falls outside the allowed

Report in writing to the local health officer the name, date of birth, and address of the person.1 The report can be made on a Confidential Morbidity reporting form, which can be found online at: www.cdph.ca.gov/pubsforms/forms/CtrldForms/pm110.pdf.

standards and may not drive if he or she does not have visual acuity of at least 20/200 best corrected vision in at least one eye.5

THE LOCAL HEALTH OFFICER WILL NOTIFY THE DMV, AND THE DMV WILL DECIDE IF: • Driving privilege should be immediately suspended.

• Reexamination is necessary.

• No action should be taken.2

WHEN TO REPORT:

Applicants for drivers’ licenses must pass a screening test with a standard of: • 20/40 with or without correction with both eyes tested together • 20/40 in one eye and 20/70 or better in the other eye with or without correction.

Those who don’t meet the screening standard must submit an eye examination report form signed by an ophthalmologist and must take and pass a driving test.5

Within seven days of diagnosing the reportable condition.3

FOR MORE INFORMATION: This chart presents excerpts WHAT TO REPORT: Must be reported: Disorders “characterized by lapses of consciousness,...[including] Alzheimer’s disease and those related disorders that are severe enough to be likely to impair a person’s ability to operate a motor vehicle.”1 “Disorders characterized by lapses of consciousness” are defined in regulations as medical conditions that involve: • A loss of consciousness or a marked reduction of alertness or responsiveness to external stimuli.

• The inability to perform one or more activities of daily living.

• Impairment of the sensory motor functions used to operate a motor vehicle.4

from the law to give an overview of reporting requirements.

For more information, see: www.dmv.ca.gov/dl/driversafety/dsmedcontraffic.htm For complicated situations, you may want to contact your attorney for advice.

REFERENCES 1 California Health and Safety Code § 103900.

2 DMV’s Reexamination Process, www.dmv.ca.gov/pubs/brochures/fast_facts/ffdl27.htm.

Accessed April 4, 2013.

3 17 CCR § 2810(a).

Types of medical conditions that may evolve to a severity level that would make driving unsafe are Alzheimer’s disease, dementia, seizure disorders, brain tumors, narcolepsy, sleep apnea, and abnormal metabolic states (including diabetes).4

4 17 CCR § 2806.

5 California Department of Motor Vehicles. Vision Conditions. http://www.dmv.ca.gov/dl/driversafety/vision_cond.htm.

Accessed April 2, 2013.

May be reported: Any condition that in the physician’s opinion would affect a person’s ability to safely operate a motor vehicle.1 Form for reporting unsafe driving conditions available at: http://apps.dmv.ca.gov/forms/ds/ds699.pdf

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THIS IS NOT A TEST Trial Lawyers have begun an all out assult on MICRA, California’s landmark tort reform law.

Join the Fight Today! Every dollar contributed to CALPAC goes directly to protecting MICRA, ensuring that your doors stay open.

Visit www.cmanet.org/micra or call 916.444.5532 for more information.

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Trial lawyers’ money grab threatens to

OVERTURN MICRA California’s trial attorneys launched an all-out assault on California’s historic tort reform law in early May of this year, which since 1975 has helped keep malpractice premiums in-check and ensured that California’s patients have access to affordable health care.

On July 24, 2013, a coalition—including the Consumer Attorneys of California and the trial lawyer-funded Consumer Watchdog group—announced intentions to seek to overturn California’s landmark Medical Injury Compensation Reform Act (MICRA) through a ballot initiative. This initiative will result in more frivolous lawsuits and increased payments to the lawyers who file them.

If successful, the trial attorney’s efforts will cause malpractice rates to skyrocket, and recreate the same conditions that threatened to throw California’s health care system into crisis during the early 1970s. Prior to MICRA, out-of-control medical liability costs were forcing community clinics, health centers, physicians and other health care providers out of practice.

California’s MICRA has been a national success story with broad public support and has safeguarded both patients and our health care delivery system for decades. Risky reforms like the ones being threatened by the trial lawyers would severely impede our state’s ability to provide health care to the poorest and most vulnerable patients. At a time when we are trying to implement federal health care reform and provide access to health care to all Californians, this is the worst possible overreach at the worst possible time.

“The threat of a ballot measure is nothing more than a money grab by trial lawyers,” says CMA President Paul R. Phinney, M.D. “And one that will come at the expense of higher health costs for all patients and decreased access for patients and clinics already struggling to keep their doors open. We cannot and will not let that happen.”

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Physicians will be victorious in this fight, but in order to do so, we need your help.

DONATE: A fight of this magnitude will be extremely costly. The California Medical Association (CMA) is urging all physicians to consider a donation to CMA’s political action committee (CALPAC), which for the last 38 years has served as the first line of defense for California’s historic physician protections.

JOIN: And if you are not already a member of CMA and SJMS, please consider joining today. By joining CMA / SJMS, you will help to ensure that the voice of California physicians is heard loud and clear in the Capitol and beyond. Together, our unified voice can move mountains.

SPEAK OUT: Sign up to be a CMA / SJMS Key Contact. As a Key Contact, we will provide you with all the tools you need to quickly and effectively deliver your message to legislators, from talking points to sample letters. CMA has some of the best lobbyists, lawyers and other advocates in the Capitol, but the most powerful weapon in advancing the cause of physicians and their patients is you. Hearing from a physician with experience from the frontlines of medicine can make all the difference for a legislator facing a complicated health care issue such as MICRA.

For more information on MICRA, and what you can do to help in the fight, visit www.cmanet.org/micra or call the SJMS office today at (209) 952-5299.

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In The News

IN THE

NEWS American Red Cross Acquires Delta Blood Bank Delta Blood Bank, a non-profit community blood bank with an excellent 55-year record of serving Northern California. Delta Blood Bank will become a wholly owned subsidiary of the American Red Cross.

The agreement is a mutual business decision which benefits both the Red Cross and the hospitals and patients served by Delta Blood Bank. The areas served by Delta Blood Bank include the five counties of San Joaquin, Stanislaus, Tuolumne, Calaveras and El Dorado.

The acquisition of Delta Blood Bank by the Red Cross will include all of Delta Blood Bank collection facilities and employees. Delta Chief Executive Officer, Dr. Benjamin Spindler will continue to oversee the Delta day-to-day operations.

‘This initiative is an effort by both organizations to control costs and to continuously improve operations and high-quality service” said Joan Manning, vice president of Red Cross Blood Services Western Division. “Additionally, this transition will result in economies of scale and blood collection efficiencies which will benefit patients, hospitals, large healthcare systems and our communities as a whole.”

“We are very excited to be working with the Red Cross” said Dr. Benjamin Spindler, CEO of Delta Blood Bank. “We remain 100 percent committed to providing a wonderful experience for all Red Cross and Delta blood donors – while maintaining a safe and adequate blood supply for area hospitals.”

Delta Blood Bank and the Red Cross are committed to a smooth and seamless transition that ensures continued availability of blood and the specialized services needed to support hospitals and patients in need of blood transfusion.

CAMGMA seeking physician participation in medical staff salary survey The California Medical Group Managers Association (CAMGMA) is asking physicians to participate in its annual Medical Staff Salary Survey. The survey collects salary and benefits information for almost 100 medical practice staff

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

Cyrus Buhari, DO, MS positions from 30 different specialties. Participants will receive free access to the survey results. The survey is open until September 15.

To participate in the survey visit http://www.camgma.com.

Cyrus Buhari, DO, MS Dr. Cyrus Buhari grew up in Stockton, California where he attended Lincoln High School. He obtained a Bachelor of Science degree in Biomedical Engineering in 1996 from Boston University. He then completed a Master of Science degree in Biomedical Engineering from the University of Southern California.

Dr. Buhari attended Western University of Health Sciences/ COMP for medical school and then completed internship and residency in Internal Medicine at UCSF Fresno Medicine

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Education Program. Following a year as Chief Resident in Internal Medicine, he became part of the inaugural class of the Adult Cardiovascular Disease Fellowship matriculating in 2007 and graduating in 2010. Following six months as UCSF Fresno core cardiology faculty, he then completed the Interventional Cardiology fellowship as its inaugural fellow.

He is ABIM board certified in Internal Medicine and Cardiovascular Disease, and board certified in Interventional Cardiology. While in Fresno after finishing his advanced fellowship training he served as the Medical Director of the VA Central California Cardiac Catheterization laboratory and Associate Program Director of the Interventional Cardiology Fellowship program at UCSF Fresno.

He has special interests in high-risk coronary intervention, structural heart disease, and percutaneous ventricular support devices. He also developed and served as the lead Cardiologist for the HeartMate II Left Ventricular Assist Device (LVAD) program at Community Regional Medical Center in Fresno, CA. He is Assistant Clinical Professor of Medicine at UCSF and gives lectures for the teaching program throughout the year.

Dr. Cyrus Buhari has returned to his home town of Stockton to join in practice with his father at San Joaquin Cardiology Medical Group. He is a rabid San Diego Charger fan and attends home games throughout the NFL season with his wife and 2 children.

Introducing Brian Price, Physician Liaison Brian Price, new Physician Liaison for Dignity Health/St. Joseph’s, has maintained long-standing relationships within the San Joaquin County medical community as a pharmaceutical representative and manager. With over twenty years of experience in the health care industry, Brian is looking forward to re-establishing these professional connections in his new role as physician liaison for St. Joseph’s Medical and Behavioral Health Centers.

Brian will be responsible for promoting the hospital’s Heart Center, Regional Cancer Center, Women and Infants Center, Imaging Centers, and Behavioral Health Centers.

Please take advantage of the opportunity to contact Brian with any questions about the new programs and services available at St. Joseph’s or ways to make your interaction with the Hospital and Behavioral Health Center as easy and efficient as possible.

Brian Price, Physician Liaison Brian can be reached using PerfectServe, in his office at (209) 461-5109, on his mobile phone (209) 712-7362 or via email at brian.price@ dignityhealth.org

FALL 2013

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In The News

IN THE

NEWS Dr. Takeuchi is a graduate of the California School of Podiatric Medicine at Samuel Merritt University in Oakland, California.

He completed his internship at Scripps Mercy Hospital in San Diego and his residency at Kaiser Permanente in Sacramento and South Sacramento.

Dr. Matthew J. Takeuchi

Dr. Jaicharan Iyengar

Drs. Matthew J. Takeuchi and Jaicharan Iyengar Join Alpine Orthopaedic Medical Group in Stockton Alpine Orthopaedic Medical Group, Inc. of 2388 N. California Street, Stockton, California is pleased to announce the association of Matthew J. Takeuchi,

D.P.M., Podiatrist, and of Jaicharan J. Iyengar, M.D. Orthopaedic surgeon, who have recently joined the practice.

Dr. Takeuchi is a graduate of the California School of Podiatric Medicine at Samuel Merritt University in Oakland, California. He completed his internship at Scripps Mercy Hospital in San Diego

HAVE SOMETHING TO SHARE? We welcome submissions to our In-the-News Section from our community healthcare partners. We prefer Word files and .jpg images and may edit for space restrictions. Send your files to lisa@sjcms.org one month prior to publication (Aug 1 for the Fall issue, Nov 1 for the Winter issue)

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In The News

IN THE

NEWS “The SILVER-AMI study will help to identify risk factors in the older population in order to reduce hospital readmissions, complications, and mortality,” explained Dr. George Charos, St. Joseph’s physician champion for the study. “This is our second Yale sponsored clinical trial studying variables such as gender, age, and symptom presentation in the heart attack patient population.”

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and his residency at Kaiser Permanente in Sacramento and South Sacramento.

Dr. Takeuchi treats foot and ankle fractures, injuries, arthritis, and diabetic complications.

Dr. Iyengar is a graduate of the University of California, San Francisco School of Medicine. He completed his orthopaedic internship and residency programs at the University of California in San Francisco. He completed a fellowship at Columbia University in New York subspecializing in Shoulder, Elbow, & Sports Medicine. Dr. Iyengar specializes in shoulder and elbow issues, but also provides general orthopaedic care.

Drs. Takeuchi and Iyengar are accepting new patients and is a provider for most plans. To schedule an appointment, please call (209) 9467200.

For more information on Alpine Orthopaedic Medical Group, Inc., its providers and other services offered by Alpine Orthopaedic Medical Group, Inc., visit the group’s website, www.alpineorthopaedic.com St. Joseph’s Partners with Yale University for Cardiac Study St. Joseph’s Medical Center has partnered with Yale University to conduct to launch the Comprehensive Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction (SILVER-AMI) study to better understand what is driving outcomes in patients 75 years and

older hospitalized with heart attacks (myocardial infarctions). SILVERAMI is a five-year study that will enroll approximately 3,000 patients from 75 sites across the United States.

“The SILVER-AMI study will help to identify risk factors in the older population in order to reduce hospital readmissions, complications, and mortality,” explained Dr. George Charos, St. Joseph’s physician champion for the study. “This is our second Yale sponsored clinical trial studying variables such as gender, age, and symptom presentation in the heart attack patient population.”

This study will provide critical

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In The News

information about the fastest growing segment of the heart attack population – the elderly. Although growing in numbers, elderly patients have historically been excluded from cardiology clinical trials. As a result, clinicians are left with little information about how to best treat such patients, and patients are left with little information about what to expect after

their heart attack.

In addition to studying traditional medical outcomes, such as hospital readmission, the SILVER-AMI study is also focusing on outcomes that matter most to older patients – include ability to function independently, symptoms, and quality of life. “We are grateful for the tremendous support and commitment from St. Joseph’s Medical

You Have a Choice Choose Quality (209) 957-3888 www.hospicesj.org James Saffier, MD On-Site Medical Director Hospice & Palliative Care Internal Medicine

Center and Dr. George Charos for making this important study possible,” said Yale Associate Professor Dr. Sarwat Chaudhry.

To learn more about the SILVER-AMI study, please visit our website at www.silver. yale.edu. To learn more about St. Joseph’s Heart Center, visit www.StJosephsCares. org/Heart.

Wild Violets Alma Arthur, wife of the late Dr. William Arthur, recently published a book, “Wild Violets”. It is the story of the two dramatic decades between 1929-1949, which intertwines the events and happenings locally, nationally and globally with her coming of age and finally graduating from Charity Hospital School of Nursing.

There are survival stories of sharing and helping each other in the Great Depression; there’s Big Bands and jitterbugging, sports, horse racing, two world’s fairs, many funny and sad anecdotes, coverage of Pearl Harbor, the battles in the South Pacific and Europe. There are sad accounts of losing dear friends and relatives in WWII. Last is graduating from Nursing School and the myriad of tales of patients and the wonderful doctors with whom she worked. An autographed copy may be purchased from Alma for $22/paperback and $28/hard cover.

She may be reached at 209-477-3800.

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DocBookMD

DocBookMD

Case Study Join the mobile revolution Read how your colleagues all over California are taking advantage of the latest technology by using the DocBookMD app to securely send HIPAAcompliant messages directly from their iPad, iPhone and Android devices.

Case study A patient arrives in the emergency department (ED) after injuring his toe while mowing his lawn. The ED physician determines that the wound can be treated with antibiotics and local care. He calls the on-call orthopedic surgeon.

The ED physician describes the wound and what is shown in the X-rays to the orthopedic surgeon.

The orthopedic surgeon is unsure of the diagnosis, having just treated a patient who lost his toe due to necrosis after being lost in follow up. The orthopedic surgeon must decide whether to accept the ED diagnosis or go to the ED and see the patient in person.

Due to his recent experience, the orthopedic surgeon requests that X-rays and photos of the wound be sent to his smartphone through DocBookMD. Within minutes, the orthopedic surgeon reviews the images and agrees with the ED physician’s assessment of the wound. The patient does not need to see a specialist.

The patient is released from the ED much quicker and received more appropriate care. The orthopedic surgeon could be sure the wound was not severe and did not require him to see the patient in the ED. He avoided an unnecessary trip to the ED and was able to participate in his family event.

DocBookMD Physicians in California now have access to a tool that can help them communicate more efficiently and save time and money in the process. That tool is DocBookMD, a physicians-only smartphone app that allows physicians to:

• Send HIPAA-compliant text messages and photos. Message content can include diagnosis, test results, or medical history. Physicians can also add a high-resolution image of an EKG, an X-ray, lab report, or anything that can be photographed with a smartphone.

• Assign an urgency setting to outgoing text messages. Physicians can assign each message a 5-minute, 15-minute, or normal response time. If the physician does not answer the message within 5 minutes or if the message does not get to the physician, the sender will receive a message back stating that the message did not make it.

• Enable enhanced notifications. The physician can enter a cell phone number to receive text messages or an email address to receive notifications that DocBookMD messages are waiting. The email feature will send a weekly reminder to view DocBookMD messages.

Submitted by: Dr. A, orthopedic surgeon and trauma specialist, Austin TX

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• Search a local county medical society directory.

Physicians can look up other physicians in their county by first or last name or by specialty.

Physicians can then contact other physicians by messaging, office phone, cell phone, or email.

• Search a local pharmacy directory. Physicians can search for a local pharmacy alphabetically or find a pharmacy by zip code. Users can also create a “favorites” list of physicians or pharmacies.

DocBookMD is offered through county and state medical societies to their members and is currently available throughout 36 states.

Can you text that to me?

DocBookMD has been available since 2010 and currently more than 18,000 physicians use the app.

Dallas nephrologist Ruben Velez, MD uses the DocBookMD texting feature frequently. “It has made communication better and faster, particularly

about patients in hospitals,” he says. “I can also get a summary about discharged patients from the hospital.” Dr. Velez also uses the app to find contact information for referring physicians.

One of the most popular features of the app is texting, as DocBookMD offers physicians one of the only ways to text patient information securely and in a way that meets HIPAA requirements.

“As we say, a photograph is worth a thousand words, and with DocBookMD, I can have the emergency department physicians send me all the information, with a photograph of a hand injury, or a face laceration,” says Austin plastic surgeon Rocco Piazza, MD. “I know right where it is, and I can tell them right away what we need to do or where we need to go, assess whether it’s something I need to see right now, or if it can wait until morning.”

Texting features are one reason why medical professional liability carriers sponsor the app and support its use among physicians. Carriers believe DocBookMD can improve communication and help physicians practice safe medicine.

TMLT Chairman Stuart McDonald, MD, uses DocBook and is “particularly excited about the ability to contact physicians through a secure network to request consults or provide follow-up information. This saves a significant amount of time that would previously be spent on hold or waiting for a return call,” Dr. McDonald says. “The ability to know whether or not my message has been read in a timely manner helps prevent delays in patient care.”

Medical society benefits In addition to helping physicians communicate and collaborate, DocBookMD also helps medical societies build membership. This benefits physicians by creating a stronger medical society and a louder voice for physician advocacy.

Physicians also have access to a broader referral base and more opportunities for networking and community-building.

Join DocBookMD DocBookMD is available for iPad, iPhone, and Android devices and is provided at no charge to members of the California Medical Association.

To register or for more information, please visit www.docbookmd.com.

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SUMMER 2013

Members-Only Benefits

Contact CMA Today!

Members can offset the price of their annual dues when using CMA membership services and discounts. Thanks to CMA’s group buying power, members receive deep discounts on everything from magazines to office supplies to insurance products.

When you join CMA, you hire a powerful professional staff to protect the viability of your practice. By protecting your practice from legal, legislative, and regulatory intrusions, your CMA membership lets you focus on what’s really important: your patients.

1-800-786-4262 www.cmanet.org/benefits

Legal Services CMA On-Call: CMA’s Health Law Library has over 4,500 pages of up-to-date legal information on a variety of subjects of everyday importance to practicing physicians. Accessible to members at www.cmanet.org/cma-on-call or by calling 800.786.4262.

Legal Services: CMA’s legal department provides members with information and resources about laws and regulations that impact the practice of medicine. While CMA staff cannot provide physicians with individual legal advice, our health law information specialists, with the support of CMA legal counsel, will help you find legal information and resources on a multitude of healthlaw related issues.

Professional Development CME Tracking/Credentialing: CMA’s Institute for Medical Quality certifies CME activity for credentialing purposes to the Medical Board of California, as well as to hospitals, health plans, specialty societies, and others. CME Certification is $29 a year for CMA members, $49 for nonmembers. IMQ, 415.882.5151 or www.imq.org.

CMA Webinar Series: CMA’s webinar series gives physicians the opportunity to watch online presentations on important topics of interest and interact with legal and financial experts from the comfort of their homes or offices. The webinars are free to CMA members and their staff. All of our webinars are also archived for on-demand viewing at any time in our resource library. There are currently more than 100 archived webinars on topics ranging from HIPAA, to health reform, to coding, billing, and compliance. www.cmanet.org/webinars.

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FALL 2013

SJMS > Member Only Benefits

CMA Seminar Series: Experts from CMA’s various centers travel

CMA Practice Resources (CPR): CMA’s free monthly e-mail

to local county medical socities throughout the state, holding live seminars for members and their staff on a variety of issues.

Contact your local county medical society for more information.

bulletin from CMA’s Center for Economic Services. This bulletin is full of tips and tools to help physicians and their office staff improve practice efficiency and viability.

ICD-10 Training: The transition to ICD-

CMA’s Press Clips: CMA’s daily news roundup, provides a quick

10 will take strategic planning and considerable preparation. CMA has partnered with the largest and most respected coding organization, AAPC, to provide our members with a complete suite of ICD-10 solutions at steeply discounted rates. Visit www. cmanet.org/aapc for more information.

Certified Professional Coder Program: CMA members and their staff receive big discounts on Certified Professional Coder (CPC) training and certificates from AAPC. AAPC’s CPC credential is the gold standard for medical coding in physician office settings.

Contact your local county medical society for more information.

Practice Management CMA Reimbursement Help Center: Trouble getting paid? In the past two years, CMA’s practice management experts recouped over $5.5 million from insurance carriers on behalf of physician members. CMA provides members with one-on-one assistance to identify, prevent and fight unfair payment practices. Reach CMA’s reimbursement experts at 888.401.5911.

CMA Payor Contract Analysis: CMA members have free access to objective written analyses of major health plan contracts at www. cmanet.org/ces. Each analysis is designed to help physicians understand their rights and options when contracting with a third party payor, as well as which contract provisions are prohibited by California law.

Publications CMA produces a number of publications to keep members up to date on the latest health care news and information affecting the practice of medicine in California. Subscribe to any of these newsletters online at www.cmanet.org/newsletters.

CMA Alert: CMA’s bi-weekly e-newsletter provides up-to-date information on many issues of critical importance to California physicians.

CMA Reform Essentials: CMA Reform Essentials is a regular publication designed to provide readers with the latest developments of California’s implementation of federal health care reform.

FALL 2013

but meaningful overview of the day’s health care news.

Insurance Marsh Insurance Services: As the primary insurance advisor for CMA and its affiliated county organizations, Marsh offers a wide variety of sponsored insurance plans and services for members.

With healthcare reform impacting members as employers, you need to be speaking with a knowledgeable advisor to consider your medical plan offerings, in or out of the health exchange, for themselves, their employees and dependents in the months and years ahead.

Designed to cover a multitude of insurance needs for your practice and personal needs the sponsored plans include three types of disability plans, three group life insurance programs, workers’ compensation, employment practices (with access to employment counsel included ), dental plans and personal insurance concierge services to help with you insurance planning.

More information on Marsh’s sponsored benefit program can be found at www.countyCMAmemberinsurance.com or call 800-842-3761

Auto and Homeowners Insurance: Discounted auto and homeowners insurance for CMA members. Mercury Insurance Group, 888.637.2431 or www.mercuryinsurance.com/cma.

NORCAL Mutual Insurance Company: SJMS has endorsed NORCAL Mutual’s medical liability program since 1975.

Financial Services Personal and Professional Banking Services: Union Bank has developed a package of discounted banking services specifically for CMA members, with up to $2,400 in savings offers for your practice. To learn more about business credit and checking accounts, merchant services, payroll processing solutions and treasury management solutions offered by Union Bank, visit www.unionbank.com/CMA.

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Society Members can rely on us for OSHA/HIPAA Compliance & Medical Waste Disposal. ®

Compliance Solutions For Healthcare™

Paying too much for your Medical Waste?

Confused About OSHA/HIPAA Compliance?

Call us for a FREE Consultation and Quote at 650.655.2045 SJMS Members Receive: • • • • • •

We Pick-Up All Medical Waste Streams: • • • • • • • •

30% discount from normal prices No long -term contracts Pay only for what is picked-up and no more No extra surcharges, fuel fees or taxes 12 years of proven track record Vendor of choice for 8 other medical societies

Contaminated Sharps Regulated Medical Waste (Red Bags) Pathological/Microbiological (Red Bags) Hazardous Chemicals (i.e. Cold Sterile, X-Ray Solution, Mercury, Lead) Expired Pharmaceuticals Dental Amalgam Waste (traps, scraps and cartridge) Chemotherapy Waste Fluorescent Bulbs, Alkaline Batteries and Computer Monitors

Schedule Your NO-CHARGE Compliance Evaluation and Receive A Comprehensive Report For The Following Areas: • • • • •

Cal-OSHA Requirements HIPAA Requirements Board Requirements Dept. of Health Requirements EPA Requirements

• • • • •

Safety Equipment Evaluation Fire and Earthquake Evaluation Chemical and Bio Hazard Storage Cross Contamination Personal Protective Equipment

®

Compliance Solutions For Healthcare™

SAN JOAQUIN PHYSICIAN 2013 Call38888.323.0583 or 650.655.2045 or visit enviromerica.com for an immediateFALL quote

“After working with another firm for over a year

to develop a new website with little results and SJMS > Member Only Benefits lots of aggravation, we hired Mayaco. In a short time we had a fully operational website that met our rigorous requirements. The Mayaco staff could not be more responsive and technically savvy. Our website is easy to navigate, attractive and a great tool for our membership.”

Mary Lou Licwinko, JD, MHSA Executive Director/CEO San Francisco Medical Society

Physician Practice Websites: Mayaco Design and Marketing

advisory firm that specializes in helping physicians effectively manage their medical school debt and other financial matters.

Members receive a $50 discount on 12 months of service. A coupon code is required to access this discount. Get your code at www.cmanet.org/benefits or call 800.786.4262.

offers CMA members deeply-discounted website design services for their practice starting at $1,250 Contact Mayaco at 209 .9 57.8629 or visit www. mayaco.com for more information.

Wells Fargo Advisors: Enjoy access to our partner, Wells Fargo

HIPAA

Advisors, LLC, for financial advice and guidance from medical school through retirement. Dedicated regional advisors are available to address your financial needs. Learn more about these services and special CMA member benefits at Features www.cmanet.org/wells.

Total # of Pages

Mobile Apps: Prescriber’s Letter:

Compliance: PrivaPlan offers HIPAA privacy and security compliance resource kits custom tailored to California’s regulations to CMA members at a discounted rate. Find Premier out more at www.privaplan.com.

Basic Package Package 6

Staff Training for Website Updates Mobile-Friendly Web Design Unique Web Address Downloadable Forms Google Maps for Location Physician Bios Personalized Email Rotating Home Page Banner Patient Appointment Request Helpful Resources Video Support Helpful Health News & Fitness information

Evide nce -ba se d drug therapy recommendations Onetime Cost for office Website available online at no charge ($250 value). Call the society CMA Member Discount at 209.952.5299 for more information.

CMA Member Price

DocBookMD: CMA members are eligible for a free download of the DocBookMD smart phone app which allows them to securely send HIPAA-compliant messages directly from their iPad, iPhone and Android devices. Find out more at www.docbookmd.com or by contacting your county society.

FR MO IE BIL ND E LY

Medical School Debt Management: GL Advisor is a financial

25

a a a a a

a Staples: Save up EXCLUSIVE to 80% on a

Up to 3 Up to 3

MedicAlert:

a office supplies CMA andMember equipment Benefit a a from Staples, Inc. Visit www.

Up to 10 6 orcmanet.org/benefits more to access the a members-only discount link. a

a a MedicAlert is a a nonprofit foundation with over 50 For more information:

$1,950

$3,950

www.mayaco.com years of- $700 lifesaving experience - $1,000 identifying and providing vital (209) 957-8629 medical$1,250 information to emergency personnel for over 4 million $2,950 members worldwide. CMA members and their patients save $10 on new adult enrollments and $2.95 on Kid Smart Enrollments.

MedicAlert, www.medicalert.org/cma or 800.253.7880.

Security Prescriptions:

Get 15% off tamper-resistant security prescription pads and printer paper. RX Security, www.rxsecurity.com/cma.php.

Epocrates: CMA members get a discount on all Epocrates mobile and online products. Save 30% on subscriptions to Epocrates products such as the #1 rated Epocrates Essentials.

Epocrates provides point-of-care access (via mobile devices and the web) to information on drugs, diseases and diagnostics. www.cmanet.org/benefits.

Magazine Subscriptions: 50% off subscriptions to hundreds of popular magazines, with a best price match guarantee.

Subscription Services Inc., www.buymags.com/cma or 800.289.6247.

Car Rentals: Save up to 25% on car rentals for business or

Practice Services: EnviroMerica: EnviroMerica offers CMA members heavily discounted medical waste removal and regulatory compliance services. Through EnviroMerica, CMA members can protect themselves from regulatory fines, receive compliance consultations and properly dispose of medical waste at a fraction of the cost charged by competitors. Find out more at www.enviromerica.com or by calling 650.655.2045.

FALL 2013

personal travel. Members-only coupon codes are required to access this benefit. Get your code at www.cmanet.org/benefits or call 800.786.426

Crown Enterprises: Offering the finest IT support and EHR implementation services available to medical practices. Call us today for a complimentary consultation at (209) 390-4670

SAN JOAQUIN PHYSICIAN

39

Sponsored Insurance Programs Overview for Members of the San Joaquin Medical Society/CMA Marsh/Seabury & Smith Insurance Program Management serves as the insurance advisor for the San Joaquin Medical Society, CMA and their members. We design and implement sponsored insurance plans and services available only to members and their employees — with discounted pricing, enhanced coverage or both. The following is a brief program overview:

Protect Your Practice Medical – Healthcare reform is here.

We can assist you in evaluating group and individual health insurance options for you and your employees both in and out of the exchange. Also, save with qualified high deductible health plans and a health savings account. Go to www.MarshHealthOptions.com for information.

Workers’ Compensation – Required of all employers, it covers your employees in the event of a job-related injury. Members receive competitive rates.

Health Savings Accounts – Open a CMA Health Savings Account online, use federal tax deductions and earn interest on a federally tax free basis. Unused funds roll over each year.

Employment Practices Liability Insurance – Protect yourself from discrimination, sexual harassment and wrongful termination claims. The plan includes risk management training (web-based), an employment law information hotline and insurance coverage for judgments and defense costs up to $1,000,000. Ask about the Special First Time Buyers program.

Group Disability Plan (3+ members/ employees) – Monthly disability benefits of up to $15,000. Definition of Occupation

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Protect Your Family includes Own Specialty. No medical underwriting, with timely enrollment, up to the Guaranteed Issue amount. 10% member discount, plus 5% MGMA discount.

Group Term Life Program (3+ members/ employees) – No medical underwriting, with timely enrollment, up to the Guaranteed Issue amount. 10% member discount, plus 5% MGMA discount.

Business Overhead Expense – Protect your practice with disability insurance up to $10,000 per month. Don’t divert personal disability income to pay for normal fixed office expenses. In a group setting, it pays the member’s share of fixed expenses.

Covered expenses include your rent, utilities, employee salaries, society dues and professional liability premiums.

Business Owners Package Program This coverage provides important business liability and property protection. Protects your practice against financial loss resulting from claims of actual or alleged damage caused to others. Protects your furniture, fixtures and inventory to help repair or replace a loss. Data breach coverage is now available.

Professional Liability – We can help place your professional liability coverage with NORCAL Mutual, SJMS’s sponsored insurer.

Long Term Disability Plan – Protect your most important asset — your ability to earn an income! You may apply for up to $10,000 per month in benefits. The plan includes Medical Specialty Definition of Disability and a residual disability benefit.

Level Term Life – You and your spouse may apply for up to $1,000,000 of 10 or 20 year Level Term Life insurance. Rates are projected to remain level during the first 10 or 20 years of the policy reducing the long term costs of the policy significantly.

Individual Medical Plans – Healthcare reform is here. Utilize the Marsh online private health exchange to evaluate individual health insurance options for you and your dependents age 26 and over, both in and out of the exchange. Also, save with qualified high deductible health plans and a health savings account.

Long Term Care – Members are eligible to receive a 5% premium discount on Long Term Care policies. The discount also applies to your spouse, parents or parents-in-law.

Special plans for group practices can also be developed.

Group Universal Life – This plan provides permanent life insurance protection with limits up to $1,000,000. An optional cash accumulation account enables you to contribute certain amounts in the cash account and earn interest (minimum of 4%) on a tax deferred basis.

FALL 2013

We Encourage You To Use Your Member Benefits!

Our Client Advisors are available at 800-842-3761 to discuss how these programs can benefit you! Visit our websites at www.CountyCMAMemberInsurance.com or www.MarshHealthOptions.com for more information.

Group Dental – Up to $2,000 annual benefit. No deductible for preventive benefits.

Employee coverage is available. Members may also enroll without their employees during special open enrollment periods each year.

High Limit Disability – This plan provides additional disability limits up to $25,000 per month on a guaranteed basis. Members are eligible for a 20% discount.

Personal Insurance Concierge – This benefit helps physicians analyze, transfer, and manage risks relating to their personal exposures — e.g., homes, automobiles, valuables, fine art, yachts — all through a single point of contact. Call 855-CMA-9855 for more information.

Marsh, SJMS and CMA do not provide tax or legal advice. Please consult with your personal advisors on any of these issues.

68475 (9/13) ©Seabury & Smith, Inc., 2013 777 South Figueroa Street, Los Angeles, CA 90017 CMACounty.Insurance@marsh.com www.CountyCMAMemberInsurance.com 800-842-3761

d/b/a in CA Seabury & Smith Insurance Program Management CA Ins. Lic. #0633005 AR Ins. Lic. #245544 FALL 2013

Health Care Reform: 2014 Marks a New Era Health care reform is in full-swing with the heftiest legislation set for 2014 — when health insurance will become available to millions of Americans who were previously uninsured.

Starting January 1, 2014, most Americans will be required to have health insurance.

In addition, health insurance exchanges will be available to facilitate access to coverage.

Changes Coming in 2014 • Individual Mandate – Most individuals are required to have and maintain health insurance effective January 1, 2014. There are exceptions for certain individuals.

• Penalty – If you elect not to purchase coverage, you are required to pay a penalty ■ in 2014: the greater of $95/individual (3 per family), or 1% of income.

■ In 2015: the greater of $325/ individual (3 per family), or 2% of income.

■ In 2016: the greater of $695/ individual (3 per family), or 2.5% of income.

• Guaranteed Issue – Insurance companies must sell coverage to everyone, regardless of pre-existing conditions, and can’t charge more based on health or gender.

• Health Insurance Exchange (Covered California) – Individuals without access to affordable, employer-sponsored plans that provide qualifying coverage can enroll in plans offered either through the individual insurance market or through health insurance exchanges with coverage beginning January 1, 2014.

Open enrollment commences on October 1, 2013. If individuals don’t enroll with the exchange during the initial open enrollment period, they will have to wait until next year’s open enrollment period to obtain coverage.

• Subsidies – Individuals and families may qualify for federal tax credits and

benefit subsidies only through the exchange. Tax credits are available to those who meet certain income requirements and do not have access to affordable health insurance that meets minimum coverage standards offered through their employer or another government program. Eligibility for tax credits is based on family income and size.

• Premiums – Premiums can only vary by age, geography, and family composition.

They may not vary by gender or health conditions.

• Annual or lifetime limits: Individual and group plans may not impose limits on essential benefits.

• Out-of-Pocket expenses: Limits out-of-pocket expenses for co-pays, co-insurance, deductibles, etc. to $6,350 per individual to a maximum of $12,700/family annually.

Small Groups (2–50 employees) There is no requirement under ACA for small businesses to provide coverage to their employees. In addition to the above guidelines, changes for small groups include: • Risk Adjustment Factors (RAF’s): The RAF’s common to small groups are eliminated. All groups between 2–50 employees will be rated at 1.0.

• Limit on maximum small group plan deductibles are now $2,000/ individual; $4,000/family*.

• Waiting period for new full-time employees must not exceed 90 days.

(60 days in California.)

• Tax credits through Covered California to help cover the cost of premiums if the employer: ■ Employs 25 or fewer employees.

■ Pays annual wages averaging less than $50,000 per full-time equivalent employee.

■ Provides at least 50% of the cost of health care coverage for their employees. * Exceptions apply SAN JOAQUIN PHYSICIAN

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Public Health

Update

REPORTING, TESTING AND PRECAUTIONS: Contact and airborne precautions are recommended for management of hospitalized patients suspected of having any of these virial infections.

If any of these viruses are suspected, clinicians should immediately notify San Joaquin County Public Health Services (SJCPHS) Communicable Disease Program (209-468-3822) so appropriate testing can be coordinated. The SJCPHS Laboratory (209468-3460) can be contacted to arrangements for transport of the specimens to the SJCPHS Laboratory for testing and submission to the state laboratory.

Emerging Novel Viruses Middle East Respiratory Syndrome is a viral respiratory illness first reported in Saudi Arabia in 2012 caused by a novel coronavirus which is now called Middle East Respiratory Syndrome Coronavirus (MERS-CoV). MERS-CoV is most similar to coronaviruses found in bats.

As of August 12, 2013, 94 laboratoryconfirmed cases have been reported by the World Health Organization (WHO). All diagnosed cases were among people who

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resided in or traveled to four countries (Saudi Arabia, United Arab Emirates, Qatar, or Jordan) within 14 days of their symptom onset, or who had close contact with people who resided in or traveled to those countries. To date, no cases have been reported in the United States, although cases have been identified in Europe.

Most cases of MERS-CoV have had severe acute respiratory illness with

Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

symptoms of fever, cough, and shortness of breath. About half of these people died. Recent data suggest that mild respiratory illness might be part of the clinical spectrum of MERS-CoV infection, and that initial presentation might not include respiratory symptoms. Although this virus has spread from ill people to others through close contact there is no evidence of sustained person-to-person transmission.

FALL 2013

Healthcare professionals should evaluate patients for MERS-CoV infection if they develop fever and pneumonia within 14 days after traveling to countries in or near the Arabian Peninsula. Providers should also evaluate patients for MERS-CoV infection if they have had close contact with a symptomatic recent traveler from this area who has fever and acute respiratory illness.

CDC recommends collecting multiple specimens from different sites at different times after symptom onset. Lower respiratory specimens are preferred, but collecting nasopharyngeal and oropharyngeal specimens, as well as stool and serum, are strongly recommended. Positive results for another respiratory pathogen should not preclude testing for MERS-CoV. More information can be found at the CDC website: http://www.cdc.gov/coronavirus/mers.

or other animals; eat only food that is fully cooked, including poultry; and practice good hand hygiene. Clinicians should consider the possibility of avian influenza A (H7N9) virus infection in persons presenting with acute febrile respiratory illness and appropriate recent travel

Avian Influenza A (H7N9) Virus in China: The H7N9 virus is a new avian influenza A strain that was first reported in humans by China on April 1, 2013. It was also detected in poultry in China. As of July, the World Health Organization has reported 134 laboratory confirmed cases. Some mild illness was seen, but most patients had severe respiratory illness and 43 people died. Many but not all of the human H7N9 cases are reported to have had contact with poultry. China is following up on close contacts of people infected with H7N9 to assess whether human-to-human spread of this virus is occurring. At this time, there is no evidence of sustained person-to-person transmission. To date no cases of H7N9 have been detected outside of China.

The Centers for Disease Control and Prevention (CDC) has no travel restrictions for China at this time. The CDC also does not recommend prescribing antiviral drugs for prophylaxis or self-treatment of H7N9 influenza. Travelers should follow standard precautions such as avoid touching birds, pigs,

FALL 2013

or exposure history. Additional information can be found at the following CDC websites. http://www.cdc.gov/flu/avianflu/h7n9-virus. htm http://www.cdc.gov/flu/avianflu/h7n9antiviral-treatment.htm.

Variant Influenza Virus (H3N2v) in the U.S.:

Influenza viruses that normally circulate in pigs are called “variant� influenza viruses when they are detected in people. The influenza A H3N2 variant virus (H3N2v) contains the matrix (M) gene from the 2009 H1N1 pandemic virus, and was first detected in pigs in the United States in 2010. Cases were first identified in people in the U.S. in July 2011; in that year only 12 cases were reported from 5 states. In 2012, 309 cases of H3N2v infection were detected in 12 states.

In 2013 so far 16 cases have been reported in 3 states. To date no cases have been reported in California.

Most H3N2v infections have occurred in children who had exposure to swine; many of the exposures occurred at agricultural fairs. The H3N2v virus is related to human flu viruses from the 1990s, so adults should have some immunity against these viruses, but young children probably do not. H3N2v virus infection cannot be distinguished by clinical features from seasonal influenza A or B virus infection, or from infection with other respiratory viruses that can cause influenza-like illness (fever and either cough or sore throat). Therefore, the key to identifying possible H3N2v virus infection is a history of swine exposure in the week prior to illness onset. Additional information can be found at the following CDC website. http:// www.cdc.gov/flu/swineflu/h3n2v-clinician.htm.

SAN JOAQUIN PHYSICIAN

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practice manager Free to SJMS/CMA Members!

resources

The Office Manager’s Forum empowers physicians and their medical staff with valuable tools via expert led educational sessions from industry professionals who are committed to delivering quality health care.

For more than 130 years, the San Joaquin Medical Society (SJMS) has been at the forefront of current medicine, providing its physician’s and their staff with assistance and valuable practice resources. SJMS is proud to offer the Office Manager’s Forum, a monthly educational seminar designed to enhance the healthcare environment with professional development opportunities while providing solutions to some of the challenges that come from managing a practice.

Attendees gain knowledge on a broad array of topics related to the field of medical staff services, office management, billing and coding, human resources, accounting and back office support.

The Office Manager’s Forum is held on the second Wednesday of each month from 11:00AM – 1:00PM at Papapavlo’s in Stockton and includes a complimentary lunch. Attendance is always FREE to our members. Non-members are welcome and may attend for one month at no cost to experience one of the quality benefits that comes with Society Membership ($35.00 thereafter).

Registration required.

For more information or to be added to the mailing list email Jessica Peluso, SJMS Membership coordinator, at Jessica@SJCMS. org or call (209) 952-5299.

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SAN JOAQUIN PHYSICIAN

FALL 2013

SEPTEMBER 12TH, 2013:

KNOWING YOUR RIGHTS AND STOPPING UNFAIR PAYMENT PRACTICES 11:00AM to 1:00PM

Mark Lane, Associate Director in the CMA’s Center for Economic Services. 18 years of experience allowed him to understand the needs and positions of both Physicians and Payors, making him an ideal candidate to educate providers on overcoming the everchanging challenges of the healthcare landscape.

OCTOBER 9TH, 2013:

“ICD-10-PCS & CLINICAL DOCUMENTATION” 11:00AM to 1:00PM

The goal of this presentation is to give you a better understanding of the history of ICD-10PCS. Examples and testing of ICD-10-PCS will be given and in addition to that, ways to improve your clinical documentation will be explained.

Mary Louise Applebaum, MBA, RHIA, CCS AHIMA Approved ICD-10-CM/PCS Trainer and Ambassador Mary has been in healthcare since 1983 with experience in small and large hospitals and physician offices. Mary Louise is a Registered Health Information Administrator and has served as coding and tumor registry manager, consultant, health information management (HIM) director and adjunct faculty at Cosumnes River and Modesto Community colleges teaching ICD-9-CM and CPT courses.

ARE YOU READING CPR? CPR contains the latest in Practice Management Resources, Updates and Information.

May 2012

In this issue:

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HOW DO PATIENTS USE THE INTERNET --AND SMARTPHONES -- TO FIND PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS AND SERVICES? 11:00AM to 1:00PM

Over 80% of the people online use the Internet to find physicians and healthcare professionals. Tips on how to reduce staff calls and improve being found online. Basics also of having a website that can be used on smartphones.

Steve Morales ~ Mayaco Marketing & Internet; “At MAYACO we design web sites that work for YOU and your clients. Each one is completely custom with a design and functionality that fit your needs and those of your customers.”

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ces CMA resour

Medical-Legal Librar y (Formerly CMA On-Ca ll)

NOVEMBER 13TH, 2013:

certain surgical

al Library Medical-Leg A On-Call) CM (Formerly

e Cross Anthem Blu Health Care Update on Up e on two ed datAnthe two ment Managissue BlueofCross tm s pending with the Department the Deofpar Managed Health Care

CMA Practice Resources (CPR) is a free monthly e-mail bulletin from CMA’s Center for Economic Services. This bulletin is full of tips and tools to help physicians

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FALL 2013

and their office staff improve practice efficiency and viability.

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SAN JOAQUIN PHYSICIAN

45

BARNONE

These Correctional Health Care Leaders The California Health Care Facility at Stockton will pump $1 billion a year into the Central Valley economy if the California Department of Corrections and Rehabilitation predictions come true. This $900 million prison medical and mental health facility is activated and the State is hiring approximately 3,000 physicians, nurses, medical support staff, mental health providers and prison custodial staff.

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FALL 2013

story By Lita Wallach l photos by dale goff

Are Locking in a New Era of Health Care FALL 2013

SAN JOAQUIN PHYSICIAN

47

Bar None > The California Health Care Facility

The facility is designed and now operating around a shared services model that includes, California Correctional Health Care Services (CCHCS), Department of State Hospitals (DSH) and California Department of Corrections and Rehabilitation (CDCR). These three identities are closely monitored by a Federal Court Receiver’s Office to ensure that the State complies with a settlement agreement to improve medical and mental health care for inmates within the state’s prison system. Likely because three separate names and functions with responsibilities for one facility can be confusing, the Stockton facility is commonly known as the California Health Care Facility.

WHY IT IS HERE

Front and center to why this facility is here is at the heart of prison reform in California and directly related to the Eighth Amendment to the United States Constitution that prohibits, “cruel and unusual punishment of the incarcerated.” This 222- year-old law serves as a basis for a 2009 California Prison Healthcare Receivership’s approval of the Stockton prison project.

The legal document cites that it will “help bring the State of California’s prison medical and mental health care services into Constitutional compliance.” In 2013, Stockton is now home to the first of its kind correctional heath care facility for an anticipated 1,700 of the sickest inmates in California.

In the States, “Turn Around Action Plan”, the focus is

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on bringing the prison health care delivery system up to Constitutional standards. The six standards include:

Ensure timely access to health care services Improve the medical program Strengthen the health care workforce Implement quality assurance and continuous improvement Establish medical support infrastructure Provide health care and health care related facilities

LEADERSHIP

Under the gun to address these elements, the State was facing a massive redesign of medical and mental health care delivery in one of the nation’s largest prison systems. Because leadership is critical to any mission, the State selected a team that possessed a variety of experiences. Now, Oliver Lau, M.D. Chief Medical Executive, John Rekart, PhD, Chief of Mental Health, Allan Jennings, RN, Chief Nursing Executive, Larry Fong, Chief Executive Officer and Stirling Price, LCSW, Executive Director, Department of State Hospitals comprise an ‘A-Team’ of medical and mental health leaders at Stockton’s CHCF. This team plus the facility’s top leader, Warden Ron Rackley intend to make this facility the most cost-effective and quality correctional facility in the State.

This article takes a close look at the top of the California Health Care Facility and their viewpoints about caring for a population in a humane way.

It’s a job that not everyone is cut out to do.

FALL 2013

“The Stockton facility represents the state’s largest investment in providing “It didn’t cross my mind to go into correctional health or to be in a correctional medical care and mental health treatment to inmates who managerial role,” said Dr. Lau. “But when I entered the military as a reservist, have the most severe and long-term needs,” said Larry Fong, CCHCS I was deployed to provide indigent care during a medical humanitarian CEO. “Individuals in lead positions at the Stockton facility all commit to mission. I realized that it’s not just the medicine you deliver, but it’s about organizationally work as a team across three state entities of the California treating people humanely. This helped shape my mind. So, I thought why not Correctional Health Care Services, Department of State Hospitals and work where I can shape inmate health care?” the California Department of Corrections. Three large and very different His military experience in such places as Jamaica, Afghanistan, Middle state organizations need to interact on a variety of operational necessities to East and Germany helped to frame much of his thinking. Dr. Lau was often function effectively. the only physician Gauging the desire for a battalion aid “The Stockton facility represents the state’s largest to do the best job station.’ “Whatever investment in providing correctional medical care and possible, I think we resources we had, mental health treatment to inmates who have the most do quite well.” we made it work,” severe and long-term needs” - Larry Fong, CCHCS CEO “We are the said Dr. Lau. largest correctional “At times I was health care facility fortunate to have in the country,” said Oliver Lau, M.D., Chief Medical Executive. We have a a nurse assisting me. We had to make efficient use of medical logistics and very complex mission and our facility now receives the sickest inmates from limited supplies. . At one point, I was responsible for a Calvary Unit. If a all 33 institutions throughout California. We will have a lot of older people convoy was hit by IED, I was responsible for caring for the wounded and for who have spent their lives inside a correctional facility. One-third of our counseling surviving soldiers. That wasn’t easy. Today, working in an inmate inmates suffer from severe mental illness and experience a lot of psychounit….well, that’s not that tough. I can do this.” social issues and chronic pain. Some are in their end-of-life and we treat them As a result of his experiences in the military, Dr. Lau specializes in humanely.”

Utilization Management. “Our inmates are not better served with increased Dr. Lau never planned to work in correctional health care. After graduating costs,” said Dr. Lau. “With our “UM” in place, inmates have increased access from John Hopkins University with a master’s degree in chemistry and and a better quality of care. CCHCS is a hybrid institution, so I want my from Eastern Virginia Medical School with a Doctor of Medicine, Dr. Lau physicians to know their patients intimately so we can manage their health intended to become a primary care physician. care early on and avoid the most costly end-of-life care. We take a holistic

FALL 2013

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Bar None > The California Health Care Facility

approach which improves outcomes and reduces long-term costs.”

As the facility’s Chief Medical Executive who oversees health care administration, procurement, contracts, daily operations of all medical, radiology, pharmacy, lab services, dialysis, nutritional and rehabilitation programs, Dr. Lau is highly trained and certified in medical leadership, Utilization Management and has practiced medicine in a full spectrum family medicine and urgent care services. What most people do not know is that Dr. Lau has received over 10 honors and awards and most of them relate to how he exemplifies the ethical ideas of medicine. “When you live in the same environment as inmates, you notice when they don’t look right and can sometimes anticipate the care they need. We get to know these patients because it’s the humane thing to do. But at the same time, we know this type of practice improves overall safety for staff and other inmates, plus it has an impact on reducing the cost of care. All these things are important in a prison environment,” said Dr. Lau. Some people have asked how can the State save money on prison health care when it spends $900 million to build a new model such as in Stockton.

“By consolidating medical and mental health facilities we anticipate breaking even in about five years,” said Dr. Lau. “Under the old system, each of the 33 prisons around the State held a variety of service contracts with vendors, such as for acute care in hospitals, transport companies, pharmacies, ancillary services such as dialysis, lab services and more. Yes, we must pay to transport inmates to the Stockton facility, but once here, we can do a much better job at controlling quality of care and we can reduce our costs.”

An example of improved quality and cost is the 25-unit Medically

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Guarded Unit at San Joaquin General Hospital. “We contract with community partners, such as San Joaquin General Hospital for acute care.

We also have contracts with St. Joseph’s Medical Center and Doctor’s Hospital in Manteca for overflow beds. We are building relationships with these community partners, we meet regularly and we have a common goal of quality care,” said Dr. Lau. The Medically Guarded Unit at San Joaquin General Hospital is a physician faculty run program. “It’s a very restricted unit,” said Sheila Kapre, M.D., Chief Medical Officer at San Joaquin General Hospital. “This partnership with CHCF has a positive effect on the hospital’s Residency Program.” Overseen by an Attending Physician, San Joaquin General Hospital’s Residents take care of the patients on the unit. “In addition to the general population, we have experience in caring for specialized populations such as inmate care. The CHCF is a partnership that works quite well. It’s a specialized learning environment for our Residents because they are in constant contact with the patients. It adds to the value of their training because it exposes them to another area of specialized care. “Ultimately when Residents go out to look for a job, they’ll be well-equipped to work with a variety of patient populations.”

This community partnership benefits both CHCF and the hospital.

According David Culberson, CEO of San Joaquin General, “The Medically Guarded Unit means consistent census at the hospital and that is important for many reasons. It benefits the teaching program and overall helps to cover operating costs for the entire hospital.”

FALL 2013

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Bar None > The California Health Care Facility

MENTAL HEALTH FACILITIES

On July 12, 2013 both the Los Angeles Times and California Healthline reported on a United States judge’s probe into prison-based mental health facilities. There are weekly updates about the status of mental health care in California. At Stockton’s CCHCS, medical and mental health leaders pay close attention to reports directly related to their daily progress. In a report entitled, “Achieving a Constitutional Level of Medical Care in California’s Prisons: Monthly Report of Federal Receiver’s Turnaround Plan of Action (RTPA)” the Receiver monitors monthly performance metrics related to the six elements of the RTPA. These reports are intended to provide stakeholders, including the Court, counsel, the public, CCHCS employees and anyone else who is interested with performance updates about the status of mental health care inside California’s prisons.

Over ten years ago, a Presidential Commission called, “New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America” stated that it “seeks to improve the quality and availability of mental health services.” This report and others indicates that getting a handle on improvements in mental health care can have positive results in reducing violence inside and outside prison walls. In addition, it affects the quality and safety of the lives of those who suffer and those who make a career in treating mental illness.

An individual who is under the scrutiny of federal courts, district courts, federal receiver, three state departments of corrections, the media, the public and the governor of California, is one of the new leaders at CHCF, Dr. John Rekart, PhD, Chief of Mental Health, California Health Care Facility Mental health Services, CCHCS. Dr. Rekart worked in private practice followed by nine years at the Deuel Vocational Institution in Tracy before joining CHCF in 2011. Initially, he worked with facility design and construction and with stakeholders to finalize the Stockton CHCF. Now, Dr. Rekart is involved in activation and programs for the most severe mental health inmates in the state.

“I was very fortunate to see this project from the planning stages to implementation and the progress has been amazing,” said Dr. Rekart.

“Serving the mental health needs of this underserved population is quite the challenge. However, we truly are a unique facility and up to par in taking on this challenge. We have the full support of all departments in providing the individualized therapy required for this patient population.”

The majority of the 1,700 inmates will be served in licensed beds because of the severity of their symptoms.

The facility is divided into five major areas:

1. Mental Health Crisis Beds – 98 psychiatric inpatient crisis beds 2. High Acuity Medical Beds – 360 medical beds for inmate patients with chronic and troublesome medical symptoms 3. Low Acuity Medical Beds – 560 medical beds for inmate patients with more stable and less severe medical conditions 4. Acute Psychiatric beds – 82 beds, supervised and staffed by the Department of State Hospitals 5. Intermediate Psychiatric Beds - 432 beds, supervised and staffed by DSH

FALL 2013

MENTAL HEALTH CRISIS BEDS 98 BEDS Inmate-patients who are in acute crisis will be transferred to CCHCF from other prisons from around the state. Those in a crisis bed will have been determined to either be a danger to themselves, a danger to others, or gravely disabled. The length of stay in this program is 10 days or less and inmate-patients are seen daily by a clinician and every seven days by an interdisciplinary treatment team.

HIGH ACUITY MEDICAL BEDS 360 BEDS

Inmate-patients at this level of care will have severe medical issues and symptoms, such as those with chronic diabetes, severe cardiac disease, pulmonary disease, cancer and will require a high level of medical and nursing care.

LOW ACUITY MEDICAL BEDS 560 BEDS

Inmate-patients at this level have less secure medical illness and require a lower level of nursing care.

The most predominant diseases suffered by inmate-patients are medical or surgical, but many will also have co-morbid mental illness. Some are able to attend school or work and are seen every 90 days by a clinician. Others with more severe mental illness that impacts their daily functioning are seen once a week by a clinician and every 90 days by a treatment team.

DEPARTMENT OF STATE HOSPITALS

ACUTE PSYCHIATRIC BEDS 82 BEDS

This is an acute level of care for those with serious mental illness who require a longer inpatient stay of approximately 30 days.

SAN JOAQUIN PHYSICIAN

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Bar None > The California Health Care Facility

Positions for Department of State Hospital at Stockton Facility Profession

# of DSH employees # of DSH employees currently in that role Dec. 2013

Psychiatric Technician. . . . . . 158. . . . . . . . . . . . . . . . . 426 Psychiatrist . . . . . . . . . . . . . . . 9. . . . . . . . . . . . . . . . . . 35 Psychologist . . . . . . . . . . . . . . 21 . . . . . . . . . . . . . . . . . 35 Registered Nurse. . . . . . . . . . . 74 . . . . . . . . . . . . . . . . . 182 Clinical Social Workers. . . . . . 10 . . . . . . . . . . . . . . . . . 35 Rehabilitation Therapists. . . . . 8. . . . . . . . . . . . . . . . . . 35 Custodians. . . . . . . . . . . . . . . . 13 . . . . . . . . . . . . . . . . . 17

Positions for California Correctional Health Care Services at Stockton Facility Profession

# of CCHCS employees

# of CCHCS employees in that role Dec 2013

Physicians and Surgeons. . . . . 12 . . . . . . . . . . . . . . . . . 16 Chief Physician & Surgeon . . . 1. . . . . . . . . . . . . . . . . . . 2 Physician Assistant . . . . . . . . . 15 . . . . . . . . . . . . . . . . . 17 & Nurse Practitioner Certified Nursing Assistant. . .143. . . . . . . . . . . . . . . . . 203 Licensed Vocational Nurse. . . . 75 . . . . . . . . . . . . . . . . . 122 Registered Nurse RN. . . . . . . 103. . . . . . . . . . . . . . . . . 161 Supervising Nurse RN II. . . . . . 21 . . . . . . . . . . . . . . . . . 27 Supervising Nurse RN III. . . . . 3. . . . . . . . . . . . . . . . . . . 4 Public Health Nurse RN. . . . . . 1. . . . . . . . . . . . . . . . . . . 1 Nurse RN Instructor. . . . . . . . . 3. . . . . . . . . . . . . . . . . . . 3 Psychiatric Technicians. . . . . . 10 . . . . . . . . . . . . . . . . . 29 Registered Dietition. . . . . . . . . 2. . . . . . . . . . . . . . . . . . . 4 Pharmacist I. . . . . . . . . . . . . . . 3. . . . . . . . . . . . . . . . . . 11 Pharmacy Technician. . . . . . . . 5. . . . . . . . . . . . . . . . . . 18 Speech Pathologist . . . . . . . . . 2. . . . . . . . . . . . . . . . . . . 1 Staff Psychiatrist . . . . . . . . . . . 6. . . . . . . . . . . . . . . . . . 19 Social Worker. . . . . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . 6 Clinical Psychologist. . . . . . . . 8. . . . . . . . . . . . . . . . . . 25 Senior Psychologist. . . . . . . . . 2. . . . . . . . . . . . . . . . . . . 3 Dentist. . . . . . . . . . . . . . . . . . . 1. . . . . . . . . . . . . . . . . . . 3 Supervising Dentist. . . . . . . . . 1. . . . . . . . . . . . . . . . . . . 1 Dental Hygenist. . . . . . . . . . . . 1. . . . . . . . . . . . . . . . . . . 1 Dental Assistant. . . . . . . . . . . . 1. . . . . . . . . . . . . . . . . . . 4 Office Technicians. . . . . . . . . . 24 . . . . . . . . . . . . . . . . . 40 Analysts. . . . . . . . . . . . . . . . . . 6. . . . . . . . . . . . . . . . . . . 7 Health Records Tech I . . . . . . . 11 . . . . . . . . . . . . . . . . . 16 Custodian. . . . . . . . . . . . . . . . .7. . . . . . . . . . . . . . . . . . 12

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SAN JOAQUIN PHYSICIAN

DEPARTMENT OF STATE HOSPITALS

INTERMEDIATE PSYCHIATRIC 432 BEDS

Inmate-patients at this level of care have a serious mental illness and receive extended treatment beyond the acute level and length of stay ranges from 6-10 months.

DEWITT NELSON CORRECTIONAL ANNEX (ADJACENT TO CHCF IN STOCKTON OPENS IN FEBRUARY 2014)

There will be 1,133 beds for inmate-patient general population plus those who suffer from more severe psychiatric conditions.

Other services are located right on the unit, such as in physician examination, consultation and group therapy rooms.

Most services are centrally located where the inmates are housed.

“In lower acuity housing, inmate-patients are encouraged to interact in programs as much as possible under the observation and direction of nursing and custody staff, including attending daily groups,” said Dr. Rekart.

At the heart of this new design is the way that CCHCS integrates health care into a correctional environment. “It’s a different way of moving forward, said Dr. Rekart. “By addressing and appropriately treating illnesses, the inmatepatient becomes more stabilized. This in turn allows for improved functioning and programming. Overall, this helps to keep everyone safer and secure.”

“We have to be willing to look at the past and how we can improve care in the future,” said Dr. Rekart. “Every day we are developing a culture of collaboration from supervisors, custody and health care. We’ve come a long way because it’s not about “Us and Them…..it’s about working together.”

Dr. Rekart prefers to refer to inmates as inmate-patient. “We designed the facility integrating all the correctional aspects needed, but also took into consideration how to facilitate the healing aspect needed for our inmate-patient populations.”

Access to care and free movement concepts were

FALL 2013

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FALL 2013

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Bar None > The California Health Care Facility

incorporated into the facility’s mental health services.

“The lack of free movement within the prison environment can sometimes hinder therapeutic interventions, so we are working to facilitate the improvement of access to care. It’s a challenge; however we’ll see improved outcomes and overall safety and security for our inmate-patients and staff.”

opinions are becoming more optimistic about the impact of the Stockton facility on the local health care workforce. The editorial states, “But rather than viewing this as a problem, this area should see it as an opportunity to train the various health care professionals that will be needed by the state Corrections Department, public health and the private sector.”

NURSING IN A CCHCS ENVIRONMENT

With the size of the Department of State Hospitals facility at the Stockton site alone, the need for both medical and mental health professionals is great. The DSH tapped one of their own who had experience in expansion and activation of beds at DSH-Vacaville to oversee the development and activation of DSH beds at Stockton’s CHCF. Sterling Price, LCSW is the Executive Director at the

Nurses make up a large part of the CCHCF at Stockton. As of August 1, 2013 CCHCF has filled over 300 nursing positions and expects to fill over 200 more, including nurse practitioners, certified nursing assistants, licensed vocational nurses, registered nurses, public health nurses and nursing instructors. This number doesn’t include those needed for the Department of State Hospitals or the Department of Corrections and Rehabilitation. Many represent nurses who have transferred from other facilities around the state.

“It’s exciting to open and activate a facility as large as Stockton,” said Allan Jennings, Chief Nurse Executive. “I’m a Stockton native, and I’ve worked at Folsom State Prison and Deuel Vocational Institution in Tracy prior to coming to this position.”

According to Mr. Jennings, “As nurses, we’re the eyes and ears for CCHCS and we are with patients 24/7. We don’t call them inmate-patients, we just call them patients. I don’t know the outside opinion of the people we treat, but we have sick people in here and we keep their best interest in mind.”

No-one denies that nursing is a difficult task, but according to Mr. Jennings, some inmate-patients don’t even want to be cared for. “We have to build a trusting relationship and this kind of nursing is specialized. We maintain good relationships with our community partners. In fact, we just recently met with the nursing director and assistant director from San Joaquin General Hospital and relationships are very positive.”

It helps to work for a great team. “I’ve known Dr. Rekart for 15 years and I’ve known Dr. Lau for several years. We meet every day along with Warden Ron Rackley and our CEO, Larry Fong. Dr. Lau is always involved in quality and he makes sure that patients have what they need. Custody staff also helps to put our nurses at ease. We’re like a little city. Here is works better than I ever could imagine.”

The CHCF is like its own city and even little cities need to reach beyond their borders into the community at large. How do these chief executives achieve the six goals in the Turn Around Action Plan and engage in important community dialogue?

It’s not to say that the CCHCS executives have a lot of time on their hands to go out meeting with community health, education and business folks. But in spite of their demanding schedules, especially during this activation phase, they have been doing just that. In July, Dr. Lau and Larry Fong met with the Community Health Leadership Council to provide updates about activation and answered questions about community workforce issues. They also met with San Joaquin County officials to learn more about what they can do to mitigate any impacts of mental health and medical professionals from leaving local jobs to go work for the State.

There has been a lot of press in local newspapers and television and recently a newspaper editorial that refreshed readers that the “huge prison hospital in Stockton….would siphon off medical personnel already in short supply.” But

Department of State Hospitals facility at Stockton’s CHCF. “I never expected to be doing what I’m doing today,” said Mr. Price. “I’ve worked my way up from social worker to various supervisory and managerial positions within the state. My attitude was let me get in there and help with the activation. In working with Warden Ron Rackley and CEO Larry Fong and the rest of the team, we’re in this together to make this the best mental and medical care that corrections has to offer. This means that includes the community. We work closely with San Joaquin Delta College to help them produce more psychiatric technicians in their programs and we are becoming a placement site for student interns. We’re playing an important role in encouraging future employees for our organization as well as for San Joaquin County and local private employers.”

Sometimes unlikely partners make the best of things. “We didn’t anticipate having a significant partnership with the CHCF. But we’re likely going to work together to recruit prospects for both of us,” said Vic Singh, LCSW, Director of San Joaquin County Behavioral Health Services. “We’ve lost ten psychiatric technicians who went to work for Stockton’s CHCF recently and that is a big loss for us. We didn’t anticipate the negative impact of their draw. But, we also consider this to be a short term issue balanced with a long-term partnership. We realize that the Stockton facility is in start-up mode and they are under pressure to hire the staff they need and we might lose staff in that process.”

Bar None > The California Health Care Facility

It is apparent that CHCF leaders are aware of their impact on the community. “We are concerned about the needs of our community partners and we realize that as large as we are, we will likely impact the local healthcare workforce. Overall, we are positively impacting the community. However, we learned that short term issues, such as some health care workers leaving other local employers to come here, causes a hardship on some. We believe this is a short term issue and we are making investments to train additional professionals who can continue to fill

the community’s much needed health care positions at local hospitals and clinics. We will do our best to work with our community health care partners to solve issues together. We want San Joaquin County to become known as the place that draws health care professionals at all levels to come here to work throughout the entire community,” said Dr. Lau. “When it comes to staffing shortages, not everyone finds that working in a prison is the best fit for them.

People who come here to work from other parts of the state might transition from our workforce to

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another job in the community, such as the County or the private sector,” said Mr. Price.

Lasting relationships are built on trust. If the chief executives are an example of how the California Health Care Facility integrates into the community, then the future looks good. Their commitment is more than what the State has offered this community to lessen negative impacts, such as providing $1.35 million to San Joaquin Delta Community College over five years to expand its Psychiatric Technician program, $700,000 over four years to Stockton Unified School District’s Health Careers Academy High School, $2.2 million to build a Medically Guarded Unit at San Joaquin General Hospital, $1.9 million to mitigate effects on transportation, $795,000 to compensate for lost wildlife habitat and $292,000 to preserve farmland.

Dr. Lau, Dr. Rekart, Allan Jennings, Larry Fong, Stirling Price and Ron Rackley are reaching out to the community with open minds and ears.

“Once Larry and Dr. Lau learned of our healthcare workforce and training issues, they were very responsive and very concerned. They were immediately thinking how to help solve our problem.” said Kathy Hart, PhD, President, San Joaquin Delta Community College. Those gentlemen are extremely cooperative.”

“I think it’s about mutual respect versus competition for resources. For example we can work together with the Health Careers Academy High School and San Joaquin Delta’s Psychiatric Technician program on a job fair. In the long run, if we collaborate it’s better for everyone,” said Dr. Rekart.

There are no shortages to challenges in a variety of health care issues. As demand increases for care inside and outside the correctional setting, there will also be more competition for a qualified healthcare workforce. Cooperation among community partners to work together to grow a local healthcare workforce and attract workers to San Joaquin County is a positive step.

“We are looking forward to a long and positive relationship with the CCHCS, CDCR and Department of State Hospitals and we welcome their leadership team to the community,” said Ken Cohen, Director of San Joaquin County Health Care Services.

“When the community comes together, good things happen,” said Mr. Fong.

FALL 2013

San Joaquin County Office of Education prepares all San Joaquin County kids for college and careers!

• Enrichment opportunities • Career preparation • Innovative programs to fit individual needs • College readiness • Helping teachers help kids

The Medical Assistant course presents all the elements necessary to meet the objective of becoming successfully employed as a Medical Assistant. This hands-on course offers both front and back office training. Students will become prepared for working in the Medical Assistant Industry. Graduates of the program will earn a Medical Assistant certificate of completion.

Training includes, but is not limited to: • Medical Terminology • Body Structure and Function • Law and Ethics • Safety and Maintenance • Office Skills • Communications • Assisting the Physician • Socio-economics

SJCOE – where kids come first! • www.sjcoe.org/wherekidscomefirst • (209) 468.5930

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FALL 2013

DECISION MEDICINE: TURNING DREAMS INTO REALITIES

This past July marked the 11th year of the Decision Medicine Program. In the third quarter of 2000 edition of the San Joaquin Physician Magazine, Dr. Kwabena Adubofour proposed the idea of creating the Decision Medicine Program to encourage local high school students to pursue a career in medicine.

By the fourth quarter of 2001, the first year of Decision Medicine had been completed and highlighted in the magazine. Although it started out as an idea, it turned into a reality. Six students from both Edison High School and Stagg High School were selected to participate in the six-week program (12 day), where they shadowed physicians in a variety of medical settings. On July 18, 2001, Dr. Adubofour was quoted by The Record envisioning “possibly teaming up with University of the Pacific to make the program more intensive and academic.” In the span of 10 years, that is exactly what happened. For the next four years of the program, the number of selected students went from six to twelve and they represented various high schools within Stockton. In 2008, Michael Steenburgh became the Executive Director of the San Joaquin Medical Society and had even bigger visions for the program. The program had been dormant for the two years before Steenburgh and he made it a priority to bring it back and make it even better. The program was marketed to every high school in the San Joaquin County and over 100 applications were received every year going forward. The program was ultimately restructured to accommodate 24 high school students for a two-week intensive program. 208 students have been through the program and we are currently working to follow-up with the students. story By Vanessa Armendariz

A YEAR OF FIRSTS

This year, the program received a record 160 applications. . The final 24 students represented 14 different high schools and 5 different cities.

Their average GPA was 4.23 and their combined accomplishments were astonishing. With the ongoing success of the program, Decision Medicine was featured on the front page of Stockton’s The Record, the Modesto Bee, Vida en el Valle, as well as Fox40 news. This was the first year that the participants were interviewed about the program on television. As we walked through the halls of some of the local hospitals, there were multiple occasions where people would approach the group, acknowledging that they had seen the

FALL 2013

article in the newspaper. They praised the students and were thrilled to see that such a program could exist here in San Joaquin County.

The program kicks off with the Orientation at Venture Academy Ropes Course. This is an important day of team building. The ropes course challenged the students both mentally and physically and allowed them to become more comfortable with one another before the program began. This year was also the first year that our new Executive Director, Lisa Richmond, was able to participate in the program. After hearing the positive feedback from the students and witnessing the impact it had on their lives, she already has ideas on how to further enhance the program.

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Decision Medicine > 2013

THE PROGRAM Day One:

UC Davis Medical School and Shriner’s Hospital The first day of the program was spent at UC Davis Medical School and Shriner’s Hospital. At UC Davis, the students were able to learn how to take a patient’s medical history, they learned about the San Joaquin Valley PRIME Program, and engaged in a question & answer forum with current medical students. At Shriner’s Hospital, the students were inspired by a thirteen year old patient who had suffered from a severe burn. He brought everyone to tears as he spoke to the students about never giving

to healthcare for the homeless. The students were able to tour both the Gleason House, which serves the homeless population as well as Channel Medical Clinic, which serves low-income patients. All of the students were humbled by their experience and realized the importance of providing healthcare to populations that need it the most. On this day, two students were also selected to shadow Dr. Rick Rawson all-day in surgery, which was a rewarding experience.

Day Five:

The fifth day of the program was dedicated to “giving back” to the community. The students toured St. Mary’s Dining Hall and learned about the various services that they offer free of charge. They also helped sort bags of medication for the medical clinic.

The second half of the day was spent at the Hospice of San Joaquin, where the students learned about healthcare for the elderly population as well as end-of-life care.

Day Six:

up on a dream, the importance of treating everyone the same, regardless of their physical appearance, and more. The students were also able to participate in medical role play with the children.

Day Two:

The second day of the program was at St. Joseph’s Medical Center. The students were able to tour various departments of the hospital including the Cardiac Cath Lab, Maternity/OB, Oncology, Radiology, SIM, and the Operating Room. In the operating room, the students were able to dress in “bunny suits” to experience suiting in for a surgery.

During lunch, many different physicians talked with the students about their personal journeys to medicine and provided them with words of wisdom and encouragement. All of the participants were also CPR Certified by the end of the day.

Day Three:

The third day of the program allowed students to shadow a physician for the day. All students were paired one-on-one with a physician that practiced in the field of medicine that they were specifically interested in. This gave them a first-hand look at the day-in-the-life of a doctor.

Day Four:

The fourth day of the program exposed the students

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Day six of the program was at Dameron Hospital where the students learned about basic hematology. They were able to use lab techniques to determine their blood typesand learned how to make blood smears. The students were also able to view photos of real-life crime scene investigations with forensic pathologist, Dr. Robert Lawrence. Later in the day, the students were able to tour the research laboratory, the pathology department, and an ambulance that was set-up outside of the hospital.

Day Seven:

Day seven took place at the University of the Pacific.

The students toured the university and were able to talk to an admission advisor. They also engaged in a lecture by Dr. Michelle Amaral about the economics of Healthcare. With the many changes currently occurring in healthcare, it was great to learn about the impact that they will have on physicians and patients. The second half of the day was spent at the Community Center for the Blind and Visually Impaired, where students got to learn about the many different services that are offered to people with visual impairments.

Day Eight:

The eighth day of the program looked very similar to an episode of Grey’s Anatomy. The students started their morning by going on rounds with medical students, residents, and the attending physicians at San Joaquin General Hospital. They also toured various departments including Radiology,

Maternity, and the Emergency Room.

Day Nine:

The ninth day of the program was spent at the Kaiser Permanente Hospital in Modesto. The students toured various departments of the hospital and also got to participate in a simulated baby delivery in the simulation lab. They also engaged in an interactive question and answer forum with various Kaiser Physicians.

Day Ten:

The last day of the program was spent in San Francisco at the California Pacific Medical Centers.

The students learned about limb-reattachment and microsurgical procedures from Dr. Gregory Buncke and about the field of neurology from Dr. David Tong. The students also learned about Electrophysiology and Arrhythmia Management, followed by the dissection of pig hearts with Dr. Sachin Shah and Dr. Robert Rho. We ended our day in San Francisco at Pier 39, where we had a celebration dinner at Bubba Gump’s.

THE IMPACT

As you can see, every day of the program exposed the students to a different facet of medicine. With 24 students, and a wide range of interests, it was key to expose them to as many specialties as possible.

“Today, only 16 out of 58 California counties have enough primary care physicians. San Joaquin County has only one primary care physician for every 1,690 citizens while it ranks 47th in health factors such as incidents of adult smoking and obesity.” (The Record, May 12, 2013) The need for physicians in the valley is increasing and one way to combat this need is to encourage local students to pursue medicine. This theme was reiterated each day as all of the health professionals stressed the importance of pursuing the path to a career in medicine and returning to San Joaquin County to practice.

This message was emphasized at the celebration banquet by keynote speakers Dr. Joseph Zeiter Jr. and Dr. Soraya Esteva. Dr. Zeiter, a Stockton native, was able to relate to the students about being a homegrown physician who was committed to serving in his hometown. Dr. Soraya Esteva further inspired the students by acknowledging the challenges that she faced and ultimately overcame as a Latina female pursuing medicine. For most of these students, becoming a physician was a goal that seemed impossible. Through Decision Medicine, they were equipped with the resources, inspiration, and motivation to turn their dream into a reality.

FALL 2013

FALL 2013

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EHR Best Practices:

E-Communication: The Potential and the Pitfalls

October 26, 2013 Breakfast– 8:00 am, Presentation – 8:30-10:30 a.m.

CME - 2 AMA PRA Category 1 Credits™ Stockton Golf and Country Club

To register please call the medical society at 209.952.5299 Educational Objectives

By reviewing different modes of electronic communication (including text messaging, email, and social media) and their impact on patient care and privacy, this presentation will support your ability to: • Apply risk management strategies to minimize risks associated with the use of e-Communication • Increase awareness of risks associated with use of e-Communication • Ensure patient privacy is protected

Faculty

Jane Mock Risk Management Specialist NORCAL Mutual Insurance Company

CME Information and Disclosure

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of NORCAL Mutual Insurance Company and San Joaquin County Medical Society. NORCAL Mutual Insurance Company is accredited by the ACCME to provide continuing medical education for physicians.

NORCAL Mutual Insurance Company designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The faculty member—Jane Mock—has no relevant financial relationships to disclose. Planners from NORCAL include Jo Townson (CME Manager) and Kirsten Padgett (Regional Risk Management Manager)—both of whom have no relevant financial interests to disclose. The planner from SJCMS is Lisa Richmond, who has no relevant financial interests to disclose.

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FALL 2013

18 NEW

MEMBERS IN THE PAST 60 DAYS!

...and even more on the way.

Paynesha Anderson M.D. OB/GYN Sutter Gould Medical Foundation 2545 W Hammer Lane Stockton, CA 95209 (209) 948-5940 Howard University College of Medicine: 2005 John Ellyson M.D. Emergency Medicine 815 Court Street, Ste 4 Jackson, CA 95642 (209) 223-4413 West Virginia University School of Medicine: 1966 Dale Helman M.D. Neurology Central California Neurology Medical Group 2027 Grand Canal Blvd, Ste 29 Stockton, CA 95207 (209) 373-1335 Pritzker School of Medicine: 1984 Jaicharan Iyengar M.D. Orthopaedic Surgery Alpine Orthopaedic Medical Group 2488 N California Street Stockton, CA 95204 (209) 948-3333 University of California School of MedicalS.F.: 2007 Robert Jackson M.D. Dermatology Kaiser Permanente-Stockton 7373 West Lane

FALL 2013

Stockton, CA 95210 (209) 476-3300 Meharry Medical College: 1978 Daniel Levinsohn M.D. Ophthalmology Center for Sight 1899 W March Lane Stockton, CA 95207 (209) 623-4700 Albert Einstein College of Medicine: 2008 Deanna Louie M.D. Ophthalmology Center for Sight 1899 W March Lane Stockton, CA 95207 (209) 623-4700 University of Michigan Medical School: 2008 Taymour Malak M.D. Family Practice 2800 N California St, Ste 11 Stockton, CA 95204 (209) 465-5891 Abbasis Faculty of Medical University of Ain Shams: 1977 Benjamin Morrison M.D. Family Practice Community Medical Centers, Inc 701 E Channel Stockton, CA 95202 (209) 944-4700 Medical College of Va Commonwealth University School Med: 2000

Petre Motiu M.D. OB/GYN 52 Laurel Street Valley Springs, CA 95252 (209) 772-1190 Georgetown University School of Medicine: 1993 Julio Narvaez M.D. Opthalmology Delta Eye Medical Group 1617 St. Mark’s Plaza, Ste D Stockton, CA 95207 (209) 478-1797 Loma Linda University School of Medicine: 1992 Anil Neelakantan M.D. Neurology w Sutter Gould Medical Foundation 2505 W Hammer Lane Stockton, CA 95209 (209) 954-3370 University of Kerala: 2002 Dang Nguyen M.D. Family Practice Kaiser Permanente-Manteca 1721 W Yosemite Ave Manteca, CA 95337 (209) 825-3700 Western University of Health Sciences: 2005 Lan Quang M.D. Nephrology 1610 North El Dorado St #17 Stockton, CA 95204

(209) 465-5107 Drexel University College of Medicine: 2007 Anna Robinov M.D. OB/GYN Kaiser Permanente-Stockton 7373 West Lane Stockton, CA 95210 (209) 476-2000 University of California Davis Medical School: 2008 Alisa Sabin M.D. Urgent Care Sutter Gould Medical Foundation 2545 W Hammer Lane Stockton, CA 95209 (209) 954-4040 Creighton University School of Medicine: 1995 Diane Sanders M.D. Pathology Delta Pathology 3133 W March Lane, Ste 1040 Stockton, CA 95219 (209) 477-4432 St. George’s University School of Medicine: 2007 Valerie Sugiyama M.D. OB/GYN Sutter Gould Medical Foundation 2545 W Hammer Lane Stockton, CA 95209 (209) 948-5940 University of California Irvine: 2002

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2013 Education Series SEPT 11

Sept. 11: California’s Health Benefit Exchange: The Positives and Perils of Contracting Brett Johnson • 12:15 – 1:45 p.m.

Beginning in 2014, California’s private health insurance market will never look the same – individuals and small employers will be able to purchase health insurance coverage through the state’s health insurance exchange, named Covered California. It is estimated that by the end of 2016, over one in five Californians will get their health insurance through the Exchange. In October of 2013, Californians will be able to access the Covered California website and begin enrolling in plans for the 2014 benefit year. Depending on health plans’ distribution of enrollees, a surge of physician contracting efforts may occur as these plans attempt to ensure adequate networks are in place prior to January 1, 2014. In this presentation, you will learn more about California’s exchange and what it will mean for physicians. You will also gain an understanding of some of the risks and benefits of being contracted to provide services to exchange enrollees.

SEPT 12

Sept. 12: ICD-10 Documentation for Physicians: Part 1 AAPC • 12:15 – 1:15 p.m.

Continued on Sept. 19 and 26.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD-10, but for all the regulations surrounding your practice today.

SEPT 18

Sept. 18: Recipe for Financial Success: Key Steps to Increasing Your Net Income Debra Phairas • 12:15 – 1:15 p.m.

Physicians and office managers need business management skills, particularly in the financial area. This workshop will teach critical skills in analyzing the practice profit/loss statement, accounts receivable ratios and staffing patterns and how to access specialty comparison norms. At least one source of comparison data specific to your medical specialty will be given to each participant.

SEPT 19

Sept. 19: ICD-10 Documentation for Physicians: Part 2 AAPC • 12:15 – 1:15 p.m.

Continued from Sept. 12 and ends Sept. 26.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD-10, but for all the regulations surrounding your practice today.

SEPT 25

Sept. 25: Appropriate Prescribing and Dispensing: New Measures Medical Board • 12:15 – 1:15 p.m.

Representatives from the Medical Board of California will discuss outcomes from the Forum to Promote Appropriate Prescribing and Dispensing, held February 2013, including what the Board is proposing/supporting; what the legislature is proposing, and how these measures will be implemented if adopted.

SEPT 26

Sept. 26: ICD-10 Documentation for Physicians: Part 3 AAPC • 12:15 – 1:15 p.m.

Continued from Sept. 12 and 19.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD-10, but for all the regulations surrounding your practice today.

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FALL 2013

OCT 2

OCT 30

NOV 6 NOV 13

Oct. 2: Successful Medi-Cal Provider Enrollment for Physician Providers DHCS • 12:15 – 1:45 p.m.

Physicians must re-enroll in Medi-Cal as one of the provisions of the Affordable Care Act (ACA). This training will cover basic instructions and guidelines on the proper way to complete a Provider Enrollment Application Package. We will discuss the importance of reviewing and understanding program requirements and how to avoid common mistakes when completing enrollment forms. We will also cover specialized physician enrollments, important changes to the program due to ACA implementation, and where to find additional program information and PED contact information.

Oct. 30: CMS Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties CMS • 12:15 – 1:45 p.m.

Presented by the Centers for Medicare & Medicaid Services (CMS), webinar attendees will understand the background and rationale for CMS incentives and payment adjustments that affect physicians, including the Physician Quality Reporting System (PQRS), the ePrescribing (eRx) Incentive Program, the Electronic Health Record (EHR) Incentive Program, and the new Value Modifier (VM) program; be able to define what actions they need to take to receive each incentive and avoid payment adjustments; and know where to go to obtain further information about CMS quality programs and stay abreast of future developments.

Nov. 6: External Auditors and You: Medi-Cal Recovery Audit Contract Process DHCS • 12:15 – 1:15 p.m.

Presented by the Department of Health Care Services (DHCS), this webinar will help you gain information on the current status of the Medi-Cal external audit contract process, understand rules and timelines for implementation, and understand how to work with external auditors.

Nov. 13: Managing Difficult Employees and Reducing Conflicts Debra Phairas • 12:15 – 1:45 p.m.

Very few medical or business schools teach hands-on human resources management skills and techniques. This information-packed workshop will teach you the secrets of how to lead, coach and manage difficult employees; set practice values; and reduce conflict in the practice.

DEC 4

Dec. 4: Medicare: 2014 New Rules Michele Kelly • 12:15 – 1:15 p.m.

This webinar will focus on final rules from the Medicare Physician Fee Schedule that will affect physician practices during 2014 and beyond.

This will help you prepare for any continuing or new programs that may negatively impact payments, as well as prepare you for revisions to policies that may impact your billing and reimbursement.

DEC 5

Dec. 5: ICD-10 Documentation for Physicians: Part 1 AAPC • 12:15 – 1:15 p.m.

Continued on Dec. 12 and 19.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

DEC 12

Dec. 12: ICD-10 Documentation for Physicians: Part 2 AAPC • 12:15 – 1:15 p.m.

Continued from Dec. 5 and ends Dec. 19 This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

DEC 19

Dec. 19: ICD-10 Documentation for Physicians: Part 3 AAPC • 12:15 – 1:15 p.m.

Continued from Dec. 5 and 12.

This three-part series covers the key information necessary to understand key documentation elements to help you not only prepare for ICD10, but for all the regulations surrounding your practice today.

The above webinars are being hosted by the California Medical Association. Please register at www.cmanet.org/events. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar. Questions? Call the CMA Member Help Line at (800)786-4262.

Please note that this calendar does not include CMA’s ICD-10 training courses to be offered in 2013.

FALL 2013

SAN JOAQUIN PHYSICIAN

67

We Celebrate Excellence – Corey S. Maas, MD, FACS CAP member and founder of “Books for Botox®” community outreach program, benefitting the libraries of underfunded public schools

800-252-7706 www.CAPphysicians.com

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Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.

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FALL 2013

In Memoriam

In Memoriam David Allen Stadtner

He was forever quick to help people in need, always identifying with the underdog. He touched the lives of many in Stockton and worldwide. He will be remembered for the acts of goodness he performed.

FALL 2013

DAVID ALLEN STADTNER October 20, 1917 - July 15, 2013 David Allen Stadtner, 95, passed away on July 15, 2013, at O’Connor Woods, a Stockton retirement community. David was born in Stockton to Ann, from Belarus, Russia, and Leo, from Rumania. He moved to San Francisco with Ann when he was five, following his parents’ separation. He and his late sister, Winifred, were placed by their mother in a home for Jewish children, Homewood Terrace, San Francisco, until he was sixteen. He worked his way through Fresno State College and later completed his medical degree, Washington University, St. Louis. In 1944 he married Harriet (Tasha) Stadtner, nee Davidson, also of Stockton, the daughter of Ida and Saul Davidson, immigrants from Belarus.

The young couple moved to Augusta, Georgia, where David trained as an Army doctor for the anticipated invasion of Japan. The war over, he participated in the demobilization of US troops while in the Philippines in late 1945.

Returning to Stockton in 1946, he began practicing pediatrics.

Dr. Stadtner and Tasha raised three sons, Don (65), Barre (62) and Torrey (58). He later became the first allergist in Stockton, with his office on North California Street until his retirement at the age of 68. He practiced medicine with ‘old school’ values, when the first question to the patient was not “What’s your insurance company?” but rather “How long have you had a fever?” He made medical house-calls and treated indigent patients on a sliding scale. He also volunteered at the County Hospital. Such special qualities made him beloved by his patients. Dr. Stadtner was a member of the San Joaquin Medical Society for over 60 years. He served on numerous committees and was a powerful advocate for improving public health in San Joaquin County.

His many interests included Judo and Aikido, earning black belts, and escrima, Filipino stick fighting. An accomplished fencer, he earned medals in national tournaments even into his 80’s. He also served once as the US Judo team doctor at the Olympics. He played tennis, and was also a decent shot with a pistol in the Army. A voracious reader, his interests ran broadly, from medical journals to history and contemporary events.

Over many decades he volunteered in many countries, such as Thailand, Somalia, Afghanistan, Nigeria, to name a few, accompanied often by Tasha. They were also among the first Americans visiting China and Russia, fostering goodwill.

He was forever quick to help people in need, always identifying with the underdog. He touched the lives of many in Stockton and worldwide. He will be remembered for the acts of goodness he performed.

He leaves behind his wife Tasha, his three sons, three grandchildren, Alex, Solomon and Martin, and a great-grandson, Oliver.

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